ECMO


3
ECMO


Mauer Biscotti III, MD1, Matthew A. Goldshore, MD, PhD, MPH2, and Jeremy W. Cannon, MD, SM3,4


1 Division of General Surgery, Department of Surgery, San Antonio Military Medical Center, San Antonio, TX, USA


2 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA


3 Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA


4 Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA



  1. A 45‐year‐old previously healthy man was a pedestrian struck by a motor vehicle resulting in multiple injuries including traumatic brain injury with a subarachnoid hemorrhage (SAH), multiple rib fractures, pulmonary contusion, hemothorax, splenic laceration, and a pelvic fracture. On postinjury day 5, he developed severe hypoxemic respiratory failure (PaO2:FiO2 ratio of 70 on FiO2 of 1) and was diagnosed with an MRSA pneumonia. Workup for other causes of respiratory failure or sepsis was negative, and there was no evidence of SAH progression or torso hemorrhage on his most recent imaging. Which of the following should be performed before considering this patient for extracorporeal membrane oxygenation (ECMO)?

    1. High‐frequency oscillatory ventilation
    2. Airway pressure release ventilation
    3. Prone positioning
    4. Rib fracture stabilization
    5. Decompressive laparotomy

    This patient is potentially a good candidate for venovenous extracorporeal membrane oxygenation (ECMO) for hypoxemic respiratory failure. The basic principles for determining a patient’s candidacy for ECMO include lack of response to conventional ventilator management and rescue interventions for severe hypoxemic or hypercarbic respiratory failure, an underlying process that is potentially reversible, and no contraindications to ECMO. The ventilator should be optimized for acute respiratory distress syndrome (ARDS) management, and proning can be employed as a rescue intervention to optimize gas exchange. Chemical paralysis can also be used along with deep sedation, particularly in the setting of ventilator dyssynchrony. If the patient’s oxygenation does not improve, ECMO is reasonable so long as his traumatic brain injury is not severe, his intracranial bleeding has stabilized, and there is no ongoing torso hemorrhage. The RESP score calculator can be used to quantify the patient’s projected outcome on ECMO (https://www.elso.org/Resources/ECMOOutcomePredictionScores.aspx).


    High‐frequency oscillatory ventilation requires special expertise and does not offer any clear survival benefit for this patient. Airway pressure release ventilation (APRV) is better suited to awake patients with moderate respiratory failure and ventilator synchrony problems. Rib fracture stabilization should be performed earlier in the hospital course. The patient would not likely benefit from this procedure and also would be unlikely to significantly improve with this intervention. In the absence of abdominal compartment syndrome or refractory intracranial pressure elevation, decompressive laparotomy has no role in the management of this patient.


    Answer: C


    Brodie D, Bacchetta M . Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011; 365(20):1905–14. doi: https://doi.org/10.1056/NEJMct1103720. PMID: 22087681.


    Brodie D, Slutsky AS, Combes A . Extracorporeal life support for adults with respiratory failure and related indications: a review. JAMA. 2019; 322(6):557–568. doi: https://doi.org/10.1001/jama.2019.9302. PMID: 31408142.


    Bullen EC, Teijeiro‐Paradis R, Fan E . How i select which patients with ARDS should be treated with venovenous extracorporeal membrane oxygenation. Chest. 2020; 158(3):1036–1045. doi: https://doi.org/10.1016/j.chest.2020.04.016. Epub 2020 Apr 21. PMID: 32330459.


    Cannon JW, Gutsche JT, Brodie D . Optimal strategies for severe acute respiratory distress syndrome. Crit Care Clin. 2017; 33(2):259–275. doi: https://doi.org/10.1016/j.ccc.2016.12.010. PMID: 28284294.


    ELSO Guidelines for Adult Respiratory Failure (2017). Extracorporeal Life Support Organization, Version 1. https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf (accessed 4 August 2017).


    Schmidt M, Bailey M, Sheldrake J, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med. 2014; 189(11):1374–82. doi: https://doi.org/10.1164/rccm.201311‐2023OC. PMID: 24693864.


