9/17/2014. Good Morning! 14th Annual Western Kansas Respiratory Care Seminar. 14th Annual Western Kansas Respiratory Care Seminar 28th

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1 Good Morning! 14th Annual Western Kansas Respiratory Care Seminar Current Status of Extracorporeal Membrane Oxygenation (ECMO) in Infants and Adults Kelly D. Hedlund, MS, CCP Chief Perfusionist Michael E. DeBakey Heart Institute Hays, Kansas 14th Annual Western Kansas Respiratory Care Seminar 28th Trends Current Status of Extracorporeal Membrane Oxygenation (ECMO) in Infants and Adults Kelly D. Hedlund, MS, CCP Chief Perfusionist Michael E. DeBakey Heart Institute Hays, Kansas 1

2 Extra-Corporeal Membrane Oxygenation (ECMO) prolonged partial venoarterial bypass achieved via extrathoracic cannulation for support of a patient in respiratory, cardiac, or combined failure which is refractory to all other conventional modes of treatment. - Robert H. Bartlett, M.D. Extracorporeal Life Support Manual for Neonatal Patients 10th Edition, 1994 ACRONYMS CPS (Cardiopulmonary Support) Partial Bypass ECMO (Extra-Corporeal Membrane Oxygenation) ECCO2R (Extra-Corporeal CO2 Removal) Fem-Fem Bypass CPA (Circulatory & Pulmonary Assist) Veno-Arterial Cannulation Arterial return Membrane oxygenator Carot id artery Internal jugular/ SVC Blood pump Venous drainage Venous drainage IVC Femoral vein Femoral artery Membrane oxygenator Blood pump Arterial return 2

3 Veno-Arterial Cannulation 3

4 Veno-Arterial Cannulation Veno-Arterial Cannula Complete cardiopulmonary bypass Out: Right atrium via internal jugular In: Aortic arch via carotid Requires ligation of cannulated carotid! 4

5 NORMAL LUNG DISEASED LUNG 5

6 DISEASED LUNG Capillary leak Hyaline membranes Surfactant depletion Collapse/consolidation V/Q mismatch Reduced compliance Neutrophil infiltration and cytokine release DISEASED LUNG PATHOLOGIES POTENTIALLY TREATABLE BY ECMO Aspiration pneumonia ARDS trauma ARDS sepsis ARDS obstetric Pneumonia viral bacterial atypical Pancreatitis Drowning Burns - smoke inhalation Pulmonary embolus Tricyclic Antidepressant OD Viral myocarditis Post CPB failure to wean 6

7 ECMO PROVIDES PROLONGED RESPIRATORY AND CARDIAC SUPPORT DOES NOT TREAT UNDERLYING PATHOLOGY ALLOWS SUPPORT WHILE THE DISEASE PROCESS RESOLVES OR REVERSES ONLY APPROPRIATE IF UNDERLYING PATHOLOGY IS POTENTIALLY REVERSIBLE 7

8 HISTORY OF ECMO EXPERIMENTS INTO PROLONGED CPB HILL - FIRST ADULT ECMO - AORTIC RUPTURE BARTLETT - FIRST SUCCESSFUL NEONATAL ECMO USA 18 CENTERS PERFORMING ECMO GATTINONI - 50% SURVIVAL IN ADULT ECMO ELSO REGISTRY ECMO CENTERS WORLDWIDE 8

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10 Why the Dismal Results? 1. High anticoagulation and bleeding complications 2. High pressure ventilation used even DURING ECMO 3. Mean duration of ventilation prior to ECMO was 9 days 4. Varying techniques from center to center 5. Crude oxygenators and pumps used Old - The Kolobow Oxygenator The Kolobow spiral coil membrane oxygenator (Medtronic) was developed in the early 1970 s made of silicone rubber Was the only ECMO Oxygenator approved in the U.S. for long term support Used by 97% of ELSO centers in

11 New - QUADROX Oxygenator Priming 250 cc Blood Flow.5 7L/min Surface area 1.8m² Polymethylpentene (PMP) Polymethylpentene (PMP) membranes are now FDA approved for up to 14 days of continuous use. 11

12 Transition in Pump Technology Roller Centrifugal OLD trauma to blood NEW gentle to blood LUNG MANAGEMENT DURING ECMO FIO2-0.3 PEEP 10cm H20 PEAK INSPIRATORY PRESSURE 20cm H2O RATE 5-10/min REDUCE: BAROTRAUMA OXYGEN TOXICITY MYOCARDIAL DEPRESSION Is ECMO a viable and effective modality for treating pulmonary failure when conventional treatment fails? 12

13 Published on line September 16,

14 CESAR Trial Participating Centers Bristol Royal Infirmary St James Leeds Royal Liverpool University Hospitals (3) University of WalesCardiff South Manchester Royal Infirmary, Edinburgh Morriston, Swansea North Devon District Gloucester Royal Walsgrave Queen Elizabeth, Gateshead Royal Chesterfield Derby Royal Infirmary Derby City Milton Keynes General Crosshouse, Kilmarnock Pilgrim, Boston Cheltenham Queen s, Burton-on Trent Llandough, Penarth Macclesfield North Staffordshire, Stoke-on- Trent Wrexham Maelor West Suffolk Chase Farm, Enfield CRITERIA FOR ACCEPTANCE Age <65 years Reasonable long term outlook No contraindication to anticoagulation IPPV < 7 days Reversible pathology Optimum conventional treatment tried 14

15 CESAR Trial Results A multi-center randomized controlled study Multiple investigators with hundreds of clinicians 16% benefit survival without disability in patients referred to ECMO centers over group with conventional ventilation alone 63% survival ECMO group/ 47% conventional group May be cost effective to transfer patients with reversible ARDS to large ECMO center for treatment Yearly registry reports On-site training for ECMO specialists Textbooks, newsletters, videos, website Funding of ECMO-related research 15

16 ELSO Registry Affiliated Centers Total U.S. Active Centers = 105 Hunches and intuitive impressions are essential for getting the work started, but it is only through the quality of the numbers at the end that the truth can be told. - Lewis Thomas Biostatistics in Medicine Science 198:675,