ECMO: Choice/Technique

Transcription

1 ECMO: Choice/Technique Joseph B. Zwischenberger MD Johnston-Wright Professor Chairman: Department of Surgery Surgeon-in-Chief UK Healthcare (mobile) The University of Kentucky Lexington, Kentucky

2 Presenter Disclosure Information Joseph B. Zwischenberger, M.D. Research supported in part through Competitive funding: National Institutes of Health (SBIR,STTR,T-32) Contracts: MC3, Ann Arbor Mi Exotherm, Lexington Ky W-Z Biotek, Lexington Ky Maquet Patent: Avalon Elite (4 more, 3 pending) Novalung Free App: Zwisch Me

3 Bartlett/Zwischenberger 1984

4 VENOVENOUS ECMO Single, Double Lumen Cannula For total gas exchange alone Kendall 1989 Zwischenberger/Drake Prototype ASAIO J 1984

5 Oxygen transfer Carbon Dioxide Removal

6 CO 2 Removal CO 2 removal and O 2 transfer are uncoupled: CO 2 is transferred across the membrane gas exchanger Low Frequency Ventilation: O 2 diffuses across the native lungs Ted Kolobow 1977

7 AVCO 2 R: Carbon Dioxide Removal (get the bad air out) with a low-resistance gas exchanger in a simple arterio-venous shunt Zwischenberger 1996

8 Arteriovenous CO 2 Removal = PECLA NOVALUNG (Europe): Survival 70% percutaneous cannulation of femoral artery (10-12 Fr) and vein (16-18 Fr) Flow ml/min for CO 2 Removal >3000 patients

9 Impact of CO 2 Homeostasis CO 2 flux is greatly reduced by AVCO 2 R, and may be important in: organ tissue neutrophil apoptosis resolution of inflammation maintaining a normal alveolar milieu Zwischenberger et. al. Ann Surg 2007;246:

10 The higher pump flow, the more recirculation ( ) Effective flow ( ) no longer increases as pump flow increases

11 VV Triple site cannulation Minimizes recirculation maximizes venous drainage improves gas exchange 2003

12 Avalon Elite Catheter Placement: image guidance required Flouro insertion with ECHO positioning Wang/Zwischenberger 2007

13 Newborn with Meconium Aspiration on Avalon Elite VVDL ECMO 6 days: No Recirculation 2009 Blue blood out Red blood in

14 United Kingdom H1N1 ECMO vs Conventional care 69 ECMO patients in 4 centers Matched pairs study, 3 methods ECMO CC survival % Individual Propensity score Genmatch Conclusion: ECMO survival 76% Conventional Care 49%

15 56 yo idiopathic pulmonary fibrosis:uncomplicated bilateral lung tx 3/08 12/08 Trichosporon pneumonia, post-infectious obliterative bronchiolitis. Listed for redo transplant Feb 08. Alert Chuck Hoopes (UCSF ): the first Ambulatory Lung Assist patient using Avalon Cannula, Quadrox and Centrimag!! IVC TV SVC IVC RV Total gas exchange - no recirculation SVC

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18 Exercise at the bedside

19 Securing cannula for ambulation and sterilization

20 VA ECMO Sport Model Optional V-VA or WEAN to DLC VV All configurations allow ambulation Bacchetta 2012

21 Tips for percutaneous technique 1 Guidewire placement Ultrasound vessel identification Vascular transducer to guide needle Fluoroscopy ensures guidewire location Encouraged for single-lumen cannula placement Recommended for dual-lumen cannula placement Echocardiography Precise placement for flow: dual-lumen cannula Guidewire should have no resistance 21

22 Complications - prevention Vessel perforation Ultrasound for intraluminal placement Fluoroscopy to identify guidewire Atrial perforation Fluoroscopy for guidewire placement Wrong vessel cannulation Ultrasound for vessel identification Inadequate drainage Malpositioning Inadequate cannula size 22

23 This is ECMO? walking bypass RA to Ao cannulation (BiV failure, PHTN s/p PEA..to HLTx) walking ECMO dual lumen Avalon VV (hypoxia, hypercapnea secondary BOS.. to redo BLTx) ambulatory right heart bypass PA to LA cannulation (RV failure, hypoxia, PHTN s/p PEA..to BLTx)

