ECMO in Cardiac Arrest

1. ECMO in Cardiac Arrest
Johnny iliff

2. references
 LITFL
 Alfred Hospital
 ECMO Project

3. What is it?
 ECMO is extra-corporeal membrane oxygenation
 extracorporeal life support (ECLS) may be a better term
 The extracorporeal circuit allows for the oxygenation and
removal of carbon dioxide from blood
 used as a supportive strategy in patients who have a high risk
of death despite conventional therapy

4. Why are we considering it in the ED for
CardiacArrest
 “Patients with refractory ventricular fibrillation receiving E-
CPR tended to have higher survival rates and significantly
improved neurological outcomes when compared with those
receiving C-CPR”. Managing cardiac arrest with refractory ventricular fibrillation in
the emergency department:Conventional cardiopulmonary resuscitation versus
extracorporeal cardiopulmonary resuscitation􏰀 -Fu-Yuan Siao et al. RESUSCITATION April
2015
 Drive to start ECMO in SCGHED

5. Indications
 acute, severe REVERSIBLE respiratory or cardiac failure with
a high risk of death that is refractory to conventional
management
 poor gas exchange
 compliance < 0.5mL/cmH2O/kg
 P:F ratio < 100
 shunt fraction > 30%

6. Absolute Contraindications
 progressive non-recoverable cardiac disease (not transplant
candidate)
 progressive and non-recoverable respiratory disease (irrespective
of transplant status)
 chronic severe pulmonary hypertension
 advanced malignancy
 GVHD
 >120kg
 unwitnessed cardiac arrest

7. Relative Contraindications
 age > 75
 multi-trauma with multiple bleeding sites
 CPR > 60 minutes
 multiple organ failure
 CNS injury

8. Types
 VV = veno-venous
 VA = veno-arterial: peripheral or central
 Veno-pulmonary artery ECMO (provides short-term right
ventricular and respiratory support following LVAD insertion)
 high (2 venous cannulae) vs low flow (1 venous cannula)

9. VV ECMO
 most common mode
 venous drainage from large central veins -> oxygenator ->
venous system near RA
 support for severe respiratory failure (no cardiac dysfunction)
 Proven to be improve survival @6months (63% vrs 47%) with
acute respiratory failure

10. VV ECMO

11. Pathology
 pneumonia
 ARDS
 -acute GVHD
 pulmonary contusion
 smoke inhalation
 status asthmaticus
 airway obstruction
 aspiration
 bridge to lung transplant
 drowning

12. VA ECMO
 venous drainage from large central veins -> oxygenator ->
arterial system in aorta
 support for cardiac failure (+/- respiratory failure)

14. Pathology
 graft failure post heart or heart lung transplant
 non-ischaemic cardiogenic shock
 failure to wean post CPB
 bridge to LVAD
 drug OD
 Sepsis
 PE
 cardiac or major vessel trauma
 massive pulmonary haemorrhage
 pulmonary trauma
 acute anaphylaxis

15. The ALFRED guidelines
 Patients in the E&TC with out-of-hospital cardiac arrest which is refractory to
standard advanced cardiac life support (ACLS) treatmentAND:
 The patient meets ALL the following criteria in regards to the characteristics of
the arrest:
 Likely due to Respiratory or Cardiac cause
 Witnessed arrest
 Chest compressions started within 10 mins
 Less than 60 mins duration in total
 12-70 years old
 No major co-morbidities

16.  The patient is profoundly hypothermic (<32°C) due to
accidental exposure
 The patient has taken a significant overdose of a vaso-active
drug(s) (i.e. β-Blocker, tricyclic acid, digoxin etc)
 Any other cause where there is likely to be reversibility of the
cardiac arrest if an artificial circulation can be provided
 In order to ensure that out-of-hospital cardiac arrest patients
arrive within a short time-frame, eligible patients will be
transported by ambulance with an AutopulseTM as soon as
possible after the initiation of ACLS

17. STEPs
1. Identify potential patient
2. US guided Line-Venous and Arterial (Training Required)
3. Prime Circuit (Training Required)
4. Attach Circuit
5. Intensive Care
6. Optimize and treat potential casues

18. Cannulation
 It’s central access, what’s the big deal?

22. The Circuit

23.  https://www.youtube.com/watch?v=OM27HovykWY