  2. A 62‐year‐old man with a history of alcoholic cirrhosis (MELD 18), active alcohol abuse, mild aortic valve insufficiency, type II diabetes, and obesity (BMI = 35) presents to the emergency department with an ST‐elevation MI. He is immediately taken to the cardiac catheterization lab for percutaneous coronary intervention; a left anterior descending artery culprit lesion is successfully stented. However, postprocedure, he remains in profound shock on very high doses of intravenous epinephrine, norepinephrine, and vasopressin. Arterial blood pressure is 85/40 mm Hg. A bedside echocardiogram indicates significant left ventricular dysfunction with an ejection fraction of 25%. The cardiologist is requesting veno‐arterial (VA) ECMO given the patient’s shock state. Which of the following patient characteristics is the strongest contraindication for providing ECMO support?

    1. Age of 62
    2. Morbid obesity (BMI 35)
    3. Mild aortic valve insufficiency
    4. Alcoholic cirrhosis
    5. Immediately post‐MI with LV dysfunction

    This patient is a poor candidate for several reasons; however, cirrhosis is the strongest contraindication to this therapy as it portends a poor overall outcome. Chronic end‐organ dysfunction with no exit strategy (such as transplant for which this patient is not a candidate given his active alcohol abuse) is an absolute contraindication to ECMO.


    Advanced age is a relative contraindication to ECMO, with age of 65 often used as a cutoff in older literature. However, VA ECMO in patients up to 75 years of age has proven safe and effective. Obesity is no longer a contraindication to ECMO, and in select patients it may even be protective. Severe aortic valve insufficiency is a relative contraindication to VA ECMO. Mild aortic valve insufficiency may require venting of the left ventricle with a microaxial pump, atrial septostomy, or LV drainage cannula, but it is not in itself a contraindication to VA ECMO. Cardiogenic shock after myocardial infarction is a reasonable indication for VA ECMO. It may also be considered in other forms of cardiogenic shock, including myocarditis, pulmonary embolism, and postcardiotomy. It may also be used to manage heart failure with a plan to bridge to permanent ventricular assist device placement or transplant.


    Answer: D


    Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out‐of‐hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open‐label, randomised controlled trial. Lancet. 2020 Nov 12:S0140–6736(20)32338‐2. doi: https://doi.org/10.1016/S0140‐6736(20)32338‐2. Epub ahead of print. PMID: 33197396.


    Lee SN, Jo MS, Yoo KD . Impact of age on extracorporeal membrane oxygenation survival of patients with cardiac failure. Clin Interv Aging. 2017 Aug 24; 12:1347–1353. doi: https://doi.org/10.2147/CIA.S142994. PMID: 28883715; PMCID: PMC5576703.


    Salna M, Chicotka S, Biscotti M III, et al. Morbid obesity is not a contraindication to transport on extracorporeal support. Eur J Cardiothorac Surg. 2018; 53(4):793–798. doi: https://doi.org/10.1093/ejcts/ezx452. PMID: 29253111.


    Makdisi G, Wang IW . Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis. 2015; 7(7):E166–76. doi: https://doi.org/10.3978/j.issn.2072‐1439.2015.07.17. PMID: 26380745; PMCID: PMC4522501.


  3. A 45‐year‐old previously healthy man was a pedestrian struck by a motor vehicle resulting in multiple injuries including traumatic brain injury with a subarachnoid hemorrhage (SAH), multiple rib fractures, pulmonary contusion, hemothorax, splenic laceration, and a pelvic fracture. On postinjury day 5, he developed severe hypoxemic respiratory failure (PaO2:FiO2 ratio of 70 on FiO2 of 100%) and was diagnosed with an MRSA pneumonia. Workup for other causes of respiratory failure or sepsis was negative, and there was no evidence of SAH progression or torso hemorrhage on his most recent imaging. His hypoxemic respiratory failure did not improve with proning and neuromuscular blockade. What is the optimal ECMO cannulation

    strategy for this patient?



    1. Femoral venous drainage, carotid arterial reinfusion
    2. Femoral venous drainage, femoral arterial reinfusion
    3. Femoral venous drainage, jugular venous reinfusion
    4. Femoral venous drainage, femoral venous reinfusion
    5. Jugular venous drainage, right atrial reinfusion (dual lumen cannula)

    This patient has no evidence of cardiac failure, so veno‐arterial cannulation is unnecessary. This approach increases the potential for an arterial injury or thromboembolic event, will significantly increase the patient’s cardiac afterload, and may not provide adequate oxygenation.


