1. ECMO Extra Corporeal Membrane oxygenation
Jennifer Tronson & Fitsum Tesfa
RSPT 234

2. History

3. 1953 to Today
1953 Gibbon uses artificial oxygenation and perfusion for the first successful open heart.
1954 Lillehei successfully utilizes live volunteers to serve as live cardiopulmonary bypass.
1955 The Mayo clinic improved on Gibbon’s device and used it in the repair of an atrial septal defect.
1965 Rashkind et al successfully used bubble oxygenation to support a dying neonate.
1969 Dorson et al utilized a membrane oxygenator for cardiopulmonary bypass in infants.
1975 Bartlett et al first successfully used ECMO in neonates with severe respiratory distress.

4. Indications

5. Neonates
PPHN, MAS, RDS, Group B streptococcal sepsis, asphyxia and CDH
Gestational age of 34 weeks or more
Birthweight of 2000g or more
Mechanical ventilation for days or less
Reversible lung injury
Failure with maximal medical therapy
OI greater than 40 in 3 of 5 postductal ABGs
Acute deterioration

6. Pediatrics
Decreased Cardiac Output due to right, left and biventricular failure post CHD repair
Bridge to Cardiac Transplant

7. Contraindications

8. Neonatal Lethal chromosomal disorder Irreversible brain damage
Uncontrolled bleeding
Grade III or greater IVH
Untreatable cardiac malformation
Coagulopathy

9. Other Contraindications
Irreversible Organ Damage
ARDS longer than 7 days
Advanced age, greater than 65
Prolonged CPR

10. Set Up

11. Types of ECMO VA-ECMO VV-ECMO Higher PaO2 Lower perfusion rates
Bypasses pulmonary circulation
Decreases pulmonary artery pressures
Provides cardiac support
Requires arterial cannulation
Lower PaO2 is achieved
Higher perfusion rates
Maintains pulmonary blood flow
Elevates mixed venous PO2
No cardiac support
Requires only venous cannulation

12. VA-ECMO Set to provide 50-200ml/kg CO
Start at 100ml/kg and titrate up or down based on blood gas results.
Typically titrating down to 50ml/kg indicates readiness to wean.
Sweep (flow) is adjusted based on CO2 removal needs
O2% is set to achieve a PaO2 of 250mmHg on blood gas drawn at the pump.

13. Monitoring

14. Blood Gas Three draw sites Patient’s femoral artery
Monitors the patient’s mixed blood- ECMO and Pulmonary
Patients venous return to the ECMO machine
Monitors the patient’s O2 consumption
ECMO pump
Monitors the blood that is going to the patient from the ECMO machine

15. CBC &Chemistry Hbg maintained at 12-15 g/dl by using pRBCs
Plt maintained above 100,00/mcl with transfusions
ACT maintained at to avoid bleeding
Fluids and electrolytes need to be monitored and hyper-alimentation should be used to compensate for the high energy requirements.

16. Ventilator
Pip should be monitored to avoid increasing damage to the lungs
Compliance should be monitored to trend improvement or worsening in underlying respiratory condition
PEEP should be kept sufficiently high to reduce atelectatic sheer injury and low enough to not interfere with CO

17. Manipulations

18. Based on blood gas results
Insufficient PaO2 in the descending aorta draw (femoral) is improved by increasing the percentage of CO provided by the ECMO machine and/or increasing FiO2 on the ventilator
Excessive CO2 at this draw can be corrected by increasing the gas flow on the ECMO device to remove more CO2 before sending the blood back to the body or increasing VE on the ventilator

19. Based on blood gas results
Insufficient PaO2 at the venous return draw is indicative of oxygenation that is insufficient for the bodies O2 consumption. Determine cause of increased O2 consumption and address cause or correct by increasing oxygenation with the percentage of CO provided by the ECMO device or increasing the FiO2 or MAP on the ventilator.

20. Complications & Hazards

21. Impaired Venous Drainage
Impaired venous drainage can cause low circuit flow and high pump speeds in both venoarterial and venovenous ECMO. This can be caused by a drainage cannula being poorly positioned or by hypovolemia.
Signs of hypovolemia can include low CVP and hypotension.
You may see “chattering” in the tubing.

22. Tubing Blockages
Another cause for low circuit flow and high pump speeds can be due to kinks in the tubing or a thrombus.
Check for a decreased PO2 if obstruction is suspected.
Check for resistance in the oxygenator. Normal pressure drop across the oxygenator is 50.
Replace the affected circuit if thrombus is present.

23. Complications
Heparin resistance may occur due to antithrombin III deficiency or administration of excess heparin.
Recirculation in venovenous ECMO
Clotting of the circuit is a common problem: oxygenator failure, consumption coagulopathy and emboli.
Damage to the internal jugular vein may cause mediastinal bleeding.

24. Complications Seizures Intracranial bleeds
Hemorrhagic complications and a decreased platelet count.
Developing coagulopathy.
Air trapped in the circuit.
Pneumothorax

25. Works Cited
leManager/e76ef78eabcusersshyerdocuments elsoguidelinesforadultcardiacfailure1.3.pdf
leManager/8588d1a580cusersshyerdocument selsoguidelinesforneonatalrespiratoryfailure1 3.pdf
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