ecmo and refractory hypoxemia
TRANSCRIPT
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ECMO and refractory Hypoxemia
Dr. Vinay Dhingra MD FRCPC Clinical Associate Professor of Medicine
Clinical Lead Critical Care BCPSQC Medical Director Quality VGH
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Disclosures
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ARDS
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Lancet 1967; 2:319-323
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Acute Phase
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Acute lung injury: •hypoxemia • risk factor • Bilateral • infiltrates •No left atrl. htn. •PaO2/FiO2 < 300
ARDS:
PaO2/FiO2 < 200
Acute Lung Injury and Acute Respiratory Distress
Syndrome PaO2/FiO2 201-300
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Ventilator Induced/Associated Lung Injury
• Barotrauma – High pressure lung injury (pneumothorax etc)
• Oxygen Toxicity • Volutrauma
– Damage by overdistention
• Atelectotrauma – Repeated recruitment and collapse. Shear injury
• Biotrauma – Inflammation release by injurious ventilation
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Ventilator Induced Lung Injury Overdistention
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Ventilator Induced Lung Injury: EM
Overdistention
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Atelectotrauma
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High Volume Ventilation Low Volume
Ventilation
⊕ Regional PEEP Overinflation (-) PEEP
Increased Surfactant ⊕ Microvascular Inactivation Permeability
Atelectasis Increased (-) Filtration PEEP ⊕
Pulmonary Edema ⊕ Alveolar Flooding PEEP
PEEP (-) Reduction in (-) Lung Distensible Repetitive Opening Volume and Closing of Distal Lung Units
Leukocyte Inflammation Activation and Infiltration
Distal Lung Tissue Damage
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Mechanical Ventilation
Biochemical Injury Biophysical Injury � shear � overdistention � cyclic stretch � ↑ intrathoracic pressure
Cytokines, complement
prostanoids, leukotrienes
reactive oxygen species
bacteria • ↑ alveolar-capillary permeability
• ↓ cardiac output
• ↓ organ perfusion
neutrophils Distal Organs • tissue injury secondary to inflammatory mediators/cells
• impaired oxygen delivery
• bacteremia
MSOF
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Mortality from ARDS
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The Berlin Defini,on
• Within 1 week of insult Timing
• Bilateral opaci,es consistent with pulmonary oedema on CXR or CT Imaging
• Not fully explained by cardiac failure/fluid overload • Echo may help Origin • Mild -‐ Pa/FiO2 < 300 • Moderate -‐ Pa/FiO2 < 200 • Severe -‐ Pa/FiO2 < 100 Categories
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Mortality and MV duration
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Mild Moderate Severe
Dura%o
n (Days)
Mortality (%
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Mortality
MV dura,on
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Refractory Hypoxemia Options
• Esophageal Balloon (PEEP) • Prone Positioning • Inh NO • NMB • HFOV • APRV
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Berlin ARDS Definition 2013
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What is ECMO?
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ECMO Is Not CPB
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Early Extracorporeal Circulation
• Reached clinical application in mid to late 1950’s • Use limited in duration due to activation of blood
components • Due to early oxygenators with direct air-blood
interface • Duration of use limited to few hours (Cardiac
Surgical Procedures)
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Silicone membrane lung
• Dimethylpolysilxane (DMPS, silicone) • Discovered in 1957 • By 1963 used in construction of
oxygenators suitable for long-term support • Paved the way for long term
extracorporeal circulation
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1972 Hill
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1975 Bartlett
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1996 • First
Neonatal ECMO Patient celebrates her 21st Birthday
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ECLS History Adult Respiratory Clinical Trials • 1979 NIH-ARDS randomized trial • 1986 Gattinoni ECCO2R cohort trial • 1986 Morris ECCO2R rdm trial • 2007 Peek CESAR randomized trial
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NIH Adult ECMO Study Zapol WM et al JAMA 1979,242:20;2193-96
• Prospective randomized study (9 Centres)
• Acute respiratory failure (ARF)
• 90 adults selected by common
• Entry criteria: FAST: PO2<50mmhg on FIO2=1,PEEP>5. SLOW: PO2<50 for>12hours onFIO2>0.6, PEEP >5,
• 48 conventional mechanical ventilation, 42 mechanical ventilation supplemented with partial venoarterial bypass
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Insights into NIH Trial • Little or no center
experience • VA ECMO • Antiquated (surgical)
cannulation • High levels of
anticoagulation • Excessive blood loss • No concept of lung rest –
ventilators remained at same settings
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Milan ECCO2R Trial
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Morris ECCO2R-LFPPV Trial
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PRIMARY HYPOTHESES For patients with severe but potentially reversible respiratory failure, ECMO: Will increase the rate of survival without severe disability by six months post randomisation. Will be cost effective, compared to conventional ventilatory support.
