EXTRACORPOREAL MEMBRANE

OXYGENATION ECMO/ECLS
Dr. Rheecha Joshi
 ECMO
• supporting blood gas exchange using a membrane oxygenator

• Venous blood is pumped through the oxygenator, where gas exchange occurs,
and is actively re-warmed before being pumped to the patient, via either the
venous or arterial circulation

• Respiratory failure remained the primary indication for ECMO until the late
1980s

• With growing experience, cardiac ECMO has begun to make the transition
from “rescue” therapy, to “therapeutic” and even “preventive” therapy
Respiratory ECMO in adults
• VV ECMO for CO2 removal and oxygenation, and a lung protective ventilatory strategy
inorder to “rest” the lungs and provide optimal conditions for recovery of lung function

• only patients with acute and potentially reversible processes are candidates.Chronic and
irreversible pathology, such as malignancy, systemic or interstitial diseases affecting the
lungs, are not suitable for management with ECMO

• Premorbid condition of the patient

• Duration of ventilation – prolonged ventilation with high airway pressures and/or high
inspired oxygen concentrations (FiO 2 ) may pose a contraindication to ECMO as the
likelihood of ventilator-induced lung injury (VILI) becoming irreversible injury ( increases
with the duration of mechanical ventilation)
Cardiac ECMI in adults
• Cardiac ECMO, conducted as VA ECMO, involves passive drainage of blood via the
venous cannula, which is then pumped through the oxygenator into the arterial
circulation

• used as mechanical circulatory support in patients who fail to wean from

cardiopulmonary bypass to allow the heart time to recover after cardiac surgery

• provision of biventricular and pulmonary support

• A proportion of patients who don’t recover sufficient cardiac function to be

successfully weaned from ECMO can be supported with VADs and be bridged to either
recovery or transplantation
Indication of ECMO
• Respiratory
Neonatal and pediatrics: Meconium Aspiration syndrome, persistent pulmonary
hypertension of newborn, Severe pneumonia ,Congenital diaphragmatic hernia

Adult: Severe Pneumonia, ARDS, Severe bronchial asthma, Smoke inhalational

injury , Thoracic trauma with lung contusion

• Cardiac:
cardiac arrest, failure to wean from CPB, fulminant myocarditis, cardiac trauma,
cardiogenic shock, pulmonary edema, pulmonary embolism, Hypothermia, VAD
placement, pulmonary embolectomy
Types
veno-venous (VV) ECMO , in which blood is returned to the patient via
a vein
• only provides gas exchange

veno-arterial (VA) ECMO , in which the blood is returned to an artery

• provides gas exchange as well as direct cardiac support, as arterial
circulatory flow is augmented by the pump in the ECMO circuit
 ECMO
circuit
• draining /venous cannulae
• plastic tubing
• a centrifugal or roller pump
• an oxygenator with gas supplies
• a heat exchanger; and
• an arterial cannula
• The back-up battery
• The transonic flowmeter
Percutaneous ECMO support attained via femoral
vessel access
• Blood flows via the venous cannula(e) to the pump, which pumps it
through the oxygenator where gas exchange takes place
• Many oxygenators have an integral heat exchanger to re-warm the
blood
• From the oxygenator the blood is returned to the patient, either into
a large vein – VV ECMO – or an artery – VA ECMO
• in contrast to most cardiopulmonary bypass circuits the ECMO circuit
is “closed,” lacking a reservoir
• In a closed system, flow is dependent on venous return to the circuit
at all times and related to circulating volume and vascular resistance
Cannulae – are steel wire reinforced tubes of appropriate diameter
• The resistance to flow fall in relation to the reciprocal of the fourth power of the
radius (Rα 1/r4). This means the greater the diameter of the tubing the easier flow
becomes.
• Thus, a shorter cannula with a greater internal diameter will provide higher flows
through the ECMO circuit.
• Typical sizes for adults are: arterial : 17–21 F venous: 21–28 F double lumen venous:
27–31 F