    The most common cannulation strategy for venovenous ECMO is femoral drainage and jugular reinfusion. A multistage, large‐bore venous drainage cannula will adequately support the gas exchange needs for most adult patients (4–6 L/min flow) without risking flow limitations or recirculation that can be a problem with the bilateral femoral‐femoral venovenous approach. Single site cannulation with a dual lumen cannula facilitates early ambulation for ECMO patients; it is commonly used for those awaiting a lung transplant.


    Answer: C


    Cannon JW, Gutsche JT, Brodie D . Optimal strategies for severe acute respiratory distress syndrome. Crit Care Clin. 2017; 33(2):259–275. doi: https://doi.org/10.1016/j.ccc.2016.12.010. PMID: 28284294.


    ELSO Guidelines for Adult Respiratory Failure (2017). Extracorporeal Life Support Organization, Version 1. https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf (accessed 4 August 2017).


    ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support (2017). Extracorporeal Life Support Organization, Version 1. https://www.elso.org/Portals/0/ELSO%20Guidelines%20General%20All%20ECLS%20Version%201_4.pdf (accessed 4 August 2017).


  4. A 58‐year‐old man is on day 2 of veno‐arterial ECMO support after an aspiration event led to a cardiac arrest. He is cannulated via his left common femoral vein for drainage and right common femoral artery for reinfusion. He is on a low‐dose epinephrine infusion with a blood pressure of 110/60 mm Hg and a normal lactate level. He has no signs of renal, hepatic, or neurologic injury. On transthoracic echocardiography, his left ventricular ejection fraction has improved from 10% on day 1 to 30% on day 2. His left ventricular size appears normal with no obvious valvular abnormalities. He has responded well to furosemide and his fluid balance is 3L negative since initiation of ECMO. His pulmonary capillary wedge pressure is 12 mm Hg. His chest x‐ray shows bilateral lower lobe infiltrates. However, his upper body peripheral oxygen PaO2 is 40 mm Hg despite maximal ARDSnet appropriate ventilator settings, while his lower body PaO2 remains > 200 mm Hg. What is the next best step in his management?

    1. Place a left ventricular microaxial percutaneous ventricular assist device for left ventricular venting.
    2. Increase total VA ECMO flows to improve upper body saturation.
    3. Add a second‐line inopressor in addition to epinephrine.
    4. Place a venous reinfusion ECMO cannula and convert the patient’s configuration to VA‐V ECMO.
    5. Perform an atrial septostomy for left ventricular unloading.

    Left ventricular venting is commonly employed in patients supported on peripheral VA ECMO when the native cardiac function is not robust enough to overcome the increased afterload generated by the VA ECMO circuit, which leads to left ventricular distention. This patient shows no signs of left ventricular distention with a normal PCWP, no signs of aortic or mitral insufficiency, and an improving ejection fraction. Performing LV decompression with a septostomy or mechanical device is likely unnecessary in this patient.


    There is no evidence of renal or hepatic impairment and cardiac function has improved, making an increase in cardiac output, especially to the lower body (whether increased arterial flow or increased inopressor support), unnecessary. Rather, this patient is likely suffering from severe respiratory failure from aspiration pneumonitis rather than left‐sided heart failure and pulmonary edema. While his lower body oxygen delivery is adequate, the oxygen delivery to the coronary and cerebral circulation is likely not, with a PaO2 of 40 mm Hg. Addition of a venous reinfusion limb to convert to a hybrid VA‐V ECMO circuit will provide additional oxygenation support and is the most useful next step.


    Answer: D


    Russo JJ, Aleksova N, Pitcher I, et al. Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock. J Am Coll Cardiol. 2019; 73(6):654–662. doi: https://doi.org/10.1016/j.jacc.2018.10.085. PMID: 30765031.


  5. While on venovenous ECMO, which of the following ventilator strategies should be used to provide lung protection and recovery?
    Schematic illustration of VA-V ECMO circuit.

    Figure 3.1 VA‐V ECMO circuit.


    Source: From Biscotti M., Lee A,, Basner RC., et al. Hybrid configurations via percutaneous access for extracorporeal membrane oxygenation: a single‐center experience. ASAIO J. 2014;60(6):635–42. with permission.



