ECMO and refractory Hypoxemia

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1 ECMO and refractory Hypoxemia Dr. Vinay Dhingra MD FRCPC Clinical Associate Professor of Medicine Clinical Lead Critical Care BCPSQC Medical Director Quality VGH

2 Disclosures

3 ARDS

4 Lancet 1967; 2:

5

6

7 Acute Phase

8 Acute Lung Injury and Acute Respiratory Distress Syndrome PaO 2 /FiO ARDS: PaO 2 /FiO 2 < 200 Acute lung injury: hypoxemia risk factor Bilateral infiltrates No left atrl. htn. PaO 2 /FiO 2 < 300

9 Ventilator Induced/Associated Lung Injury Barotrauma High pressure lung injury (pneumothorax etc) Oxygen Toxicity Volutrauma Damage by overdistention Atelectotrauma Repeated recruitment and collapse. Shear injury Biotrauma Inflammation release by injurious ventilation

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12 Ventilator Induced Lung Injury Overdistention

13 Ventilator Induced Lung Injury: EM Overdistention

14 Atelectotrauma

15 High Volume Ventilation Low Volume Ventilation Regional Overinflation PEEP (-) PEEP Increased Surfactant Microvascular Inactivation Permeability Atelectasis Increased (-) Filtration PEEP Pulmonary Edema PEEP (-) Alveolar Flooding PEEP Reduction in (-) Lung Distensible Repetitive Opening Volume and Closing of Distal Lung Units Distal Lung Tissue Damage Leukocyte Inflammation Activation and Infiltration

16 Mechanical Ventilation Cytokines, complement prostanoids, leukotrienes reactive oxygen species Biochemical Injury Biophysical Injury shear overdistention cyclic stretch intrathoracic pressure bacteria alveolar-capillary permeability cardiac output organ perfusion neutrophils Distal Organs tissue injury secondary to inflammatory mediators/cells impaired oxygen delivery bacteremia MSOF

17 Mortality from ARDS

18 The Berlin Defini,on Timing Within 1 week of insult Imaging Bilateral opaci,es consistent with pulmonary oedema on CXR or CT Origin Not fully explained by cardiac failure/fluid overload Echo may help Categories Mild - Pa/FiO2 < 300 Moderate - Pa/FiO2 < 200 Severe - Pa/FiO2 < 100

19 Mortality and MV duration Mortality (%) Dura%on (Days) Mortality MV dura,on Mild Moderate Severe 0

20 Refractory Hypoxemia Options Esophageal Balloon (PEEP) Prone Positioning Inh NO NMB HFOV APRV

21 Berlin ARDS Definition 2013

22 What is ECMO?

23 ECMO Is Not CPB

24

25 Early Extracorporeal Circulation Reached clinical application in mid to late 1950 s Use limited in duration due to activation of blood components Due to early oxygenators with direct air-blood interface Duration of use limited to few hours (Cardiac Surgical Procedures)

26 Silicone membrane lung Dimethylpolysilxane (DMPS, silicone) Discovered in 1957 By 1963 used in construction of oxygenators suitable for long-term support Paved the way for long term extracorporeal circulation

27 1972 Hill

28 1975 Bartlett

29

30 First Neonatal ECMO Patient celebrates her 21st Birthday 1996

31 ECLS History Adult Respiratory Clinical Trials 1979 NIH-ARDS randomized trial 1986 Gattinoni ECCO2R cohort trial 1986 Morris ECCO2R rdm trial 2007 Peek CESAR randomized trial

32 NIH Adult ECMO Study Zapol WM et al JAMA 1979,242:20; Prospective randomized study (9 Centres) Acute respiratory failure (ARF) 90 adults selected by common Entry criteria: FAST: PO2<50mmhg on FIO2=1,PEEP>5. SLOW: PO2<50 for>12hours onfio2>0.6, PEEP >5, 48 conventional mechanical ventilation, 42 mechanical ventilation supplemented with partial venoarterial bypass

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34 Insights into NIH Trial Little or no center experience VA ECMO Antiquated (surgical) cannulation High levels of anticoagulation Excessive blood loss No concept of lung rest ventilators remained at same settings

35 Milan ECCO2R Trial

36 Morris ECCO2R-LFPPV Trial

37

38

39 PRIMARY HYPOTHESES For patients with severe but potentially reversible respiratory failure, ECMO: Will increase the rate of survival without severe disability by six months post randomisation. Will be cost effective, compared to conventional ventilatory support.