Tubing – usually made of PVC or silicon

• The tubing length is kept as short as possible to reduce surface area and priming
volume.
Pump – the centrifugal pump and the roller pump

Centrifugal pump:
• are totally nonocclusive and afterload-dependent
• An increase in downstream resistance, such as significant hypertension, will
decrease forward flow to the body
• a flowmeter is incorporated in the arterial outflow to quantitate the actual
pump output
• If the pump outflow become occluded, the pump will not generate excessive
pressure and will not rupture the arterial line.
• Similarly, the pump will not generate significant negative pressure if the inflow
becomes occluded. This protects against cavitation and microembolus formation
CentriMag (Levitronix), RotaFlow (Maquet) and BioConsole 550 (Medtronic
Perfusion)
Roller pumps –
• are positive displacement devices that compress the plastic tubing and physically push
blood forwards. Venous drainage is passive
• Excessive negative pressure and cavitation can occur
• Servoregulator

Heat exchanger –
• warms the blood before it is returned to the heart, thus allowing patient temperature
regulation through the ECMO circuit. Most adult oxygenators have an integral heat
exchanger
• the transfer of energy occurs by circulating nonsterile water in a countercurrent fashion
against the circulating blood
Oxygenators
• “membrane lungs” as their function is gas exchange. Three types of oxygenators
are commonly used: - silicone spiral coil oxygenators; polypropylene oxygenators;
and poly-methyl pentene (PMP) oxygenators
• three principles involved:
i) The membrane of the oxygenator must be thin enough to allow easy exchange of
oxygen, carbon dioxide and moisture.
ii) The surface area of the membrane must be sufficiently large to allow adequate
gas exchange to the patient’s blood volume in a reasonable time.
iii) The gas flow to the membrane will run in an opposite direction to the flow of
blood. This counter-current mechanism maximise the contact of the blood with a
high oxygen tension at the other side of the membrane.
Hollow-fiber membrane oxygenator with an
integrated heat-exchange system
• The microporous membrane provides the necessary gas-transfer via
the micropores where there is direct blood-gas interface with minimal
resistance to diffusion

• Increasing the total gas flow rate increases CO2 removal (increasing
the “sweep”) by reducing the gas-phase CO2 partial pressure and
promoting diffusion

• Blood oxygenation is controlled simply by changing the fraction of O2

in the gas supplied to the oxygenator
Bridge –
• connecting channel between the arterial and venous limbs of the circuit. It is
used as a bypass when it is necessary to isolate the patient from the circuit,
i.e., blood can be re-circulated within the ECMO circuit in order to prevent
stagnation and coagulation.

• Isolation of the patient from the circuit may be required during circuit
maintenance, or during a trial of weaning from VA ECMO.

• When not in use the bridge is either not inserted or kept clamped and
flushed every 10–15 minutes
Anticoagulation –

• ACT is usually maintained in the 160–180 seconds range and the rate
of heparin infusion is titrated accordingly

• prevention of clotting within the circuit without causing excessive

bleeding
Cannulation- central, peripheral
• Central cannulation is indicated because of either severe peripheral
vascular disease or the desire to deliver the highly oxygenated blood
directly to the coronary arteries and the cerebral circulation

• the existing right atrial and aortic cannulas are used

• The catheters are brought through the chest wall through separate
stab wounds, and after bleeding is secured, the chest is covered, but
not closed, over mediastinal drainage tubes
• An alternative central cannulation site is the axillary artery

• Direct cannulation -> associated with progressive edema of the arm

• the best strategy to maintain arm perfusion is to expose the axillary

artery and sew a 6 or 8 mm graft to the vessel as a “chimney.”

