ECMO

By Cindy Baurax Jessica Hugdahl Marivel Rios Vali Sollock

Biological Question

Does ECMO provide life support in severe respiratory failure by allowing time for injured lungs to recover?

Hypothesis

The selective use of ECMO for acute respiratory failure will increase survival rates over conventional mechanical ventilation.

ECMO which is Extra-corporeal membrane oxygenation, is a temporary life support system used for patients who have failed traditional mechanical ventilation.

INDICATIONS

The need for ECMO is when a patient who has received appropriate medical management has:

a PaO2 of 50-60mmHg, when the PIP is >35cmH20 FiO2 is 100% for conventional ventilation without improvement of oxygenation while on high frequency ventilation over a six hour period.

Patient Selection

Limiting the duration of ECMO to <30 days due to increased risks of complications after approximately fourteen days of therapy.

TWO TYPES OF ECMO:

Veno-arterial bypass - supports the heart and lungs

Requires two cannulae-one in jugular vein and one in the carotid artery

Veno-venous bypass supports the lungs only

Requires one cannula- jugular vein

Link to Picture of ECMO tubing when connected to patient

POTENTIAL RISKS

Insertion of a tube into a blood vessel has an increased risk of infection. Brain damage from head bleed Surgical site bleeding Pneumothorax Hypertension Cardiac Dysrhythmias Abnormal creatin and bilirubin values Intraventricular hemorrhage

Air in circuit Pump malfunction Clots in the circuits Pump malfunction Heat exchanger malfuntion

Potential Benefits

Being on ECMO will rest the lungs and heart so that there is an increased survival rate.

CONTRAINDICATIONS

Intracerebral hemorrhage Severe brain damage Multiple congenital anomalies Irreversible brain damage Weight <2.0Kg

Necrotizing Pneumonia Multiple organ failure Metastatic disease Major CNS injury Gestational age <34 weeks Overwhelming Sepsis Parental Refusal

TREATMENT FOR CHILDREN:

Hyaline membrane disease Meconium Aspiration Persistant Fetal Circulation Congenital Diaphragmatic Hernia Cardiac Anomalies

TREATMENT FOR ADULTS:

Adult Respiratory Distress Syndrome (ARDS) Non-necrotizing pneumonias Pulmonary contusion Other reversible respiratory and cardiac failure not responsive to other measures Post cardiac surgery

Preliminary Diagnostic Studies:

Head Ultrasound Coagulation Status Platelet Count Calcium and Electrolyte levels White Blood Cell Count Hemoglobin and Hematocrit levels Blood type and Cross

Weaning Parameters:

A trial period without ECMO when the patient demonstrates adequate gas exchange and is on reasonable ventilator settings and tolerates a pump flow of 10-20mL/kg/min with the minimum of 200 mL/min.

METHODOLOGY

STUDY #1 This study involved 128 neonates on ECMO from October 1985 to September 1998. Patients had either severe acute hypoxemic respiratory failure or severe acute hypercarbic respiratory failure unresponsive to maximal conventional management. Inclusion criteria P/F ratio < or = 100 or refractory hypercarbia with ph < or = 7.0. Each subjects parents were given a consent form explaining the procedure. The data collected in this study were lung compliance that was dividend of the tidal volume and the difference between the end inspiratory pressure and PEEP.

Study #2

This study involved 50 adult patients (older than 16 years old) between the years 1989 and 1995 with refractory respiratory failure. Patients who had contraindications to ECMO were not eligible for this study. Each subject was given a consent form explaining the procedure. The data collected in the study was: P/F ratio, PIP, PEEP and the time ventilated.

Methodology Instruments Used

Study #1- ECMO machine Study #2- Two membrane lungs (ultrox1) with integral heat exchangers are arranged in parallel with counter current gas flow; 100% oxygen is used as the sweep gas. Roller pumps (Stockert) with Seabrook bladder box servo control are used. Blood raceway tubing is Tygon S65HL (Norton Performance Plastics). Heaters (Cincinnati Sub-Zero) are used to maintain normothermia.

Statistics
Study #1 MEAN Pre ECMO time ventilated (days) 4.7 Study #2 MEAN 3.19 Average Mean 3.95

PIP cmH2O

25

39.6

32.3

PEEP cmH2O

10

7.5

P/F ratio mmHg

58

65

61.5

Survival Rate (days)

58%

66%

62%

Discussion

Patients with respiratory failure usually respond favorably to various forms of mechanical ventilation with PEEP, permissive hypercapnia, and inhalation pulmonary vasodilators. Using these methods, survival rates > 60% have been documented. There remains, however, a small number of patients with respiratory failure whose pulmonary gas exchange cannot be improved by the above mentioned methods. ECMO may be a therapeutic option during the acute phase of the disease.

Recommendations

These studies were done on patients who failed conventional mechanical ventilation. In the past few years the use of ECMO as a therapeutic option has been usurped by high frequency oscillation ventilation with the addition of inhalation nitric oxide.

Continued

Further studies should be done on patients that fail these more advanced options and retain a PaO2 <50mmHg for >2 hours at FiO2 100% and PEEP >5cmH2O. These studies will test the absolute effectiveness of ECMO. If the survival rates in this group are not significantly greater than the high frequency oscillation plus inhaled nitric oxide, the use of the expensive and invasive procedure of ECMO may no longer be warranted.

References

Swankiker, F., Kolla, S., Moler, F., Custer, J., Grams, R., Bartlett, R., Hirschl, R. (2000). Extracorporeal Life Support Outcome for 128 Pediatric Patients With Respiratory Failure. Journal of Pediatric Surgery, 35, 197202. Abstract obtained July 8, 2006, from Google at www.google.com Peek, G., Moore, H., Moore, N., Sosnowski, A., Firmin, R.(1997). Extracorporeal Membrane Oxygenation for Adult Respiratory Failure. Chest, 112, 759-764. Abstract obtained July 8, 2006, from Google at www.google.com