24 walking bypass RA to Ao cannulation with pump/oxygenator (BiV failure, PHTN s/p PE..to HLTx)

25 The oxyrvad RA to PA with pump/oxygenator RA graft 28 angled metal tip outflow 10 mm Dacron PA inflow

26 Pumpless ExtraCorporeal Lung Assist ( PA-LA) pulmonary bypass supra-systemic pulmonary pressures do not require a centrifugal pump

27 Fem-Fem Walking VA V-AV support Partial VA ECMO/Partial VV ECMO SVC EuroELSO 2015: ambulatory FEM-FEM ECMO is feasible

28 Selection of ECLS Support Mode /Configuration Keshavjee ECMO Red Book, 4 th edition, 2011

29 Does anyone with severe respiratory failure really benefit from mechanical intubation and positive pressure ventilation?..with ECMO.. VV DLC ECMO pre BLTx (cystic fibrosis) *prevent barotrauma and activation of inflammatory mediators *Limit end organ injury *avoid sedation and muscle atrophy (frailty) 20/22 consecutive ambulatory ECMO adult patients are alive to 6 months

30 AATS 5/2015: 12 ECMO talks AATS Guidelines: Bridge to transplant and Extracorporeal lung support: Ambulatory ECMO recommended (Bacchetta and Cypel 2015)

31 SUMMARY OF RECENT REPORTS* CHRONOLOGICALLY OF THE USE OF ECMO AS BRIDGE TO LUNG TRANSPLANT (*SERIES WITH MORE THAN 10 PATIENTS) REFERENCE YR PATIENTS DURATION (RANGE) Hoopes b (2-53) VV DLC (10) VV (1) VA (10) PA LA (2) RA Ao (3) Comb 5) MODE OF ECLS BRIDGE (%) SURVIVAL 1 YR (%) 87 Dellgren (1-229) VV DLC (3) VV (11) VA (6) Hayanga NA Not specified NA 80 Hoetzenecker (0-95) VV DLC (23) VV (7) VA (7) PA-LA (9) ECCO2R (12) Comb (13) Todd ( ) VV DLC (9) VV (2)

32 Hybrid ECMO for Heart and Lung Failure Many now using Distal Limb perfusion routinely 2016

33 ecpr: ER ECMO Survey of Centers participating in Extracorporeal Life Support Organization (ELSO) VA ECMO with groin cannulation Cardiology, CT, Emerg Med, Vascular Over 33% of centers that submit adult ECMO perform ED ECMO Resuscitation 107 (2016) 38-46

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35 40% Peds 30% Adult Thiagarajan RR, et al. ASAIO 2017, 63(1):60-67

36 ECMO Transport Safety and Outcomes of Mobile ECMO Using a Bicaval Dual-Stage Venous Catheter Improved in hospital survival 86% (44 pts) vs Conventional ECMO 79% (126 pts) ASAIO J 2017; 63: Transportation of Patients on ECMO: Center Experience and Literature Review 38 manuscripts plus experience (1481 pts) Survival: Adult (62%) Pediatrics (68%) Ann Intensive Care (2017) 7:14

37 ECMO FUTURE Catheter based Technology (Ambulatory) Neonates, Children, Adults Acute Severe Respiratory failure Acute Cardiac support ER Transport Resuscitation/Shock Transplantation Recipient Support Donor Support: DCD Organ Block Support : Lung in a Box

38 You should ALWAYS listen to a harmonica player Will play for drinks and tips

39 ECMO: Choice/Technique Joseph B. Zwischenberger MD Johnston-Wright Professor Chairman: Department of Surgery Surgeon-in-Chief UK Healthcare (mobile) The University of Kentucky Lexington, Kentucky

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41 ECMO: Cannulation Techniques Joseph B. Zwischenberger MD Johnston-Wright Professor Chairman: Department of Surgery Surgeon-in-Chief UK Healthcare (mobile) The University of Kentucky Lexington, Kentucky

