Extracorporeal Life Support (ECLS)
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- Millicent Harmon
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1 Extracorporeal Life Support (ECLS) Moderatore: A. Spagna Discussant M. Rugna, A. Peris, G. Gerosa, M. Raimondi, P. Rosi ADRIANO PERIS- CURE INTENSIVE DEL TRAUMA E SUPPORTI EXTRACORPOREI AOUC- FIRENZE
2 PLANNING 1. Basics of ECLS oriented to OHCA 2. ECLS: missing link or process 3. Point of view 4. Reengineering or not 5. Final remarks
3 Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database (CMPD) for the period 1 January 2004 to 31 December 2014.
4 1. Basics of ECLS oriented to OHCA For the lung Acute Respiratory Failure For the heart Cardiac arrest Cardiac Shock
5 1.1 Basics of ECLS oriented to CA ECLS to assist CPR (ECPR) both in hospital cardiac arrest (IHCA) and in out-of-hospital cardiac arrest (OHCA) Probability to ROSC decreases with the duration of CPR
6 1.2 ECLS: missing link or process ECLS FINAL DESTINATION (Recovery; NHBD)
7 2. ECLS: missing link or process
8 2.1 ECLS: missing link or process
9 2.2 ECLS: missing link or process Variable entry criteria Initial conventional CPR is failing Standard ALS measures are not successful ECLS to take time(can/pci) VA-ECMO after successful resuscitation Refractory cardiogenic shock when all else fails
10 2.3 ECLS: missing link or process Propensity studies: which patient for ECLS The propensity score reflects the probability of receiving ECLS therapy location of the arrest (IHCA versus OHCA) witnessed or unwitnessed arrest presumed cardiac origin duration of CPR Subjects with similar clinical characteristics
11 2.4 ECLS: missing link or process Results... Propensity Score (IHCA) Short- and long-term benefits over CCPR irrespective of ROSB/ROSC. No difference in survival or neurological when administered after ROSB/ROSC following prolonged CPR (Lin, 2010) Meta-analysis (generic) continuous field of cardiac failure, ranging from cardiogenic shock to cardiac arrest Refractory cardiac arrest: increased survival and favourable neurological outcomes in the ECLS Cardiogenic shock: increased survival with ECLS compared with IABP. ECLS as an adjuvant therapy for not only IHCA, but also for OHCA. (Wang, 2014; Ouweneel1, 2016)
12 3. POINT OF VIEW Situations perceived as favorable in ECLS Witnessed cardiac arrest Shockable rhythms High quality cpr Little comorbidity Severe hypothermia Poisoning Myocardial infarction Pulmonary embolism
13 3.1 POINT OF VIEW ECLS vs Multiorgan Disfunction in refractory cardiogenic shock post-cardiac arrest (Pineton, 2016)
14 3.2 POINT OF VIEW ON ECLS 1. Adequate global oxygen delivery (CO x CaO2) needs to be upgraded to a more extensive multiple organ support concept 2. PreHosp/Hosp interface: transition from one phase of central low flow (preh) towards a phase of compartmental flow (inh)
15 3.3 POINT OF VIEW Low level virtual DO2 Middle level virtual DO2 Two DO2 hemi-systems
16 3.4 POINT OF VIEW Veno-Arterial By-Pass with Reduced Pulmonary Flow
17 3.5 POINT OF VIEW Anticipates ECLS in Preh Care Flow maintenance Optimal ECMO blood-flow Screening for ECLS Central venous saturation, lactic acid Limit target organ hypoxemia Higher ECMO elevated after-load of the heart and risk for pulmonary oedema Save target vessels MAP: needs higher ECMO bloodflow and/or higher doses of vasopressors If ROSC manage CO2 AVOID Hypothermia Hyperoxaemia Hypocapnia with alkalosis Two separated circulations, ECMO and native heart after ROSC Intra-cavitary clot formation Higher blood-flow requires larger cannulae risk of leg ischaemia
18 4. REENGINEERING OR NOT ECLS systems are not available everywhere ECLS is intended to gain time
19 4.1 NEED RENGENEERING OR NOT ECLS what changes in hospital Reproducibility of fasttrack Strong preh system conditioning Process-outcome Widespread pathtechnology What asks ECLS team to 118 Sharing propensity score approach Sharing Health Technology Assessment - Flow maintenance - Limit target organ hypoxemia - Control CO2 if ROSC Adapting Skills
20 5. Final remarks ECLS: process that starts from the territory Main theme: flow continuity Consensus on patient recruitment in prehospital phase ECLS anticipation
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