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Inclusion Criteria ✦ Potentially reversible respiratory failure ✦ Murray score > 3.0 ✦ hypercapnoea pH <7.20 ✦ aged 18-65 years
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Exclusion Criteria
1. duration of high pressure and high FIO2 ventilation < 7 days
2. no contra-indication to limited heparinisation
3. no contra-indication to continuation of active treatment
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Patients considered potentially eligible for trial (n=766)
Did not receive ECMO support (n=22)
Received ECMO support (n=68)
n=90 Information available for primary outcome n=87
Randomised (n=180)
Non-availability of ECMO bed (n=103) Murray score <3 or pH >7.2 (n=99) High pressure ventilation >7 days (n=86) Other* (n=298)
Not randomised (n=586)
Conventional Ventilation (n=90) ECMO (n=90)
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0.00
0.25
0.50
0.75
1.00
0 50 100 150 200Analysis time (days)
Conventional ECMO
Kaplan-Meier survival estimates, by allocation
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TECHNOLOGICAL ADVANCES
Oxygenators Pump Systems Cannulation Techniques Heater- Cooling Devices Pressure Monitoring Capabilities Tubing Changes Flow and Blood Monitoring Anticoagulation Advances Gas Blenders
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Oxygenators using Nanoporous Hollow Fiber
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Nanoporous Oxygenator
• Good long term • Less platelet
aggregation • Minimal
haemolysis • Current Gold
Standard
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Centrifugal Pump Designs
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Cannulation Changes
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ECMO v1, 1975-2008 • It works BUT, very
complex • It can fail suddenly
with blowout, air, clot • Thrombogenic and
bleeding requiring ++ products
• Vascular access complex
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ECMO v2, 2008- • New low resistance lungs can
be used with low pressure pumps, are less thrombogenic making it much safer
• Inherently safe self regulating circuit
• Safer easier vascular access • Prevent ICU syndrome, more
awake, alert and ?mobile patients
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ECMO Risk-Benefit
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During swine flu 332 referrals
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• Data collected from SwiFT Study • Web based study with data collected
from 192 acute hospitals throughout the UK
• ECMO Patients matched by – Individual Matching – Propensity Matching – GenMatch Matching
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23.7% versus 52.5 % mortality
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BC Guidelines: Veno-Venous (VV) Extra-Corporeal Life Support (Sept 2015)
Adult Indications: Severe Acute Respiratory Failure (ARDS): 1. P/F ratio is < 50 mmHg when FiO2 = 1 for at least 3 hrs, despite
use of other protective ventilation strategies
2. P/F ratio is < 80 mmHg when FiO2 = 1 for more than 6 hrs, despite use of other protective ventilation strategies
3. Associated with use of protective ventilation strategies there is respiratory acidosis (pH < 7.20 for > 6 hrs)
4. P/F < 100 with a trajectory of worsening hypoxemia despite optimization of ventilation and adjunct therapies.
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Additional Considerations 1. The use of VV-ECMO should only be considered if the underlying
process is potentially reversible
2. The indications for ECLS must be based on a collective and multidisciplinary decision. The indications for ECLS should be discussed case-by-case
3. There is no indication for veno-arterial (VA) ECLS in ARDS when respiratory failure is isolated
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Contraindications A. The impossibility of using anticoagulation treatment is a classic
contraindication to ECMO
B. The risk-benefit ratio of ECMO in ARDS should be considered unfavorable in cases of:
1. Hemorrhagic or potentially hemorrhagic intracranial lesions 2. Coma following cardiac arrest 3. ARDS in which the patient has already been mechanically
ventilated for more than seven days 4. Immunocompromised 5. Significant multisystem organ failure
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ECMO: in BC • Where do we perform
ECMO? • Everywhere? • Limited Hospitals
sites? • Stabilize and
Transfer? • Does size of program
matter?
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Best Practices for ARF: Volumes and Critical Mass ECMOnet (2014)
• Expected Volumes – Occurrence of ARF severe to warrant consideration of
ECMO (Excluding Pandemics) • 5-10/million population
• Critical Mass • Better outcomes with increased volumes 25-30 cases/y
• Learning Curve (to establish competency) – Minimal 20 cases for start up for optimal results
• Education requirements – Ongoing CME/ ECMO training
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ECMO and ARF Final Considerations
• Overall significant technological changes leading to increased survivability
• Gone from case reports to now true option for care in right patient
• Early recognition and referral to ECMO centre is key to success
• Potentially significant transport issues • Increase in cases improves survivability