Applications of Extracorporeal Membrane Oxygenation (ECMO) Macau Society of Emergency and Critical Care Medicine Inaugural Ceremony cum Scientific Meeting 2011 Applications of Extracorporeal Membrane Oxygenation (ECMO) Dr. Yan Wing Wa Chief of Service (ICU), Pamela Youde Nethersole Eastern Hospital, HKSAR Chairman, Hong Kong Society of Critical Care Medicine Chairman, Specialty Board of Critical Care Medicine, HKCP 23 July 2011

Extracorporeal Membrane Oxygenation (ECMO) 體外膜氧合 葉克膜體外心肺輔助器(葉克膜) 人工肺/人工心肺(香港式稱)

2nd September 2010 3

Types of ECMO V-V ECMO V-A ECMO Bad lung good Heart Good lung VV (veno-venous) Support severe respiratory failure without co-existing major cardiac dysfunction VA (venous-arterial) Support severe cardiac failure (with or without respiratory failure) Bad lung good Heart Good lung Bad heart V-V  X V-A peripheral V-A Central (not required) 4

Set Up System console Oxygenator Return cannula Centrifugal pump Access cannula Air/O2 blender Warmer

Return cannula Access cannula

Principles of ECMO Temporary support the failed lung Not suitable for irreversible lung failure Less suitable for the lung condition required long time to heal (complication risk > benefit) Buy time for the lung to recover Keep patient alive Create an optimal condition for the lung to heal Avoid complications related to ECMO

Indications Principles Reversible life threatening disease Un-response to conventional therapy At the discretion of the critical care / intensive care team Absence of contraindication

Contraindications Vary between different institutions In general Progressive & Non-recoverable diseases Terminal diseases Contraindication to anticoagulation

Complications of ECMO Vessel damage during insertion Unidentified heart failure Bleeding Circuit thrombosis Oxygenator failure Haemolysis Air embolism Circuit rupture Infection Access recirculation

Single ECMO centre at Glenfield Hospital, UK CESAR Study Conventional ventilation or ECMO for Severe Adult Respiratory failure Lancet 2009, 374:1351-63 Single ECMO centre at Glenfield Hospital, UK Survival without severe disability (confined to bed, or unable to dress/wash oneself) by 6 months ECMO: 57 in 90 patients (63%) Conventional ventilation: 41 in 87 patients (47%) Relative risk reduction in favour of ECMO 0.69 (0.05–0.97; P = 0.03) NNT to save one life without severe disability is 6 BMC Health Services Research. 2006 Dec 23;6:163 Preliminary results : announced at 37th Society of Critical Care Medicine Congress in Honolulu in February 2008 12 12

68(34%) required ECMO out of 133 patients with IPPV ECMO for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators JAMA. 2009;302(17):1888-1895. Published online October 12, 2009(doi:10.1001/jama.2009.1535) During winter 2009 (1 June 2009 to 31 August 2009), Australia & New Zealand ICUs 68(34%) required ECMO out of 133 patients with IPPV For patients given ECMO 48/68 (71%) survived ICU 32/68 (47%) survived hospital 16/68 (24%) still in hospital 6/68 (9%) still in ICU 14/68 (21%) died

Indications for VV-ECMO Potentially reversible and life-threatening respiratory failure unresponsive to optimum conventional ventilation and therapy. Severe respiratory failure was defined in the CESAR trial as: Murray score* ≥3.0; or Uncompensated hypercapnia with pH ≤ 7.20

Hong Kong Med J 2010;16:447-54

Pandemic Influenza H1N1 in Hong Kong

Summary of Cases May 1, 2009 to Feb 28, 2010. 3 ICUs

Hong Kong ECMO referral centres Pamela Youde Nethersole Eastern Hospital Prince of Wales Hospital Queen Elizabeth Hospital Queen Mary Hospital

Reasons for ECMO (PYNEH) VV-ECMO Influenza A H1N1 pandemic: 14 Human metapneumovirus: 1 Mycoplasma pneumoniae: 1 Pneumococcus: 1 Streptococcus constellatus: 1 Pseudomonas areuginosa: 1 Unknown: 2 Paraquat poisoning: 1 VA-ECMO Viral myocarditis: 1

Statistics of Patients Treated with ECMO in PYNEH ICU Male/Female: 12 / 11 Age distribution 15-25: 3 26-35: 1 36-45: 8 46-55: 7 56-60: 3 >60: 1

Referrals PYNEH: 14 Canossa Hospital ICU: 2 KWH ICU: 1 NDH ICU: 1 POH ICU: 1 RH ICU: 1 TMH ICU: 3

1 1 3 1 1 2 11 N  PYNEH  Other Hong Kong Hospitals

ECMO and RRT CRRT incorporated into an ECMO circuit

Duration of ECMO 4 days: 3 5 days: 4 6 days: 7 7 days: 3 8 days: 1

Outcome Died: 2 (8.7%) Home: 18 Rehab hospital: 1 Still in ICU: 2 Paraquat poisoning (100ml 24% paraquat) Viral myocarditis (VA-ECMO) Home: 18 Rehab hospital: 1 Still in ICU: 2

Severe Myocarditis F/15, good past health Pulseless VT & Vf requiring repeated defibrillation & CPR (total duration: 162 mins) VA-ECMO started (procedure time: 110mins)

