Traditional Extracorporeal Membrane Oxygenation Research Articles

Abstract 199: Use Of Hybrid Veno-venous-pulmonary Artery ECMO In A Patient With Respiratory Failure Secondary To COVID-19

Background: Extracorporeal membrane oxygenation (ECMO) is a form of cardio-pulmonary life support used for patients with respiratory and/or cardiac failure. Hybrid ECMO is a sophisticated circuit to match the exact hemodynamic demands in patients who are refractory to traditional ECMO settings. Case: A 43-year-old male presented with dyspnea for four days. On physical examination, he exhibited increased work of breathing and decreased breath sounds bilaterally. Pulse oximetry was 70% on room air, minimally improved to 75% on maximum high flow nasal cannula. He was found to be COVID-19 positive and demonstrated diffuse bilateral lung consolidation on CT chest consistent with severe acute respiratory distress syndrome. Patient was intubated but continued to show poor oxygenation with P/F ratio of 71 (Normal: >400). Veno-Venous (VV) ECMO was started with cannulations into the right femoral vein (RFV) and right internal jugular vein (RIJV); this resulted in an initial improvement of partial pressure of oxygen (pO2) in arterial blood gas. However, within a few days, pO2 started to decrease with visual evidence of recirculation of oxygenated blood into the venous drainage line. A transthoracic echocardiography revealed severe pulmonary artery (PA) hypertension secondary to respiratory failure with PA pressure of 116mmHg (Normal: 18-25mmHg). This prompted a revision of the ECMO circuit to offload the right ventricle. Revised circuit included a cannula in the RFV for venous drainage and oxygenated venous return through two pathways: cannula in the RIJV (approximately 1 liter return), and a third cannula inserted through the left subclavian vein terminating into the main PA (approximately 4 liters return). Hereon, patient was able to maintain adequate pO2 for the remainder of his hospital stay until he was transferred to a lung transplant center. Conclusion: Our case illustrates the clinical sophistication of hybrid VV-PA ECMO - especially in patients with PA hypertension and impending right-sided heart failure. As respiratory failure secondary to COVID-19 becomes more prevalent, hybrid ECMO may provide a practical solution to protect the right heart in the journey to lung transplant.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 in Shanghai, China.

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.

Paracorporeal Lung Devices: Thinking Outside the Box.

Extracorporeal Membrane Oxygenation (ECMO) is a resource intensive, life-preserving support system that has seen ever-expanding clinical indications as technology and collective experience has matured. Clinicians caring for patients who develop pulmonary failure secondary to cardiac failure can find themselves in unique situations where traditional ECMO may not be the ideal clinical solution. Existing paracorporeal ventricular assist device (VAD) technology or unique patient physiologies offer the opportunity for thinking “outside the box.” Hybrid ECMO approaches include splicing oxygenators into paracorporeal VAD systems and alternative cannulation strategies to provide a staged approach to transition a patient from ECMO to a VAD. Alternative technologies include the adaptation of ECMO and extracorporeal CO2 removal systems for specific physiologies and pediatric aged patients. This chapter will focus on: (1) hybrid and alternative approaches to extracorporeal support for pulmonary failure, (2) patient selection and, (3) technical considerations of these therapies. By examining the successes and challenges of the relatively select patients treated with these approaches, we hope to spur appropriate research and development to expand the clinical armamentarium of extracorporeal technology.

Hybrid extracorporeal membrane oxygenation.

Veno-venous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) therapy is widely used in critically ill patients with refractory cardiogenic shock and cardiac arrest or suffering from severe respiratory failure. Besides traditional ECMO cannulation, changes in patients' conditions or the occurrence of specific complications (i.e., cerebral hypoxia or left ventricular dilation) may require modifications in cannulation strategies or the combination of ECMO with additional invasive or minimally invasive procedures, to improve organ function and ECMO efficiency. In this review, we described all these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema. Although few data are still available about the effectiveness of such interventions, clinicians should be aware of these advances in ECMO management to improve the management of more complex cases.

Low-Dose Heparin Anticoagulation During Extracorporeal Life Support for Acute Respiratory Distress Syndrome in Conscious Sheep.

