C H R I S T O P H E R PA L M E R , M D A S S I S TA N T P R O F E S S O R
D E PA R T M E N T O F A N E S T H E S I A D I V I S I O N O F C R I T I C A L C A R E & E M E R G E N C Y M E D I C I N E
C O D E 3 C O N F E R E N C E 1 0 / 1 4 / 2 0 1 6
An Introduction To ECMO & Why Do YOU Care?
DISCLOSURES
No relevant financial interests to disclose
ECMO
What The Hell Are You Talking About?
Goals
• ECMO Basics • Indications • EMS involvement
Collapsed At Work…
Not Good…
The Definition of Insanity
Choose Wisely
ECMO Center
Crash ECMO Cannulation
Alive & Well
ECMO History
Now what??
ECMO 101
Advanced, temporary life support for the heart and/or lungs Allows time for organ recovery **or transplant/LVAD placement**
Similar to cardiac bypass But can be done at the bedside
Can be maintained for weeks
ECMO 101
ECMO Circuit
Venous-Arterial ECMO
“Cardiac ecmo” Venous drainage / Arterial inflow
Provides both cardiovascular support and respiratory support
Typical indications: Cardiogenic shock – MI Refractory cardiac arrest Severe cardiomyopathy Massive PE Drug OD (BB/CCB/psych meds/etc.)
Venous Arterial(VA) ECMO
Veno-Venous ECMO
“Respiratory” ECMO Venous drainage / Venous inflow (oxygenated)
Allows lung rest Small TV, prevents volutrauma/barotrauma/oxygen toxicity
Does not “fix” primary problem – buys time Indications: Inability to oxygenate and/or ventilate
ARDS from any cause – pneumonia, aspiration, inhalation Severe asthma Awaiting lung txp**
Veno-Venous (VV) ECMO
VV ECMO Concept
VV ECMO Single Cannula
Future…Ventilator Free??
Show Me The DATA!!
Cesar trial (2009) SAVE-J trial (2014) CHEER trial (2015) ~50% OHCA survival
Future trials EOLIA trial for ARDS (2018 completion target)
Complications
Bleeding Stroke (clots) Sepsis Cannula dislodgement Limb ischemia
Contraindications
Absolute Any condition that would not allow anticoagulation
Relative Advanced age Major Co-morbidities
Met. Cancer Terminal illness
EMS & ECMO Involvement
1. ECMO patient transfer 2. Bringing appropriate out-of-hospital ECMO
candidates to ECMO centers for initiation
EMS ECMO Transport – The A Team
Attention To Detail
Cannula sites Infusions Monitoring devices
Practice?? Yes…
ECMO Candidate Selection
Prime ECMO Candidates
Don’t give up! Young(ish) Relatively healthy (presumed) Witnessed arrests/short downtime
MI Arrhythmias Tox/Overdose Drowning (cold) or hypothermia Asthmatics Pulmonary embolism
Call ahead Earlier placed on ECMO the better (<60 min)
ECMO Survivor
My Hope for the Future…