Page 662 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 53: Extracorporeal Lung Support 481

mechanical ventilation before initiation of ECMO was 2 (1-5) days.
The initial mode of ECMO was veno-venous in 93% and veno-arterial
in 7% of patients. Median (IQR) duration of ECMO support was
10 (7-15) days. Hemorrhagic complications occurred in 54% of
patients, most commonly at the ECMO cannulation sites. At the time
of reporting, 48 of the 68 patients (71%; 95% CI 60%-82%) survived to
ICU discharge, of whom 32 survived to hospital discharge. Fourteen
patients (21%; 95% CI 11%-30%) had died and 6 remained in the ICU,
2 of whom were still receiving ECMO. The patients treated with ECMO
had longer duration of mechanical ventilation (median [IQR], 18 [9-27]
vs 8 [4-14] days; p = .001), ICU stay (median [IQR], 22 [13-32]
vs 12 [7-18] days; p = .001), and greater ICU mortality (14 [23%] vs
12 [9%]; p = .01).
A report from France of the use of ECMO in patients with H1N1-
related ARDS documented that mean duration of ECMO support was
12 ± 14 days (3-47 days) with a survival rate of 83.3% with a mean
follow-up period of approximately 14 months. These patients had severe
1.0. The patients
hypoxemia with a mean Pa O 2 of 57 (range 41-74) on Fi O 2
who died on ECMO support had refractory septic shock. 69
In comparison, the University of Utah reported experience in 47 patients
with 2009 Influenza A (H1N1), 30 patients with ARDS. Eighty-three FIGURE 53-11. ECMO use in severe trauma. Miniaturized ECMO device (PLS-Set, MAQUET
percent of the 47 patients survived, including 73% of patients with Cardiopulmonary AG, Hechingen, Germany). (1) Gas exchange membrane; (2) Centrifugal
ARDS, without use of rescue ARDS therapies such as inhaled NO or pump; (3) Control unit; (4) Heat exchange unit; (5) Pre- and post-membrane pressure displays.
epoprostenol, prone positioning, HFOV, or ECMO. 70 (Used with permission of J Crumley, University of Iowa.)
A recent report compared outcomes of H1N1-related ARDS patients
referred and transferred for ECMO with a matched cohort who were
not referred for ECMO. Of 80 ECMO-referred patients, 69 received
71
ECMO (86.3%) and 22 died (27.5%) prior to discharge from the hospital. as a bridge to and support for pulmonary thromboendarterectomy or
From a pool of 1756 patients, there were 59 matched pairs of ECMO- catheter-directed thrombolysis in some cases. 75-79 A report of 21 patients
referred patients and non-ECMO-referred patients identified using with massive pulmonary emboli who received ECMO (most were
individual matching, 75 matched pairs identified using propensity VA-ECMO support) reported an overall survival rate of 62%, with a
score matching, and 75 matched pairs identified using GenMatch mean duration of ECMO support of 5.4 days. 80
matching. The hospital mortality rate was 23.7% for ECMO-referred
patients versus 52.5% for non-ECMO-referred patients (RR, 0.45 [95% ■ AMBULATORY ECMO
CI 0.26-0.79]; p = .006) when individual matching was used; 24.0%
versus 46.7%, respectively (RR, 0.51 [95% CI 0.31-0.81]; p = .008) VV-ECMO is now being used as a therapeutic option to bridge patients
when propensity score matching was used; and 24.0% versus 50.7%, with advanced lung disease to lung transplantation, avoiding the use of
81-84
respectively (RR, 0.47 [95% CI 0.31-0.72]; p = .001) when GenMatch mechanical ventilation and allowing aggressive physical rehabilitation.
matching was used. The authors concluded that for patients with Early application of VV-ECMO soon after development of acute
H1N1-related ARDS, referral and transfer to an ECMO center was respiratory failure requiring mechanical ventilation in these patients is
85,86
associated with lower hospital mortality compared with matched non- key. This strategy has been enabled by the introduction of the bica-
ECMO-referred patients. val dual-lumen ECMO cannula placed via the internal jugular vein. In
a review of the first 10 patients treated at a single institution with this
■ ECMO IN TRAUMA strategy, the mean ECMO duration was 20 (9-59) days, with average
mean blood flows of 3.5 (1.6-4.9) L/min, and levels of CO removal
2
Adult trauma patients with severe multisystem injury are at risk for and O transfer of 228 (54-570) mL/min and 127 (36-529) mL/min,
2
severe hypoxemia, and in those patients who do not respond to standard respectively. Six of 10 patients were weaned from respiratory sup-
and rescue strategies for severe hypoxemia, ECMO is increasingly being port (n = 4) or underwent transplantation (n = 2) and survived to
used. A report of 10 adult trauma patients (mean age 32 ± 14 years, discharge from the hospital. The remaining 4 patients died of sepsis
72
47 [36-90], all requiring (n = 3) and withdrawal of care after renal failure (n = 1). Four of
mean injury severity score 73 ± 14, Pa O 2 /Fi O 2
vasopressors) underwent heparin-free ECMO for a mean duration of the 6 surviving patients were extubated and ambulatory while still
5 days with a 60% survival rate (Fig. 53-11). 73 on ECMO.
ECMO was also used for the first time in combat evacuation for a
22-year old US Army soldier wounded in Afghanistan, suffering from ■ ECMO GUIDELINES
gunshot wound to the chest that required damage-control thoracotomy
with clamping of the hilum of the right lung, resulting in severe hypoxemia. The ELSO was established in 1989, and the ELSO data registry was
The Landstuhl Regional Medical Center’s Lung Rescue Team flew to the established in 1984 (http://www.elso.med.umich.edu/). This registry
combat support hospital and performed ECMO cannulation, and has been vital in advancing the clinical use of ECMO and determina-
then transported him on VV-ECMO via aeromedical evacuation from tion of ECMO outcomes. Currently, 141 centers contribute data to the
Afghanistan to Germany. He required right pneumonectomy and ELSO ECMO registry. The ELSO Web site also contains management
ECMO support for 24 days, but recovered fully. 74 guidelines, references, training and education materials, and a member
list with contacts. The ELSO ECMO guidelines (General and Patient-
■ ECMO FOR PULMONARY EMBOLI Specific) are available from the ELSO Web site and contain important
and complete information regarding initiation and maintenance of
ECMO is increasingly being used in patients with severe hypoxemia and ECMO support through decannulation and discontinuation of ECMO
hemodynamic instability related to massive pulmonary embolus, and (http://www.elso.med.umich.edu/guide.htm).

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