ECMO
introduction for CVS
ECMO
extracorporeal membrane oxygenation
ECMO
(Extracorporeal Life Support)
ECLS
ECMO
prolonged partial cardiopulmonary bypass
ECMO
prolonged partial cardiopulmonary bypass
Up to several weeks
ECMO
prolonged partial cardiopulmonary bypass
The patient’s heart & lungs must work.
ECMO vs CPB
• Venous reservoir
CPB
CPB vs ECMO CPB ECMO
Site OR ICU
Venous reservoir Yes No
Heparin (ACT) >600 160-220
Autotransfusion Yes No
Hypothermia Yes No
Hemolysis Yes No
Hemodilution Yes No
Arterial filter Yes No
ECMO
• Short-term cardiopulmonary support
• Buy time to decide the next step
– Recovery
– Transplantation
– long-term device (ventricular assist device)
– Operation (CABG, pulmonary embolectomy,..)
– Give-up
for lung
1. support : O2 supply & CO2 removal
2. rest : reduce ventilator induced lung injury
for heart
support : improve systemic perfusion
rest :
↓catecholamine
↓myocardial work
decrease preload requirement and congestion
ECMO Mode
• VV - ECMO
• VA - ECMO
VV-ECMO
indication : for lung disease only
purpose : to decrease barotrauma ( to prevent ventilator-induced lung injury)
ventilator setting :
PC mode, PEEP >10 , PIP < 30
VR --> PaCO2, FiO2--> PaO2
VA-ECMO
advantage :
1. both lung & heart support
2. higher PaO2
For hemodynamic support
ECMO type
• Centrifugal pump + hollow fiber oxygenator
– Advantages: rapid priming, heparin binding
– Disadvantages: plasma leak, pump thrombosis
ECMO type
• Centrifugal pump + hollow fiber oxygenator
– Advantages: rapid priming, heparin binding
– Disadvantages: plasma leak, pump thrombosis
• Roller pump + silicone membrane oxygenator
– Advantages: prolonged use, less hemolysis (?)
– Disadvantages: difficult priming, no heparin binding
ECMO choice for a patient
• Emergency? centrifugal
• Duration? roller
• Bleeding risk? centrifugal
• Transport ? centrifugal
ECMO is mainly for neonatal respiratory diseases. (45.9%)
Surfactant therapy
NO inhalation
High frequency oscillatory ventilation
Prone positioning
General critical care
ECMO for neonatal lung diseases is decreasing.
ECMO in NTUH
( 1994 Aug. 11 2013 Dec. 31 )
Neonatal lung disease 17(11) MCS 1517
ARDS 298(121) Post-cardiotomy 481(148)
Lung THx 55(33) Acute myocarditis 125(80)
Pulmonary embolism 28(13) Cardiomyopathy 203(71)
Neurosurgery 4(3) AMI 301(97)
NHBD 26 CHD 63(22)
Others 20(13) Septic shock 116(10)
PH and RV failure 32(9)
Acute rejection 33(8)
Others of MCS 163(55)
TOTAL : 1965
ECMO for adult ARDS
H1N1
Why there is ECMO at NTUH ?
NTUH Heart Transplantation
0
5
10
15
20
25
30
35
40
45
1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007
What happened in 1995?
• Try to increase heart transplantation number!
• Our advantage?
• strategy vs tactics
• If a low cardiac output patient come to our
hospital, what can we do ?
• A complete heart failure treatment program
Treatment of low cardiac output
• Drug
digoxin, diuretics, ACEI, ARB, aldosterone antagonist
Carvedilol, metoprolol, bisoprolol
milrinone
dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol
PGE1
NO inhalation
• Mechanical circulatory support
IABP
VAD (Heartmate, Thortec, biopump, roller pump, others)
ECMO
• Surgery
Batista operation, SVR
heart transplantation (orthotopic, heterotopic)
heart-lung transplantation
Treatment of low cardiac output
• Drug
digoxin, diuretics, ACEI, ARB, aldosterone antagonist
Carvedilol, metoprolol, bisoprolol
milrinone
dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol
PGE1
NO inhalation
• Mechanical circulatory support
IABP
VAD (Heartmate, Thortec, biopump, roller pump, others)
ECMO
• Surgery
Batista operation, SVR
heart transplantation (orthotopic, heterotopic)
heart-lung transplantation
Case Demonstration
ECMO
mechanical circulatory support
VA-ECMO
• A good condition before HTx
• This can guarantee a good result !
• In the past?
