King Faisal Specialist Hospital

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King Faisal Specialist Hospital Research
CentreRiyadh, Saudi Arabia
ECMO
AT
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by Ahmed Jammali Chief Perfusionist, Director of
Perfusion School King Faisal Heart Institute
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Some words about "ECMO"
ECMO Extra Corporeal Membrane Oxygenation
E(C)LS Extra Corporeal Lung Support
ECLA Extra Corporeal Lung Assistance
ECCO2-R Extra Corporeal C0 2 - Removal
AREC Assistance Respiratoire Extra Corporelle
?
ECMO
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Nursing
Neonatology
Respiratory Therapy
EEG
Biomedical Instrumentation
Pediatric Surgery
Ultrasound
Blood bank
Cardiology
Clinical Lab
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Early History
John Gibbon
1932

• Laboratory Research

John Gibbon
1953
First successful open heart surgery using
pump-oxygenator
1951-1954

• hypothermia
• cross-circulation

OTHER TECHNIQUES
1955

• Refinement of equipment in
• extracorporeal circulation

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ECMO IN CHILDREN
The ECMO therapy was not possible on newborn and
children until small membranes came in use and a
lower doses of heparin was possible to minimize
the risk of bleeding in the brain (1985).
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1990
1985
1986
1987
1988
1989
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Roller pump

• A lot of centers use roller pumps to drive their
  ECMO's.
• positive displacement pump - output dependent on
  speed of pump
• Disadvantages
• They can generate extremely high negative
  pressure where there is inadequate venous
  drainage, or obstruction on the venous side.

Tubing wears with time. This produces both
spallation and eventually the possibility of
rupture.
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EXTRACORPOREAL LIFE SUPPORT
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Servo regulation and roller pumps
A collapsible "bladder" with a servomechanism,
which prevents negative pressure on the venous
side of the circuit and air entrainment.


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Centrifugal pump
Centrifugal pumps are also used in ECMO centers
Although non-occlusive, they can still generate a
sufficient negative pressure in the presence of
venous obstruction to cause haemolysis. Since
they are non-occlusive devices, they are not
amenable to servo regulation.
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Centrifugal pump
Advantages
If the device is set to provide constant energy,
the flow / afterload variation could be seen as
advantageous. It is safer in that it is unlikely
to cause over-pressurization.
preload flow
afterload flow
preload flow
afterload flow
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Comparison of the Gas Diffusing Properties of the
Physiologic and Artificial Lung
Property
Natural Lung
Artificial Lung
.8 - approx. 30 3 seconds 300 - 760 mmHg
0 - approx. 40 mmHg approx. 5 - 15 L./min
Surface area Gas exch. exposure
time Ventilation gas O2 tension Ventilation gas
CO2 tension Ventilation gas at rest
50 - 200 sq. M .75 seconds 100 mmHg approx.
40 mmHg approx. 4.2 l./min.
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Artificial lung
Most popular devices are those constructed of
silicone membranes, the Kolobow and Ultrox
series. Fiber oxygenators have been used
successfully in ECMO also. Their major advantage
is that they are amenable to surface treatment
(coating)
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Cannulation ConfigurationsVeno-Arterial
Blood is drained from the venous circulation,
pumped through an artificial lung and returned to
arterial system. Blood therefore bypasses the
pulmonary circulation.
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Veno-Arterial ECMO
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VENO-VENOUS
The blood is withdrawn from the venous system and
returned via the oxygenator to the venous
circulation.
Cannulation of two large veins for withdrawal
and return or Single cannula (with two lumens)
that allows both drainage and reinfusion.
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VENO-VENO ECMO
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Various measuring monitoring
Pressures should be measured both pre- and post
membrane. this monitor circuit and cannula
obstruction and any increase in resistance within
the oxygenator.
Venous saturation during veno-arterial bypass, is
the best indication of the adequacy of tissue
oxygenation.
During veno-venous bypass patient arterial
saturation is a more useful measurement.
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ELSO Overall Statistics(Jan 2001)
Number Survived ECMO Survived to discharge Survived discharge
Neonatal Respiratory 16,033 13,744 12,534 78
Neonatal Cardiac 1,385 757 527 38
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ELSO Overall Statistics (Jan 2001)
Number Survived ECMO Survived to discharge Survived discharge
Paediatric Respiratory 2,011 1,249 1,106 55
Paediatric Cardiac 1,994 1,070 804 40
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ELSO Overall Statistics (Jan 2001)
Number Survived ECMO Survived to discharge Survived discharge
Adult Respiratory 612 333 306 50
Adult Cardiac 305 123 98 32
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EXTRACORPOREAL LIFE SUPPORT AT KFSHRC
The ECMO survival post-cardiac surgery was found
to be averaging 45, and ECMO for respiratory
conditions only the average was 90.
The results vary from one center to another and
the reasons could be related to
co-morbidity
Indication
timing
Patient Selection
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ECMO at KFSH RC
CASES
2000
2001
2002
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ECMO CIRCUIT AND EQUIPMENTS
Two types of ECMO circuit systems in our
institution. The open system for the first 24
hours of ECMO run.
1. Easy, fast, and safe priming and de-airing of
the circuit.

