Extracorporeal membrane oxygenation.
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Transcript of Extracorporeal membrane oxygenation.
The Alfred Intensive Care Unit, Melbourne, Australia
Extracorporeal Membrane Oxygenation
for Acute Cardiac Support
Professor David KayeDepartment of Cardiology, Alfred
Hospital, Australia
The Alfred Intensive Care Unit, Melbourne, Australia
The Alfred Intensive Care Unit, Melbourne, Australia
MCS in Cardiogenic Shock: Case 1
• Friday afternoon (!)• Tx waiting list (severe biventricular DCM) patient presents
unwell (cold, shutdown) – BP 70 initially on CCU• Inotropes commenced – dobutamine, adrenaline….• BP to 50, decreasing conscious state … Code called• Urgent echo
The Alfred Intensive Care Unit, Melbourne, Australia
MCS in Cardiogenic Shock: Case 1
The Alfred Intensive Care Unit, Melbourne, Australia
Cardiogenic Shock Defined
When to consider MCS
• Cardiac Index < 2.2L/min/m2 despite adequate filling• Evidence of hypoperfusion (eg CNS, renal, lactate>2)• SBP<90 mmHg
– Despite catecholamines– Need to evaluate trajectory
The Alfred Intensive Care Unit, Melbourne, Australia
Causes of Cardiogenic Shock
Cooper & Panza Cardiol Clinics 2013
The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes in Cardiogenic Shock
2000 2002 20062004
Mortality rate GRACE Registry – MI Outcomes
No impact of IABPIe SHOCK, SHOCK II
The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes in Cardiogenic Shock
• Proven predictors of outcome:– APACHE Score, cytokines (eg IL-6)– Cardiac indices (eg CI, BNP) not helpful
AgeGCSTempMAPHRRRFiO2PaO2Art pH
Na+
K+
CrARF (Y/N?)HctWCCPre-existing severe ilness??
The Alfred Intensive Care Unit, Melbourne, Australia
Maximizing Outcomes in CS
• Early recognition of definite CS– Inotrope refractory, emerging end-organ dysfn
• Optimal timing of MCS deployment• Optimal form of MCS• Limiting the complications of MCS• Optimal timing of weaning from MCS or converting to long-term MCS
The Alfred Intensive Care Unit, Melbourne, Australia
Timing of MCS
• No randomized studies re timing• USpella Registry – cardiogenic shock + PCI
AMI withCardiogenic
Shock (n=154)
Impella 2.5 Pre-PCI (n=63)
Impella 2.5Post-PCI (n=91)
O’Neil J Interv Cardiol 2013
Inotropes 81%Acidosis 74%Ventilated 66%Lactate >4mmol/L 57%Shock > 6hrs 53%
The Alfred Intensive Care Unit, Melbourne, Australia
Emergency & Emergent MCS
Chronic
Worsening HF(Intermacs 2-3)
Acute
Cardiogenic shock
CPR
Nature of Heart Failure
Presentation MCS Option Outcome
Short Term MCSEg ECMO
VADLong Term
Recovery(+/- medical
therapy)
Destination
Bridge to Transplant
Elective/semi-elective
BTD
The Alfred Intensive Care Unit, Melbourne, Australia
Comparative forms of MCS
IABP Impella 2.5 ECMOCannulae 7.9Fr 13Fr 21Fr venous
19 Fr arterialInsertion time 5-10 mins 10-15mins 10-15minsSupport <1L/min 2.5L/min 4-6L/minLimb Ischemia risk
Low-Interm Interm IntermNB Backflow
Management complexities
+ ++ +++
Oxygenation YesRV Support Yes
The Alfred Intensive Care Unit, Melbourne, Australia
MCS Options in Cardiogenic Shock
-acute VAD deployment in cardiogenic shock (INTERMACS 1) and particularly cardiac arrest/Bi-Ventricular failure is associated with poor outcome
ISHLT 2013
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO: Intermediate term MCS. Case 2
Day 2-3Lymphocytic myocarditis- case 2
Day 10Day 5
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO Outcomes
Allen J Intensive Care 2011
Multiple small case series
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO in Cardiogenic Shock
• Sheu et al retrospective review of outcomes in profound cardiac shock in MI (SBP<75mmHg on inotropes)
Crit Card med 2010
Multiple Logistic Regrn
OR p valueECMO 0.22 0.021TIMI<2 4.07 0.036CHF 13.37 0.028
The Alfred Intensive Care Unit, Melbourne, Australia
STEMI N-STEMI
ECMO in Cardiogenic Shock
IABP aloneIABP alone
IABP+ECMO IABP+ECMO
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO Retrieval and Outcomes
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO: Emerging PopulationsMechanical CPR• Increasingly utilized by hospitals and EMS• Two large randomized trials LINC & CIRC indicated safe and equivalent to
good manual CPR• Potentially useful to facilitate prolonged CPR during transport• ? Management of these patients –a bridge to ECMO??
