Extracorporeal Membrane Oxygenation

Chapter 13 Extracorporeal Membrane Oxygenation



Michael G. Fitzsimons, MD, FCCP , Michael N.Andrawes, MD




1 What is extracorporeal membrane oxygenation (ECMO)?


ECMO is a means to provide peripheral oxygenation, ventilation, and circulation to a variety of patients with diseases of the heart and/or lungs for periods of days or weeks. The lungs of patients with severe respiratory failure have an impaired ability to perform the necessary functions of the thoracic cavity, primarily oxygenation and ventilation. Data show that patients with respiratory failure who cannot receive oxygenation or ventilation adequately with use of low tidal volumes without high plateau pressures can be treated with ECMO successfully. Certain patients with hemodynamic failure who lack the ability to meet the metabolic demands of the organs of the body despite pharmacologic support may also benefit from ECMO.



2 What is the history of ECMO?


ECMO was developed as an extension of cardiopulmonary bypass. The first reported use of ECMO for respiratory failure in an adult patient was reported in 1972 in a young man with adult respiratory distress syndrome after a motor vehicle accident. This was followed in 1976 by the first use of ECMO in neonatal patients. Since its development ECMO has been shown to improve survival in neonates with respiratory failure from a variety of causes compared with more traditional therapy. The benefits in adult patients are more controversial.



3 How is ECMO different from cardiopulmonary bypass?


Cardiopulmonary bypass was developed as a means to provide short-term support to patients undergoing cardiac surgery. The setup necessary for cardiopulmonary bypass is also designed to accomplish several other tasks including suction and venting of the field and cardiac chambers and administration of cardioplegia (Table 13-1).


Table 13-1 Differences and Similarities Between ECMO and Cardiopulmonary Bypass



















































Parameter ECMO Cardiopulmonary Bypass
Oxygenation Yes Yes
Ventilation Yes Yes
Circulatory support Yes Yes
Venous reservoir No Yes
Ability to deliver cardioplegia No Yes
Ability to administer medications into circuit No Yes
Supplemental pumps (e.g., suction, vent) No Yes
Heating and cooling Yes Yes
Ability to adjust oxygenation Yes Yes
Ability to add fluids directly to circuit No Yes
Ability to administer anesthetics in line No Yes


4 What are clinical situations where ECMO may be beneficial?


ECMO has been used for the short-term hemodynamic and respiratory support for numerous conditions (Box 13-1).



Box 13-1 Potential Clinical Uses of ECMO




image Adult respiratory distress syndrome


image Acute respiratory failure associated with viral infection


image Bridge to heart transplantation


image Bridge to lung transplantation


image Acute massive pulmonary emboli


image Primary graft failure after heart transplantation


image Right ventricular failure after heart transplantation


image Severe refractory status asthmaticus


image Low cardiac output syndrome after cardiopulmonary bypass


image Support during liver transplantation


image Hemodynamics and respiratory support during surgery for mediastinal mass excision


image Support during carinal resection


image Support during high-risk percutaneous coronary interventions


image Support during high-risk electrophysiology procedures


image Burn-associated respiratory failure


image Respiratory failure due to near drowning


image Respiratory support for congenital diaphragmatic hernia


image Rewarming after accidental hypothermia


image Reexpansion pulmonary edema


image Severe myocarditis


image Post obstructive pulmonary edema


image Pancreatitis


image Fat emboli syndrome


image Amniotic fluid embolism


image Drug overdose



5 Are there any diagnostic modalities that may indicate when emergent ECMO is indicated?


Transesophageal echocardiography (TEE) allows real-time assessment of cardiac function. Acute pulmonary thromboemboli, amniotic fluid embolism, and air emboli cause an acute pressure overload on the right ventricle. Acute right ventricular pressure overload results in ventricular dilatation, tricuspid regurgitation, and a shift of the interventricular septum toward the left, further impairing filling of the left ventricle and a reduction in cardiac output. TEE may also be used to guide proper placement of the venous return cannula into the right atrium when ECMO is initiated.

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Jul 6, 2016 | Posted by in CRITICAL CARE | Comments Off on Extracorporeal Membrane Oxygenation

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