Extracorporeal Membrane Oxygenation: An Overview

Melissa Brunsvold, MD FACS Women’s Heart Conference February 10, 2017 Disclosures

• No financial disclosures • Patients have consented for the use of their images • I don’t endorse any specific branded product. • ECMO for respiratory support outside of CPB in the OR is an off-label use of the equipment and technology. Pulmonary Embolism after C-section Initial ABG

• 10/2/2015 13:11 • pH Arterial: 6.94 (LL) • pCO2 Arterial: 87 (HH) • PO2 Arterial: 62 (L) • FIO2: 100%. Cannulated at Fairview Ridges Initial angiogram RLL open Post Procedure Hospital Course

• Arrived 10/2 19:30 – Directly to IR for suction embolectomy • Decannulated 10/3 PM • 1 day ECMO run • Decannulated to mechanical ventilation • Discharged to Acute Rehab 11/5 • Home 11/17 Hospital Course

PEA arrest twice, requiring ECMO 1. Laparotomy-hematoma evacuation 2. Abdominal washouts, final closure 3. Pelvic /abdominal abscess 4. Superficial DVT of cephalic vein in right arm 5. Right groin hematoma 6. Acute kidney injury 7. Allergic reaction to medication - rash 8. Protein/calorie malnutrition 9. Acute blood loss anemia 10. Acute pain 11. Pressure ulcer posterior skull One year later What is ECMO? University of Minnesota What is ECMO? Real life Real life Cardiac support Venoarterial ECMO Venoarterial support

• Most commonly post-cardiotomy support – Patients fail to wean from CPB in the OR – Temporary • Cardiogenic shock – Bridge to transplant – Bridge to Ventricular Assist Device (VAD) What is supported

• Venoarterial (VA) ECMO – Draws blood off the central venous system and returns it to the arterial system – Bypasses the heart and lungs – For support of the heart Cannulation Peripheral VA

Journal of Thoracic Disease Vol 7 No 7 (July 2015) International Overall Patient Outcomes International Overall Patient Outcomes Cardiac Arrest: Epidemiology

US statistics Unadjusted Survival of EMS-Treated Patients with Out-of-Hospital Cardiac • 600,000 CA/year Arrest 35 • 400,000 are OHCA 30 • 3rd leading cause of 25 death 20 • 80% of all survivors 15 present with VT/VF 10 • Of ACLS therapies, (%) Survival only early CPR and 5 early defibrillation 0 2006 2007 2008 2009 2010 improve survival Overall VT/VF PEA Asystole

Adapted from Daya et al, Resuscitation, 2015 Cardiac Arrest: ECMO and PCI

• Inclusion: age 18-75 • Lactate <18 • EtCO2 >10

• Cannulate for ECMO to allow cessation of CPR facilitating percutaneous coronary intervention Arrest Characteristics/Outcomes

Cardiac Arrest Characteristics N (%) Treatment N (%)

Bystander CPR ECMO 25 (78)

Yes 22 (69) Intra-aortic balloon pump 6 (19)

No 10 (31) PCI 26 (81)

Intermittent ROSC prior to CCL 16 (50) Ostial/Proximal CAD 20 (63)

Times, min Outcomes N (%) 911 to first responder 5.2 Survival to 19 (76) 911 to CCL arrival 53 Decannulation CLL arrival, on ECMO 6.3 ECMO Duration (h) 61

EtCO2 (mmHg) 34 Survival to Discharge 21 (66)

Initial ABG pH 7.09 CPC 1 or 2 20 (63)

Lactic Acid 11.3 Respiratory support Venovenous ECMO ECMO for ARDS

5/28/2012 14:20 5/28/2012 16:42 pH Arterial: 7.19 (LL) pH Arterial: 7.23 (L) pCO2 Arterial: 62 (H) pCO2 Arterial: 61 (H) PO2 Arterial: 53 (L) PO2 Arterial: 39 (LL) Bicarbonate Arterial: 23 Bicarbonate Arterial: 25 Base Deficit Art: 6.0 Base Deficit Art: 4.1 What is supported

• Venovenous (VV) ECMO – Draws blood off the central venous system and returns it to the same place – Doesn’t bypass anything – Respiratory support only Cannulation peripheral VV

Journal of Thoracic Disease Vol 7 No 7 (July 2015) Peripheral Cannulation VV

Anesthesiology 12 2013, Vol.119, 1474-1489. Cartoon setup

From: http://kimskollam.com/extracorporeal-membrane-oxygenation-ecmo/ accessed Nov 17,2016 Prevalence of ARDS

Ferguson et al. Critical Care 2007 11:R96 doi:10.1186/cc6113 ARDS Management- OLD Does it work for respiratory failure in adults?

• 1971: NIH trial in moribund patients - 90% mortality. • 1986 Gattinoni: 49% survival (nonrandomized) • 1992 Morris: No survival benefit over computerized vent management Recent success

• CESAR, OSCILLATE, OSCAR trials • Advances – Cannulation – Transport – Management CESAR Trial UK 2006

63% 47% New Algorithm

Earlier to ECMO International Overall Patient Outcomes ECMO for Adult ARDS University of Minnesota volume

ECMO Cases through Oct 2016 ECMO References

1. Extracorporeal Life Support Organization Database. http://www.elso.org/Registry/DataRequest.aspx 2. Ferguson,N et al. High-Frequency Oscillation in Early Acute Respiratory Distress Syndrome. OSCILLATE Trial. NEJM Jan 2013. 3. Giesbrecht GG. Cold stress, near drowning and accidental hypothermia: a review. Aviat Space Environ Med 2000; 71:733. 4. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D; CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009 Oct 17;374(9698):1351-63 5. Ruttman et al Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest. J of Thor Cardiovasc Surg 2007 134:3 594– 600 6. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010; 81:1400. Thank you!

Melissa Brunsvold, MD FACS 612-716-3414 [email protected]