ECMO Experience from ECMO-ICU, Karolinska X Curso de Ventilacion Mecanica en Anestesia, Cuidados Criticos y Transplantes Madrid 2012
International numbers Totally since 1989; 46500 patients as of July 2011 Survival 2010 Neonatal 69% Pediatric 59% Adult 56%
Total survival except ECPR 2011 70 60 50 40 30 20 10 0 Adult Neo Ped Total Number 30 27 13 70 Survival ECMO 19 18 11 48 Survival hospital 19 18 10 47 % 63% 67% 85% 69%
Título del eje 40 Patient distribution ECM0-unit 1987-2011 35 30 25 20 15 Neo Ped Adult 10 5 0
70 ECMO transports 1996-2011 60 50 40 30 Karolinska Other ECMO units 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Criterias - cardiac Each one of the following symptoms of hypoperfusion and / or cardiac failure - after volume substitution ( 60 ml / kg, or CVP> 10) and inotropy / vasopressor support - constitutes an indication for ECMO. Plasma lactate> 5 mmol / L without improvement for> 30 min SvO2 <55% (estimated cardiac index <2) for> 60 min Rapid deterioration of ventricular function or severely impaired ventricular function Severe arrhythmia leading to poor perfusion Not possible to come off ECC Ongoing CPR Inotropic Equivalents (IU)> 50 for 60 min, and> 45 for 8 hours. Patients with myocarditis or post-cardiotomy : IE> 40
Criterias - cardiac Inotropic Equivalent (IE) Dopamine 1 x µg/kg/min = Dobutamine 1 x µg/kg/min = Adrenaline 100 x µg/kg/min = Noradrenaline 100 x µg/kg/min = Milrinone 15 x µg/kg/min = TOTAL SUM =
Criterias - pulmonary Each one of the following symptoms of respiratory failure constitutes an indication for ECMO. Infants OI> 45 for 6 hours on a ventilator and / or HFO OI> 35 for more than 12 hours Exceeds maximum recommended settings on the respirator / HFO: PIP> 35 for 8 hours ΔP> 55 for 8 hours Hz < 10 under 8 timmar MAP/CDP > 18 cmh 2 O under 8 timmar
Criterias - pulmonary Children and adults Murray score above 3.0 Carbon dioxide retention with a ph <7.10 for 4 hours Acute deterioration on conventional treatment: PaO2 <4.0 kpa at some time during treatment PaO2 <5.5 kpa during 2 hours
Murray score Chest x-ray No alveolar consolidation 0 Alveolar consolidation limited to 1 quadrant 1 Alveolar consolidation limited to 2 quadrant 2 Alveolar consolidation limited to 3 quadrant 3 Alveolar consolidation limited to 4 quadrant 4 Hypoxemia PaO 2 /FiO 2 >40 kpa 0 PaO 2 /FiO 2 30 40 kpa 1 100 % FiO 2 during 20 min PaO 2 /FiO 2 23 29 kpa 2 PaO 2 /FiO 2 13 22 kpa 3 PaO 2 /FiO 2 <12 kpa 4 PEEP PEEP <5 cmh 2 O 0 PEEP 6 8 cmh 2 O 1 PEEP 9 11 cmh 2 O 2 PEEP 12 14 cmh 2 O 3 PEEP > 15 cmh 2 O 4 Compliance Compliance >80 ml/cm H 2 O 0 Compliance >60 79 ml/cm H 2 O 1 Tidal volume / (PIP Compliance >40 59 ml/cm H 2 O 2 PEEP) Compliance >20 39 ml/cm H 2 O 3 Compliance >19 ml/cm H 2 O 4
Bridge to heart transplantation Same criterias for ECMO as any other patient Should be accepted for transplantation prior to ECMO initiation Answer from transplantation within 72 hours about acceptability ECMO support as long as the patient is not able to sufficiently ventilate herself on ventilator When low pressure and FiO 2 <30% convert to ventricular assist device
Bridge to lung transplantation Same criterias for ECMO as any other patient Should be accepted for transplantation prior to ECMO initiation Answer from transplantation within 72 hours about acceptability ECMO support as long as the patient is not able to sufficiently ventilate herself on ventilator
Veno Venous ECMO Draw desaturated blood from right atrium and return saturated blood to the right atrium. Double cannulation Single cannulation with double lumen cannula
Veno Venous ECMO Double cannulation approach
Veno Venous ECMO Single cannulation with double lumen cannula approach
Avalon cannula
Veno Venous ECMO Single cannulation with double lumen cannula approach
Veno venous ECMO Single cannulation with double lumen cannula approach
Veno Venous ECMO Single cannulation with double lumen cannula approach Always perform an ECHO to verify position of the Avalon cannula
Veno Venous ECMO Recirculation
Veno Venous ECMO Recirculation
Veno Venous ECMO Recirculation Determents of recirculation Amount of blood flow Size of right atrium Cardiac output (ie amount of blood returning to the right atrium) Cannula position/s (lateral returning holes position versus the tricuspid valve) Right ventricle cardiac output (ie pulmonary resistance)
Veno Venous ECMO Increased pulmonary resistance
Veno Venous ECMO Increased pulmonary resistance
Veno venous ECMO Increased pulmonary resistance
Veno venous ECMO Increased pulmonary resistance
When not to go for Veno Venous ECMO Cardiac failure High inotropic or vasopressor needs High pulmonary resistance In all other cases choose venovenous support
Veno Arterial ECMO Drawing desaturated blood from right atrium Returning saturated blood in the femoral artery In neonates and small children the saturated blood is returned in the carotid artery
Veno Arterial ECMO
Veno Arterial ECMO Descending perfusion cannula
Veno Arterial ECMO
Veno Arterial ECMO
Veno Arterial ECMO
Veno Arterial ECMO Multistage cannulas
Veno Arterial ECMO Multistage cannulas
Veno Arterial ECMO Multistage cannulas
Oxygenator The lungs of the ECMO machine Determents for ventilation Surface area Blood flow Sweep gas flow (ie carbon dioxide)
Oxygenator Carbon dioxide A 70 kg man at rest produces roughly 200 ml/min of carbon dioxide The oxygenator transports 200ml/min/m 2
Oxygenator Carbon dioxide Quadrox
Oxygenator Oxygen Determents of oxygen transport Surface area Oxygen partial pressure of the blood in the oxygenator Blood flow Any oxygen exchange in the lungs and right chamber cardiac output through the lungs (Sweep gas flow)
Oxygenator Oxygen Blood flow Rapid blood flow trough the oxygenator affects oxygen uptake due to a diminished time for the erytrocytes to take up oxygen
Oxygenator Oxygen Blood flow Rapid bloodflow trough the oxygenator afects oxygen uptake due to a diminished time for the erytrocytes to take up oxygen Rated flow
Rated flow The pumpflow where maximum oxygenation of the blood occurs where the venous blood is saturated to 75% and the arterial blood is saturated to 100% leaving the oxygenator. After this pumpflow no futher increase in oxygenation will occur.
Oxygenator Oxygen Oxygen consumption of a normal built man is around 200 ml / min at rest Can rise to over 400 ml / min in sepsis
Oxygenator Oxygen Quadrox
Oxygenator Oxygen Sepsis Quadrox
Oxygenator
Oxygenator Double oxygenator
Oxygenator Double oxygenator
Oxygenator Double venous cannulation
Oxygenator Double venous cannulation
Oxygenator Double oxygenators