Ecmo en el distress respiratorio agudo otra herramienta para el intensivista

Results of ECMO…

In the context of acute
refractory respiratory failure

NEJM, 1972

¢  24 yrs old male
¢  Blunt thoracic
trauma
¢  « Shock Lung »

¢  VA ECMO for 75h

¢  Fully recovered

NEJM, 1972

Bramson
ECMO
machine

Data from
retrospective cohorts…

¢  ELSO registry from 1986–2006
¢  1,473 patients with severe respiratory
failure
l  50% survived to hospital discharge
¢  Median age was 34 years.
¢  Most patients (78%) supported with
venovenous ECMO

¢  Multivariate logistic regression model
¢  Pre-ECMO factors associated with increased
odds of death were
l  Increasing age
l  Decreased weight
l  Days on mechanical ventilation before ECMO
l  Arterial blood pH < 7.18
l  Hispanic and Asian race vs. white race
l  ECMO VA vs. ECMO VV

Specific potential
indications?

In the case of massive
pulmonary emboli

What did we learn from
randomized trials?

¢  UK, 2001-2006
¢  ECMO provided only at the Glenfield
Hospital, Leicester
¢  Entry criteria:
l  Adult patients (18-65 years)
l  Severe, but potentially reversible ARDS
l  Murray score ≥3.0, or
l  Uncompensated hypercapnia: pH <7.20

The CESAR trial

¢  Primary outcome measure
l  Death or severe disability 6 months
l  Severe disability defined as being both
"confined to bed" and "unable to wash
or dress oneself“
¢  Secondary outcomes
l  Death at 6 months, at hospital
discharge
l  HRQL, costs…

¢  Time from
randomization
to death
¢  Log rank
p = 0.03

ECMO : potential indications

•  Refractory hypoxemia: PaO2/FiO2 < 50, persistent *

Despite: FiO2 > 80 %, PEEP (≤ 20 cmH2O)

targeting Pplat = 32 cmH2O, prone position +/- NOi

•  Plateau Pressure ≥ 35 cmH2O

despite reducing PEEP to 5 cmH2O

AND reducing Vt to 4 ml/kg providing that pH ≥ 7,15
* : Should also account for disease’s type and evolution

Where to perform ECMO?

•  Experienced centers:
•  With Heart surgeons, intensivists, perfusionists, nurses….
•  All experienced in the management of ECMO devices

•  ECMO programs should include a
mobile ECMO retrieval team
•  Available 24H/7D
•  Nationwide or regional EMCO networks necessary

ECMO configuration for
acute respiratory failure

Should always be venovenous…
…Except in the case of severe
associated cardiogenic shock

Peripheral VA ECMO is not
indicated for ARF because…
¢  Flow competition in the aorta
l  Heart vs. ECMO pump
¢  If pulmonary function is impaired
l  The “Harlequin” syndrome
• “Blue head”: deoxygenated blood directed
to the upper part of the body
•  “Red legs”: hyperoxygenated blood in the
lower part of the body
¢  Not possible to rest the lungs
l  Vt, Pplat and FiO2 cannot be reduced

Peripheral VA ECMO is not
indicated for ARF because…
¢  VA ECMO increases LV afterload
l  Risk of myocardial damage/stunning
¢  Complications associated with the
arterial line in VA femoro-femoral ECMO
l  Leg ischemia
l  Arterial embolism
l  Massive arterial hemorrhage

Blood oxygenation objectives
in VV ECMO
¢  SaO2 >86-88%
¢  May be difficult to obtain more…

l  Because of blood recirculation
l  Even if FiO2 set at 100% on the
machine
¢  CO2 elimination much easier

RECIRCULATION:
The major limitation of VV ECMO
¢  Factors increasing Recirculation
l  Proximity of venous catheter tips
l  Low cardiac output
l  Hypovolemia and decreased RA
blood content
l  Increased pump flow

How to optimize blood oxygenation?

¢  Minimize recirculation
l  Cannulas adequately (re)positionned
l  Fluid loading to correct hypovolemia
l  Adjust pump flow

¢  ECMO flow objective:
l  Pump flow: the major determinant of oxygenation
•  >5 - 6 l/min or >3 L/m² or >70% of CO
l  USE LARGE DRAINAGE CANNULAS!!!
¢  Other parameters
l  Red cells transfusion: Hb >10 g/dl

VV ECMO Circuit
configuration for acute
respiratory failure
ECMO cannulas
Jugulo-femoral… Femoro-jugular?
One… Two… Three…???

Femoro-Jugular configuration

19 Fr return cannula

27 Fr drainage cannula

Avalon Cannula:
Solution to recirculation???

Conclusion

¢  For the most severe forms of acute respiratory
failure, ECMO:
l  Replaces pulmonary function
l  Allows ultraprotective MV settings
l  Should allow facilitated lung healing
¢  Only experienced centers should run these programs
l  With a mobile ECMO retrieval team available 24H/7D
¢  Still a controversy on the use of ECMO
l  Need for a confirmation trial

La Pitié: Louis XIX, 1656…
To 2010…

La Chapelle Institut de Cardiologie

Designing
a new trial…
EOLIA:
ECMO to rescue Lung
Injury in severe ARDS

EOLIA: ECMO to rescue Lung Injury
in severe ARDS
¢  Multicenter international randomized controlled trial
¢  Best care possible in the ECMO arm
l  ECMO initiated asap for every patient randomized
•  Using the most recent ECMO technology
•  CardioHelp, from Maquet
l  Inclusion of some non-ECMO centers with a mobile
ECMO rescue team available from the referral center
in less than 1 hour
•  Transport of randomized patients to the referral center
UNDER ECMO
•  ECMO managed only in highly experienced centers
l  “Highly protective” MV
•  Plateau pressure limited to ≤ 20 cm H2O

in severe ARDS
¢  Best care possible in the control arm
l  MV protocolized using the
“high PEEP – high recruitment” strategy of
the EXPRESS trial
l  To limit plateau pressure <28-30 cm H2O
•  Vt limited to 6 ml/kg IBW
l  “Ethical” cross-over option to ECMO if the
patient develops refractory hypoxemia

in severe ARDS

Ecmo en el distress respiratorio agudo otra herramienta para el intensivista

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Ecmo en el distress respiratorio agudo otra herramienta para el intensivista