Article Figures & Data
Figures
- FIGURE 1
Extracorporeal membrane oxygenation (ECMO).
- FIGURE 2
Four configurations of extracorporeal membrane oxygenation (ECMO).
- FIGURE 3
Clinical decision-making in use of extracorporeal membrane oxygenation (ECMO) in respiratory failure.
- FIGURE 4
Clinical decision-making in utilization of extracorporeal membrane oxygenation (ECMO) in cardiogenic shock.
Tables
- TABLE 1
Recent studies of extracorporeal membrane oxygenation (ECMO) in respiratory failure
Authors Year No. of patients Hours on mechanical ventilation before ECMOc Pao2/ Fio2c Venovenous ECMO (%) Days on ECMO Mortality (%) Peek et al8 2009 90a 29 (17–69)c 76 (30)d 100% 9 (6–16) 37% Davies et al9 2009 68 48 (24–120) 56 (48–63) 93% 10 (7–15) 21% Noah et al10 2011 69 96 (48–168) 55 (46–63) 84% 9 (6–12) 24% Patroniti et al11 2011 49b 48 (24–120) 63 (56–79) 100% 10 (7–17) 29% Pham et al12 2013 123 48 (24–120) 63 (21)d 87% 11 (8–22) 36% Schmidt et al13 2013 140 120 (24–264) 53 (43–60) 95% 15 (8–30) 40% Schmidt et al14 2014 2,355 57 (19–151) 59 (48–75) 82% 7 (4–13) 57% Hypoxic respiratory failure indications Acute respiratory distress syndrome due to any cause
Bridge to lung transplant
Primary graft failure of lung transplantPao2/Fio2 < 150 while the patient is receiving Fio2 > 90% and high positive end-expiratory pressure (15–20 cm H2O)
Murray score ≥ 2
Inability to maintain airway plateau pressure ≤ 30 cm H2OHypercapneic respiratory failure indications Exacerbation of chronic obstructive pulmonary disease
Status asthmaticusPaco2 > 80 mm Hg
pH < 7.15
Airway plateau pressure ≤ 30 cm H2OCardiac failure indications
Myocardial infarction-associated cardiogenic shock
Fulminant myocarditis
Sepsis-associated myocardial depression
Extracorporeal cardiopulmonary resuscitation
Postcardiotomy or post-heart transplant cardiogenic shock
Primary graft failure after heart transplant
Bridge to ventricular assist device implantation or heart transplantAbsolute contraindications Uncontrolled active hemorrhage
Terminal illness
Irreversible or end-stage heart or lung failure in patients who are not candidates for transplantRelative contraindications More than 7 days on mechanical ventilation with high Fio2 or high-pressure ventilation
Nonpulmonary organ dysfunction, especially renal failure
Irreversible central nervous system dysfunction
Malignancy, solid-organ transplant, or immunosuppression
Conditions precluding use of anticoagulation
Advanced age
Weight > 125 kgVenovenous ECMO Venoarterial ECMO Aim Oxygenation and carbon dioxide removal Maintain tissue perfusion ECMO circuit Adjust sweep gas oxygen fraction and flow rate to maintain ventilation needs Adjust pump flow to maintain cardiac output needs Mechanical ventilation Minimize tidal volume and fraction of inspired oxygen (Fio2) to reduce ventilator-induced lung injury (but peripheral capillary oxygen saturation should be kept ≥ 86%) Maintain lung protective ventilation but adjust FiO2 to ensure upper body oxygenation (especially in patients on peripheral venoarterial ECMO) Anticoagulation Conservative anticoagulation with target activated partial thromboplastin time 4–60 seconds Moderate anticoagulation to minimize thrombus formation in oxygenator that would result in distal stroke (target activated partial thromboplastin time 60–80 seconds) Weaninga Readiness assessment when there is improvement in lung compliance and tidal volumes Readiness assessment when there is myocardial recovery with improved pulse pressure and contractility on echocardiography Circuit weaning: Maintain on standard ventilator settings (FiO2 ≤ 0.5, positive end-expiratory pressure ≤ 10 cm H2O, airway plateau pressure ≤ 30 cm H2O) and reduce flow rate of sweep gas to ≤ 2 L/minute; wean off if able to maintain adequate respiratory rate and gas exchange in 2–4 hours Circuit weaning: Reduce pump flow rates in increments of 0.5 L to 2 L/minute over 24–36 hoursb; wean in surgical setting if able to maintain stable mean arterial pressure and central venous pressure and acceptable contractility on echocardiography; may require brief period of inotropic support after weaning Complications Patient: Hemorrhage (intracranial and gastrointestinal bleeding are common), infection, renal failure Patient: Hemorrhage (intracranial and gastrointestinal bleeding are common), infections, renal failure, lower limb ischemia, thromboembolism at cannulation site, harlequin syndrome Mechanical: Inappropriate cannulation leading to insufficient oxygenation, vessel wall injury, thrombus formation within the circuit, pulmonary or systemic thromboembolism or air embolism from circuit Mechanical: Inappropriate cannulation leading to insufficient oxygenation, vessel wall injury, thrombus formation within the circuit, pulmonary or systemic thromboembolism or air embolism from circuit