ECMO VAD HTx
Mechanical circulatory support
Heart failure:
Medical treatment
MCS
• IABP (intra-aortic balloon pump)
• ECMO (extracorporeal membrane oxygenation)
• VAD (ventricular assist device)
• TAH (total artificial heart)
IABP Because of its relative non-invasiveness,
The first choice of MCS
But, disadvantages:
– Small BW
– RV failure
– Tachyarrhythmia
– CPR
– AR
– Aortic aneurysm
– Atherosclerosis
– etc (KTx)
– Limited cardiac support ( ~1 L/min)
VAD disadvantage :
1. thoracotomy: time delay, general anesthesia,
transport to OR, OP risk
2. technique demanding
3. RV failure in LVAD
LV failure in RVAD
too complex in BVAD
4. Bleeding
5. Pediatric sized device for children (?)
Ventricular Assist Device
(VAD)
• Only in stable patients with anticipated
long-term use
• Not for critical patients with unsure
diagnosis
ECMO advantage :
1. Rapid priming, bedside, local anesthesia,
→ easy, quick, safe (ECPR)
2. Much cheaper than VAD
3. support for RV, LV, lung
(safe in unknown conditions)
4. Carmeda Bioactive Surface (BAS)
5. for both adults and children
6. neck, femoral, thoracic
ECMO advantage :
1. Rapid priming, bedside, local anesthesia,
→ easy, quick, safe (ECPR)
2. Much cheaper than VAD
3. support for RV, LV, lung
(safe in unknown conditions)
4. Carmeda Bioactive Surface (BAS)
5. for both adults and children
6. neck, femoral, thoracic
flexible
ECMO
mode site oxygenator pump
V-A Neck Medtronic Centrifugal
V-V Axillar Medos roller
VV-A Thoracic Jostra
VV-V Femoral silicone
V-VA
A-V
Very flexible
ECMO VAD HTx
Different patients
different situations
different treatments
2005 Jan. 5
Press conference at NTUH
11 y/r, boy, HTX after 18 days of ECMO support
ECMO --- > VAD --- > HTx
Treatment of low cardiac output
• Drug
digoxin, diuretics, ACEI, ARB, aldosterone antagonist
Carvedilol, metoprolol, bisoprolol
milrinone
dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol
PGE1
NO
• Mechanical circulatory support
IABP
ECMO
VAD (Heartmate, Thortec, biopump, roller pump)
• Surgery
Batista operation, SVR
heart transplantation (orthotopic, heterotopic)
heart-lung transplantation
A part, but important part of the whole system.
ECMO
respiratory support for ARDS
VV-ECMO
An Example
• A 33-yr-old, male
• Flame burn
– 20% TBSA 2nd burn
– 2.5% TBSA 3rd burn
– Inhalation injury
Vicious cycle in ARDS
personal experience
ARDS
hypercarbia Vs hypoxemia
1. permissive hypercarbia
2. do not overventilate to improve ABG
3. treat ARDS with ECMO earlier
Result
survivors Non-survivors
Sex (M/F) 4/3 11/6
age 31.7+13.5 41.4+22.1
PaO2/FiO2 66 54
PEEP 12 12
ARDS score 3.6 3.6
ATN 1/7 10/17
Patient source
Burn 2 2
CVS 2 2
GS 1 8
Med
NS
1
1
4
1
ECMO for ARDS
1/3 successful rate, why ?
1. ARDS vs MOF
2. time competition
a. slow recovery of ARDS
b. complication of long-term ECMO
Indications of ECMO in the near future • As a mechanical circulatory support:
– Post-cardiotomy cardiogenic shock
– Double bridge (ECMO VAD HTx)
– Acute myocarditis
– AMI cardiogenic shock (ECPR)
– Shock due to heart stunning
• Replace CPB:
– Lung transplantation
– Heart-lung support during the operation
– Non-heart-beating-donor support
– Rescue for acute pulmonary embolism
– Airway surgery, airway trauma
– hypothermia
• Ventilatory support
– Asthma
– ARDS
– Neonatal pulmonary diseases
ECMO in NTUH
( 1994 Aug. 11 2009 Dec. 31 )
Neonatal lung disease 2 MCS 990
ARDS 179 ( 73 ) Post-cardiotomy 379 ( 115 )
Lung THx 50 Acute myocarditis 78 ( 45 )
Pulmonary embolism 19 ( 8 ) Cardiomyopathy 119 ( 45 )
Neurosurgery 4 AMI 194 ( 50 )
NHBD 26 CHD 25 ( 6 )
Others 13 ( 6 ) Septic shock 66 ( 8 )
PH and RV failure 17 ( 2 )
Acute rejection 17 ( 2 )
Others of MCS 98 ( 29 )
TOTAL : 1283 ( ) survival
Why ECMO succeeds in NTUH?
