Transcript ECMO - Kingwood Application Server

ECMO
By
Cindy Baurax
Jessica Hugdahl
Marivel Rios
Vali Sollock
Biological Question
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Does ECMO provide life support in
severe respiratory failure by
allowing time for injured lungs to
recover?
Hypothesis
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The selective use of ECMO for acute
respiratory failure will increase
survival rates over conventional
mechanical ventilation.
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ECMO which is Extra-corporeal
membrane oxygenation, is a
temporary life support system used
for patients who have failed
traditional mechanical ventilation.
INDICATIONS
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The need for ECMO is when a
patient who has received
appropriate medical management
has:
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a PaO2 of 50-60mmHg, when the PIP
is >35cmH20
FiO2 is 100% for conventional
ventilation
without improvement of oxygenation
while on high frequency ventilation
over a six hour period.
Patient Selection
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Limiting the duration of ECMO to
<30 days
due to increased risks of
complications after approximately
fourteen days of therapy.
TWO TYPES OF ECMO:
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Veno-arterial bypass - supports the
heart and lungs
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Requires two cannulae-one in jugular
vein and one in the carotid artery
Veno-venous bypass – supports the
lungs only
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Requires one cannula- jugular vein
Link to Picture of ECMO tubing when connected to
patient
POTENTIAL RISKS
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Insertion of a tube into a
blood vessel has an
increased risk of
infection.
Brain damage from head
bleed
Surgical site bleeding
Pneumothorax
Hypertension
Cardiac Dysrhythmias
Abnormal creatin and
bilirubin values
Intraventricular
hemorrhage
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Air in circuit
Pump malfunction
Clots in the circuits
Pump malfunction
Heat exchanger
malfuntion
Potential Benefits
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Being on ECMO will rest the lungs
and heart so that there is an
increased survival rate.
CONTRAINDICATIONS
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Intracerebral
hemorrhage
Severe brain
damage
Multiple congenital
anomalies
Irreversible brain
damage
Weight <2.0Kg
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Necrotizing
Pneumonia
Multiple organ
failure
Metastatic disease
Major CNS injury
Gestational age
<34 weeks
Overwhelming
Sepsis
Parental Refusal
TREATMENT FOR CHILDREN:
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Hyaline membrane disease
Meconium Aspiration
Persistant Fetal Circulation
Congenital Diaphragmatic Hernia
Cardiac Anomalies
TREATMENT FOR ADULTS:
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Adult Respiratory Distress
Syndrome (ARDS)
Non-necrotizing pneumonias
Pulmonary contusion
Other reversible respiratory and
cardiac failure not responsive to
other measures
Post cardiac surgery
Preliminary Diagnostic Studies:
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Head Ultrasound
Coagulation Status
Platelet Count
Calcium and Electrolyte levels
White Blood Cell Count
Hemoglobin and Hematocrit levels
Blood type and Cross
Weaning Parameters:
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A trial period without ECMO when
the patient demonstrates adequate
gas exchange and is on reasonable
ventilator settings and tolerates a
pump flow of 10-20mL/kg/min with
the minimum of 200 mL/min.
METHODOLOGY
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STUDY #1
 This study involved 128 neonates on ECMO
from October 1985 to September 1998.
Patients had either severe acute hypoxemic
respiratory failure or severe acute hypercarbic
respiratory failure unresponsive to maximal
conventional management. Inclusion criteria
P/F ratio < or = 100 or refractory hypercarbia
with ph < or = 7.0. Each subject’s parents
were given a consent form explaining the
procedure.
 The data collected in this study were lung
compliance that was dividend of the tidal
volume and the difference between the end
inspiratory pressure and PEEP.
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Study #2
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This study involved 50 adult patients (older than 16
years old) between the years 1989 and 1995 with
refractory respiratory failure. Patients who had
contraindications to ECMO were not eligible for this
study. Each subject was given a consent form
explaining the procedure.
The data collected in the study was: P/F ratio, PIP,
PEEP and the time ventilated.
Methodology Instruments Used
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Study #1- ECMO machine
Study #2- Two membrane lungs (ultrox1)
with integral heat exchangers are
arranged in parallel with counter current
gas flow; 100% oxygen is used as the
sweep gas. Roller pumps (Stockert) with
Seabrook bladder box servo control are
used. Blood raceway tubing is Tygon S65HL (Norton Performance Plastics).
Heaters (Cincinnati Sub-Zero) are used to
maintain normothermia.
Statistics
Study #1 MEAN
Study #2
MEAN
Average
Mean
4.7
3.19
3.95
PIP cmH2O
25
39.6
32.3
PEEP cmH2O
5
10
7.5
P/F ratio mmHg
58
65
61.5
Survival Rate (days)
58%
66%
62%
Pre ECMO time ventilated (days)
Discussion
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Patients with respiratory failure usually
respond favorably to various forms of
mechanical ventilation with PEEP,
permissive hypercapnia, and inhalation
pulmonary vasodilators. Using these
methods, survival rates > 60% have been
documented. There remains, however, a
small number of patients with respiratory
failure whose pulmonary gas exchange
cannot be improved by the above
mentioned methods. ECMO may be a
therapeutic option during the acute phase
of the disease.
Recommendations
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These studies were done on
patients who failed conventional
mechanical ventilation. In the past
few years the use of ECMO as a
therapeutic option has been
usurped by high frequency
oscillation ventilation with the
addition of inhalation nitric oxide.
Continued
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Further studies should be done on
patients that fail these more advanced
options and retain a PaO2 <50mmHg for
>2 hours at FiO2 100% and PEEP
>5cmH2O. These studies will test the
absolute effectiveness of ECMO. If the
survival rates in this group are not
significantly greater than the high
frequency oscillation plus inhaled nitric
oxide, the use of the expensive and
invasive procedure of ECMO may no
longer be warranted.
References
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Swankiker, F., Kolla, S., Moler, F., Custer, J., Grams, R., Bartlett, R., Hirschl,
R. (2000). Extracorporeal Life Support Outcome for 128 Pediatric Patients
With Respiratory Failure. Journal of Pediatric Surgery, 35, 197-202.
Abstract obtained July 8, 2006, from Google at www.google.com
Peek, G., Moore, H., Moore, N., Sosnowski, A., Firmin, R.(1997).
Extracorporeal Membrane Oxygenation for Adult Respiratory Failure. Chest,
112, 759-764. Abstract obtained July 8, 2006, from Google at
www.google.com