Percutaneous, ultrasound-guided single- and multisite cannulation for veno-venous extracorporeal membrane oxygenation in neonates.

Hybrid and parallel extracorporeal membrane oxygenation circuits

Severe cases of coronavirus disease 2019 (COVID-19) cannot be adequately managed with mechanical ventilation alone. The role and outcome of extracorporeal membrane oxygenation (ECMO) in the management of COVID-19 is currently unclear. Eight COVID-19 patients have received ECMO support in Shanghai with seven with venovenous (VV) ECMO support and one veno arterial (VA) ECMO during cardiopulmonary resuscitation. As of March 25, 2020, four patients died (50% mortality), three patients (37.5%) were successfully weaned off ECMO after 22, 40, and 47 days support, respectively, but remain on mechanical ventilation. One patient is still on VV ECMO with mechanical ventilation. The partial pressure of oxygen/fractional of inspired oxygen ratio before ECMO initiation was between 54 and 76, and all were well below 100. The duration of mechanical ventilation before ECMO ranged from 4 to 21 days. Except the one emergent VA ECMO during cardiopulmonary resuscitation, other patients were on ECMO support for between 18 and 47 days. In conclusion, ensuring effective, timely, and safe ECMO support in COVID-19 is key to improving clinical outcomes. Extracorporeal membrane oxygenation support might be an integral part of the critical care provided for COVID-19 patients in centers with advanced ECMO expertise.

Venovenous versus venoarterial extracorporeal membrane oxygenation in congenital diaphragmatic hernia

The Right Ventricle During Veno-Venous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: Can We Protect the Injured Ventricle?

Extracorporeal membrane oxygenation in infants with meconium aspiration syndrome: a decade of experience with venovenous ECMO

Peripartum use of Extracorporeal Membrane Oxygenation (ECMO) in a Patient Suffering from COVID-19 Severe Acute Respiratory Distress Syndrome (ARDS): A Case Report

Long-Term Outcomes Are Important: Extracorporeal Membrane Oxygenation for COVID-19

Venovenous extracorporeal membrane oxygenation in neonates with respiratory failure

Introduction: Echocardiography (ECHO) plays a fundamental role in the management of patients supported with extracorporeal membrane oxygenation (ECMO). 1 It is particularly useful for the detection of cardiac complications that may arise during ECMO. It helps in many ways during the ECMO run, as presented in Table 1. Table 1 Indications for ECMO therapy. 3 ECMO is a rescue therapy used to provide cardiac and/or respiratory support for critically ill patients in whom maximal conventional medical management has failed VV ECMO provides adequate oxygenation and carbon dioxide removal in isolated refractory respiratory failure VA ECMO is used when support is required for cardiac and/or respiratory failure. ECHO helps to identify or exclude new reversible pathology, which could be the actual cause of patient hemodynamic deterioration (cardiac tamponade/undiagnosed valvular lesions and left ventricular (LV) dysfunction), thus avoiding the need for ECMO support. It also helps to provide information about contraindications, for example aortic dissection. Identification of significant aortic regurgitation (AR) is a relative contraindication in veno-arterial (VA) ECMO, in which the LV afterload is increased, leading to a further increase in AR. It also provides information on aortic atherosclerosis, thus guiding the intensivist in deciding the cannulation sites (central versus peripheral) or the technique (surgical versus percutaneous). ECHO also helps to evaluate the right heart morphology for any structural abnormality, which could impede the positioning of venous cannula for veno-venous (VV) ECMO or VA ECMO. ECHO aids in diagnosing complications during ECMO: The diagnosis of upper limb hyperperfusion relies heavily on clinical features, with imaging utilized more to determine etiology. Transthoracic echocardiography (TTE) may add incremental value to the diagnosis of arterial upper limb hyperperfusion during ECMO support with an axillary artery, and it can be easily and quickly performed at the bedside. 2 ECHO has a crucial role during ECMO cannulation as it guides the correct placement of the ECMO cannulas. TTE may not have the adequate spatial resolution to guide ECMO cannulation, and therefore transesophageal echocardiography (TEE) is essential. There should be a direct communication between the operator and the echocardiologist as to the site of the indented cannula insertion. For example, in VV ECMO, when one cannula is used for access and another to return the blood, the position of the access cannula tip is in the proximal inferior vena cava (IVC), just before the entry into the right atrium (RA). On the other hand, the optimal position for the return cannula is in the mid-RA, but well clear from the interatrial septum and the tricuspid valve. This can be determined with ECHO. ECHO is critical in the detection and management of specific complications that may arise during ECMO support. Because TTE has limited spatial resolution, TEE is usually used to detect these complications. ECHO enables rapid assessment of cannula positioning, cardiac filling, cardiac function, and evidence of chamber compression from tamponade. The detection of cardiac tamponade and the assessment of the significance of pericardial effusion or collection can be difficult in patients supported with ECMO as the heart is in a partially bypassed state. Complications in any part of the ECMO circuit can be well seen on ECHO as well as thrombosis on 2D or 3D ECHO. Conclusion: ECHO is mandatory during the initiation of ECMO, cannula insertion, hemodynamic monitoring, and detection of complications during weaning.