40 Inclusion Criteria Potentially reversible respiratory failure Murray score > 3.0 hypercapnoea ph <7.20 aged years

41 Exclusion Criteria 1. duration of high pressure and high FIO 2 ventilation < 7 days 2. no contra-indication to limited heparinisation 3. no contra-indication to continuation of active treatment

42 Patients considered potentially eligible for trial (n=766) Not randomised (n=586) Randomised (n=180) Non-availability of ECMO bed (n=103) Murray score <3 or ph >7.2 (n=99) High pressure ventilation >7 days (n=86) Other* (n=298) ECMO (n=90) Conventional Ventilation (n=90) Received ECMO support (n=68) Did not receive ECMO support (n=22) n=90 Information available for primary outcome n=87

43 Kaplan-Meier survival estimates, by allocation Analysis time (days) Conventional ECMO

44 Oxygenators Pump Systems Cannulation Techniques Heater- Cooling Devices Pressure Monitoring Capabilities Tubing Changes Flow and Blood Monitoring Anticoagulation Advances Gas Blenders TECHNOLOGICAL ADVANCES

45 Oxygenators using Nanoporous Hollow Fiber

46 Nanoporous Oxygenator Good long term Less platelet aggregation Minimal haemolysis Current Gold Standard

47 Centrifugal Pump Designs

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49 Cannulation Changes

50

51

52 ECMO v1, It works BUT, very complex It can fail suddenly with blowout, air, clot Thrombogenic and bleeding requiring ++ products Vascular access complex

53 ECMO v2, 2008 New low resistance lungs can be used with low pressure pumps, are less thrombogenic making it much safer Inherently safe self regulating circuit Safer easier vascular access Prevent ICU syndrome, more awake, alert and?mobile patients

54 ECMO Risk-Benefit

55

56 During swine flu 332 referrals

57 Data collected from SwiFT Study Web based study with data collected from 192 acute hospitals throughout the UK ECMO Patients matched by Individual Matching Propensity Matching GenMatch Matching

58 23.7% versus 52.5 % mortality

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68 BC Guidelines: Veno-Venous (VV) Extra- Corporeal Life Support (Sept 2015) Adult Indications: Severe Acute Respiratory Failure (ARDS): 1. P/F ratio is < 50 mmhg when FiO2 = 1 for at least 3 hrs, despite use of other protective ventilation strategies 2. P/F ratio is < 80 mmhg when FiO2 = 1 for more than 6 hrs, despite use of other protective ventilation strategies 3. Associated with use of protective ventilation strategies there is respiratory acidosis (ph < 7.20 for > 6 hrs) 4. P/F < 100 with a trajectory of worsening hypoxemia despite optimization of ventilation and adjunct therapies.

69 Additional Considerations 1. The use of VV-ECMO should only be considered if the underlying process is potentially reversible 2. The indications for ECLS must be based on a collective and multidisciplinary decision. The indications for ECLS should be discussed case-by-case 3. There is no indication for veno-arterial (VA) ECLS in ARDS when respiratory failure is isolated

70 Contraindications A. The impossibility of using anticoagulation treatment is a classic contraindication to ECMO B. The risk-benefit ratio of ECMO in ARDS should be considered unfavorable in cases of: 1. Hemorrhagic or potentially hemorrhagic intracranial lesions 2. Coma following cardiac arrest 3. ARDS in which the patient has already been mechanically ventilated for more than seven days 4. Immunocompromised 5. Significant multisystem organ failure

71 ECMO: in BC Where do we perform ECMO? Everywhere? Limited Hospitals sites? Stabilize and Transfer? Does size of program matter?

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75 Best Practices for ARF: Volumes and Critical Mass ECMOnet (2014) Expected Volumes Occurrence of ARF severe to warrant consideration of ECMO (Excluding Pandemics) 5-10/million population Critical Mass Better outcomes with increased volumes cases/y Learning Curve (to establish competency) Minimal 20 cases for start up for optimal results Education requirements Ongoing CME/ ECMO training

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77 ECMO and ARF Final Considerations Overall significant technological changes leading to increased survivability Gone from case reports to now true option for care in right patient Early recognition and referral to ECMO centre is key to success Potentially significant transport issues Increase in cases improves survivability

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