Weaning Protocols for V-A and V-V ECLS

JEFF RILEY MHPE, CCP

UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER

Disclosures

▪ No financial disclosures in regard to this presentation

System Chief Perfusionist at University Hospitals Cleveland Medical Center

▪ High performing expert team of 12 CCPs working at main campus and six satellite programs

Presentation Goals

▪ Focus on ECMO “Discontinuation” and current “evidence”

▪ Compare and contrast V-A and V-V ECLS▪ Simulating V-A and V-V ECLS

▪ Steps for discontinuation / weaning▪ V-A and / vs. V-V

▪ Review basic principles:▪ Indications / contraindications – first step to weaning▪ LV / RV decompression▪ V-A Mixing Cloud▪ CCO, Flotrac▪ Permissive hypercapnia▪ Oxygen Challenge Test

Veno-Venous versus Veno-Arterial ECMO

Item V-A ECMO V-V ECMO Comment

ECC Venous

cannulation

Internal jugular,

right atrium

Femoral vein, IVC,

SVC

Cerebral drainage

ECC Arterial re-

entry

Right common

carotid, distal

artery

Internal jugular,

right atrium

Cerebral perfusion

ECC Target flow

rate

Replace cardiac

function; 80-100%

CO

50-80% venous

return; Rely on

cardiac function

Monitor for V-V re-

circulation; Monitor

RV CO

Cardiac filling

pressures

Decompress RA,

PAD, LA, PA,

decrease pulse

pressure

Maintain RAP,

PAD, LA, pulse

pressure

Monitor for intra-

and extra-cardiac

shunts

Oxygenation

(VO2)

Replace 80 -100%

VO2

Supplement 50 –

80% VO2

V-V is pure

respiratory assist

Ventilation (CO2) Replace 80 -100%

VCO2

Supplement 50 –

80% VCO2

V-A is cardiac and

respiratory assist The ELSO Red Book

5

The V-A ECMO Patient Interface

Patient

Lungs

Patient

Systemic Circulation

Right

Heart

Left

Heart

Artificial

Heart

Artificial

Lung

Jugular (RA) R Carotid (Arch)

NN

N = node

Mixing Cloud

▪ Regional distribution of ECC arterial re-entry blood versus LV output

▪ Ascending aorta

▪ Axillary artery

▪ Femoral artery

▪ Distribution of ECC arterial blood can confuse V-A weaning

Indirect Measures of LV CO

Decompress the Left & Right Ventricle

• IABP

• LV / PA venting

• Wean to Impella or

durable LVAD

• Bridge to cardiac

transplant

• Veno-Pulmonary

ECMO

– TH ProTec Duo

RA – PA Support

with Oxygenator

Side bar

ExtraCorporeal Life Support Organization

▪ www.elso.org

▪ Training

▪ Guidelines

▪ Simulation

▪ Annual Conference

▪ World-Wide Chapters

▪ ELSO International Database

14

The V-V ECMO Patient Interface

Patient

Lungs

Patient

Systemic Circulation

Right

Heart

Left

Heart

Artificial

Heart

Artificial

Lung

IVC

SVC

aka: ECCO2R

Use 2 oxygenators?

pO2(PA)

pO2(ECC)

PvO2

Indications

Monitoring

Discontinuation

Follow up

Oxygen Challenge Test (OCT)

▪ Are the lungs ready for wean?

▪ Perform OCT for patient lungs

▪ Is the oxygenator still viable?

▪ Perform OCT for ECMO oxygenator

Indications for V-V respiratory support

▪ Major criteria

▪ Acute pulmonary disease

▪ Possibility of recovery from disease

▪ Complementary criteria

▪ PaO2/FiO2 ratio< 50 mmHg with an FiO2 = 1.00 for one hour

▪ PaO2 / FiO2 ratio < 50 mmHg with an FiO2 > 0.8 for 3 hours

▪ Hypercapnia with a pH < 7.20 despite RR > 35 BPN with high TVs

▪ Murray’s score > 3.0 with clinical deterioration

▪ Relative contraindications

▪ Respiratory ECMO Survival Prediction www.respscore.com

▪ Age > 75 years

▪ Mechanical ventilation generally >7 days

Monitoring and Weaning V-V ECMO

▪ Maintain HB > 8-10 g/dL in absence of hypoxemia

▪ Maintain SpO2 > 85%

▪ If ECC SvO2 > 60% SpO2 is acceptable

▪ What is ECMO ECC DO2i?

▪ What percent of patient VO2 and VCO2 is being contributed by ECMO ECC? By patient’s lungs

▪ End tidal CO2 from ETT and oxygenator exit

▪ Ready to wean? Perform OCT for native lung

▪ To wean: Maintain ECMO ECC blood flow rate

▪ Set ventilator

▪ Decrease oxygenator FiO2

▪ Decease oxygenator sweep gas

Monitoring and Weaning V-V ECMO

▪ Maintain HB > 8-10 g/dL in absence of hypoxemia

▪ Maintain SpO2 > 85%

▪ If ECC SvO2 > 60% SpO2 is acceptable

▪ What percent of patient VO2 and VCO2 is being contributed by ECMO ECC? By patient’s lungs

▪ End tidal CO2 from ETT and oxygenator exit

▪ Ready to wean? Perform OCT for native lung

▪ To wean: Maintain ECMO ECC blood flow rate

▪ Set ventilator

▪ Decrease oxygenator FiO2

▪ Decease oxygenator sweep gas

Permissive Hypercapnia

Evidence?

ECMO Weaning Summary Points

▪ Success starts with indications for ECMO initiation

▪ Discontinuation plan before ECMO initiation

▪ V-A weaning is about echocardiography

▪ Wean by withdrawal of ECMO blood flow

▪ V-V weaning is about native lung function

▪ Wean by withdrawal of ECC oxygenator FiO2 and gas sweep rate

Thank you

Jeffrey.riley@UHHospitals.org

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