ECMO Experience from ECMO-ICU, Karolinska
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1 ECMO Experience from ECMO-ICU, Karolinska X Curso de Ventilacion Mecanica en Anestesia, Cuidados Criticos y Transplantes Madrid 2012
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4 International numbers Totally since 1989; patients as of July 2011 Survival 2010 Neonatal 69% Pediatric 59% Adult 56%
5 Total survival except ECPR Adult Neo Ped Total Number Survival ECMO Survival hospital % 63% 67% 85% 69%
6 Título del eje 40 Patient distribution ECM0-unit Neo Ped Adult
7 70 ECMO transports Karolinska Other ECMO units
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9 Criterias - cardiac Each one of the following symptoms of hypoperfusion and / or cardiac failure - after volume substitution ( 60 ml / kg, or CVP> 10) and inotropy / vasopressor support - constitutes an indication for ECMO. Plasma lactate> 5 mmol / L without improvement for> 30 min SvO2 <55% (estimated cardiac index <2) for> 60 min Rapid deterioration of ventricular function or severely impaired ventricular function Severe arrhythmia leading to poor perfusion Not possible to come off ECC Ongoing CPR Inotropic Equivalents (IU)> 50 for 60 min, and> 45 for 8 hours. Patients with myocarditis or post-cardiotomy : IE> 40
10 Criterias - cardiac Inotropic Equivalent (IE) Dopamine 1 x µg/kg/min = Dobutamine 1 x µg/kg/min = Adrenaline 100 x µg/kg/min = Noradrenaline 100 x µg/kg/min = Milrinone 15 x µg/kg/min = TOTAL SUM =
11 Criterias - pulmonary Each one of the following symptoms of respiratory failure constitutes an indication for ECMO. Infants OI> 45 for 6 hours on a ventilator and / or HFO OI> 35 for more than 12 hours Exceeds maximum recommended settings on the respirator / HFO: PIP> 35 for 8 hours ΔP> 55 for 8 hours Hz < 10 under 8 timmar MAP/CDP > 18 cmh 2 O under 8 timmar
12 Criterias - pulmonary Children and adults Murray score above 3.0 Carbon dioxide retention with a ph <7.10 for 4 hours Acute deterioration on conventional treatment: PaO2 <4.0 kpa at some time during treatment PaO2 <5.5 kpa during 2 hours
13 Murray score Chest x-ray No alveolar consolidation 0 Alveolar consolidation limited to 1 quadrant 1 Alveolar consolidation limited to 2 quadrant 2 Alveolar consolidation limited to 3 quadrant 3 Alveolar consolidation limited to 4 quadrant 4 Hypoxemia PaO 2 /FiO 2 >40 kpa 0 PaO 2 /FiO kpa % FiO 2 during 20 min PaO 2 /FiO kpa 2 PaO 2 /FiO kpa 3 PaO 2 /FiO 2 <12 kpa 4 PEEP PEEP <5 cmh 2 O 0 PEEP 6 8 cmh 2 O 1 PEEP 9 11 cmh 2 O 2 PEEP cmh 2 O 3 PEEP > 15 cmh 2 O 4 Compliance Compliance >80 ml/cm H 2 O 0 Compliance >60 79 ml/cm H 2 O 1 Tidal volume / (PIP Compliance >40 59 ml/cm H 2 O 2 PEEP) Compliance >20 39 ml/cm H 2 O 3 Compliance >19 ml/cm H 2 O 4
14 Bridge to heart transplantation Same criterias for ECMO as any other patient Should be accepted for transplantation prior to ECMO initiation Answer from transplantation within 72 hours about acceptability ECMO support as long as the patient is not able to sufficiently ventilate herself on ventilator When low pressure and FiO 2 <30% convert to ventricular assist device
15 Bridge to lung transplantation Same criterias for ECMO as any other patient Should be accepted for transplantation prior to ECMO initiation Answer from transplantation within 72 hours about acceptability ECMO support as long as the patient is not able to sufficiently ventilate herself on ventilator
16 Veno Venous ECMO Draw desaturated blood from right atrium and return saturated blood to the right atrium. Double cannulation Single cannulation with double lumen cannula
17 Veno Venous ECMO Double cannulation approach
18 Veno Venous ECMO Single cannulation with double lumen cannula approach
19 Avalon cannula
20 Veno Venous ECMO Single cannulation with double lumen cannula approach
21 Veno venous ECMO Single cannulation with double lumen cannula approach
22 Veno Venous ECMO Single cannulation with double lumen cannula approach Always perform an ECHO to verify position of the Avalon cannula
23 Veno Venous ECMO Recirculation
24 Veno Venous ECMO Recirculation
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26 Veno Venous ECMO Recirculation Determents of recirculation Amount of blood flow Size of right atrium Cardiac output (ie amount of blood returning to the right atrium) Cannula position/s (lateral returning holes position versus the tricuspid valve) Right ventricle cardiac output (ie pulmonary resistance)
27 Veno Venous ECMO Increased pulmonary resistance
28 Veno Venous ECMO Increased pulmonary resistance
29 Veno venous ECMO Increased pulmonary resistance
30 Veno venous ECMO Increased pulmonary resistance
31 When not to go for Veno Venous ECMO Cardiac failure High inotropic or vasopressor needs High pulmonary resistance In all other cases choose venovenous support
32 Veno Arterial ECMO Drawing desaturated blood from right atrium Returning saturated blood in the femoral artery In neonates and small children the saturated blood is returned in the carotid artery
33 Veno Arterial ECMO
34 Veno Arterial ECMO Descending perfusion cannula
35 Veno Arterial ECMO
36 Veno Arterial ECMO
37 Veno Arterial ECMO
38 Veno Arterial ECMO Multistage cannulas
39 Veno Arterial ECMO Multistage cannulas
40 Veno Arterial ECMO Multistage cannulas
41 Oxygenator The lungs of the ECMO machine Determents for ventilation Surface area Blood flow Sweep gas flow (ie carbon dioxide)
42 Oxygenator Carbon dioxide A 70 kg man at rest produces roughly 200 ml/min of carbon dioxide The oxygenator transports 200ml/min/m 2
43 Oxygenator Carbon dioxide Quadrox
44 Oxygenator Oxygen Determents of oxygen transport Surface area Oxygen partial pressure of the blood in the oxygenator Blood flow Any oxygen exchange in the lungs and right chamber cardiac output through the lungs (Sweep gas flow)
45 Oxygenator Oxygen Blood flow Rapid blood flow trough the oxygenator affects oxygen uptake due to a diminished time for the erytrocytes to take up oxygen
46 Oxygenator Oxygen Blood flow Rapid bloodflow trough the oxygenator afects oxygen uptake due to a diminished time for the erytrocytes to take up oxygen Rated flow
47 Rated flow The pumpflow where maximum oxygenation of the blood occurs where the venous blood is saturated to 75% and the arterial blood is saturated to 100% leaving the oxygenator. After this pumpflow no futher increase in oxygenation will occur.
48 Oxygenator Oxygen Oxygen consumption of a normal built man is around 200 ml / min at rest Can rise to over 400 ml / min in sepsis
49 Oxygenator Oxygen Quadrox
50 Oxygenator Oxygen Sepsis Quadrox
51 Oxygenator
52 Oxygenator Double oxygenator
53 Oxygenator Double oxygenator
54 Oxygenator Double venous cannulation
55 Oxygenator Double venous cannulation
56 Oxygenator Double oxygenators
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