• The cannula then is place in the graft and tied securely with several
circumferential umbilical tapes.
Peripheral cannulation
• Seldinger’s technique

• A stab incision is made in the skin with a no. 11 blade knife, a needle is
inserted through the stab incision into the vessel, and a guidewire is
advanced gently. Dilators then are passed sequentially to gently dilate the
tract and the insertion point in the vessel

• The cannulas then are inserted, the guidewire is removed, and a clamp is
applied. For venous drainage, a long two-stage cannula (Fem-Flex II,
Research Medical, Inc., Midvale, UT) is directed into the femoral vein to
thelevel of the right atrium under TEE guidance.
To minimize limb complications from
ischemia
• 10F perfusion cannula is placed in the superficial femoral artery distal to the primary
arterial inflow cannula to perfuse the leg .
• This cannula is connected to a tubing circuit that is spliced into the arterial circuit with a
Y-connector. The distal cannula directs continuous flow into the leg and significantly
reduces problems with leg ischemia

OR

• An alternative strategy is to completely mobilize the common femoral artery and sew a
6 or 8 mm short Dacron graft to its anterior surface as a “chimney.” The graft serves as
the conduit for the arterial cannula, and no obstruction to distal flow exists
• Physiologically, ECLS - unload the right ventricle
but will not unload the ejecting left ventricle, though LV preload is
decreased

• ECLS as an RVAD (with outflow to the pulmonary artery via the right
ventricular outflow tract) may be used only in patients with good function of
the left ventricle

• In normal LVEF:
the marked reduction in preload and small increase in afterload produced by
the arterial inflow  reduces wall stress and produces smaller end-diastolic
left ventricular volumes because the heart is able to eject the blood it receives
If the heart is dilated and poorly contracting
• the marked increase in afterload offsets any change in end-diastolic left
ventricular volume produced by bypassing the heart

• heart remains dilated because the left ventricle cannot eject sufficient
volume against the increased afterload to reduce either end-diastolic or
end-systolic volume

• This increase left ventricular wall stress and myocardial oxygen

consumption
• An IABP or other means is used to unload the left ventricle
mechanically and reduce left ventricular wall stress

• IABP : to decrease the increased afterload imposed by ECLS and add

pulsatility to the continuous flow generated by the centrifugal pump

• atrial septostomy to decompress the left ventricle if the pulmonary

artery pressures remain elevated
Mangement
• Specialist ECMO nurses or perfusionists

• conduct hourly checks for loose connections, bleeding from cannulation sites
and clots within the circuit

• manage anticoagulation by measuring hourly ACTs to titrate the heparin

infusion. A typical infusion dose to maintain adequate anticoagulation is 20–60
IU/kg/hour. Usually the ACT is maintained between 160 and 180 seconds

• Circuit blood flow and sweep gas are adjusted to maintain the desired blood
gas parameters.
• Total oxygen delivery (each minute) = Haemoglobin concentration x
1.35 x (Arterial saturation - Mixed Venous Saturation) x FLOW

Thus oxygen delivery can be increased by :

1) Increasing the haemoglobin concentration in the arterial blood.
2) Increasing the saturation of the arterial blood.
3) Increasing the flow or cardiac output
• Evidence of clots in the pump head requires a change

• Leakage of plasma across the membrane from the blood phase to the gas
phase  gradually decreasing the efficiency of the oxygenator and increasing
resistance to flow , necessitating oxygenator exchanges

• ECLS flows of 4 to 6 L/min are possible at pump speeds of 3000 to 3200 rpm

• Higher pump speeds increases mechanical trauma to blood cells

• Other means of improving flow -transfusion of blood, crystalloid, or other

colloid solutions to increase the overall circulating volume
Daily laboratory routine

• hematological investigations – full blood count, platelets;

• biochemistry – urea, electrolytes, creatinine, liver function tests, plasma-free Hb;
and coagulation profile – INR, serum fibrinogen, aPTT
Ventilation –
• airway pressures should be restricted to <30 cmH 2 O irrespective of tidal
volumes to avoid barotrauma or volutrauma;
• PEEP of 10–15 cmH 2 O to prevent further atelectasis
• respiratory rate should be limited to 8–10 breaths per min
• FiO 2 is reduced to the lowest possible setting to avoid further damage through
generation of free oxygen radicals
• Steroids – in treating the inflammatory processes during ECMO and ARDS.
• Methyl prednisolone: A loading dose of 1 mg/kg followed by an infusion of

