Episode 9 - The rEVOLUTION of ECMO
What are the indications for ECMO beyond ARDS and refractory cardiogenic shock? In which patients should we consider eCPR and is this the new standard of care for patients sustaining out-of-hospital cardiac arrest? Finally, how do I work towards safely and efficiently weaning my patient from VV or VA ECMO?
These are just a few of the questions that we address on Rounds with our guest faculty member and Director of the UCLA Adult ECMO Program, Dr. Peyman Benharash. In this comprehensive review of ECMO we also explore the regionalization of ECMO care here in Los Angeles County, as well as the day-to-day considerations that you want to bear in mind when assessing and caring for your patients requiring extracorporeal life support.
Learning Objectives
By the end of rounds you should be able to:
1. Understand the indications & contraindications to VV and VA ECMO support
2. Describe the basic components of an ECMO circuit
3. Describe the role of eCPR in the management of adult patients with out-of-hospital cardiac arrest
4. Discuss key management strategies to safely wean patients from ECMO
5. Describe common complications of ECMO and strategies to mitigate them
Take Home Points
ECMO is time-sensitive, therefore, early and safe cannulation is an important determinant of outcome
ECMO is a bridge to therapy
Use of scoring systems like the Murray Score may be useful to stratify the severity of ARDS among patients being considered for VV ECMO support
The indications for ECMO are expanding to include technically challenging operative cases
eCPR is a promising therapy for patients presenting to an ECMO center of excellence with refractory VF/VT cardiac arrest
ECMO therapy, particularly VA ECMO, may affect virtually organ system
The potential role of ECMO therapy during the current COVID-19 pandemic remains to be defined
Time Stamps
00:12 Introduction
01:16 Overview of Rounds
02:13 The rise of ECMO
02:46 CESAR & EOLIA trials summarized
05:40 Venovenous (VV) vs. Venoarterial (VA) ECMO
08:24 How to decide whether or not to place a patient on VA ECMO?
10:33 Timing & indications for ECMO support
11:38 Murray Score explained
12:24 Contraindications & patient selection for VV & VA ECMO
13:56 Expanding indications for ECMO
15:23 ECMO in the Setting of Trauma: Pneumonectomy & Retrohepatic IVC injuries
17:45 Regionalization of ECMO in Los Angeles County
21:52 Who should be cannulating?
23:22 Approach to cannulation
24:50 Distal perfusion catheters for VA ECMO
26:10 Differences between VV & VA ECMO
28:24 The W5H of eCPR
34:26 Considerations for access for VV ECMO
35:53 Avalon catheter
37:51 VV versus VA ECMO circuits/set-up explained
43:30 Getting your patient off of ECMO & other key considerations
48:56 Vasopressor & inotropic therapy during VA ECMO
50:31 Virchow’s triad, antithrombotic therapy & bleeding on ECMO
54:30 AKI, end-organ dysfunction & the daily assessment of patients on ECMO
57:22 ECMO 2.0 & the role of evolving technologies
61:20 Role of ECMO during the COVID-19 pandemic
66:45 Take-home points
68:38 Outro
Core Concepts, Equations, and Other Stuff
Vasoactive Inotrope Score (VIS)
Murray Score
Recommended Reading
Articles
Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial [published correction appears in Lancet. 2009 Oct 17;374(9698):1330]. Lancet. 2009;374(9698):1351‐1363. doi:10.1016/S0140-6736(09)61069-2
Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(21):1965‐1975. doi:10.1056/NEJMoa1800385
Mosier, J.M., Kelsey, M., Raz, Y. et al. Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions. Crit Care 19, 431 (2015). https://doi.org/10.1186/s13054-015-1155-7
