Extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation
Intervention
ICD-10-PCS	Z92.81
ICD-9-CM	39.65
MeSH	29295
MedlinePlus	007234
HCPCS-L2	36822

In intensive care medicine, extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique of providing both cardiac and respiratory support oxygen to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function. Initial cannulation of a patient receiving ECMO is performed by a surgeon and maintenance of the patient is the responsibility of the ECMO Specialist who gives 24/7 monitoring care for the duration of the ECMO treatment.

Types

Veno-arterial (VA) ECMO for cardiac or respiratory failure.

Veno-venous (VV) ECMO for respiratory failure.

There are several forms of ECMO, the two most common of which are veno-arterial (VA) and veno-venous (VV). In both modalities, blood drained from the venous system is oxygenated outside of the body. In VA ECMO, this blood is returned to the arterial system and in VV ECMO the blood is returned to the venous system. In VV ECMO, no cardiac support is provided.

Veno-arterial (VA)

In veno-arterial ECMO – a venous cannula is usually placed in the right common femoral vein for extraction and an arterial cannula is usually placed into the right femoral artery for infusion. The tip of the femoral venous cannula should be maintained near the junction of the inferior vena cava and right atrium, while the tip of the femoral arterial cannula is maintained in the iliac artery. In adults accessing the femoral artery is preferred because the insertion is simpler.

Veno-venous (VV)

In Veno-venous ECMO – venous cannulae are usually placed in the right common femoral vein for drainage and right internal jugular vein for infusion.

Outcomes

The clinical outcomes of patients undergoing ECMO can be categorized according to the indication for the ECMO: severe acute respiratory failure or cardiac failure.

Acute respiratory failure

With acute respiratory failure use of ECMO has been shown to improve survival rates. Survival rates from 50—70 percent have been reported in observational and uncontrolled clinical trials. The survival rates reported are better than historical survival rates.

Cardiac failure

Venoarterial (VA) ECMO can provide acute support in cardiogenic shock or cardiac arrest in adults. Assuming that the brain function is normal or only minimally impaired, ECMO is provided until the patient recovers or receives a long-term ventricular assist device as a bridge to cardiac transplantation.

Indications

ECMO schema

ECMO circuit

Guidelines that describe the indications and practice of ECMO are published by the Extracorporeal Life Support Organization (ELSO). Criteria for the initiation of ECMO include acute severe cardiac or pulmonary failure that is potentially reversible and unresponsive to conventional management. Examples of clinical situations that may prompt the initiation of ECMO include the following:

• Hypoxemic respiratory failure with a ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) of <100 mmHg despite optimization of the ventilator settings, including the Fraction of Inspired Oxygen (FiO2), positive end-expiratory pressure (PEEP), and inspiratory to expiratory (I:E) ratio
• Hypercapnic respiratory failure with an arterial pH <7.20
• Refractory cardiogenic shock
• Cardiac arrest
• Failure to wean from cardiopulmonary bypass after cardiac surgery
• As a bridge to either cardiac transplantation or placement of a ventricular assist device

Contraindications

Most contraindications are relative, balancing the risks of the procedure (including the risk of using valuable resources which could be used for others) vs. the potential benefits. The relative contraindications are:

1. Conditions incompatible with normal life if the patient recovers
2. Preexisting conditions which affect the quality of life (CNS status, end stage malignancy, risk of systemic bleeding with anticoagulation)
3. Age and size of patient
4. Futility: patients who are too sick, have been on conventional therapy too long, or have a fatal diagnosis.

Initiation

ECMO should only be performed by clinicians with training and experience in its initiation, maintenance, and discontinuation. Once it has been decided that ECMO will be initiated, the patient is anticoagulated with intravenous heparin and then the cannulae are inserted. ECMO support is initiated once the cannulae are connected to the appropriate limbs of the ECMO circuit.

Cannulation

Cannulae are usually placed percutaneously by the Seldinger technique.^{[citation needed]} The largest cannulas that can be placed in the vessels are used.^{[citation needed]}

Titration

Following cannulation, the patient is connected to the ECMO circuit and the blood flow is increased until respiratory and hemodynamic status is stable.

Maintenance

Respiratory therapist Michelle Sirra takes a blood sample from 3-day-old Stuart Parker in preparation for transfer to an Extracorporeal Membrane Oxygenation unit on Friday, July 21, in San Juan, Puerto Rico

Once the initial respiratory and hemodynamic goals have been achieved, the blood flow is maintained at that rate. Frequent assessment and adjustments are facilitated by continuous venous oximetry, which directly measures the oxyhemoglobin saturation of the blood in the venous limb of the ECMO circuit.

Special considerations

VV ECMO is typically used for respiratory failure, while VA ECMO is used for cardiac failure. There are unique considerations for each type of ECMO, which influence management.

Blood flow

Near maximum flow rates are usually desired during VV ECMO to optimize oxygen delivery. In contrast, the flow rate used during VA ECMO must be high enough to provide adequate perfusion pressure and venous oxyhemoglobin saturation (measured on drainage blood), but low enough to provide sufficient preload to maintain left ventricular output.

