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ECMO (U nderstanding and Management )

ECMO (U nderstanding and Management ). 조선대학교병원 흉부외과 배 대 양. 조선대학교병원 흉부외과 배 대 양. Concepts. ECMO = E xtra- C orporeal M embrane O xygenation ECLS = E xtra- C orporeal L ife S upport PCPS = P ercutaneous C ardio- P ulmonary S upport

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ECMO (U nderstanding and Management )

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  1. ECMO (Understanding and Management) • 조선대학교병원 흉부외과 • 배 대 양 조선대학교병원 흉부외과 배 대 양

  2. Concepts • ECMO = Extra-Corporeal Membrane Oxygenation • ECLS = Extra-Corporeal Life Support • PCPS = PercutaneousCardio-Pulmonary Support • ECCO₂R = Extra-Corporeal CO₂ Removal • PECLA = PumplessExtra-Corporeal Lung Assist • ECPR = Extra-Corporeal Cardio-Pulmonary Resuscitation

  3. Basic principle of ECMO • Blood is drained from the Venous system(right atrium) • Blood is oxygenated • Excess CO₂ is removed • Oxygenated blood is returned to Arterial system(VA ECMO) -(or for VV ECMO into the right atrium) • ECMO blood mixes with blood ejected from left ventricle

  4. Advantage of ECMO • Provide of cardiac and/or pulmonary support Simple & rapid peripheral insertion of cannulas • Performed during cardiopulmonary resuscitation -> time to recovery • Less costly than other forms of mechanical circulatory support

  5. ECMO Type Veno-arterial (VA) type : for cardiac/respiratory support - Reversible cardiogenic shock - Non ischemic cardiogenic shock - Cardiomyopathy (bridge to CT) - Post cardiac surgery (unable to wean) - Acute myocarditis - Does not maintain vital signs, and adverse drug reactions induced heart failure

  6. ECMO Type Veno-venous (VV) type : for respiratory support, no hemodynamic support - ARDS (H1A1) - Severe pneumonia (Bacterial, viral or aspiration) - Acute lung failure following LTX - Air way obstruction - Assist for lung surgery (Tracheal papilloma) - Near drowning

  7. Contra-indication • Severe irreversible cardiac failure • Severe irreversible respiratory failure • Severe irreversible brain injury • Significant CPR( > 60min, out of Hospital arrest ) • Uncontrolled metabolic acidosis • Terminal disease / malignancy • Multiple traumatic origin with uncontrolled bleeding

  8. Bio-pump (Medtronic)

  9. CAPIOX EBS (Terumo)

  10. QUADROX PLS (MAQUET)

  11. AV-ECCO2R “Novalung”

  12. Oxygenator Polymethylpentene (PMP) membrane Gas diffusion membrane -> No plasma leak possible Very low pressure drop -> Low resistance + low hemolysis Eliminate plasma leakage, prevent formation of microbubble -> Increased valid time -> Proved for 28days PMP membrane 1.8 m2 Polyurethane 0.6 m2 Oxygenator

  13. Configuration

  14. Anti-coagulation • Heparin infused 50-100u/kg at the time of cannulation • Continuous infusion 10-15u/kg/hr ( within 2 hours after start) • 2 hours after start decreased 4-8u/kg/hr

  15. Anti-coagulation • Aimed ACT (Activated Clotting Time): 180-200 sec • ≪ 139 sec : 2u/kg/hr ↑ ACT q 30min • 140 - 159 : 1u/kg/hr ↑ ACT q 30min • 160 - 200 : No change ACT q 1hr • 201 - 250 : 1u/kg/hr ↓ ACT q 30min • ≫ 250 sec : 2u/kg/hr ↓ ACT q 30min

  16. Anti-coagulation • Nafamostatmesilate (Futhan) : Bleeding tendency Pt. • ECMO weaning time (ECMO flow 1.5-2L/min) -> 200-250 sec

  17. Ventilator management • Ventilator manage at low setting to allow lung rest • Minimize atelectasis, maximize oxygenation • Low respiratory rate with long inspiratory time inspiratory pressure 10cmH2O low Peak inspiratory pressure (<25cmH2O), low FiO2 (<30%), • PEEP 10cmH2O (high PEEP level inhibit venous return) • Blood gas management : ECMO >> ventilator

  18. Complication • Bleeding - d/t systemic anticoagulation, thrombocytopenia, thrombocytopathy - Cannulation site, operation site, mucous membrane, GI bleeding, brain parenchyma - Optimal anticoagulation state : optimal ACT, PLT transfusion : > 80,000 10³/μl HCT : 35~40% • Thrombosis • Infection - Prevention : Sterile insertion, if possible percutaneous ECMO

  19. Complication • Leg ischemia : V-A type -> femoral artery access • Leg ischemia Sign - coldness - Skin color change - Leg rigidity - Foot drop • Separate perfusion line placed in the superficial femoral artery (distal perfusion line)

  20. Complication • Plasma leak • Limitation: Oxygenator long term support

  21. Complication • Insufficient anticoagulation

  22. Two circulation (Harlequin) syndrome

  23. ECMO weaning • Weaning criteria Pump flow 10-20ml/kg/min, Min. 200ml/min -> maintain Vital sign. • V-A ECMO : C.I > 2.2 L/min/m², MAP > 60mmHg, LAP < 20mmHg, CVP, PCO2, PO2, Echo on EF > 40% • V-V ECMO : FIO2 < 30%, Gas flow< 2L/min -> maintain well ABGA

  24. Decannulation • After heparin stop for 30 – 60min • Femoral artery was cannulated by cut down vascular repair will be required • Percutaneous access can be removed directly and bleeding controlled by topical compression • When removing venous cannula in spotaneous breathing state, air can enter venous blood through the side hole -> valsalvamaneuver on ventilator or short-term pharmacological paralysis

  25. HELP( Heart Lung Support with PCPS )

  26. PCPS Cost • QUADROX PLS SET 3,490,390 • BIO-PUMP SET 388,790 • FEMORAL ARTERY CANNULA 257,390 • FEMORAL VENOUS CANNULA 257,390 • 부분 체외순환 483,000 • 부분 체외순환 (10시간초과 익일부터1일당) 253,600 • ILA MEMBRANE VENTILATOR 3,173,080 (“Novalung”)

  27. Thank you ...

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