Upon admission to ward

During CPR and ECMO cannulae insertion

Backflow cannula to right superficial femoral artery was inserted by surgeon at bedside

Backflow cannula to superficial femoral artery Photos showing backflow cannulae & ECMO + CVVH circuit Before After

Day 1 2 3 4 5 6 7 8 9 10 11 SBP MAP DBP NIBP Temp HR RR ICP

Day 6 Return of sinus rhythm

Weaning of VA ECMO Trial of ECMO weaning on Day 7 ECMO flow reduced, noradrenaline and dobutamine infusion increased to facilitate weaning Ventilator support and anticoagulation increased Successfully weaned off ECMO and decannulated on Day 8 (ECMO duration: 7 days) However,

CT brain on Day 10 Certified brain death on Day 11

Likely Future Indications for ECMO in Hong Kong ICUs VV-ECMO More wide spread use, may extend to bacterial pneumonia besides viral pneumonitis VA-ECMO Poisoning with profound cardiac suppression Viral myocarditis Peri-cardiac operation in cardiothoracic centres Extracorporeal-Cardiopulmonary resuscitation (eCPR)

e-CPR Experience in Taipei Veteran General Hospital Structured Considered for CPR >10 mins Determined within 10 mins Onsite setup in another 10 mins (i.e. eCPR setup within 30 mins) A primed ECMO circuit is available at all times Early recognition of complications and aggressive management The doctor setting up the circuit would be responsible for all circuit complications throughout the whole hospitalization

Lancet 2008;372:554-61

Crit Care Med 2011;39:Epub

Team work

Learn together through practice

Continued Education

Conclusion ECMO is Life saving and should be provided to indicated patients (Overseas & Hong Kong experience) It is feasibel to start ECMO service Department & Hospital determination We are most happy to share with you our experience

Acknowledgement PYNEH hospital top management PYNEH ICU doctors 任燕珍醫生 Dr Loretta Yam, CCE, HKEC (until 30 April 2011) 劉楚釗醫生Dr CC Lau, CCE, HKEC (since 1 May 2011) PYNEH ICU doctors 陳勁松 Dr Chan King Chung, Kenny, AC 劉俊穎 Dr Lau Chun Wing, Arthur, AC 林倩雯 Dr Lam Sin Man, Grace, AC 沈海平 Dr Shum Hoi Ping, AC 胡曉琳 Dr Wu Hiu Lam, RS 梁玉華 Dr Leung Yuk Wah, Natalie, RS 關明哲 Dr Kwan Ming Chit, Arthur, RS 譚靄欣 Dr Tam Oi Yan, Jackie, RT 張莉莉 Dr Chang Li Li, Lily, RT 張詠詩 Dr Cheung Wing Sze, Emily, RT

Acknowledgements (2) PYNEH ICU nurses Chung, Hing-yee RN, Yeung, Chau-kwan RN, Po, Pui-chun RN, Chan, Yim-yu RN, Wong, Hoi-lee RN, Liu, Yan-chi Kylie RN, Chun, Yuen-kwan Emily RN, Liu, Sing-kwan Benjamin RN, Cheung, Yin-pui Shirley RN, Chau, Hau-yan RN, Mok, Chi-man RN, Leung, Ka-yue RN, Wong, Sze-ting RN, Ip, Tsui-yuk Joey RN, Luk, Wai-Ha Veronica RN, Lai, Siu-cheong RN, Chang, Lai-fan RN, Mui, Sze-yuen Kevin RN, Wong, Tang-tat RN, Hung, Pui-yan RN, Wong, Hoi-yan RN, Wong, Pui-yan Pauline, RN , Wong, Wickon RN, Chin, Sau-wai RN, Tong, Wing-yam RN, Wong, Chun-fai RN, Wang, Mei-kei RN, Yiu, Man-ching RN, Ng, Sze-wah RN, Cheung, Wah-ling RN, Wong, Ka-po RN, Yeung, Kai-jone RN, Au, Pui-man RN, Lam, Yin-yu RN, Hon, Hiu-shan RN, Mak, Hiu Yan RN, Chow, Pik-ki RN, Wong, Hoi-ching RN, Yu, Hoi-lam RN, Chan, Peggy RN, Ho, Yin-ting Stephanie RN, Wong, Chui-ying Caroline RN PYNEH ICU nurses Chan, Shuk Ching, Christine, DOM, Kwok, Lai-ping Nora, WM, So, Hang-mui, NS, Lau, Lan, NO, Lui, Kam-cheung, NO, Chan, Shiu-kee Danny, NO, Kwan, Yuen-fan Eva, NO, Lau, Yuk-yin, APN, Fok, See-kee, APN, Lee, Chun-heung, APN, Chiu, Mei-chun, APN, Lo, Wan-Po Joanna, APN, Ng, Ching-ping, APN, Li, Siu-chun, RN, Lui, Wai-king RN, Chan, Siu-cheung RN, Tang, Wai-yan RN, Wong, Wo-ming RN, Yeung, Mei-wa RN, Tam, Yuen-fan RN, Cheung, Wai-han RN, Chan, Yuet-king RN, Fung, Mei-lan RN,

Thank you for your attention. This presentation file can be downloaded at our Society website www.hksccm.org