3rd BEACH Course - Session 1

Indications and contraindications (S Bouchez)

The origins of ECMO, the story of the Lindberg pump - link

Indications for ECMO

• No absolute inidications
• Institute specific
• Multiple studies with variable outcomes

Advantages of ECMO

• Immediate improvement of hemodynamics
• Oxygenation & metabolic restauration
• Technical not difficult (relative)
• Bedside
• Compared to other options : $

Simplistically,

• Respiratory failure --> VV ECMO
• Circulatory failure --> VA ECMO

VV ECMO

1. 80% mortality risk 
   
   • PaO2/FiO2 < 100 on FiO2> 90%
   • +/- Murray score 3-4, AOI >80, APSS 8
   • despite optimal care for 6 hours or less
2. CO2 retention
   • despite high Pplat (> 30mmHg)
3. Other
   • Severe air leak syndromes
   • Respiratory collapse ( blocked airways…)
   • Surgery (trachea…)

 

VA ECMO

1. Cardiogenic shock
   • Acute coronary syndrome
   • Myocarditis
   • Pulmonary embolism
   • Post-cardiotomy
2. Periprocedural support
   • PCI
   • Surgery
3. Sepsis (in some centers)

Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art

Management of cardiogenic shock complicating myocardial infarction: an update 2019

IN CONCLUSION

Selection of the right patient at the right time

When to start and stop ECMO

Avoid Bridge to nowhere

 

ECMO Principles and Different Modes

VV-ECMO functions as an artificial lung working in addition to the patient's own failing lungs

• To maintain gas exchanges
• To allow protective ventilation
• To allow “lung rest”
• To allow “lung recovery”
• To gain time for LTx

Cardiac ECMO 

Multiple configurations - The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support - a position paper of the Extracorporeal Life Support Organization

Anticoagulation and ECMO

Anticoagulation Practices during Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure. A Systematic Review.

Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis.

Monitoring coagulation on ECMO

• Combination of ACT, aPTT, anti Xa with
  • ATIII
  • Platelet count / function
  • Fibrinogen
  • Viscoelastic test (How fast- how strong- for how long?)

NO SINGLE TEST may be considered adequate to guide (UFH) management