42 Cannulae choice Oxygen Consumption determines Delivery Newborn: Child: Adult: 5-8 cc O 2 /kg/min 4-6 cc O 2 /kg/min 3-5 cc O 2 /kg/min Translated into flow (for normal Hgb) Neonate Pediatric Adult 100 to 150 ml/min/kg 75 to 100 ml/min/kg 50 to 75 ml/min/kg 42

43 Cannulae choice Venous drainage Determines the flow Drains blood Passively Actively Venous Drainage will be the most important factor in determining the maximum flow Biggest and Shortest cannula practical 43

44 Cannulae choice Hagen-Poiseuille: laminar pipe flow Increasing diameter is best way to increase flow Minimize length Q = P π 128 d µ 4 L Cannulae Circuit 44

45 Percutaneous Cannulation Percutaneous method Seldinger technique Non-surgical Preferred for venovenous Low incidence of bleeding complications Sizes to 31+ French Decannulation is non-surgical Withdrawal and suture of tract or quick close 45

46 Internal Jugular Cannulation 46

47 Femoral Vein Cannulation 47

48 Avalon Dual Lumen Courtesy R Firmin, Leicester, UK 48

49 Two-cannula single-lumen cannulation Venousreturn Membrane oxygenator Internal Jugular/ SVC Femoral vein Blood pump Venous drainage 49

50 Three-cannula single-lumen cannulation Venous drainage Blood pump IVC Femoral vein Femoral vein Membrane oxygenator 50 Venous return

51 VVA - Hybrid VV and VA Partial cardiac support Venousreturn Assures oxygenated blood to brain and coronaries Internal jugular/ SVC All percutaneous Membrane oxygenator IVC Femoral artery Femoral vein Can convert VV to VVA if more cardiac support is needed Blood pump Arterial return Venous drainage 51

52 Avalon dual-lumen: Fr sizes 52

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54 Unconventional Institutional Volume Outcome Associations in Adult ECMO in the US No significant survival difference between Low, Medium and High volume ECMO programs in bridge to Heart or Lung transplant patients McCarthy et.al. Presented at STSA 11/15

55 Goal: Ambulatory Paracorporeal Artificial Lung Grant Concept 2003

56 Disclosures Check x Check x No Relevant Financial Interests to Report Products discussed for patient use are FDA approved Many products discussed are used extended label 56

57 Learning Objectives Cannulation How to choose a cannulae How to put it in Initiation Process 57

58 Cannulation: Achilles' heel of ECMO Venousreturn Membrane oxygenator Internal Jugular/ SVC Femoral vein Blood pump Venous drainage 58

59 Cannulation The first of many opportunities to kill your patient Choices Venous cannulae Diameter Length Which vein How many Arterial Diameter Length Which artery Protect the limb 59

60 Cannulae choice What are we doing? Supporting tissue level perfusion Function of metabolism Metabolism requires fueloxygen The fire of life Oxygen delivery is a function of: Oxygen content Sats Hgb Blood flow rate 60

61 Cannulae choice OK, I can determine flow. Which cannulae do I use? 61

62 Cannulae choice Mode of cannulation Why are we doing this again? Tissue level perfusion Gas exchange failure? Venovenous Venoarterial Perfusion failure? Venoarterial 62

63 Cannulae choice Single lumen Double lumen Arterial Venous Various lengths Various diameters 63

64 Cannulae choice How much flow do you want? Almost always more then you get Pressure Flow relationship M number Experimentally measured per cannulae 64

65 Cannulae choice Finally, you can choose your cannulae. About time! 65

66 Now, you only have to choose your: Pump? Oxygenator? Tubing diameter? Tubing length? How many connectors? What kind of access? What kind of monitors Bladder? Bridge? Protocols Training Education Competencies Data base Quality Order sets Labs? Transfusion strategies Counseling sessions 66

67 Percutaneous Cannulation techniques how to put it in Primary technique for adult venovenous support Semi-open (surgically-guided percutaneous) Visual guidance of percutaneous insertion Developed for neonatal VV cannulation An option for adult cannulation Open (surgical venotomy) Traditional approach to cannulation Requires vessel ligation Backup option for failed percutaneous technique 67

