Description
ECMO is a form of life support that uses a machine to oxygenate the blood outside of the body used for patients with severe respiratory or cardiac failure who are not responding to conventional treatment. ECMO can be used in both adult and pediatric patients. Hemodynamic parameters such as heart rate, blood pressure, and oxygen saturation are closely monitored during ECMO management. The goal of ECMO management is to provide temporary support for the patient until their own cardiac or respiratory function can be restored.
Résumé
- ECMO (Extracorporeal Membrane Oxygenation) is an extracorporeal therapy that provides long-term respiratory or cardiac support. It involves taking blood out of the body, running it through a machine to oxygenate it, and returning it to the patient. ECMO can be used as a bridge to recovery, transplant, decision-making in emergencies, or mechanical cardiac support.
- The history of ECMO originates from cardiac bypass machines, with the challenge being to extend bypass support from minutes to days. Key advancements included the development of hollow fiber oxygenators. Dr. Bartlett's successful use of an animal ECMO machine on a newborn with meconium aspiration marked the first successful human ECMO case.
- Indications for ECMO include respiratory support (VV ECMO) for conditions like ARDS, pneumonia, and lung trauma, and cardiac support (VA ECMO) for cardiac shock, post-cardiac surgery complications, and myocardial infarction. Newer indications include drug overdoses, myocarditis, and extra-corporeal cardiopulmonary resuscitation (ECPR).
- VV ECMO involves draining blood from one major vein and returning it to another, while VA ECMO drains blood from a vein and returns it to an artery, usually the femoral artery. The CISA trial demonstrated mortality benefits in adults with severe respiratory failure, while the EOLEar trial had design issues. ECMO is most effective in specialized centers.
- VV ECMO typically involves a femoral-jugular approach, with cannulas placed in the IVC and jugular vein. A risk score helps determine survival prediction based on age, immunocompromised status, ventilation duration, cause of ARDS, and organ dysfunction. Ultrasound guidance is used for cannula insertion, minimizing complications.
- A typical ECMO machine includes a centrifugal pump that generates high-speed rotation to draw and propel blood, and a hollow fiber oxygenator for gas exchange. The machine uses a circuit to flow blood from the patient, through the pump and oxygenator, and back to the patient. Blood flow, oxygen, and sweep gas settings are crucial for effective gas exchange.
- Managing the machine involves monitoring flow and pressures (T1, T2, T3) to identify potential issues like tubing obstructions or oxygenator problems. Patient management includes daily examinations for CNS bleeds, adjusting sedation, monitoring respiratory parameters and lung compliance, checking lines for infection, and ensuring adequate nutrition.
- Managing oxygenation involves adjusting blood flow, addressing recirculation, and managing the patient's oxygen requirements. Ventilator management in ECMO prioritizes lung rest, with minimal ventilation settings (pressure control of 10, PEEP of 10, respiratory rate of 10), targeting saturations of 85-95% and avoiding permissive hypercapnia.
- Coagulation management is critical to balance pro-thrombotic risks with the risk of bleeding. Unfractionated heparin is commonly used, monitored via ACT, with a target range of 180-220 seconds. HIT is a major concern, with alternatives such as bivalirudin and argatroban available. Pharmacology requires dose adjustments due to altered volume of distribution and drug adsorption onto the circuit.
- Weaning from ECMO begins with improving lung compliance and gradually reducing FiO2 and sweep gas flow. Once stable, sweep gas flow is turned off for 24 hours before decannulation. Post-decannulation, a venous Doppler assesses for thrombus. Tracheostomy is often necessary due to prolonged intubation. Mobilization on ECMO is possible with physiotherapy and specialized staffing.
Exemple de certificat
À propos des intervenants
Dr Pavan Vala
Dr Pavan Vala, MBBS, MD, FCCM(TMH), EDIC, FFICM(UK), consultant, soins intensifs et ECMO
Commentaires
Commentaires
Vous devez être connecté pour laisser un commentaire.