• Easy, fast, and safe priming and de-airing
• of the circuit.
• 2. Safe on air handling from venous cannulation.
• 3. Give time to control bleeding
• 4. Volume can be added into the circuit,
• if needed, faster, easier and in greater
  quantities
• 5. Frequent arterial and venous sampling can be
• done easily.

2. Safe on air handling from venous cannulation.
3. Give time to control bleeding.
4. Volume can be added into the circuit, if
needed, faster, easier and in greater
quantities.
5. Frequent arterial and venous sampling can be
done easily.
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ECMO CIRCUIT AND EQUIPMENTS
The Closed System
Since an open system circuit can cause hemolysis,
micro and/or macro air embolism, especially if VR
is not carefully watched for safe volume level,
as well as an open system may increase infection
rate when used for long period of time.

• The open system will be changed
• into closed system for the rest of ECMO run.

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FLOW CALCULATION
1. Patients height (cm), and patient's weight
(kg.)
2. BSA the square root of (kg x ht) divided by
3600
? WT(kg) x ht(cm) 3600
3. CI (l/m2) starting with minimum of 2.4 and
aiming for maximum of 3.5
4. Flow CI x BSA CO
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RESPIRATORY ECMO
Causes of Respiratory Failure
Respiratory distress syndrome, Meconium
aspiration, Congenital diaphragmatic hernia,
Persistent pulmonary hypertension Management in
the ICU with medications, different mode of
ventilations, and nitric oxide(NO).
The potential hazard of the above treatment is
secondary lung damage due to positive pressure
ventilation and exposure to high F102 levels, and
eventually cardiovascular compromise.
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RESPIRATORY ECMO
In order to assess the extent of respiratory
failure, the oxygenation index(OI) is a useful
parameter. OI is calculated from Mean airway
pressure, FI02 and Pa02
OI Mean airway pressure x F102 x 100
Pa02
This OI is widely used, and the value gt 40 is
felt to predict historically at least 80
mortality without ECMO.
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RESPIRATORY ECMO
Mean airway pressure may be measured directly by
the ventilator, or calculated as
Map Peak air. pres. x Insp. time (s)PEEP x
Exp. time (s )
Insp.
Exp. time (s)
Veno-venous ECMO is the most suitable modality to
be used for those conditions where the support is
meant to be for oxygenation and ventilation.
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CARDIAC ECMO
Pediatric ECMO
A) Indications
1. Severe sepsis, hypercyanosis, and severe
pulmonary hypertension not responding to
conventional therapy including nitric oxide (NO).
2. Myocarditis or cardiomyopathy in conditions
where patient failed to respond to maximum
medical therapy.
3. Persistent pulmonary hypertension.
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Indications
4. Anomalous coronary artery preoperative and
postoperative support to maximize myocardial
recovery.
5. Malignant dysrrhythmias ECMO may offer some
benefit until adequate medical management is
provided and the dosage of medication is adjusted.
6. Post cardiac surgery (most common) when there
is a failure to wean off cardiopulmonary bypass,
failure to respond to maximum treatment, cardiac
arrest, cardiogenic shock, or as a bridge to
transplant.
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Contraindications
1. Irreversible cardiopulmonary disease
2. Severe neurological dysfunctions
3. Chronic renal failure
4. Severe hepatic dysfunction
5. Malignancies or severe metabolic disorders
6. Severe coagulopathy with uncontrolled
hemorrhage and massive hemolysis
7. Cardiac arrest that lasted, with or without
conventional resuscitation, for more than 60
minutes.
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Adult ECMO
Indications
1. Post cardiac surgery in cases where there is
a failure to wean off cardiopulmonary bypass,
failure to respond to maximum medical therapy,
cardiac arrest, cardiogenic shock, and as a
bridge to cardiac transplant.
2. Myocarditis or reversible cardiomyopathy.
3. Malignant dysrrhythmias.
4. Severe pulmonary failure.
5. Severe sepsis.
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Contraindications
(Same as contraindications in the pediatric
ECMO), age above 70 year or any other
contraindication to cardiac transplantation.
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PRE-ECMO ASSESSMENT
1. The family
Parents or any of the close family members
should be informed in a simple language about the
ECMO support in terms of its advantages, and the
possible or expected outcome. Also, they should
be aware of the alternative and the availability
of other options and predicted time for weaning
the ECMO support irrespective to the outcome.
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PRE-ECMO ASSESSMENT
2) Cardiorespiratory system
Diagnosis and treatment (medical or surgical) and
reversible or not.
3) Other systems
The neurological, renal and hepatic systems need
to be evaluated in order to accomplish an
acceptable outcome with ECMO support.
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PRE-ECMO ASSESSMENT
4) Indications and Contraindications
Each case should be reviewed and evaluated in the
light of indications and contraindications to