What is New in ECMO for COVID-19?

Funding Acknowledgements Type of funding sources: None. Background The use of veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has significantly increased in the last decade. However, there is substantial variability in practice patterns between institutions. To date, the optimal ECMO program model is unclear and possible differences between ECMO centers in staffing, organization and team structure have been poorly characterized. Purpose Our aim was to describe contemporary practices of care for patients undergoing ECMO in tertiary cardiac centers in North America. Methods An 11-question anonymous survey was sent to all participating sites in the Critical Care Cardiology Trials Network (CCCTN), a prospective registry of advanced cardiac intensive care units (CICUs) in North America, coordinated by the TIMI Study Group. The survey evaluated ECMO staffing models, decision-making processes, cannulation and longitudinal care. Results The response rate was 100% (39/39) across CCCTN centers. The decision to proceed with VA ECMO was made as a team in 79% of the cases and in 58.3% of the VV ECMO cases, rather than by an individual specialty. An ECMO consult service was used in 67% of the centers, and integrated with the cardiogenic shock team in 58%. The most common specialty participating in the ECMO service was cardiothoracic surgery (CTS) (73.1%), followed by heart failure specialists (38.5%), with critical care cardiology (CCC) in only 23.1% of the centers (Figure 1A). In the majority of centers, VA ECMO cannulation was performed by CTS alone (46.2%), Interventional cardiology (IC) and CTS (38.5%), and IC alone (7.7%, Figure 1B). Cannulation for VA ECMO was not performed by intensivists at any center. VV ECMO cannulations were performed by CTS in 51.3%, intensivists in 17.9% and IC in 2.6% of the centers. VA ECMO patients were admitted to the cardiovascular surgical intensive care unit in 64.1% of centers, with 20.5 % admitted to the CICU (Figure 1C). VV ECMO patients were admitted to the cardiovascular surgical intensive care unit in 36.8% of sites, and the medical intensive care unit in 34.2%. The most common ECMO specialist model was having a perfusionist at the bedside, followed by nurse specialist (Figure 1D). Specialty services consulted within 24-48 hours of cannulation included physical therapy in 48.7%, palliative care in 30.8%, and bioethics in only 2.6% of centers. Simulation-based ECMO training is performed in 59% of the centers. Half (51.3%) of the centers perform ECPR, while 17.9% reported plans of developing a program. Conclusions Although there is significant variability in ECMO cannulation, location of care, staffing practices in advanced CICUs in North America, a multidisciplinary team approach is common in ECMO centers, with early involvement of physical therapy and palliative care specialists. Further research to establish the optimal model for ECMO programs is of high importance.

Patients with respiratory failure requiring inotropes or vasopressors are often placed on venoarterial (VA) extracorporeal membrane oxygenation (ECMO), as venovenous (VV) ECMO does not provide direct circulatory support. This retrospective multicenter study compared outcomes for 103 pediatric patients, with hemodynamic compromise, placed on VV ECMO for respiratory failure to those placed on VA ECMO. The primary outcome was survival to hospital discharge. Fifty-seven (55%) study participants were supported on VV ECMO. The two groups had similar PRISM III scores at pediatric intensive care unit (PICU) admission, and vasoactive-inotropic scores at ECMO cannulation. More VV ECMO patients received inhaled nitric oxide (iNO) (54.4 vs. 34.8%; p = 0.04) and had a higher oxygenation index (median 41.5 vs. 19.5; p = 0.04) pre-ECMO. More VA ECMO patients had cardiac dysfunction and cardiac arrest pre-ECMO (50 vs. 14%; p < 0.0001). In univariable analysis, survival to hospital discharge was higher in the VV vs. VA ECMO group (72 vs. 44%; p = 0.005), however, in multivariable models, cannulation type was confounded by cardiopulmonary resuscitation and was not independently associated with survival. VV survivors had longer ECMO duration compared with VA survivors (median, 7 vs. 4.5 days; p = 0.036) but similar PICU and hospital days. No significant difference was noted in functional outcomes or comorbidities at discharge. Cannulation type is not independently associated with survival to hospital discharge in pediatric patients on vasoactive infusions at the time of ECMO cannulation for respiratory indications.

Predictability model of the need for extracorporeal membrane oxygenation in neonates with meconium aspiration syndrome treated with inhaled nitric oxide

Use of ECMO in Patients With Coronavirus Disease 2019: Does the Evidence Suffice?

Invasive Hemodynamic and Physiologic Considerations in Patients Undergoing Extracorporeal Membrane Oxygenation