ECMO

Extracorporeal membrane oxygenation

Support in critically ill adult patients – is its use evidence driven?

Saurav Sengupta
Chief Clinical Perfusionist
ECMO and its importance
> Technique used to provide life support to the critically ill;

> Temporary support for patients with pulmonary or

cardiac failure (or both), when no other form of
treatment is likely to be successful [1];

> Expensive therapy, requiring the weighing of its

application, instead of other forms of treatment [1].
Fig. 1: ECMO system.

[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;
Modalities of ECMO
Blood is
Venoarterial ECMO removed
CO2
extracted
from venous
from blood
system
> Blood is drawn from the venous
system, oxygenated and pumped into
the arterial circulation;

> Provides partial or complete support Blood

reaches the Blood
of heart, and allows the oxygenation cells of the oxygenated
body
of blood [3].
Blood
returns to
arterial
system
Fig. 2
Venoarterial
ECMO system. 5
Diagram 2 Venoarterial ECMO system.

[3] Schmid C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009.
Modalities of ECMO
Venovenous ECMO Blood is
CO2
removed
extracted
from venous
> Blood is drained and returned to from blood
system
venous system, providing complete or
partial support of the lungs, as long as
the cardiac output is sufficient;
Blood
> Diseased lungs may heal while the reaches the Blood
cells of the oxygenated
potential additional injury of aggressive body

mechanical ventilation is avoided [3].

Blood
returns to
venous
system
Fig. 3
Venovenous
ECMO system. 6
Diagram 3 Venovenous ECMO system.

[3] Schmid C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009.
ECMO AT THE U of M
• Two era’s 1974 & 1986
• 1974 - 12 patients. Kolobow Membrane Lung – Roller Pump –
Adult and Peds. Patients. No Survivors
• 1986 to present - ? Patients. Several different oxygenators,
Centrifugal pump only!
• ?% overall survival
CIRCIUTS FOR ECMO
• ARTERIAL VENOUS
• VENOVENOUS
• PERIPHERAL
• CENTRAL (OPEN CHEST)
CANNULATION TECHNIQUE
NEONATE PERIPHERAL
• Neck cannulation
• Positioning of patient
• Sedation
• Surgical Prep
• Ideal Cannulae Position
Ideal Arterial Cannula
Placement A V ECMO
• Cannula in Ascending Aorta just above Aortic valve (adjacent
coronary ostia)
• Supplies oxygenated blood to coronaries and the rest of the
circulation.
• Cannula tip should avoid proximity with the Aortic valve
leaflets and stay out of left ventricle.
SINGLE CANNULA
VENOVENOUS
• Dual luman cannula
• Smallest size 14 fr. - limits use to patients above 4 kg.
• 15 Fr. – 4kg to < 9kg two lenghts
• Flow recirculation 15-30%
• Requires higher flows
• No lung rest - must ventilate
• Requires good cardiac function
VENEO/VENOUS IN ADULTS
Peripheral cannulation
• Drainage from Femoral vein
• Return SVC via Jugular access
(Or visa versa)
• Access may be percutanious or direct cut down
• Percutanious is better (less bleeding)
• Requires ventilation (no lung rest)
• Requires good cardiac function
VENO/ARTERIAL ADULTS
• Peripheral -Femoral vein, Femoral Artery
• Limited distribution of blood centrally
• Must have reversal of flow in Aorta for oxygenated blood to reach
Heart and Brain
• Must place distal perfusion cannula in Femoral artery
• Central cannulation - Aorta, Rt. Atrium
• Complete cardiopulmonary support
Indications for the use of ECMO

More Recommended*
indications
Cardiac

Bridge for patients with end-stage heart failure to heart transplant [3];

Coronary artery bypass graft surgery and valve replacement [4];

Post-cardiotomy and primary graft failure after heart transplant [5].

Less Recommended*
Severe cardiac failure (e.g. myocarditis, decompensated
cardiomyopathy, acute coronary syndrome with cardiogenic shock,
sepsis, drug related) [1], [4];

Severe trauma with coexisting bleeding shock [6].

* In published
literature

[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008; [3] Schmid
32
C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009; [4] Sidebotham D. Extracorporeal membrane
oxygenation for treating severe cardiac and respiratory disease in adults: Part 1--overview of extracorporeal membrane oxygenation. J
Cardiothorac Vasc Anesth. 2009; [5] Fiser SM. When to discontinue extracorporeal membrane oxygenation for postcardiotomy support. Ann
Thorac Surg. 2001; [6] Arlt M. Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation. 2010
Indications for the use of ECMO

More
indications
Respiratory

MoreRecommended*
Adult respiratory distress syndrome (ARDS) [1];

Recommended* Less Recommended*

Bridge for lung transplantation and primary graft failure following it [1];

Severe pneumonia and sepsis [1];

Reversable respiratory failure causes (e.g. aspiration pneumonitis,

asthma, near drowning, and Wegener granulomatosis)[4].
* In published
literature
33
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;
[4] Sidebotham D. Extracorporeal membrane oxygenation for treating severe cardiac and respiratory disease in adults: Part 1--overview of
extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth. 2009
ECMO support
ADVANTAGES

Support of the critically ill patients.

Successfully implemented in several situations (stated previously);

The benefits of ECMO were seen in the CESAR trial regardless of age, duration of
ventilation, diagnosis, and number of organs failing [7].

The heterogenic data, due to the several indications, and the lack of quality
randomized trials in adults, difficult the evaluation of the benefits of this
technique.

34

[7] Peek GJ. CESAR: a multicentre randomised controlled trial. Lancet. 2009;
ECMO support
DISADVANTAGES

Mechanical complications (e.g. oxygenator failure, tubing/circuit disruption, pump

or heat exchanger malfunction, problems with cannula placement/removal) [8];

Bleeding, coagulopathy and haemolysis [2], [8], [9];

Hemorrhages associated with anticoagulation requirements [2], [8], [9];

Compartment syndrome and leg ischemia [2], [9];

Air embolism, thromboembolism and neurological sequelae [1], [2], [10];

35
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008; [2]
Lindstrom SJ. Extracorporeal membrane oxygenation. Med J Aust. 2009; [8] Conrad SA. Extracorporeal Life Support Registry Report 2004. ASAIO
J. 2005; [9] Luo XJ. Extracorporeal membrane oxygenation for treatment of cardiac failure in adult patients. Interact Cardiovasc Thorac Surg.
2009; [10] Rossi M. Cardiopulmonary bypass in man. Ann Thorac Surg. 2004.
Aims
MAIN OBJECTIVE

> Determine if the application of the ECMO (Extracorporeal membrane

oxygenation) support is better, in detriment of the usual standard care, in
critically ill adult patients who present cardiac or respiratory failure (or both).

OTHER OBJECTIVES

 Evaluate the support of ECMO in the treatment of the least recommended

indications in the literature. 36
DO YOU HAVE ANY
QUESTIONS?

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