Question 23

Created on Mon, 06/08/2015 - 01:56
Last updated on Sun, 04/30/2017 - 18:21
Pass rate: 43%
Highest mark: 7

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A 39-year-old female is admitted to a tertiary centre and intubated and ventilated for severe Legionella pneumonia. Two days after admission to ICU she remains profoundly hypoxaemic (PaO2/FiO2 = 55), despite optimising ventilatory support and appropriate antimicrobial therapy.

a) Outline the factors that would influence your decision whether or not to institute extra-corporeal membrane oxygenation (ECMO) in this patient.

b) Outline the relative merits of veno-venous (V-V) and veno-arterial (V-A) ECMO for this patient.

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College Answer

a)
ECMO is indicated for potentially reversible life-threatening cardiac and/or respiratory failure unresponsive to conventional support, buying time for recovery from the underlying condition and specific treatment to take effect.
This patient meets criteria for ECMO with a potentially reversible condition (Legionella pneumonia) and P/F < 60 and age < 65 years.

Alternative treatment strategies
 Ensure all other strategies have been tried – (e.g. - recruitment manoeuvres, prone positioning, NO/inhaled prostacyclin, diuresis, etc.)
 Exclude easily treated reversible problem e.g. pneumothorax, mucous plugging
 Ensure optimisation of haemodynamics, consider measurement of adequacy of DO2
Exclude contra-indications / relative contra-indications – severe pre-existing organ dysfunction, presence of other severe co-morbidities e.g. advanced malignancy, co-existing irreversible lung/cardiac pathology, and presence of bleeding disorder.
Available resources – appropriate level of expertise with trained staff to insert catheters, set up, monitor and troubleshoot ECMO circuit, and adequate equipment.
(Reference to meeting unit/regional criteria for institution of ECMO, or similar, are an acceptable answer.)

b)
Choice of V-V or V-A ECMO will depend on co-existing cardiogenic shock. V-A ECMO provides complete cardio-respiratory support, whereas V-V ECMO only provides respiratory support. If profound septic shock with myocardial depression and EF<25%, V-A ECMO indicated. If adequate cardiac function then V-V ECMO indicated otherwise significant native blood pulmonary blood flow and cardiac output results in relatively hypoxic perfusion of upper body compared with lower half.
V-V ECMO also avoids risks of serious arterial injury, has less severe consequences in case or air or clot embolization, and as a low-pressure system may prolong circuit life.
Animal studies suggest preservation of pulmonary blood flow with V-V ECMO may improve recovery from lung sepsis compared with V-A ECMO.

Discussion

For a 10 mark question, this college model answer seems somewhat barren. One might expect at least a bit of a digression into ECMO. Applications of ECMO and literature regarding the use of ECMO are discussed elsewhere. In brief:

Indications for ECMO

In order to qualify for this level of critical care, one must be special in the following ways:

  • The condition must be reversible; OR the patient qualifies for a heart/lung transplant
  • The conventional management strategies have failed.

The following situations call for ECMO:

  • Cardiac arrest (in certain settings)
  • Failure to wean from cardiopulmonary bypass
  • Cardiogenic shock
  • Hypoxic respiratory failure
  • Hypercapneic respiratory failure

Contraindications for ECMO

  • Contraindications to anticoagulation: recent surgery, uncontrolled bleeding, intracranial haemorrhage
  • Irreversible condition
  • Contraindications for heart/lung transplant

Caveats to ECMO

Before subjecting a patient to such a perversely unnatural therapy, one ought to satisfy onself that every "conventional" strategy has failed. These include:

  • Recruitment manoeuvres
  • prone positioning
  • NO/inhaled prostacyclin
  • diuresis
  • Fluid resuscitation and decreased PEEP to improve V/Q matching

Veno-venous vs veno-arterial ECMO

Each has advantages and disadvantages.

