ECLS. The Basics. Jeannine Hermens Intensive Care Center UMC Utrecht

Transcription

1 ECLS The Basics Jeannine Hermens Intensive Care Center UMC Utrecht

2 Conflict of interest None

3 Terminology ECMO - ExtraCorporeal Membrane Oxygenation ECLS - ExtraCorporeal Life Support PLS - Veno-venous ECMO - Extracorporeal CO 2 removal (ECCO 2 R) - Pump Assisted Lung Protection (PALP) - Veno-arterial ECMO - Extracorporeal CPR (E-CPR) - Permanent Life Support Maquet

4 Extracorporeal Membrane Oxygenation Circuit Two BUY goals: TIME - Oxygenate - Extract carbon dioxide Daniel Brodie & Matthew Bacchetta. N Engl J Med 2011

5 First cardiopulmonary bypass Gibbon, 1953

6 History of ECMO First human ECMO - more than 40 years ago Hill JD et al. New Engl J Med 1972

7 First neonatal ECMO survivor

8 Neonatal ECMO

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10 Transport on ECMO

11 ECMO in H1N1

12 ECMO at the Louvre

13 Arlt M. et al. Resuscitation Arlt M. et al. Resuscitation. 2011

14 Hill JD et al. New Engl J Med 1972 History of ECMO First ECMO - more than 40 years ago

15 History of ECMO Evidence of beneficiance ECMO in respiratory failure 1979: VA ECMO vs conventional treatment in acute respiratory failure: both 90% mortality 1978: Kolobow and Gattinoni: ECCO2-R 2007; ELSO: 105 ECMO runs: 52% survival 2009: CESAR trial: (180 pts randomized): treatment in ECMO center beneficial (VV ECMO)

16 ECMO in cardiac failure History of ECMO Evidence of beneficiance Cove ME & MacLaren G. Critical Care. 2010

17 Extracorporeal Membrane Oxygenation Circuit Two goals: - Oxygenate - Extract carbon dioxide Daniel Brodie & Matthew Bacchetta. N Engl J Med 2011

18 Extracorporeal Membrane Oxygenation Oxygenator yanahammond.com

19 Hollow fiber Membrane oxygenator Polymethylpentene Heparin-coated High performance blood oxygenation CO 2 elimination low pressure drop Long duration 2-3 weeks Courtesy of Prof. Alain Combes, La Pitié-Salpetrière, Paris

20 Extracorporeal Membrane Oxygenation Oxygenator venous arterial

21 Extracorporeal Membrane Oxygenation Centrifugal blood pump magnetic levitation venous CentriMag designworldonline.com

22 Extracorporeal Membrane Oxygenation Centrifugal blood pump Electrical non-pneumatic non-pulsatile Centrifugal pump RPM venous Flows up 8 L/min Very reliable weeks

23 Extracorporeal Membrane Oxygenation Circuit Sidebotham D et al. Journal of Cardiothoracic and Vascular Anesthesia 2012

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25 Extracorporeal Membrane Oxygenation Veno-arterial ECMO: both respiratory and cardiac support - peripheral cannulation - central cannulation Veno-venous ECMO: only respiratory support: pneumonia complicated by ARDS

26 Veno-Arterial ECMO Peripheral Cannulation Arroyo D, Cook S - Minim Invasive Surg (2011)

27 Veno-arterial ECMO Possible circuits: femoral-femoral femoral-axillary central cannulation BP - blood pump ML - membrane lung Scaravilli V et al. In: Sangalli F et al. (eds.), ECMO-Extracorporeal Life Support in Adults, Springer-Verlag Italia 2014

28 Pages ON et al. J Thorac Cardiovasc Surg. 2009

29 Loss of LV ejection and flow Increasing ECMO blood flow Scaravilli V et al. In: Sangalli F et al. (eds.), ECMO-Extracorporeal Life Support in Adults, Springer-Verlag Italia 2014

30 Harlequin syndrome Complicating peripheral VA-ECMO

31 Harlequin syndrome Complicating peripheral VA-ECMO Mondino MG et al. In: Sangalli F et al. (eds.), ECMO-Extracorporeal Life Support in Adults, Springer-Verlag Italia 2014

32 Harlequin syndrome Complicating peripheral VA-ECMO Mondino MG et al. In: Sangalli F et al. (eds.), ECMO-Extracorporeal Life Support in Adults, Springer-Verlag Italia 2014

33 Veno-Arterial ECMO Central Cannulation Marasco SF et al. Heart, Lung and Circulation 2008

34 Veno-venous ECMO Daniel Brodie & Matthew Bacchetta. N Engl J Med 2011 Example: CO 5 L/min ECMO flow: 3.5 L/min x sat 100% L/min x sat 70% = sat 91%

35 Veno-venous ECMO Percutaneous cannulation

36 Veno-Venous ECMO cannulation principles

37 Mobilizing on ECMO Source: Criticalcarecanada.com

38 Veno-venous ECMO Beneficial properties ARDS lung rest Percutaneous insertionbed side therapy Less bleeding complications

39 After ECMO insertion Monitoring Lung rest ventilation settings: low tidals, high PEEP Heparinization Monitoring arterial blood gas: right arm!

40 ...Indications ECMO By Prof van Dijk