ABSTRACTBackground:Over 32% of burned battlefield causalities develop trauma-induced hypoxic respiratory failure, also known as acute respiratory distress syndrome (ARDS). Recently, 9 out of 10 US combat soldiers’ survived life-threatening trauma-induced ARDS supported with extracorporeal membrane oxygenation (ECMO), a portable form of cardiopulmonary bypass. Unfortunately, the size, incidence of coagulation complications, and the need for systematic anticoagulation for traditional ECMO devices have prevented widespread use of this lifesaving technology. Therefore, a compact, mobile, ECMO system using minimal anticoagulation may be the solution to reduce ARDS in critically ill military and civilian patients.Methods:We conducted a prospective cohort laboratory investigation to evaluate the coagulation function in an ovine model of oleic acid induced ARDS supported with veno-venous ECMO. The experimental design approximated the time needed to transport from a battlefield setting to an advanced facility and compared bolus versus standard heparin anticoagulation therapy.Results:Comprehensive coagulation and hemostasis assays did not show any difference because of ECMO support over 10 h between the two groups but did show changes because of injury. Platelet count and function did decrease with support on ECMO, but there was no significant bleeding or clot formation during the entire experiment.Conclusions:A bolus heparin injection is sufficient to maintain ECMO support for up to 10 h in an ovine model of ARDS. With a reduced need for systematic anticoagulation, ECMO use for battlefield trauma could reduce significant morbidity and mortality from ventilator-induced lung injury and ARDS. Future studies will investigate the mechanisms and therapies to support patients for longer periods on ECMO without coagulation complications.Level of Evidence:V—therapeutic animal experiment.

Abstract 229: Access to a Portable Miniaturized Extracorporeal Membrane Oxygenation System Increases Utilization for Cardiac Arrest Patients

Background: Extracorporeal membrane oxygenation (ECMO) has improved outcomes in patients with cardiogenic shock (CS). Recent data and guidelines have recommended the use of venous-arterial (VA) ECMO in patients who have been successfully resuscitated from cardiac arrest (ROSC) to ameliorate the effects of post-resuscitation myocardial dysfunction. Use of ECMO often involves taking a patient to the operating room delaying the onset of care. We hypothesized that utilization of the Maquet Cardiohelp, a portable miniaturized ECMO system, in the cardiac catheterization laboratory (CCL), would increase use of ECMO for cardiac arrest patients. Methods: Cardiohelp (CH) ECMO was acquired in March 2012 by our tertiary care university hospital. We performed a retrospective analysis comparing the patients who received CH ECMO from March 2012 until June 2012 to those that received Centrimag (CM), a traditional ECMO circuit, in the in the 6 months prior to March 2012. Results: All patients were treated with femoral VA ECMO with antegrade perfusion distal via a percutaneous catheter in the superficial femoral artery. Overall, more patients were treated with CH compared to CM. Compared to patients who received CM, CH patients were more likely to have been referred for ECMO after ROSC from cardiac arrest and were more likely to have been transferred directly from the Emergency Department (ED). CM patients were slightly younger and were referred for ECMO treatment primarily due to cardiogenic shock (SBP3 pressors). 30 day survival was similar in both groups and there were no cases of stroke or limb ischemia. Conclusions: Use of the portable CH ECMO system with CCL initiation is associated with increased utilization of ECMO and particularly for the treatment of ED ROSC patients. This may be due to the portability of the device and existing relationships between the CCL and the ED. Rapid utilization of ECMO for these patients may lead to improved clinical outcomes.

Simulation-Based Training of Extracorporeal Membrane Oxygenation During H1N1 Influenza Pandemic

On November 2009, the Italian health authorities set up a network of selected intensive care unit (ICU) centers (ECMOnet) to prepare for the treatment of the sickest patients of influenza A (H1N1) by means of extracorporeal membrane oxygenation (ECMO).To quickly and efficaciously train all the physicians working in the ICUs of the ECMOnet on ECMO use, we decided to take advantages of the opportunity provided by simulation technology.Simulation proved efficacious in providing adequate training and education to participants as confirmed by the survival results obtained by the group of ICUs of the ECMOnet.Our experience supports the use of simulation as a valuable alternative to animal laboratory sessions proposed by traditional ECMO training programs providing participants with cognitive, technical, and behavioral skills and allowing a proficient transfer of those skills to the real medical domain.

Asistencia respiratoria extracorpórea en la insuficiencia respiratoria grave y el SDRA. Situación actual y aplicaciones clínicas

Despite improvements in ventilation support techniques, lung protection strategies, and the application of new support treatment, acute respiratory distress syndrome continues to have a high mortality rate. Many strategies and treatments for this syndrome have been investigated over the last few year. However, the only therapeutic measure that has systematically shown to be able to improve survival is that of low volume lung protective ventilation. Thus, using a low tidal volume prevents added lung damage by the same mechanical ventilation that is essential for life support. In this context, the use of extracorporeal lung assist systems is considered an exceptional use rescue treatment in extreme cases. On the other hand, it could be a potentially useful complementary method for an ultra-protective ventilation strategy, that is, by using even lower tidal volumes. The currently available extracorporeal lung assist systems are described in this article, including high flow systems such as traditional extracorporeal membrane oxygenation, CO 2 removal systems (interventional lung assist or iLA, with or without associated centrifugal pumps), and the new low flow and less invasive systems under development. The aim of this review is to update the latest available clinical and experimental data, the indications for these devices in adult respiratory distress syndrome (ARDS), and their potential indications in other clinical situations, such as the bridge to lung transplantation, multiple organ dysfunction syndrome, or COPD.

