What ECMO IS and IS NOT: Appropriate Patient Selection and

Report
What ECMO IS and IS NOT:
Appropriate Patient Selection and
Utilization of ECMO
ECMO aka ECLS
• ECMO: Extracorporeal Membrane
Oxygenation
• ECLS: Extracorporeal Life Support
• ELSO: Extracorporeal Life Support
Organization
• www.elso.med.umich.edu/
ECLS
• Use of Mechanical Device to temporarily
(days to months) support heart or lung
function (partially or totally) during
cardiopulmonary failure, leading to organ
recovery or replacement
ECMO
• Using an oxygenator to support the cardiac
or oxygenation of a patient for and extended
period of time
• We still call it ECMO
• ECMO does not describe the CO2 removal
History
• First used in the 1970s on Adult Respiratory
patients
• 1974 first Neonatal Respiratory ECMO for
MAS (Bob Bartlett)
• NIH sponsored a study of Adult Resp. but
trial halted after only 90 patients b/c less than
10% survival
• Bartlett went on to treat respiratory distress
infants with a 75% survival rate
Why use ECMO?
• -Cardiac
• -Respiratory
• -Both
• “Acute severe heart or lung failure with high
mortality risk despite optimal conventional
therapy.”
• ECLS considered a 50% mortality risk
Disease Treated with ECMO
•
•
•
•
•
•
Persistent Pulmonary Hypertension (PPHN)
Meconium Aspiration Syndrome (MAS)
Respiratory Distress Syndrome
Congenital Diaphragmatic Hernia
Sepsis/ Pneumonia
Congenital heart Disease
•
•
•
•
Cardiomyopathy/myocarditis
ARDS
Aspiration Pneumonia
Pulmonary Embolism
ECLS Registry Report
Extracorporeal Life Support Organization
2800 Plymouth Road
Building 300, Room 303
Ann Arbor, MI 48109
Center Specific Summary
July, 2011
University of Minnesota Medical Center (130)
Overall Outcomes
Total Patients
Survived ECLS
Survived to DC or Transfer
Neonatal
Respiratory
Cardiac
ECPR
132
53
2
98
31
0
74%
58%
0%
79
17
0
60%
32%
0%
Respiratory
Cardiac
ECPR
29
74
8
14
46
6
48%
62%
75%
11
27
1
38%
36%
13%
Adult
Respiratory
Cardiac
ECPR
37
38
3
18
17
1
49%
45%
33%
9
7
0
24%
18%
0%
376
231
61%
151
40%
Pediatric
Total
Neonatal Respiratory (0-30 days)
Neonatal Respiratory Runs by Year
<=85
Annual Runs
2
Cumulative Runs
2
Average
Run Time
201
Longest
Run Time
216
No. Survived % Survived
1
50%
1990
4
10
286
542
0
0%
2011
135
140years and762
140
100%
Adult Respiratory
(18
over)
1991
51
15
401
31
60%
1992
2
17in hours. Survived
587= survival to discharge
755 or transfer based on 0number of runs 0%
Run time
Adult
by Year
1993 Respiratory Runs
1
18
408
408
1
100%
Average
Longest
1994
1 Runs by
19 Runs
265
265
0
0%
Run
Time
Run
Time
Annual Runs
Cumulative
No. Survived
% Survived
Neonatal
Respiratory
Diagnosis
1995
1
20
95
95
1
100%
1986
1
1
16Time