68 Percutaneous Cannulation Courtesy of Jonathan Haft 68

69 Surgical Cannulation Vagus nerve Proximal ligatures Carotid artery Distal ligatures Internal jugular vein Reinfusion cannula Drainage cannula 69 69

70 Introducer Comparison 70

71 Vessel Dilatation 71

72 Pharmacologic management during cannulation Deep sedation with intravenous analgesia Local infiltration anesthesia at cannulation site Elevated airway pressures Usually not a problem Short-acting neuromuscular blockade during cannula insertion Prevention of air embolism 72

73 Tips for percutaneous technique 2 Guidewire kinking Occurs when advancing dilator Usually in the tissue outside of the vessel Prevention Patient positioning straight shot Long tapered dilators (Coon s dilators) Rotational motion >> forward motion No more than 4 Fr increments retreat if needed Ensure adequate dilatation at each step Adequate tension on guidewire Minimize skin incision snug fit = less bleeding 73

74 Typical cannula sizes for percutaneous use Internal Jugular Vein size usually about 40 to 50 Fr (I ve seen 75 Fr!) 23 to 24 Fr short 27 to 31 Fr dual lumen Femoral vein Vein size usually 35 to 45 Fr 23 to 24 Fr short 24 to 28 Fr long Femoral artery 16 to 17 Fr 74

75 Right Internal Jugular Ultrasound SCM SCM RIJV CA RIJV CA 75 Courtesy of Jonathan Haft

76 Ultrasound Right Femoral 76 Courtesy of Jonathan Haft

77 Measuring vessel size Fr size = diameter * 3 Fr size circumference in mm 77

78 Jugular cannula placement 78

79 Femoral cannula placement Courtesy 79 R Firmin Leicester, UK

80 Avalon Placement 80

81 Positioning of the dual lumen cannula 81

82 Correct insertion depth Courtesy of Mark Ogino, MD IVC Port Infusion Port 82

83 Insufficient insertion depth Courtesy of Mark Ogino, MD Infusion Port 83

84 Deep insertion depth Catheter Tip Liver Diaphragm Courtesy of Mark Ogino, MD 84

85 Circuit priming Isotonic crystalloid with extracellular fluid composition Normosol-R ph 7.4, Plasmalyte Na Cl Acetate K Mg Gluconate Optional 140 meq 98 meq 27 meq 5 meq 3 meq 23 meq Albumin 25% to bring final concentration 4 to 5% 85

86 Initiation Your second opportunity to kill your patient Crashing on VA You can only look good Elective VV VA You can only look bad Be prepared Have a plan in your head Have a plan outside of your head» Say it out loud to each other» closed loop communication 86

87 Initiation Crashing on Chaotic CPR Cannulator cannulates VA Cut down Percutanous Team manages the patient Team readies the circuit Focus on your job Go on fast Air Connecting backwards 87

88 Initiation Elective When Always after midnight Always for about 6 hours Where Fluro Cath lab OR ICU Should simulate the process Elevator big enough? 88

89 Initiation How Commence support slowly Hypotension with VV Prepare with pressors Make sure blood is going the right direction Watch for air Double check each other Trust no one Giving heparin is everyone s job Change nothing until supports established Stabilize Evaluate circuit Maximum flow? Evaluate support Minimize the unnecessary Define support goals Tissue level perfusion 89

90 Initiation Commencing support Mix prime in slowly Increase pump speed slowly to achieve max flow Decrease flow to lowest level to provide adequate support Arterial saturation > 85% (lower if necessary) Physiologic goals Hemodynamics Tissue perfusion Organ function Blood flow regulated over time to meet goals 90

91 Thank you Questions? 91

92 CESAR Trial To clinicians who have witnessed firsthand ECMO s ability to salvage an unstable life that would presumably be lost without it, today s study will represent the sentinel paper on adult ECMO for years to come. After all, 63% of patients who were dying survived to 6 months with ECMO referral Zwischenberger JB, Lynch JE; Will CESAR answer the adult ECMO debate? The Lancet 2009; 374

93 ECMO: When, Where, and by Whom? Joseph B. Zwischenberger MD Johnston-Wright Professor Chairman: Department of Surgery Surgeon-in-Chief UK Healthcare (mobile) The University of Kentucky Lexington, Kentucky

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