• 1 mg/kg from day 1 to day 14,

• 0.5 mg/kg from day 15 to day 21,
• 0.25 mg/kg from day 22 to day 25 and
• 0.125 mg/kg from day 26 to day 28

• If the patient is extubated within the first 14 days, they are advanced to day 15
of therapy and then tapered off according to the schedule
Transfusion –
• to maintain a platelet count above 80 000 and hematocrit between 40
and 45%.
• Coagulation is optimized by transfusion of fresh frozen plasma and
cryoprecipitate as indicated by clotting study results

• Nutrition, antibiotic therapy and sedation

Weaning and decannulation
• VV ECMO –
• Improvements seen clinically in lung compliance, chest X-ray appearance and a reduction in
the amount of extracorporeal support required

• ECMO flow is gradually reduced; once it is down to approximately 1 l/minute, a “trial off
ECMO” is attempted.

• This involves increasing the ventilatory support and disconnecting the ECMO sweep gas flow.

• Pa O2 of >8.0 kPa , Pa CO 2 of 4.5–6.5 kPa during the “trial off ECMO” with ventilator
settings while keeping the FiO 2 <60% and respiratory rate <15 breaths/minute indicate
sufficiently good gas exchange to allow decannulation.
• VA ECMO –
• Achieving a mean blood pressure of 60 mmHg without using excessive amounts of
inotropes and evidence of adequate tissue perfusion, using indices such as blood
gases, acid–base status, serum lactate and SvO2 , on 1 l/minute of ECMO fl ow, is
adequate to begin a “trial off ECMO.”

• A 2D echocardiogram is useful to assess the contractility of the heart and any

structural and functional cardiac abnormalities

• Percutaneously placed venous cannulae are removed and a horizontal mattress

suture to close the cannulation site. Decannulation of the artery is usually done by
surgical cut-down and usually involves reconstruction of the vessel.
Complications
• Massive bleeding
• Massive transfusion
• Renal failure requiring dialysis
• Bacteremia or mediastinitis
• Air embolus: Cavitation, Occluding the outlet port
• Stroke : incidence of intracranial hemorrhage increased with female gender,
heparin use, elevated creatinine, need for dialysis, and thrombocytopenia
• Leg ischemia: thrombectomy / amputation
• Oxygenator failure requiring change and pump change
• Intracardiac clot : form within a poorly contracting, nonejecting left ventricle or
atrium
REFERENCES
• Cardiopulmonary Bypass: Principles and Practice
• Cardiac surgery in the Adult- Lawerence H Cohn
• Surgery of the chest- Sabiston and Spencer
THANK YOU …..
Monitoring and safety devices
• Ultrasonic flow measurement devices are placed to warn of low or high flows
• Drainage line pressure monitors are used to measure pressure in the venous draining cannula, which is
usually negative. When the line pressure becomes very negative (i.e., more than –70 mmHg in an adult),
it can cause a non-wire wound cannula to collapse and cause hemolysis.
• Increasingly, negative venous line pressure may indicate hypovolemia or mechanical obstruction, for
example if the tip of the cannula abuts against the vessel wall, leading to occlusion. Line pressure is also
measured on the inflow and outflow from the oxygenator to indicate oxygenator resistance. This may
rise if clots are collecting or developing in the oxygenator.
• In patients on VA ECMO venous line blood gas samples approximate to mixed venous (SVO 2 ) blood
samples and are used to assess the adequacy of extracorporeal support. A SVO 2 <65% means that
oxygen delivery to the patient is marginal and should be increased by turning up the ECMO circuit flow
rate if possible.
• Postoxygenator blood gas samples taken from the oxygenator outflow indicate the functional status of
the oxygenator: low PO 2 values imply a poorly functioning oxygenator that needs to be changed.
• During VV ECMO the arterial blood gas is used to adjust the level of support. A reduced P a O 2 (<6 kPa)
prompts an increase in blood flow and a raised P a CO 2 (>6 kPa) prompts an increase in sweep gas flow.