Extracorporeal memebrane oxygenation

Review of extra corporeal membrane oxygenation as a cardiac assist

1. EXTRA CORPOREAL
MEMBRANE OXYGENATION
(AS A CARDIAC ASSIST)
Dr Sandeep Chauhan
All India Institute of Medical
Sciences, New Delhi

2. ECMO -History
•John H. Gibbon 1935
•Dennis D. 1951
•C. Walton Lillehei `Cross-circulation`1954
•Kolff WJ & Berk HT 1944
•Theodore Kolobow `Silicon polymers`
•J Donald Hill 1971

3. ECMO -Goals
•Increased tissue oxygen delivery
•Carbon dioxide removal
•Aerobic metabolism
•Promote lung `rest`
•Temporary pulmonary / cardiac
support

4. ECMO -Indications
1.Inadequate oxygen delivery:
-Acute myocarditis
-Chronic cardiomyopathy
-Failure to wean CPB
-Post operative CHF
-Refractory arrhythmias
-Cardiac arrest

5. ECMO -Indications
2. Profound hypoxemia
3. Profound cyanosis
4. Support during catheterization

6. ECMO –Contraindications
(Relative)
1.End-stage, inoperable, irreversible
disease
2.Neurological impairment
3.Uncontrolled bleeding
4.Extremes of size & weight
5.Inaccessible vessels on CPR
6.Residual lesions

7. ECMO -Circuit
-Types: Veno-venous& Veno-arterial
-PVC tubing: Neonate & infant 1/4"
Pediatric 3/8"
Adult ½ "
-Arterialcannulae: 8 Fr –21 Fr
-Venous cannulae: 8 Fr –29 Fr
-Kendall Double Lumen Cannula

9. ECMO -Circuit
Pumps : Roller
Centrifugal
Oxygenator : Silicon Rubber Membrane
Plastic Screen Spacer
Polycarbonate Core
0.4 –4.5 m
2
surface area

11. ECMO -Circuit
# COLLAPSIBLE BLADDER :
75 ml & 135 ml
# HEAT EXCHANGER

12. ECMO -Circuit
# BRIDGE

13. ECMO -Anticoagulation
•ACT :
180 to 220 sec (< 160 sec dangerous)
• Cannulation: 75 –150 U/kg heparin
• Infusion: 25 –50 U/kg/hour

15. ECMO –VA Circuit
BODY WT.
(KG)
2-5 5-10 10-20 35-70
TUBING 1/4" 1/4" 3/8" 1/2"
RACEWAY 1/4" 3/8" 1/2" 1/2"
OXYGENA
-TOR (m
2
)
0.8 1.5 2.5 4.5
CANNULA
ART (FR)
VEN (FR)
8-14
10-16
15-20
12-17
17-21
17-19
19-21
23
PRIME
PRBC
FFP
1 UNIT
50 ML
2 UNIT
½ UNIT
3 UNIT
½ UNIT
4 UNIT
1 UNIT

16. Circuit Complications
•Cannula
•Pump
•Bladder
•Oxygenator
•Heat exchanger
•Tubing
•Embolism

17. Cannula Complications
•Wrong size
•Bleeding
•Malposition
•Clotting
•Dissection
•Decannulation

18. Bladder Complications
•Inadequate return:
-Hypovolemia
-Increased Intra Thoracic Pr.
-Venous Cannula Occlusion
-Capillary Leak Syndrome
• Air Embolism:
-High FIO
2
-Inlet Obstruction
-Gas –blood leak

19. Pump Complications
# Pump Failure
# Loss of Occlusion

20. Oxygenator Complications
-Thrombosis of Membrane, Inlet-outlet
port
-Fluid in gas phase
-Failing oxygenator:
• Decreased O
2 /CO
2 transfer
• Widened pre & post membrane gradient
• Increased hemolysis
•Coagulopathy

21. Heat Exchanger Complications
•Corrosion & leak
•Hemolysis, Dilution, Electrolyte
imbalance
•Sepsis
•Seizures, Hyponatremia, Hemolysis

22. Tubing Complications
-Loosening of junctions
-Rupture
-`Walking`

23. Patient Complications
1.RENAL FAILURE:
-Capillary leak syndrome
-Loss of auto-regulation
-Hemolysis

24. Patient Complications
2. HEMOLYSIS:
-Occlusion
-Coagulopathy

25. Patient Complications
3. INTRACRANIAL HEMORRHAGE :
-Gestational age < 35 weeks
-Birth trauma
-Thrombocytopenia
-Coagulopathy
-Sepsis
-Systemic heparinisation
-Systemic hypertension
-Seizures

26. Patient Complications
4. MYOCARDIAL STUNNING:
-Subendocardial ischemia
-Poor coronary filling
-Hypoxia –reperfusion injury

27. Patient Complications
5. PULMONARY HYPERTENSION:
-L→R shunt across PDA
-↑ Pulmonary flow
-Pulmonary edema
-Decreased systemic perfusion
-Acidosis
-Renal failure

28. Thank you!