ECMO:Conceptos Básicos

para el Internista

Rodrigo Cartín Ceba, MD, MSc

Pulmonary and Critical Care Medicine

Associate Professor of Medicine

Mayo Clinic

San José, Costa Rica

Junio 29, 2017

Generalidades

Diferentes modalidades/canulaciones

Indicaciones

Complicaciones

ECMO: Oxigenación por

membrana extracorpórea

Introduction

ECMO is utilized to manage life threatening cardiac and/or pulmonary failure when other treatment strategies have failed or are not likely to be successful.

ECMO is a modification of the traditional heart-lung circuit used for cardiopulmonary bypass.

ECMO is instituted as a temporary support to allow for treatment of reversible organ injury and organ recovery/transplant.

ECLS WILL BE IN YOUR ICU

Barbaro RP et al. AJRCCM 2015

ECMO WILL BE IN YOUR ICU!

ELSO Registry January 2017

Adult Respiratory Cases

Heart-Lung Machine

ECMO

DRAINAGEInlet - V

PUMPInlet - V

MOTOR

MEMBRANEOXYGENATOR

BLENDER

MONITORING

INTERFACE

ECMO CIRCUIT

RETURNOutlet – A or V

→Gas BlenderECMO CIRCUIT

Connected to oxygenator

Mixes air and oxygen

O2

•Dial for FiO2 (0.21-1)

Air

•Gas flow = ‘Sweep’•0-10 LPM

Principales modalidades del ECMO

Veno-Venoso (VV)

Veno-Arterial (VA)

Central Periférico

VV ECMO

Used predominantly for respiratory failure that failed conventional therapy (ARDS)

Cannulation:

Femoral-jugular

Femoral-femoral

Avalon Cannula (R IJ)

VV ECMO: Femoral-IJ cannulation

VV ECMO: Femoral-femoral cannulation

VV ECMO: Avalon Cannula

G. Schears

G. Schears

G. Schears

G. Schears

G. Schears

G. Schears

Abrams D, et al. Annals ATS 2013 Picture: Lequier L

Avalon Cannula and ambulation

Slutsky AS Ranieri VM NEJM 2014

LUNG

PROTECTIVE

VENTILATION:

Low Tidal

Volumes

Adequate

PEEP

Low plateau

pressures

ECMO Day 1

ECMO Day 2

Day 15

Reducing Recirculation

Increasing distanceBicaval cannula

Abrams 2015

VA ECMO: Indications

Acute cardiac or cardiac/pulmonary Failure

Post-cardiotomy failure

Cardiogenic Shock (MI/Viral/PE)

Bridge support (Transplant)

Post heart transplantation

Primary graft failure

Acute allograft rejection

VA ECMO: Central cannulation

Central Cannulation

VA ECMO: Peripheral cannulation

Possible configurations:

Femoral-femoral

Femoral-subclavian

IJ-subclavian

VA ECMO: Femoral cannulation

Peripheral Cannulation

VA ECMO: Upper body cannulation

Peripheral VA ECMOTwo circulation patterns competing for blood flow

“Harlequin Syndrome”

Peripheral Cannulation

Inadequate native lung function• Either due to

underlying pathology or inadequate O2 or Ventilation parameters

Significant Cardiac Ejection (myocardial recovery)

Considerations before starting ECMO

Likelihood of organ/patient recovery

CPR duration (? > 60 Min.)

Co-Morbidities

Malignancy

Advanced Age

Brain Injury

Technical/circulatory conditions

MOF

Conventional ventilator support > 7 days.

Complications of ECMO

Mechanical or circuit-related Thromboembolism

pro-coagulation vs. anticoagulation

Air Embolism Oxygenator failure Tubing rupture or

separation De-cannulation, cannula

malposition

Patient-Related Hemolysis Bleeding

DIC Thrombocytopenia

Neurological CNS hemorrhage CNS infarct

Renal (AKI) Cardiovascular Pulmonary Infection Metabolic

Lim – ECLS physiological concepts and clinical outcomes. J of Card Failure 2016

Cheng - Complications of ECMO. Ann Thorac Surg 2014

COMPLICATIONS

Complications of ECMO - Cheng. Ann Thorac Surg 2014

ECMO and nosocomial infection - Schmidt. CID 2012

COMPLICATIONS

Extracorporeal CO2 Removal: ECCO2R

PrismaLung

eCPR

cartinceba.rodrigo@mayo.edu