0%
Total Runs
Avg
Run Time16 Longest Run
Survived0
% Survived
1997
11
212
420
420
01
0%
1987
300
300
100%
CDH
44 24
164 57
511
252
57%
1998
33
65
67%
1988
5
247
330
1
33%
MAS
30
111
239
24
80%
2001
1
25
101
101
1
100%
1989
1
6
379
379
0
0%
PPHN/PFC
19 26
181 141
829
130
68%
2002
11
141
0%
1992
7
47
47
1
100%
RDS
7 278
135 154
258
510
71%
2003
11
51
51
100%
1994
154
0%
Sepsis
9
215
733
4
44%
2004
1
28
357
357
0
0%
1997
3
11
175
408
0
0%
Pneumonia
1 29
142 233
142
000
0%
2006
13
233
0%
1998
14
54
110
0%
Other
25
157 76
379
90
36%
1999
2
16
119
0%
Run time in hours. Survived = survival to discharge or transfer based on number of runs
2000
5
61 or transfer based on number
3
Run time21
in hours. Survived 42
= survival to discharge
of runs 60%
2001 Respiratory Runs
4
25
123
147
2
50%
Pediatric
by Diagnosis
Neonatal
Support
Mode
Details
2002 Respiratory 3
28
109
208
0
0%
Total Runs Avg Run Time Longest Run Time
Survived
% Survived
2003
5 Total Runs
33
62Longest Run
136
0
0%
Time
Survived
% Survived
Viral pneumonia
6 Avg Run Time
387
469
1
17%
2005
1
34
37
37
0
0%
Bacterial pneumonia
405
762
33%
VA
123 3 35
142
511167
761 0
62%
2007
1
167
0%
Aspiration pneumonia
1
23
23
0
0%
VVDL
9
316
829
2
22%
2009
3
38
70
97
1
33%
Acute resp failure, non-ARDS
345
40%
VV-VA
1 10
411
411755
04
0%
of runs 56%
Other
127 = survival to discharge
5
VV
1 Run9 time in hours. Survived
73
73357or transfer based on1number
100%
Unknown
1Run time in hours. Survived = survival to discharge or transfer based on 1number of runs 100%
Adult Respiratory Runs by Diagnosis
Run time
in hours.
= survival
to discharge
or Time
transfer based
on number of%
runs
Runs
AvgSurvived
Run Time
Longest
Run
Survived
Survived
Pediatric Respiratory SupportTotal
Mode
Details
Bacterial pneumonia
1
196
196
0
0%
Total Runs
Avg Run Time Longest Run
Survived No. % Survived
Neonatal
Respiratory Complications
No. Time
%
%
ARDS, postop/trauma
4
121
216
2
50%
Reported
Survived
VA
20
259 247
762 408 Reported 7 Survived
35%
ARDS, not postop/trauma
6
1
17%
VV
7
355
755
3
43%
Mechanical:
Oxygenator
failure
18
13.3%
11
61%
Other
27
76
208
6
22%
VV-VA
1
164
164
1
100%
Mechanical: Other tubing rupture
1
0.7%
0
0%
Survived = survival to discharge or transfer based on number of runs
Unknown
1 Run time in hours.321
32120
0%45%
Mechanical:
Pump malfunction
14.8% 0
9
Mechanical:
Heat exchanger
malfunction
2
1.5%
0
0%
Adult
Respiratory
Support
Mode
Details
Run time
in hours. Survived = survival to discharge or transfer based on number of runs
Mechanical: Clots: oxygenator
24
17.8%
20
83%
Total Runs
Avg Run Time Longest
Run Time % SurvivedNo.
% Survived
Pediatric
Respiratory
Complications
No.