Why ECMO succeeds in NTUH ?
1. NTUH
2000 beds, national hospital, 114 years
Totem of Taiwan society
Critical mass
A good background
SICU Technician
• 24 hr /day
• 365 day/ year
366 days / leap year
Core team
• A core team
• A large team
• A society
Because we can dream,
we become human being!
History is created by few people.
How to recruit a core team?
Selection?
Training?
Select trainable people.
Why ECMO succeeds in NTUH ?
1. NTUH
2000 beds, national hospital
2. extended indications enough cases (>100 cases/year)
Economic scale
Indications of ECMO in the near future • As a mechanical circulatory support:
– Post-cardiotomy cardiogenic shock
– Double bridge (ECMO VAD HTx)
– Acute myocarditis
– AMI cardiogenic shock (ECPR)
– Shock due to heart stunning
• Replace CPB:
– Lung transplantation
– Heart-lung support during the operation
– Non-heart-beating-donor support
– Rescue for acute pulmonary embolism
– Airway surgery, airway trauma
– hypothermia
• Ventilatory support
– Asthma
– ARDS
– Neonatal pulmonary diseases
Why ECMO succeeds in NTUH ?
1. NTUH
2000 beds, national hospital,
2. extended indications enough cases (>100 cases/year)
3. excellent SICU background
ECMO is a high technology treatment
• A locomotive engine Vs a whole train
• Skyscraper Vs modern city
• One more step forwards
• But reasonable enough
Why ECMO succeeds in NTUH ?
1. NTUH
2000 beds, national hospital,
2. extended indications enough cases (>100 cases/year)
3. excellent SICU background
ECMO is a high technology treatment
4. team work
CVS, ICU, nurse, technician
Why ECMO succeeds in NTUH ?
1. NTUH
2000 beds, national hospital,
2. extended indications enough cases (>100 cases/year)
3. excellent SICU background
ECMO is a high technology treatment
4. team work
CVS, ICU, nurse, technician, bypass ?
5. training program & protocol
Protocol, protocol, protocol
http://www.sicu.org
Why ECMO succeeds in NTUH ?
1. NTUH 2000 beds, national hospital,
2. extended indications enough cases (>100 cases/year)
3. excellent SICU background ECMO is a high technology treatment
4. team work CVS, ICU, nurse, technician, bypass ?
5. training program & protocol Protocol, protocol, protocol
6. continuous revision Long term development
• Case record
• M & M conference for every case
• RCA (root cause analysis)
• Continuously Revise system (0.9 theory)
Why ECMO succeeds in NTUH?
• Strong background
• A core team (select trainable team member)
– responsible
• Economic scale
• Team work
• SOP (mass production)
• Work hard and smart
All you need to set up ECMO
Put everything on the wheel
Then, OR, ICU, cath room, ES, ward, etc
ECMO cart
Taipei city/Taipei county area
= 12
ECMO success need :
1. underlying problem soon reversible
2. no severe 2nd organ damage
3. no complication from ECMO use
ECMO success need :
1. case selection (treat pt. , not Dr.)
2. early use
3. intensive ECMO care
Indications of ECMO in the near future • As a mechanical circulatory support:
– Post-cardiotomy cardiogenic shock
– Double bridge (ECMO VAD HTx)
– Acute myocarditis
– AMI cardiogenic shock (ECPR)
– Shock due to heart stunning
• Replace CPB:
– Lung transplantation
– Heart-lung support during the operation
– Non-heart-beating-donor support
– Rescue for acute pulmonary embolism
– Airway surgery, airway trauma
– hypothermia
• Ventilatory support
– Asthma
– ARDS
– Neonatal pulmonary diseases
AMI with cardiogenic shock
• 60 y/r, male, chest tightness ES, sudden
VT/Vf, DC shock, now, BP:80/50 under
dopamine 20 mcg/kg/min
• 60 y/r, male, stable angina, frequency ,
cath PTCA, LAD dissection, BP, HR
IABP, BP: 80/50
• AMI, refractory VT/Vf, DC shock 40 times
AMI & CS ECMO Cath off pump CABG ICU support
ECMO rescue for AMI with CS
• Pre-cath:
– to stabilize the patients
• During cath & revascularization
– to support the patients for procedure
• After revascularization
– To support hemodynamics until heart recovery
Post-CABG VT/Vf
J Formos Med Assoc 2002:101:283-286
A dancer
A modern medical miracle
ECMO
• Strategy weapon
• Front-line weapon
A necessity in a medical center