ECMO: the wave of the future??

Transcription

1 ECMO: the wave of the future?? 15th May 2018 P. Andrew Stephens, MD, FACEP LTC, MC, FS, DMO 19th Special Forces Group (Airborne) Surgeon Background Armored Cav Board EM Critical Care Neurocritical Care Stats ECMO Heart Lung 1

2 Meet Baby Jimmy 34 y.o. male that presented 3 days ago with Flu B Now acute respiratory and cardiac failure Flown in on Epinephrine, Norepinephrine, Vasopressin, & Dobutamine Ventilator is at 100% with 20 PEEP, Pplat >40 What is ECMO? An extracorporeal technique where lung, or heart and lung, function is supported and tissue oxygenation continues by passing deoxygenated venous blood across a membrane oxygenator and CO2 remover and then returning the well oxygenated blood to the body, thus supporting oxygen delivery to tissues 2

3 Brief History First successful use for acute respiratory distress syndrome (ARDS) described in 1972 Until 2008, only patients/year for adult respiratory failure After H1N1 (2009) & with supportive evidence from a randomized control trial (CESAR) with 16% reduction, VV ECMO use has increased (>400 patients/year. LRMC patients success and gaps ( ) BAMC 2011 and LRMC stops ECMO VA & VV VA = Venous to Arterial VV = Venous to Venous 3

4 #1 Oxygen Transfer: ECMO Requires gradient - Oxygen blender allows for a range of fraction of delivered oxygen Requires membrane surface area Also affected by blood flow - Can only increase up to a point, then limited by time ECMO Cannulation 4

5 ECMO Cannulation ECMO Cannulation 5

6 ECMO Cannulation ECMO Cannulation 6

7 ECMO Cannulation VV ECMO: ARDS Acute inflammatory cascade that is caused by: Trauma, Sepsis, Inhalation injury, Aspiration, Pancreatitis, Blood Transfusions, Pneumonia, Influenza, etc hours 40% Mortality rate in a tertiary center Patients have refractory hypoxemia unresponsive to lung recruitment, prone positioning, or higher PEEP - These patients will have signficant consolidation/collapse - baby lung at risk for VILI with conventional strategy Lung Rest - 7

8 ECMO Use & Data ECMO use has been on the rise since 2009 CEASER Non-Combat Trauma Reid et al. 52 pts w/ 79% Guirand et al. retro 102 pts 65%v 24% Bosarge et al. severe ARDS 87% v 36% Figure 1b Increase in ECMO utilization (from Extracorporeal Life Support Organization 2016). Data for 2016 are incomplete. See Inside Baby Jimmy 8

9 Military ECMO Park et al. Jan 04 - Jan ARDS pts 10% develop severe ARDS 22 CEASER 16% overall reduction (NNT = 6) Only ARDS.. ECMO in the Field Until recently pump was roller v centrifugal Heavy >20 lbs (10kgs) Battery 9

10 ECMO in the Field Easy lets go!!!!! Maybe Blood Lysis High H/H ABGs Vents Fibrenogen Cardiovascular monitoring Bleed out Equipment issues BAMC and USAF 59th MDW SECDES paper 2016 Need more patients Civilian population around BAMC 40 pts or 400 bed days (2 pts with surge 4 pts) 16-18, 17-35, 18-80??? ICU lead Use reserve physicians Transportation Most dangerous time 17-26, 18-50??? Afghanstan, Iraq, Hondorus, Columbia, Japan 10

11 Baby Jimmy VA ECMO - 3 days VV ECMO - 14 days CT ICU - 18 days MICU - 7 days Total Hospital stay >45 days Concepts and Considerations Highly skilled teams can be used anywhere and forward deployed Can use off the shelf. 11

12 References 1. Extracorporeal Life Support Organization. ECLS registry report, international summary. Jul Australia, New Zealand Extracorporeal Membrane Oxygenation Influenza I, Davies A, et al. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. Jama. 2009;302(17): Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698): Bein T, Zonies D, Philipp A, et al. Transportable extracorporeal lung support for rescue of severe respiratory failure in combat casualties. J Trauma Acute Care Surg. 2012;73(6): Ried M, Bein T, Philipp A, et al. Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience. Crit Care. 2013;17(3):R Guirand DM, Okoye OT, Schmidt BS, et al. Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study. J Trauma Acute Care Surg. 2014;76(5): Bosarge PL, Raff LA, McGwin G, Jr., et al. Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe acute respiratory distress syndrome. J Trauma Acute Care Surg Park PK, Cannon JW, Ye W, et al. Incidence and mortality of ARDS in combat casualty care. American Association for Surgery of Trauma Sheu JJ, Tsai TH, Lee FY, et al. Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med. 2010;38(9): Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med. 2013;41(5): Shin TG, Jo IJ, Sim MS, et al. Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation. International journal of cardiology. 2013;168(4): Asaumi Y, Yasuda S, Morii I, et al. Favourable clinical outcome in patients with cardiogenic shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation. Eur Heart J. 2005;26(20): Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion. 2015;30(8): Combes A, Brodie D, Bartlett R, et al. Position Paper for the Organization of Extracorporeal Membrane Oxygenation Programs for Acute Respiratory Failure in Adult Patients. Am J Respir Crit Care Med Additional References 15. Del Sorbo L, Goffi A, Goligher E, Fan E, Slutsky AS. Setting mechanical ventilation in ARDS patients during VV-ECMO: where are we? Minerva Anestesiologica 2015;81(12): Chung M, Shiloh A, Carlese A. Monitoring of the adult patient on venoarterial extracorporeal membrane oxygenation. Sci World J 2014; Article ID : Marhong JD, Telesnicki T, Munshi L, Del Sorbo L, Detsky E, Fan E. Mechanical ventilation during extracorporeal membrane oxygenation An international Survey. Ann Am Thorac Soc 2014;11(6):

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