    1. T‐piece or tracheostomy collar
    2. High‐frequency percussive ventilation
    3. High‐frequency oscillatory ventilation
    4. Volume control 8 mL/kg ideal body weight
    5. Pressure control with PEEP of 10 cm H20

    Lung protective ventilation should continue after ECMO initiation. In fact, so‐called ultra‐lung protective ventilation is often feasible once the majority of the patient’s gas exchange needs are provided by the ECMO circuit. The best current approach is likely reflected in the recently conducted EOLIA trial in which plateau airway pressure was limited to a maximum of 24 cm H2O in conjunction with PEEP > = 10 cm H2O (corresponding to a driving pressure < = 14 cm H2O), respiratory rate of 10–30 breaths/min, and FiO2 of 0.3–0.5. This can be achieved with either a volume control or a pressure control mode, but in our view, a pressure control mode is easier to apply in the setting of very low lung compliance. Often the tidal volumes will be much lower than 4 mL/kg, especially early after ECMO initiation. Furthermore, the respiratory rate should be minimized to further decrease ventilator‐induced lung injury.


    Early after ECMO initiation, patients may have significant air hunger and may also need moderate‐to‐deep sedation for a period of time. As a result, spontaneous modes of ventilation are not employed until the patient has shown some signs of stabilization or even recovery. High‐frequency percussive ventilation can help with mobilizing secretions, particular in patients with inhalation injury, but this approach is not routinely used in ECMO patients. High‐frequency oscillatory ventilation has no proven benefit in this population and may actually cause harm in some cases. Finally, volume control ventilation at this level typically results in extremely high driving pressures, especially early after ECMO initiation.


    Answer: E


    Abrams D, Schmidt M, Pham T, et al. Mechanical ventilation for acute respiratory distress syndrome during extracorporeal life support. Research and practice. Am J Respir Crit Care Med. 2020; 201(5):514–525. doi: https://doi.org/10.1164/rccm.201907‐1283CI. PMID: 31726013.


    Brodie D, Bacchetta M . Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011; 365(20):1905–14. doi: https://doi.org/10.1056/NEJMct1103720. PMID: 22087681.


    ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support (2017). Extracorporeal Life Support Organization, Version 1. https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf (accessed 4 August 2017).


  6. A 30‐year‐old previously healthy man is placed on venovenous (VV) ECMO for severe COVID‐19 pneumonia. On ECMO day 5, he is intubated but awake and interactive on minimal sedation. His morning chest x‐ray demonstrates a new right‐sided pneumothorax. After insertion of a tube thoracostomy, he continues to have a large, continuous air leak on ECMO day 7. His pulmonary compliance remains moderate‐to‐high, with a tidal volume of 7 mL/kg IBW on a positive end‐expiratory pressure (PEEP) of 5, a driving pressure of 10 cm H2O, a fraction of inspired oxygen (FiO2) of 0.5, and a respiratory rate of 20 breaths/min. He remains on ECMO support with a sweep gas flow rate of 6 liters/min. His peripheral arterial blood gas shows a pH of 7.36, PaCO2 of 47, and a PaO2 of 78. What is the best management approach for this patient’s mechanical ventilation?

    1. Extubate to high flow nasal cannula.
    2. Increase PEEP.
    3. Convert to airway pressure release ventilation (APRV) with a PHI of 30 and PLOW of 0.
    4. Sedate, paralyze, and prone positioning.
    5. Increase tidal volumes.

    This patient has a persistent continuous air leak, which can be exacerbated by continuous positive pressure ventilation. Ventilator strategies to aid in healing of bronchopleural fistulae typically include lowering airway pressures and PEEP. Strategies that include increasing PEEP, tidal volumes, or APRV can lead to higher airway pressures, which may preclude lung healing. In select cases, extubation may be a reasonable strategy, provided the patient can be sufficiently supported without tracheal intubation.


    Answer: A


    Xia J, Gu S., Li M,s et al. Spontaneous breathing in patients with severe acute respiratory distress syndrome receiving prolonged extracorporeal membrane oxygenation. BMC Pulm Med. (2019); 19 : 237. https://doi.org/10.1186/s12890‐019‐1016‐2


  7. After initiating venovenous ECMO, which strategy is most likely to minimize bleeding while also preventing clot formation in the circuit or around the cannulas?

    1. Heparin bolus and infusion
    2. Low molecular weight heparin 1.5 mg/kg twice daily
    3. Argatroban infusion
    4. Dual antiplatelet therapy

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on ECMO

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