Diuresis

Since most patients are fluid overloaded when ECMO is initiated, aggressive diuresis is warranted once the patient is stable on ECMO. Ultrafiltration can be easily added to the ECMO circuit if patients are unable to produce sufficient urine for diuresis.

Left ventricular monitoring

Left ventricular output is rigorously monitored during VA ECMO because left ventricular output can become worse.

Weaning and discontinuing

For patients with respiratory failure, improvements in radiographic appearance, pulmonary compliance, and arterial oxyhemoglobin saturation indicate that the patient may be ready to be taken off of ECMO support. For patients with cardiac failure, enhanced aortic pulsatility correlates with improved left ventricular output and indicates that the patient may be ready to be taken off of ECMO support. Once the decision has been made to discontinue ECMO, the cannulae are removed.

Veno-venous ECMO liberation trial

VV ECMO trials are performed by eliminating all countercurrent sweep gas through the oxygenator. Extracorporeal blood flow remains constant, but gas transfer does not occur. Patients are observed for several hours, during which the ventilator settings that are necessary to maintain adequate oxygenation and ventilation off ECMO are determined as indicated by arterial and venous blood gas results.

Veno-arterial ECMO liberation trial

VA ECMO trials require temporary clamping of both the drainage and infusion lines, while allowing the ECMO circuit to circulate through a bridge between the arterial and venous limbs. This prevents thrombosis of stagnant blood within the ECMO circuit. In addition, the arterial and venous lines should be flushed continuously with heparinized saline or intermittently with heparinized blood from the circuit. VA ECMO trials are generally shorter in duration than VV ECMO trials because of the higher risk of thrombus formation

Complications

A common consequence in ECMO-treated adults is neurological injury, which may include subarachnoid hemorrhage, ischemic watershed infarctions, hypoxic-ischemic encephalopathy, unexplained coma, and brain death. Fatal sepsis may occur when the large catheters inserted in the neck provide fertile field for infection. Additional risks include bleeding. In adults, ECMO survival rates are around 60%. ECMO has yet to have proven survival benefit in adults with acute respiratory distress syndrome (ARDS). In VA ECMO, patients whose cardiac function does not recover sufficiently to be weaned from ECMO may be bridged to a ventricular assist device (VAD) or transplant.

In infants aged less than 34 weeks of gestation several physiologic systems are not well-developed, especially the cerebral vasculature and germinal matrix, resulting in high sensitivity to slight changes in pH, PaO₂, and intracranial pressure. Preterm infants are at unacceptably high risk for intraventricular hemorrhage (IVH) if administered ECMO at a gestational age less than 32 weeks. Also later, given the risk of IVH, it has become standard practice to ultrasound the brain prior to administering ECMO.

Bleeding

Bleeding occurs in 30 to 40 percent of patients who receive ECMO and can be life threatening. It is due to both the necessary continuous heparin infusion and platelet dysfunction. Meticulous surgical technique, maintaining platelet counts greater than 100,000/mm3, and maintaining the target ACT reduce the likelihood of bleeding. Bleeding tendency can be identified using techniques like Sonoclot which helps in giving ACT & Platelet Function in one single test.

Thromboembolism

Systemic thromboembolism due to thrombus formation within the extracorporeal circuit is an infrequent complication that can be devastating. Its impact is greater with VA ECMO than VV ECMO because infusion is into the systemic circulation. Heparin infusion that achieves its target ACT and vigilant observation of the circuit for signs of clot formation successfully prevents thromboembolism in most patients.

Cannulation-related

A variety of complications can occur during cannulation, including vessel perforation with hemorrhage, arterial dissection, distal ischemia, and incorrect location (e.g., venous cannula within the artery). These complications are rare (<5 percent). A skilled and experienced surgeon is important to avoid or address such complications.

Heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is increasingly common among patients receiving ECMO. When HIT is suspected, the heparin infusion is usually replaced by a non-heparin anticoagulant.

Veno-Arterial specific complications

Pulmonary hemorrhage

Pulmonary hemorrhage can occur in patients who receive ECMO.

Cardiac thrombosis

There is retrograde blood flow in the ding aorta whenever the femoral artery and vein are used for VA ECMO. Stasis of the blood can occur if left ventricular output is not maintained, which may result in thrombosis.

Coronary or cerebral hypoxia

During VA ECMO, fully saturated blood infused into the femoral artery from the ECMO circuit will preferentially perfuse the lower extremities and the abdominal viscera. Blood ejected from the heart will selectively perfuse the heart, brain, and upper extremities.

Future

Applications for ECMO may expand in the future to include percutaneous temporary left ventricular assistance and low flow ECMO for CO₂ removal (ECOOR)]. In addition, new technologies will improve the simplicity and safety of ECMO, including new oxygenators, pumps, and surface coatings.

Other uses

ECMO use on cadavers can increase the viability rate of transplanted organs.