ECMO

Question 1

Lamhaut ECMO case:
- When?
Where?
Details

Answer 1

2012
32 year old caucasian male.
No PMH
Immediate BLS, 10 minutes in AED 1 shock, ROSC. Start ALS again. 
In refractory VF arrest, but with signs of life: (spontaneous inspiration and pupillary reflexes/etco2 4 kPa,) 
00:25 - ECPR arrive
01:15- ECMO commenced
HCM dx in hospital
Day 2: off ECMO
Day 21: discharged from ICU, CPC 1

Question 2

Define ECMO

Answer 2

Extra-Coporeal Membrane Oxygenation.
Circuit pumps blood through an oxygenating system for temporary life support, for patients with potentially reversible respiratory and/or cardiac failure.

Question 3

ECMO VV?

Answer 3

Venous-Venous: gas exchange only, for isolated respiratory failure.

Question 4

ECMO VA?

Answer 4

Venous-Arterial: for circulatory support

Question 5

What is a better term and why?

Answer 5

Extra-Corporeal Life Support

(better term - used for those without arrest who are unstable)

or Extra-Corporeal Cardio Pulmonary Resuscitation. (ECLS as part of initial cardiac arrest resuscitation) - only for arrest puts, not if unstable haemodynamically.

Question 6

Indications for ECMO?

Answer 6

REVERSIBLE disease process = key.

• Refractory to conventional therapy (nadequate tissue perfusion with low cardiac output state despite adequate intravascular volume, & persisting despite inotropes, vasoconstrictors +/- IABP)
• High mortality risk
• Absence of severe intracranial pathology and uncontrolled bleeding/severe coagulopathy.

Question 7

Absolute contraindications?

Answer 7

Unrecoverable heart, not a candidate for VAD/transplant.
Advanced malignancy
Neurological injury
Unwitnessed arrest/more than 10 mins no flow time.
Prolonged low-flow time.

Question 8

Relative contraindications?

Answer 8

Uncontrolled coagulopathy, chornic organ dysfunction, significant PVD, Age over 70, BMI over35.

Question 9

Why do we need ECMO?

Answer 9

The problem lies in maintaining enough circulation to either achieve ROSC or keep vital organs perfused enough to definitive treatment. Most patients die from ischaemia e.g. a reversible cause which ECMO could be used as a bridge to repercussion therapy. CPR isn’t good enough to maintain perfusion.

Question 10

Survival to ECMO time?

Answer 10

Within 30 minutes: 50%
30-60 minutes: 30%
More than 60 minute? 18%

Question 11

Big australian ECMO trail?

Answer 11

CHEER trial (Alfred hospital)

Question 12

5 pinnacle studies

Answer 12

35 year old male
- 9 year old girl 2011, drowning in warm water, submersed 20 minutes, asystole, severe lung inury. ECMO at 85 minutes from ALS start

• 48 year old male 2011, witnessed arrest end of paris marathon. less than a minute no-flow time, 30 mins of ALS and signs of life but systolic. Should have fluid resus earlier. ECPR, in persistent vegetative state.
• 6 patients Aug 2013: witnessed CA, under 70/no severe comorbidities. 2 survivors of the 6.
• 66 year old male Jan 2017, died after admission.
  French - Louvre/supermarket/street

Question 13

Where are they continuing ECMO research?

Answer 13

SAMU - Paris.

Refensburg in Germany

Question 14

SAMU requirements?

Answer 14

ECPR team (2 physicians, 1 nurse, 1 paramedic).
ECMO machine
2 units PRCs/FFP
Sedation
Therapeutic hypothermia.

Question 15

What approach in Paris?

Answer 15

Modified cut-down

Question 16

What approach in Regensburg?

Answer 16

US guided