%33%
Mechanical:
Clots: hemofilter
3
2.2%
1
VA
24
74
208
21%50%
Reported
Reported
Survived6 Survived
Mechanical:
Clots: other
12
8.9% 5
Not
Collected
11
196
408
3
27%
Mechanical: Oxygenator
Air in circuit failure
5.2%
71%
57
17.2%
1 5
20%
VV
3
93
167
1
33%
Mechanical: Pump
Cracksmalfunction
in pigtail connectors
1.5%
50%
12 2
41.4%
6 1
50%
Mechanical: Clots:
Cannula
problems
14
10.4%
7
50%
oxygenator
2
6.9%
0
0%
Run time in hours. Survived = survival to discharge or transfer based on number of runs
Hemorrhagic:
GI hemorrhage
3.0%
50%
Mechanical: Clots:
other
24
6.9%
1 2
50%
Adult Respiratory Complications
University of Minnesota Medical Center (130) Center Specific Summary - July, 2011
Cardiac Runs by Diagnosis
Age Group:
0 - 30 days
Congenital Defect
Other
Age Group:
Longest Run Time
676
311
Survived
17
1
% Survived
32%
20%
Total Runs
40
1
1
4
Avg Run Time
149
23
163
153
Longest Run Time
744
23
163
282
Survived
15
0
1
2
% Survived
38%
0%
100%
50%
Avg Run Time
115
0
169
103
199
Longest Run Time
320
0
169
103
241
Survived
8
0
0
0
1
% Survived
40%
0%
0%
0%
50%
Avg Run Time
157
47
20
61
64
Longest Run Time
279
61
45
178
220
Survived
0
0
1
1
5
% Survived
0%
0%
20%
11%
24%
1 year and < 16 years
Congenital Defect
Cardiogenic Shock
Cardiomyopathy
Myocarditis
Other
Age Group:
Avg Run Time
149
182
31 days and < 1 year
Congenital Defect
Cardiogenic Shock
Cardiomyopathy
Other
Age Group:
Total Runs
53
5
Total Runs
20
1
1
1
2
16 years and over
Congenital Defect
Cardiac Arrest
Cardiogenic Shock
Cardiomyopathy
Other
Total Runs
3
3
5
9
21
Run time in hours. Survived = survival to discharge or transfer based on number of runs
ECMO Is NOT a tool
for destination therapy in
cases of non-reversible,
non-acute injury or
illness.
Contraindications:
Relative
1. Conditions incompatible with ‘normal’ life
2. Preexisting conditions; affect quality of life
– CNS Status
– End Stage Malignancy
– Risk of systemic bleeding with Anticoagulation
3. Age and Size of Patient
4. Futility
ECMO IS for acute,
reversible injury, disease
ECMO IS NOT for nonreversible, non-acute
injury or illness
Neonatal Respiratory
• Indications:
– Oxygen Index (OI)
– OI= Mean Airway P x FiO2 x 100
Post Ductal PaO2
– OI=20 Consider ECMO
– OI= 40 ECMO indicated
• Contraindications:
– Lethal chromosomal
disorder
– Irreversible brain or organ
damage
– < 2 kg or < 34 week
– Grade III or > IVH
Pediatric Respiratory
• Indications:
– No Absolute
indications are known
• Best within 7 days of
Mechanical Ventilation
• Contraindications:
– Neurosurgical procedure or
intracranial bleed within 10
days
– Recent Surgery or trauma
– Severe Neurologic
compromise, genetic
abnormalities
– Endstage hepatic failure,
renal failure, primary PHTN
Cardiac Cases
• Indications:
– Post Op failure
– ICU: Pressor, inotropic,
Metabolic acidosis,
decreased urine output
for 6 hours
– Cardiac Arrest
– Myocarditis,
myocardiopathy, toxic
drug overdose
• Contraindications:
– Untreatable underlying
disease
– Futility
– CPR ongoing > 5 mins
Adult Respiratory Failure
• Indications:
– Hypoxic Resp. Failure
• 50% mortality:
PaO2<150 on >90%
FiO2 or Murray Score 23
• 80% Mortality: PaO2
<80 on FiO2 >90%,
Murray Score 3-4
– CO2 Retention
PaCO2>80
• Contraindications:
– High Vent settings > 7
days
– Major
immunosupprssion
• (Neutophil < 400/ml3)
– CNS Hemorrhage
– Increase mortality with
increase age
Adult Cardiac
• Indications:
– Cardiogenic Shock
• Acute MI
• Myocarditis
• Peripartum
Cardiomyopathy
• Decompensated Chronic
Heart failure
• Post cardiotomy shock
• Contraindications:
– Unrecoverable heart;
not a candidate for
transplant or VAD
– Chronic organ
dysfunction
– Prolonged CPR
– Anticoagulation issue

similar documents