ecmo - kocica 2013

7/24/2019 ECMO - Kocica 2013

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Extra Corporeal MembraneOxygenation

E. C. M. O.Mladen J. Kočica

Clinic for Cardiac Surgery, UC Clinical Centre of Serbia, Belgrade, Serbia

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E. C. . S.

Extra Corporeal i3e S4pport 5

5 67ene8er li3e i9 not 949tainable 6it7o4t94pport:

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E.C.M.O. ; &&.%.$%&.Ne69paper9

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/7e 1ir9t E.C.M.O. in Serbia ;%<.%.$%&.

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E.C.M.O. - General Strategy

S4pport o3 7eart an=>or l4ng 34n?tion6it7 an extra?orporeal me?7ani?al =e8i?e 67i?7@

– Re9tore9 a=e4ate ti994e per349ion an= oxygen=ili8ery – I9 temporary B&-$ 6ee9 – A8oi=9 ongoing iatrogeni? in4ry B8entilator,

inotrope9 ...

– "4y9 time to =e?i=e t7e next 9tep@• Recovery

• Operation (CABG, pulmonary embolectomy,..)

• Long-term support (LAV, RVA, BiVA, !A")

• !ransplantation

•

Give-up '()

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E.C.M.O. - Prin?iple9 o3 /reatment

• Se8ere 7eart an= l4ng =amage - beyon=9tan=ar= /x limit9.

• 14rt7er 9tep 4p in organ 94pport /x - more7arm t7an goo=.

• Ab9ol4te re9t - main9tay 3or organre?o8ery :::

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E.C.M.O. - Prin?iple9 o3 /reatmentB?ont=.

• Re9piration an= ?ir?4lation ?an not tae re9tt7ro4g7o4t li3e.

• ECMO appear9 a9 t7e only mae97i3tarrangement in t7i9 4n?t4re.

• It i9 al6ay9 6i9e to tae a timely =e?i9ion to

96it?7 o8er to ECMO - be3ore 9e?on=aryMO1 7a9 9et in :::

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E.C.C. an= E.C.M.O.

• ECMO ; mo=ie= ECC• CP" ; extra?orporeal oxygenation H

per349ion

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0i9tory - ECC an= ECMO

• &' - Gibbon ( arti*cial o+ygenation and erfu-ion -uortfor te *r-t -ucce--ful oen eart oeration

• &'J - ille7ei ( te cro--(circulation tecni/ue

• &'' - Kirlin ( i0ro1ed on 2ibbon3- de1ice and

-ucce--fully reaired an AS%

• &' - Ra97in= ( bubble o+ygenator a- -uort in a

neonate dying of re-iratory failure.

• & - Dor9on ( u-e of a 0e0brane o+ygenator for C!B in

infant-.

• &<% - "aLe9 5 te *r-t -ucce--ful u-e of cardiac )6A7 ECM$

• &<' - "artlett ( te *r-t -ucce--ful u-e of ul0onary )667

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/7e 1ir9t S4??e934l E.C.M.O.

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/o=ay it oo9 4ite DiLerent

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General E.C.M.O. Cir?4it S?7eme

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E.C.M.O. - P4mp

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E.C.M.O. - Oxygenator

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V.V. - E.C.M.O.

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V.A. - E.C.M.O.

A= lt R i t BV V E C M O

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A=4lt Re9piratory BV.V. E.C.M.O. -In=i?ation9

• Re8ere9ible a?4te re9piratory 3ail4re, notrepon=ing on ?on8entional /x@ – ARDS – Pne4monia B0&N& – Stat49 a9t7mati?49 – C7emi?al an= in7alation pne4moniti9 – Near =ro6ing – Po9tra4mati? l4ng ?ont49ion – "ron?7ioliti9 obliteran9 – A4toimm4ne l4ng =i9ea9e B8a9?4liti9, Goo=pa9t4re

9yn=rome• Irre8er9ible ?7roni? re9piratory 3ail4re ; only a9

a bri=ge to@ – 4ng a99i9t =e8i?e BPA ; Para?orporeal Artitial 4ng – 4ng tran9plant


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A=4lt Re9piratory BV.V. E.C.M.O. -Criteria

• In?l49ion ?riteria Bany $ ob9er8e= o8er J-7 a3termaximal me=i?al /x@&. PaO$>1iO$ <'$. Oxygen in=ex J%. M4rray ARDS, AI 9?ore J. aA gra=ient %% mm0g'. 0yper?apnia 6it7 p0 <.$ 3or more t7an 7o4r9. 4ng ?omplian?e %.' ??>?m0$O>g

• Ex?l49ion ?riteria@ –. Irre8er9ible =i9ea9e Be.g. malignan?y –. Age <' –. Patient on 8entilator 3or &' =ay9 –. IC blee=ing –. A?ti8e blee=ing 3or non ?ompre99i8e 9ite9 –. Irre8er9ible or in=eterminate ne4rologi?al 9tat49 –. Un6itne99e= arre9t or arre9t % min –.

A=8an?e= MO1

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Sing9 o3 Re?o8ery - BV.V. E.C.M.O.

&. A progre99i8e in?rea9e in SaO$ abo8e

S8O$.$. An impro8ement in SaO$ 3or a gi8en ?ir?4it

Qo6 or a re=4?e= ?ir?4it Qo6 re4ire= toa?7ie8e t7e target SaO$.

. Impro8ing l4ng ?omplian?e.J. Impro8ing ?7e9t ra=iograp7.