confirm or rule out eligibility.
5) Basic studies
CBC, electrolytes, PT, PTT, BUN, creatinine,
liver function test, blood gases, CXR and review
of all medications.
a. Cardiovascular a cardiology consultation with
an echocardiographic assessment /- cardiac
catheterization.
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PRE-ECMO ASSESSMENT
b. Nervous system neurological assessment in
addition to a brain ultrasound, /- head CT scan,
/- EEG if indicated.
c. Renal system nephrology consultation in
addition to further laboratory tests.
d. Hematological system hematology service
consultation, and more tests will be done if
required e.g. fibrinogen level.
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PRE-ECMO ASSESSMENT
N.B. For any potential case for ECMO preprimed
circuit ready to be used in any emergency call,
within two weeks from the time the circuit was
prepared We had negative cultures from a R.L.
sol. pre-primed circuit for three weeks, and
currently we working on evaluating the Oxygenator
function in a pre-primed circuit.
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INITIATION OF ECMO
Check list
1-Heparin bolus, rebolus, and maintenance. 2-ACT
level for initiation and maintenance. 3-Adjustment
of Inotropes and Vasopressors. 4-Ventilator
settings (emergency/ rest). 5-Antibiotic
(Cefuroxime) . 6-Nutrition. 7-Sedation/ Muscle
relaxant.
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ANTICOAGULATION
Check list
1- Heparin loading 50-100 U/kg.
2- Heparin reloading 25-50 U/kg.
3- Heparin maintenance.
4- ACT q60min.(stable), ql5-30min.(Initiation,
transfusion, weaning and
decannulation).
5- Increased heparin requirement with increased
U.O.P.
6- Review coagulation profile.
7- ACT 180-250/s.
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Effect on formed blood elements
Platelets adhere to the non-biological surfaces
as soon as they make contact, adhering most
readily to areas where fibrinogen has been
deposited. Further, the release of ADP and
serotonin cause platelet aggregation to occur.
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Whole body inflammatory response
Much research and development work has focused on
developing methods of lining the nonbiological
surfaces, which to some extent mimic natural
endothelial surfaces. An example of this is the
Carmeda Bonding system.
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Whole body inflammatory response
Complement activation occurs to some extent
wherever ECMO is undertaken this causes
increased capillary permeability. This can lead
to some degree of plasma leakage, leading to
oedema. This can effect tissue gas exchange, but
usually resolves itself within 1-2 days by
diuresis.
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SEPSIS
Infections that are caused by gram positive cocci
and gram negative rods organisms, are of concern
during ECMO bypass. Prophylactic intravenous
antibiotics are used at the time of cannulation
and during the run of ECMO support.
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Fluids and ElectrolytesWater Loss
Clear water is lost from the membrane lung
expired gases. The sweep gases are dry, and
are easily saturated by expired water vapour.
This does not usually represent a significant
amount in larger patients, but can be significant
in neonates or small children.
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Serum-ionized Calcium Loss
When ECMO is initiated, there is frequently a
severe drop in serum-ionized calcium, as the
result of either or both chelation of calcium ion
by citrate contained in banked blood or
hemodilution of the system.
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Serum Potassium Levels
There are many causes of potassium depletion
during ECMO, including diuresis.
The main causes of red cell damage from the
circuit are

• Inappropriate circuit design -so that jetting
  and turbulence occurs

• Mechanical damage from the pumping device

• Negative pressure where cavitation may occur.

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WEANING AND EVALUATION
Patient hemodynamic status and progression of
cardio-respiratory system recovery is monitored
to determine the time for weaning and
discontinuation of ECMO.
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Evaluation

• MV02 is an indicator of adequate tissue perfusion
  and the samples should be done repeatedly (q
  6hr.) in order to confirm the adequacy of
  perfusion.
• 2) A follow-up echocardiogram should be done in
  the 48-72 hour to study the cardiac function and
  evaluate the possibility of weaning.

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Evaluation
3) Arterial tracing as well as EKG monitor will
be an indication of any cardiac activity.
4) The filling pressure in spite of the increases
in the volume and pressure reading ensure the
recovery of the cardiovascular system.
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Evaluation
5) ECMO support will be discontinued if the
patient has been on cardiac-ECMO for more than 10
days without showing any signs of recovery.
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Weaning
Check list
1- Hemodynamic stability.
2- Blood blood products.
3- Inotropes Vasopressors.
4- Echocardiography.
5- Adjust Ventilator.
6- Max. 10 days.
7- Frequent ACTS.
8- Decannulation.
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