Schmidt, Matthieua,b; Franchineau, Guillaumea,b; Combes, Alaina,b Recent advances in venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome, Current Opinion in Critical Care: February 2019 - Volume 25 - Issue 1 - p 71-76 doi: 10.1097/MCC.0000000000000567
Pineton de Chambrun, Marca,b; Bréchot, Nicolasa,b; Combes, Alaina,bVenoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence, Current Opinion in Critical Care: August 2019 - Volume 25 - Issue 4 - p 397-402 doi: 10.1097/MCC.0000000000000627
Kalra, Rajata,∗; Kosmopoulos, Marinosa,b,∗; Goslar, Tomaza,b,c,∗; Raveendran, Ganesha; Bartos, Jason A.a; Yannopoulos, Demetrisa Extracorporeal cardiopulmonary resuscitation for cardiac arrest, Current Opinion in Critical Care: June 2020 - Volume 26 - Issue 3 - p 228-235 doi: 10.1097/MCC.0000000000000717
Krishnan, Sundara; Schmidt, Gregory A.b Hemodynamic monitoring in the extracorporeal membrane oxygenation patient, Current Opinion in Critical Care: June 2019 - Volume 25 - Issue 3 - p 285-291 doi: 10.1097/MCC.0000000000000602
Guttman, Matthew P. MD1,2; Tillmann, Bourke W. MD1,3; Pannell, Dylan MD, PhD2,4; Vallelonga, Mark CCP5; Nathens, Avery B. MD, PhD1,2,6; Haas, Barbara MD, PhD1,2,3,6 Extracorporeal Membrane Oxygenation Use in TQIP Centers, Journal of Trauma and Acute Care Surgery: April 17, 2020 - Volume Publish Ahead of Print - Issue - doi: 10.1097/TA.0000000000002756
Huang, James E. DSc; Holland, Seth R. DSc; Patrick, Joshua PhD; Piper, Lydia C. MD; Sams, Valerie G. MD Predictive survival factors of the traumatically injured on venovenous extracorporeal membrane oxygenation, Journal of Trauma and Acute Care Surgery: January 2020 - Volume 88 - Issue 1 - p 153-159 doi: 10.1097/TA.0000000000002457
Jacobs, Jordan V. MD; Hooft, Nicole M. MD; Robinson, Brenton R.; Todd, Emily; Bremner, Ross M. MD, PhD; Petersen, Scott R. MD; Smith, Michael A. MD The use of extracorporeal membrane oxygenation in blunt thoracic trauma, Journal of Trauma and Acute Care Surgery: December 2015 - Volume 79 - Issue 6 - p 1049-1054 doi: 10.1097/TA.0000000000000790
Ahmad, Sarwat B. MD; Menaker, Jay MD; Kufera, Joseph MA; O'Connor, James MD; Scalea, Thomas M. MD; Stein, Deborah M. MD, MPH Extracorporeal membrane oxygenation after traumatic injury, Journal of Trauma and Acute Care Surgery: March 2017 - Volume 82 - Issue 3 - p 587-591 doi: 10.1097/TA.0000000000001352
Guidelines
AAST Critical Care Committee Clinical Consensus: ECMO
Zonies D, Codner P, Park P for the American Association of the Surgery ofTrauma Critical Care Committee, et al AAST Critical Care Committee clinical consensus: ECMO, nutrition Extracorporeal membrane oxygenation (ECMO)Nutrition Trauma Surgery & Acute Care Open 2019;4:e000304. doi: 10.1136/tsaco-2019-000304
ELSO Guidelines for Adult Respiratory Failure August, 2017
https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf
ELSO Guidelines for Adult Cardiac Failure
https://www.elso.org/Portals/0/IGD/Archive/FileManager/e76ef78eabcusersshyerdocumentselsoguidelinesforadultcardiacfailure1.3.pdf
ELSO Guidelines for ECPR Cases
https://www.elso.org/Portals/0/IGD/Archive/FileManager/6713186745cusersshyerdocumentselsoguidelinesforecprcases1.3.pdf
ELSO Guidelines for ECMO in COVID-19
https://www.elso.org/Portals/0/Files/pdf/ELSO%20covid%20guidelines%20final.pdf
Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations from ASAIO - A "Living Working Document"!
https://asaio.org/COVID-19/assets/ASAIO-COVID19-White-Paper.pdf
Websites
UCLA ECMO Home Page
https://www.uclahealth.org/heart/ecmo
UCLA Core Lab
http://surgery.ucla.edu/corelab
Extracorporeal Life Support Organization
https://www.elso.org
American Society for Artificial Internal Organs
https://asaio.org
Podcast
EAST TraumaCast - ECMO: Overview for the Acute Care Surgeon
https://podcasts.apple.com/us/podcast/ecmo-overview-for-acute-care-surgeon-current-techniques/id464280790?i=1000409201383
