ECMO:Conceptos Básicos para el Internista€¦ · ECMO:Conceptos Básicos para el Internista...
Transcript of ECMO:Conceptos Básicos para el Internista€¦ · ECMO:Conceptos Básicos para el Internista...
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ECMO:Conceptos Básicos
para el Internista
Rodrigo Cartín Ceba, MD, MSc
Pulmonary and Critical Care Medicine
Associate Professor of Medicine
Mayo Clinic
San José, Costa Rica
Junio 29, 2017
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Generalidades
Diferentes modalidades/canulaciones
Indicaciones
Complicaciones
ECMO: Oxigenación por
membrana extracorpórea
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Introduction
ECMO is utilized to manage life threatening cardiac and/or pulmonary failure when other treatment strategies have failed or are not likely to be successful.
ECMO is a modification of the traditional heart-lung circuit used for cardiopulmonary bypass.
ECMO is instituted as a temporary support to allow for treatment of reversible organ injury and organ recovery/transplant.
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ECLS WILL BE IN YOUR ICU
Barbaro RP et al. AJRCCM 2015
ECMO WILL BE IN YOUR ICU!
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ELSO Registry January 2017
Adult Respiratory Cases
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Heart-Lung Machine
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ECMO
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DRAINAGEInlet - V
PUMPInlet - V
MOTOR
MEMBRANEOXYGENATOR
BLENDER
MONITORING
INTERFACE
ECMO CIRCUIT
RETURNOutlet – A or V
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→Gas BlenderECMO CIRCUIT
Connected to oxygenator
Mixes air and oxygen
O2
•Dial for FiO2 (0.21-1)
Air
•Gas flow = ‘Sweep’•0-10 LPM
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Principales modalidades del ECMO
Veno-Venoso (VV)
Veno-Arterial (VA)
Central Periférico
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VV ECMO
Used predominantly for respiratory failure that failed conventional therapy (ARDS)
Cannulation:
Femoral-jugular
Femoral-femoral
Avalon Cannula (R IJ)
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VV ECMO: Femoral-IJ cannulation
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VV ECMO: Femoral-femoral cannulation
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VV ECMO: Avalon Cannula
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G. Schears
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G. Schears
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G. Schears
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G. Schears
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G. Schears
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G. Schears
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Abrams D, et al. Annals ATS 2013 Picture: Lequier L
Avalon Cannula and ambulation
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Slutsky AS Ranieri VM NEJM 2014
LUNG
PROTECTIVE
VENTILATION:
Low Tidal
Volumes
Adequate
PEEP
Low plateau
pressures
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ECMO Day 1
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ECMO Day 2
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Day 15
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Reducing Recirculation
Increasing distanceBicaval cannula
Abrams 2015
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VA ECMO: Indications
Acute cardiac or cardiac/pulmonary Failure
Post-cardiotomy failure
Cardiogenic Shock (MI/Viral/PE)
Bridge support (Transplant)
Post heart transplantation
Primary graft failure
Acute allograft rejection
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VA ECMO: Central cannulation
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Central Cannulation
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VA ECMO: Peripheral cannulation
Possible configurations:
Femoral-femoral
Femoral-subclavian
IJ-subclavian
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VA ECMO: Femoral cannulation
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Peripheral Cannulation
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VA ECMO: Upper body cannulation
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Peripheral VA ECMOTwo circulation patterns competing for blood flow
“Harlequin Syndrome”
Peripheral Cannulation
Inadequate native lung function• Either due to
underlying pathology or inadequate O2 or Ventilation parameters
Significant Cardiac Ejection (myocardial recovery)
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Considerations before starting ECMO
Likelihood of organ/patient recovery
CPR duration (? > 60 Min.)
Co-Morbidities
Malignancy
Advanced Age
Brain Injury
Technical/circulatory conditions
MOF
Conventional ventilator support > 7 days.
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Complications of ECMO
Mechanical or circuit-related Thromboembolism
pro-coagulation vs. anticoagulation
Air Embolism Oxygenator failure Tubing rupture or
separation De-cannulation, cannula
malposition
Patient-Related Hemolysis Bleeding
DIC Thrombocytopenia
Neurological CNS hemorrhage CNS infarct
Renal (AKI) Cardiovascular Pulmonary Infection Metabolic
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Lim – ECLS physiological concepts and clinical outcomes. J of Card Failure 2016
Cheng - Complications of ECMO. Ann Thorac Surg 2014
COMPLICATIONS
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Complications of ECMO - Cheng. Ann Thorac Surg 2014
ECMO and nosocomial infection - Schmidt. CID 2012
COMPLICATIONS
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Extracorporeal CO2 Removal: ECCO2R
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PrismaLung
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eCPR
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