1. 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

2. 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)

3. 2nd September 2010 3

4. 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

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

7. Return cannula
Access cannula

8. 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

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

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

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

12. Single ECMO centre at Glenfield Hospital, UK
CESAR Study Conventional ventilation or ECMO for Severe Adult Respiratory failure Lancet 2009, 374:
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 Dec 23;6:163
Preliminary results : announced at 37th Society of Critical Care Medicine Congress in Honolulu in February 2008 12 12

13. 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): Published online October 12, 2009(doi: /jama )
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

15. 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

16. Hong Kong Med J 2010;16:447-54

17. Pandemic Influenza H1N1 in Hong Kong

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

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

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

22. 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

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

24. 1 1 3 1 1 2
11 N
 PYNEH
 Other Hong Kong Hospitals

26. ECMO and RRT
CRRT incorporated into an ECMO circuit

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

28. 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

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

30. Upon admission to ward

31. During CPR and ECMO cannulae insertion

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

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

34. Day
SBP MAP DBP NIBP Temp HR RR ICP

35. Day 6 Return of sinus rhythm

36. 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,

37. CT brain on Day 10
Certified brain death on Day 11

38. 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)

39. 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

40. Lancet 2008;372:554-61

41. Crit Care Med 2011;39:Epub

43. Team work

44. Learn together through practice

45. Continued Education

47. 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

48. 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

49. 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,

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