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A=4lt Re9piratory BV.V. E.C.M.O. -2eaning•

De?rea9e Qo6 at rate o3 $% ml>g>7 4p to $.'- l>min Bi.e. '% ECMOQo6• Upgra=e 8entilator 9etting9@

– 1iO$ J% – PEEP - ?m 0$O – /i=al Vol ml>g – PIP % ?m 0$O

– VE1 %• E9timation ?riteria@

– CTR impro8e= – 4ng ?omplian?e impro8e= B $% – A"G@

• #aO$ % &' mm"g

• #aCO$ ' mm"g

• p" % *.+• cvO$ % *'

• Re=4?e ECMO 1iO$ by ' e8ery 7 4ntil J% i9 rea?7e=• Maintain SpO$ %• Re=4?e ga9 Qo6 by %.' >min e8ery 7 4ntil minimal Qo6 %.' >min

i9 rea?7e=•

2EAN

A= lt C =i BV A E C M O

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A=4lt Car=ia? BV.A. E.C.M.O. -In=i?ation9

• Re8e9ible a?4te re3ra?tory ?ar=ia? 3ail4re@ – Car=iogeni? 97o? in AIM or ACS – Viral myo?ar=iti9 – Car=iogeni? 97o? 6it7 a?4te 9e8ere Ao an= Mi

reg4rgitation – Po9t ?ar=iotomy ?ar=iogeni? 97o? – 1ail4re to 6ean 3rom CP" – Poi9oning ; Ca blo?er9, beta blo?er9

• Irre8er9ible ?ar=ia? =i9ea9e9 ; only a9 a

bri=ge to@ – VAD – 0eart tran9plant


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A=4lt Car=ia? BV.A. E.C.M.O. -Criteria•

In?l49ion ?riteria Bany $ ob9er8e= o8er J-7 a3ter maximalme=i?al /x@&. Re3ra?tory arr7yt7mia9$. Car=iogeni? 97o? 6it7 7ig7 inotropi? re4irement9. a?tate le8el ' mmol> , S?8O$ ' 6it7 maximal me=i?al

/x

J. Poor ti994e per349ion B?ol= 9in, ?yano9i9, metaboli? a?i=o9i9,renal o4tp4t '% ml>7, in 9pite o3 IA"P an= inotropi? 94pport

• Ex?l49ion ?riteria@ –. Irre8er9ible =i9ea9e Be.g. malignan?y –. DCM ex?ept 3ore9eeable =e9tination /x BVAD, 0/x –. Age <' –. Patient on 8entilator 3or &' =ay9 –. IC blee=ing –. A?ti8e blee=ing 3or non ?ompre99i8e 9ite9 –. A=8an?e= MO1 –. Se8ere CNS in4ry ; en?ep7aliti9, 7ypoxi?-i9?7emi?

en?ep7alopat7y, intra?table 9ei4rie9, 8egetati8e 9tate

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Sing9 o3 Re?o8ery - BV.A. E.C.M.O.

&. An in?rea9ing bloo= pre994re 67i?7 may

nee= 8a9o=ilator9, ret4rn o3 p4l9atility ont7e arterial pre994re 6a8e3orm.

$. 1alling o3 pO$ by a rig7t ra=ial arterial linein=i?ating more bloo= i9 being p4mpe=

t7ro4g7 t7e 7eart 67i?7 may be le99 6elloxygenate=.. De?rea9ing ?entral 8eno49 an=>or

p4lmonary pre994re9.


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A=4lt Car=ia? BV.A. E.C.M.O. -2eaning

• De?rea9e Qo6 at rate o3 &% ml>g>7• Parameter9 on i=le Qo6 B&% ml>g>min@

– MAP <% mm0g – SpO$ ' –

S?8O$ <% – CTR ; impro8e= – VE1 %

• Stay on i=le Qo6 3or $ 7o4r9 B1iO$ %• 2EAN

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E.C.M.O. - Compli?ation9

E.C.M.O. Compli?ation9

Me?7ani?al ?ompli?ation9 )e.g. o+ygenator failure, tubing8circuit di-rution,u0 or eat e+canger 0alfunction, roble0- 9it cannula

lace0ent8re0o1al7

"lee=ing, ?oag4lopat7y an= 7aemoly9i9

0emorr7age9 a99o?iate= 6it7 anti?oag4lation re4irement9Compartment 9yn=rome an= leg i9?7emia

Air emboli9m, t7romboemboli9m an= ne4rologi?al 9e4elae

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ESO &$-$%&

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MCS an= 0/x - Rep4bli? o3 Serbia

ocica. %o:tor-:a di-ertaci;a. Medicin-:i fa:ultet, Beograd, <=>?. .@.

E C M O Co9t Analy9i9 B

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E.C.M.O. ; Co9t Analy9i9 Bmont79

• 1rom an e?onomi? 9tan=point,approximately &%-&$ ?a9e9 per year 6ill bene?e99ary to 49ti3y t7e expen=it4re9 3or

e4ipment, 9alary 3or an ECMO ?oor=inatoran= o8ertime.Co9t Analy9i9 Mean Co9t9 Co9t =iLeren?e

ECM$ @ @? J' <% WBH &$& Con1entional

0anage0ent@D

F 6alue er atient in a -i+ 0ont- eriod. %ata fro0 !ee: et al. )<==G7

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/7e ate9t Ne69 - Serbia /o=ay

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ANX - E.C.M.O. - 0&N& Data $%%

$%

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E.C.M.O. Center9 in Serbia

A.S.A.!.

ecmo - kocica 2013

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