Summary Listen
- Extracorporeal Life Support (ECLS) evolved from Dr. John Gibbon's cardiopulmonary bypass invention in 1953. Early bubble oxygenators caused hemolysis, leading to the development of silicon membrane oxygenators in 1957. This innovation coined the term Extracorporeal Membrane Oxygenation (ECMO) and significantly reduced complications, with early successful uses in trauma and pediatric patients. ECMO became widely recognized during the H1N1 influenza pandemic in the late 2000s.
- ECMO serves as a critical life-support intervention by temporarily bypassing the heart and lungs through an external circuit. Two main types exist: Veno-Venous (VV) ECMO provides respiratory support by draining deoxygenated blood from a peripheral vein, oxygenating it, and returning it to the venous system. Veno-Arterial (VA) ECMO supports both respiratory and cardiac function by returning oxygenated blood directly to an artery, allowing the heart to rest and heal.
- Indications for VV ECMO include severe respiratory failure (e.g., ARDS, pneumonia, status asthmaticus) and as a bridge to lung transplant. VA ECMO is used for severe cardiac failure (e.g., cardiogenic shock, myocarditis, massive pulmonary embolism, post-cardiotomy shock, cardiac arrest with ongoing CPR). Contraindications include patient refusal, advanced age (over 70), end-stage chronic diseases (COPD, ILD), non-survivable neurological injury, advanced malignancies, and severe bleeding conditions.
- The ECMO circuit comprises an oxygenator (the "artificial lung"), a pump for continuous blood flow, and a cannulation system to connect the patient to the circuit. The oxygenator facilitates gas exchange, while pumps (peristaltic or centrifugal) propel blood. Anticoagulation, typically with heparin, is crucial to prevent thrombosis within the circuit, requiring meticulous management of coagulation profiles and blood products to counteract hemolysis and bleeding risks.
- Patient selection involves assessing severe respiratory or cardiac failure, failure of conventional therapies, and potential for recovery or transplant. Pre-ECMO assessment includes imaging (chest X-ray, CT brain), echocardiography, and laboratory values (coagulation, renal function, infection screen, neurological status). Proper cannulation (peripheral or central) is vital. Management post-initiation focuses on maintaining optimal blood flow, careful anticoagulation, and managing blood product needs.
- Complications associated with ECMO are significant and include bleeding (due to anticoagulation), thrombosis (circuit clotting, emboli), infection (catheter-related, systemic), and neurological complications (cerebral emboli, hemorrhage). Meticulous management is required to mitigate these challenges, including maintaining proper mean arterial pressure to prevent hypo-perfusion and ischemia.
- Survival rates vary, with overall 5-year survival for VA ECMO at 33% and VV ECMO at 36%. These rates improve significantly (71-73%) for patients surviving beyond 30 days. Factors influencing outcomes include advanced age, timely patient enrollment, corticosteroid use, and ECMO duration. During the COVID-19 pandemic, ECMO played a crucial role, with an overall mortality rate of 48%.
- Advancements in ECMO technology include compact and ambulatory systems for inter-hospital transfers, novel closed-loop circuit designs, improved biocompatible materials, remote monitoring, and the integration of artificial intelligence for better patient data assessment and outcomes. Future directions emphasize ongoing clinical trials and research to further enhance ECMO efficacy and accessibility.
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About the Speakers
Dr. Frank Mohan
Consultant Pulmonologist, Proprietor – Shine Chest and Critical Care Hospital, Assistant Professor – Santhiram Medical College, Andhra Pradesh
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