Extracorporeal membrane oxygenation (ECMO) or extracorporeal cardiopulmonary resuscitation (ECPR): A critical life or death choice

Extracorporeal support such as traditional extracorporeal membrane oxygenation (ECMO) for patients failing to revive from in-hospital CPR with chest compressions shows promise for the future. However, a specific extracorporeal cardiopulmonary resuscitation (ECPR) strategy that addresses the issue of reperfusion injury is needed. While the implementation of traditional ECMO may have its good intentions, in reality, it may be the patient's engine of destruction if it does not address the morbid ramifications of reperfusion injury. This article discusses a specific extracorporeal strategy designed to address the various aspects of reperfusion injury when a patient undergoing chest compressions is placed on extracorporeal support.

Simulating Extracorporeal Membrane Oxygenation Emergencies to Improve Human Performance. Part I: Methodologic and Technologic Innovations

Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

A Description of a Prototype Miniature Extracorporeal Membrane Oxygenation Circuit Using Current Technologies in a Sheep Model

In the United States, standardization of neonatal extracorporeal membrane oxygenation (ECMO) circuit was achieved during the 1980s. Since that time, the consoles and components of the ECMO circuit have remained fundamentally unchanged (bladder, rollerpump, silicone membrane oxygenator). Extracorporeal technology, however, has witnessed many significant advancements in components during the past two decades. These new technologies have characteristics that may improve outcomes when applied in the ECMO arena. Understanding how these technologies perform in long-term applications is necessary. Therefore, the purpose of this project is to evaluate the performance of a miniature ECMO circuit consisting of current generation technologies in an animal model. An ECMO circuit (prime volume 145 mL) was designed that included a hollow fiber oxygenator and a remote mounted centrifugal pump. All circuit tubing and components were surface coated. Three sheep (approx 13 kg) were placed on ECMO using standard neck cannulation techniques and maintained according to clinical protocols. Technical implementation, oxygenator function, and hematological parameters were accessed. Duration of ECMO was 20, 48, and 58 hours. There was no evidence of oxygenator failure, as measured by pressure drop and oxygen transfer, in any of the procedures. No plasma leak was observed in any oxygenators. Platelet count trended downward after 24 hours. Visual inspection after ECMO showed very little evidence of gross thrombosis. This ECMO circuit design departs dramatically from the typical North American systems. The use of this console and components facilitated a 70% reduction in priming volume over a traditional ECMO circuit. Further investigations should be conducted to determine if circuit miniaturization can reduce the morbidity associated with blood product consumption and the bloods contact with the artificial surfaces of the ECMO circuitry.

Venovenous compares favorably with venoarterial access for extracorporeal membrane oxygenation in neonatal respiratory failure

Traditional extracorporeal membrane oxygenation via the venoarterial route requires cannulation and ligation of the internal jugular vein and common carotid artery. Concerns about ligation of the common carotid artery prompted development of a 14F double-lumen internal jugular vein cannula for venovenous oxygenation for neonates with respiratory failure. We retrospectively compared 22 patients supported by venovenous bypass and 20 patients supported with traditional venoarterial bypass. The two groups of patients were selected to be comparable in terms of diagnosis and severity of respiratory insufficiency. The diagnoses in both groups were limited to meconium aspiration syndrome or persistent pulmonary hypertension of the newborn. The average oxygenation indexes in the two groups were similar (46.6 venovenous, 47.2 venoarterial, p = not significant). Venovenous access allowed flow rates of more than 100 ml/kg per minute, which were adequate for gas exchange support. One patient required conversion from venovenous to venoarterial bypass because of hemodynamic instability. The average time of bypass support was 115 hours (range 24 to 338 hours) for venovenous bypass and 134 hours (range 47 to 361 hours) for venoarterial bypass (p < 0.05). The time to extubation after decannulation from extracorporeal membrane oxygenation was 133 hours (range 38 to 720 hours) for venovenous support and 100 hours (range 27 to 192 hours) for venoarterial support (p = not significant). One patient supported with venoarterial bypass had an intracranial hemorrhage. There were no documented neurologic injuries in the patients managed with venovenous bypass. There were no deaths in either group. Venovenous extracorporeal membrane oxygenation through a double-lumen cannula can adequately provide respiratory support for neonates with pulmonary failure and effectively avoids ligation of the common carotid artery.