  • VA ECMO has the advantage of providing complete cardiorespiratory support, and is therefore applicable in patients with very poor cardiac function (LVEF less than 25%)
  • VA ECMO has the disadvantage of large-bore arterial puncture, which is a major problem. VV ECMO has less vascular access issues, but is only indicated for patients with good myocardial function.

In summary, the evidence:
 

These abovementioned rules are fairly elastic. Specifically, where it comes to concerns regarding vascular access complications, it is now unclear whether VA ECMO is truly more dangerous. Similarly, where it comes to severe haemodynamic compromise, it is unclear whether VV ECMO is truly pointless.

  • In neonatal respiratory failure, back in 1996, Knight et al found that the frequency of intravascular thrombosis was significantly lower in patients receiving venovenous ECMO, and that otherwise things which were felt to be contraindications (eg. severe cardiac failure) weren't real barriers to successful VV ECMO.
  • A 2000 review agreed with this in principle, but failed to discern any difference in the rate of complications in the neonatal/paediatric population.
  • A more recent 2015 conference abstract also failed to find any difference in complications among adults.

References

UpToDate has a nice summary chapter about ECMO.

The world is sustained by the guidelines published by ELSO (the Extracorporeal Life Support Organisation)

BARTLETT, ROBERT H., et al. "Extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure." Annals of surgery 204.3 (1986): 236-245.

Peek, Giles J., et al. "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial." Lancet (London, England) 374.9698 (2009): 1351-1363.

Doll, Nicolas, et al. "Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.The Annals of thoracic surgery 77.1 (2004): 151-157.

De Waha, S., et al. "Extracorporeal membrane oxygenation in refractory cardiogenic shock-the Leipzig ECMO registry." European Heart Journal 34.suppl 1 (2013): P4025.

Chen, Yih-Sharng, et al. "Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation." Journal of the American College of Cardiology 41.2 (2003): 197-203.

Shin, Tae Gun, et al. "Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation*." Critical care medicine 39.1 (2011): 1-7.

Scanziani, Margherita, Leonello Avalli, and Roberto Fumagalli. "Extracorporeal Membrane Oxygenation Strategy in Cardiac Arrest." Resuscitation. Springer Milan, 2014. 109-117.

Davies, Andrew, et al. "Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome." JAMA: the journal of the American Medical Association 302.17 (2009): 1888-1895.

Stub, Dion, et al. "Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial)." Resuscitation 86 (2015): 88-94.

Thourani, Vinod H., et al. "Venoarterial extracorporeal membrane oxygenation (VA-ECMO) in pediatric cardiac support." The Annals of thoracic surgery 82.1 (2006): 138-145.

Kolman, D., et al. "Clinical Outcomes In Patients With Advanced Cardiopulmonary Failure Who Were Treated With Either Veno-Arterial (va) Or Veno-Venous (vv) Extra-Corporeal Membrane Oxygenation (ecmo)." Am J Respir Crit Care Med 191 (2015): A4559.

Knight, Gail R., et al. "A comparison of venovenous and venoarterial extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure." Critical care medicine 24.10 (1996): 1678-1683.

Zahraa, Jihad N., et al. "Venovenous versus venoarterial extracorporeal life support for pediatric respiratory failure: are there differences in survival and acute complications?." Critical care medicine 28.2 (2000): 521-525.

Kolman, D., et al. "Clinical Outcomes In Patients With Advanced Cardiopulmonary Failure Who Were Treated With Either Veno-Arterial (va) Or Veno-Venous (vv) Extra-Corporeal Membrane Oxygenation (ecmo)." Am J Respir Crit Care Med 191 (2015): A4559.

Bombino, Michela, Sara Redaelli, and Antonio Pesenti. "Newer indications for ECMO: pulmonary embolism, pulmonary hypertension, septic shock and trauma." ECMO-Extracorporeal Life Support in Adults. Springer Milan, 2014. 179-192.

Butt, W., and G. MacLaren. "Extracorporeal membrane oxygenation and sepsis." Crit Care Resusc 2007; 9: 76–80