1. The document discusses indications for extracorporeal membrane oxygenation (ECMO) support, including respiratory failure or circulatory failure that is potentially reversible and where ECMO may provide a "bridge" until recovery.
2. Specific indications mentioned include severe hypoxemia or hypercapnia unresponsive to conventional management for VV-ECMO, and acute coronary syndrome, myocarditis, pulmonary embolism, or post-cardiotomy shock for VA-ECMO.
3. It emphasizes the importance of patient selection and initiating ECMO at the right time to avoid bridging patients to poor long-term outcomes or death.
8. Indications for ECMO
- No absolute indications
- Institution specific
- Multiple studies with variable indications
9. Indications for ECMO
- Immediate improvement of hemodynamics
- Oxygenation & metabolic restauration
- Technical not difficult
- Bedside
- Compared to other options : $
Advantages of ECMO
- No absolute indications
- Institution specific
- Multiple studies with variable indications
11. Respiratory failure Circulatory failure
VV-ECMO VA-ECMO
Reversible process ?
Etiology ?
Within reasonable time?
Organ replacement ?
Bridge to recovery (surgery)
Bridge to decision
Bridge to Transplant / LVAD
12. 1. 80% mortality risk
- PaO2/FiO2 < 100 on FiO2> 90%
- +/- Murray score 3-4, AOI >80, APSS 8
despite optimal care for 6 hours or less
VV-ECMO
15. APPS POINTS 1 2 3
Age < 47 47- 66 > 66
PaO2/FiO2 > 158 105 -158 < 105
Plateau P < 27 27 - 30 > 30
Murray et al. 1988
Villar et al. 2016
OI = MAP x FiO2%
PaO2
MAP: mean airway pressure
OI < 5 = normal
OI > 40 = ECMO ?
Dechert et al. 2014
16. 1. 80% mortality risk
- PaO2/FiO2 < 100 on FiO2> 90%
- +/- Murray score 3-4, AOI >80, APSS 8
despite optimal care for 6 hours or less
2. CO2 retention
despite high Pplat (> 30mmHg)
3. Other
- Severe air leak syndromes
- Respiratory collapse ( blocked airways…)
- Surgery (trachea…)
VV-ECMO
17. Respiratory failure Circulatory failure
VV-ECMO VA-ECMO
Reversible process ?
Etiology ?
Within reasonable time?
Organ replacement ?
Bridge to recovery (surgery)
Bridge to decision
Bridge to Transplant / LVAD
18. Cardiogenic shock
- Acute coronary syndrome
- Myocarditis
- Pulmonary embolism
- Post-cardiotomy
Periprocedural support
- PCI
- Surgery
Sepsis (in some centers)
VA-ECMO
23. ECPR
CPR started immediately < 5 minutes
Collapse to ECPR < 60 minutes (45 min)
Holmberg et al. Resuscitation 2018
24. Cardiogenic shock
- Acute coronary syndrome
- Myocarditis
- Pulmonary embolism
- Post-cardiotomy
Periprocedural support
- PCI
- Surgery
Sepsis (in some centers)
VA-ECMO
25. Falk et al. Crit Care Med 2019
Sepsis
VV-ECMO : - ECMO output < Patient CO
- Improvement of DO2 – reversal of hypoxia
VA-ECMO : - Myocardial depression ++ (septic cardiomyopathy)
- VAV-ECMO
+ immunoabsorption techniques
26. Respiratory failure Circulatory failure
VV-ECMO VA-ECMO
Reversible process ?
Etiology ?
Within reasonable time?
Organ replacement ?
Disseminated malignancy
Severe brain injury / bleeding
Severe chronic organ dysfunction
Unwitnessed cardiac arrest
Advanced age ?
Severe peripheral vascular disease ?
27. Salna et al. Eur J CardioThor Surg 2018
In-Hospital Mortality in VA-ECMO
72 y
28. Respiratory failure Circulatory failure
VV-ECMO VA-ECMO
Etiology ?
Selection of the right patient at the right time
When to start and stop ECMO
Avoid Bridge to nowhere