The Alfred Intensive Care Unit, Melbourne, Australia
OHCA-CPR-ECMO (ECPR)First report: Resuscitation of the Moribund Patient Using Portable CPB. Mattox et al 1976
The Alfred Intensive Care Unit, Melbourne, Australia
The Rise of ECPR
• The ‘SAVE-J: Study of advanced life support for ventricular fibrillation with extracorporeal circulation in Japan’ commenced in 2008 > 30 hospitals
• The key inclusion criteria are: 1) shockable rhythm on the initial ECG;2) Persistent cardiac arrest on arrival at hospital 3) arrival at hospital within 45 min of the call for an ambulance or cardiac arrest;
and 4) cardiac arrest remaining for more than 15 min after arrival at hospital.
The Alfred Intensive Care Unit, Melbourne, Australia
1) CPR to hospital• Automated CPR enabling safe transport to hospital with effective CPR
2) Hypothermia• Initiated pre-hospital for neuroprotection
3) ECMO• Manage Refractory Cardiac arrest
4) Early Reperfusion• Coronary Angiogram• Diagnose and treat underlying aetiology
Melbourne Experience of ECPR in OHCA The CHEER study
Refractory Out-Of-Hospital Cardiac Arrest Treated With Mechanical CPR, Hypothermia, ECMO And Early Reperfusion
Aim:To study the feasibility and efficacy of a treatment pathway for patients with refractory cardiac arrest.
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO-CPR At the Alfred Hospital Melbourne Australia
Resource Intensive / But no different to Trauma Response team in number§ 2 ECMO Cannulators (Intensivists)§ 1 doctor/tech ECHO (check wires in IVC/ aorta)
§ Dr for IV cooling fluid § ECMO nurse for circuit start§ Dr / Nurse managing Autopulse§ ER team for conventional resus
Inclusion Criteria:• 18-65 years of age• with a suspected cardiac aetiology• chest compressions commenced within 10 minutes,• initial cardiac arrest rhythm of VF• automated CPR available• within 10 minutes ambulance transport time• Pilot phase during normal working hours (9am-5pm)• with the aim to commence ECMO within 60 minutes
of the initial collapse
The Alfred Intensive Care Unit, Melbourne, Australia
ECPR Results – MelbourneFirst 2 years
Stub et al Resus Oct 2014
The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes and Complications Outcomes All
N=26SurvivorsN=14
Non SurvivorsN=12
Survival to Hospital Discharge, n(%) 14 (54)
Good neuro outcome (CPC 1-2) 14 (54) 14 (100)
Wean off ECMO* 13/24 (54) 12/12 (100) 1 (7)
Median Time on ECMODays (IQR)
2 (1-5) 3 (1.8-5) 1 (1-5)
Median Time in ICU, Hours (IQR) 134 (39-291) 230 (118-320) 30 (4-134)
Median Hospital length of stay, Days 13 (1.3-22) 20 (12-26) 1 (1-8)
Bleeding, n(%) 18 (70) 10 (71) 8 (67)
Renal Replacement Therapy, n(%) 10 (39) 4 (29) 6 (50)
Peripheral Vascular Issues, n(%) 10 (39) 5 (36) 5 (42)
Stroke, n(%) 6 (23) 2 (14) 4 (33)
Stub et al Resus Oct 2014
The Alfred Intensive Care Unit, Melbourne, Australia
ECMO Practical Issues• Neurologic assessment in the ECPR scenario
– Wean sedation, CT brain/EEG, neuro consult– Always consider the appropriate exit strategy
• Increased afterload– Aortic regurgitation (* must assess pre ECMO)– Persistently elevated LVEDP (pulm edema)/LV stasis
• May require LV or LA venting: NB prove APO is due to high PCWP etc
• Differential (upper body hypoxia)– Monitor R radial blood gases– Due to inadequate venous return: consider further cannulae options
• Lower limb ischemia– Diligent monitoring, backflow cannulae
• Weaning & conversion to LVAD
The Alfred Intensive Care Unit, Melbourne, Australia
Summary
• ECMO provides a cost-effective, rapidly achievable interim approach to ‘full’ MCS in the ‘right’ patient
• ECMO MCS provides the clinical team with an opportunity to make considered decisions about the best clinical strategy for the patient (and family)
• Positive long-term outcomes can be achieved when managed by multi-disciplinary MCS teams