Adult ECMO - Perfusion.com

Adult ECMO 

30 th Annual Cardiothoracic Surgery 

Symposium 

March 4, 2010 

Newport tB Beach, CA 

Ian R Shearer, BS, CCP, LP 

Perfusion Services 

Duke University Hospital 

Durham, NC

Learning gObjec Objectives –Adult ECMO 

At the end of this lecture, the participant p 

will have 

gained a greater understanding of the following: 

• Background on adult respiratory distress syndrome 

• Techniques associated with ECMO 

• Clinical i l benefits and complications 

• New trends with technology 

There are no financial or professional relationships to be disclosed. 

Most devices utilized for ECMO are off label/standard of care.

History of ECMO 

1953 Gibbon 1 st successful use of CPB 

1967 Kolobow developed spiral coil membrane 

1972 Hill 1 st successful adult ECMO 

1976 Bartlett 1 st successful neonatal ECMO 

1979 NIH Study 

1989 ELSO established 

ECMO is indicated d when the patient t has an acute, 

potentially reversible, life-threatening form of respiratory 

failure which is unresponsive to conventional therapy.

Why ECMO? 

Respiratory failure 

ARDS 

Pneumonia (bacterial or viral) 

Multiple trauma 

Massive blood transfusions 

Aspiration pneumonitis 

Chemical pneumonitis 

Acute pancreatitis 

Near drowning 

Smoke inhalation 

Legionnaire’sdisease 

Reactive Airway disease 

Status asthmaticus 

Cardiac Failure 

Post bypass 

Myocarditis 

Cardiomyopathy 

Bridge to transplant 

Rescue/resuscitation

ARDS 

ARDS describes the clinical and radiographic 

manifestations i of acute direct or indirect pulmonary 

inflammatory states. 

The focus of infection or tissue injury establishes a systemic 

inflammatory response which initiates the ARDS 

process. 

The pulmonary endothelium is injured through the release 

of vasoactive mediators, proteases and toxic oxygen 

radicals. Initiating gp 

phase lasts several hours.

ARDS 

Exudative phase – progression of injury to interstitium and 

alveolar cells, capillary leak, formation of hyaline 

membranes. Edema leading to decreasing lung compliance 

and intrapulmonary shunting. 

Proliferative (regenerative) phase – gradual reduction of 

inflammatory process, proliferation of type II 

pneumocytes. Fibrosis starts. Continued interstitial 

edema. 

Fibrotic phase – deposition of collagen in interstitial spaces 

and in collapsed alveolar spaces. 

Self limiting with rapid recovery or if severe and 

prolonged leads to largely irreversible lung injury.

ARDS 

Mortality related to organ failure (NIH Study 1980) 

Age 12-65 

Age > 65 

n mortality 

n mortality 

Pul failure only 162 40% 59 69% 

Pul + 2 organs 103 74% 44 91% 

Pul + 3 organs 74 80% 32 95% 

Overall 490 61% 196 81% 

ECLS in Critical Care 

Zwischenberger, Bartlett 

1995

Experience with ECLS for pulmonary 

support in severe ARF 

Site 

n survival 

Marburg 130 48% 

Milan 89 45% 

Paris 43 44% 

Ann Arbor 40 45% 

Berlin 28 61% 

Stockholm 26 35% 

ECLS in Critical Care 

Zwischenberger, Bartlett 

1995

Adult ECMO Inclusion Criteria 

• REVERSIBLE disease process 

• Refractory to “max” conventional therapy 

• High risk of mortality (> 80-90%) 

• Absence of severe intracranial pathology 

• Absence of uncontrolled bleeding/severe 

coagulopathy

Adult ECMO Inclusion Criteria 

• Oxygenation Index: (FiO 2 x MAP)/PaO 2 

OI > 40 

• Duration of ventilation 

Adult ECMO Exclusion Criteria 

Contraindication to systemic anticoagulation 

(except surface –coatings) 

Underlying severe immunodeficiency 

Neurologic devastation 

Unwitnessed/prolonged cardiac arrest 

Limitations of life support 

Limited life expectancy

ELSO Registry Jan 2010



Conventional vs Alternative Circuits 

Silicone membrane 

oxygenator 

high resistance 

requires CO2 flush 

Non-coated 

Good air-trapping 

Roller vs Centrifugal Pump 

Bladder w/ shunt? 

Slow setup 

Large prime volume 

Long term ? 

Prone to clotting 

Difficult to change out 

Hollow fiber oxygenator 

Centrifugal pump head 

Coated Surface (heparin, other) 

Bladder? 

Alternative bridge 

Rapid setup 

Low prime 

Short term/long term 

Easy to change out

Evolution of ECMO 

Stasis in development despite emerging technologies 

1983 1989 1996 2004

Duke Adult ECMO 2002 

Console 

Circuit

Hemolytic Characteristics of Three 

Commercially Available Centrifugal Blood 

Pumps 

D. Scott Lawson, BS, CCP, Richard Ing, MB, BCh, FCA(SA), Ira M. Cheifetz, MD, 

Rich Walczak, BS, CCP, Damian Craig, MS, Scott Schulman, MD, Frank Kern, MD, 

Ian R. Shearer, BS, CCP, Andrew Lodge, MD, James Jaggers, MD 

Pediatr Crit Care Med 2005 Vol. 6, No. 5

Methods 

• Ex-vivo experiment using heparinized, fresh bovine 

whole blood. 

• Two test runs for each of the four blood pump were 

achieved on three consecutive days for a total of six test 

runs for each of the four pumps (n = 24). The testing 

order of the pumps was randomized. 

Lawson et al 

Pediatr Crit Care Med 2005 Vol. 6, No. 5

Bench top Study

Mean NIH values in mg/100L 

70.00 

60.00 

* p value < 0.05 

* 

61.1717 

50.00 

40.00 

NIH 

34.50 

33.00 

30.00 

29.67 

20.00 

10.00 

0.00 

Revolution Rotaflow BP-80 Roller pump

Maquet QUADROX - Blood Flow 

De-airing 

membrane 

e 

Luer port 

pre chamber 

blood in 

blood out

QUADROX AND QUADROX D - MEMBRANE 

STRUCTURES 

Microporous membrane 

Diffusion membrane 

pore size max.

Maquet Quadrox D Oxygenation 

System Features & Benefits 

FDA approved for 6 hours 

Low priming volume of 250 ml 

Low membrane surface area 1.8 m² 

Flow range 0.5lpm – 7lpm 

Very high transfer rate of O 2 and CO 2 

Most efficient integrated heat exchanger on the market 

Oxygenator with lowest pressure drop on the market 

Very easy de-airing due to integrated hydrophobic de-airing membrane 

Unique squared and symmetrical design 

Standardized Safeline or Bioline Treatment of the membrane 

High predictability and reliability of performance factors 

Maquet/AG, Maquet-Inc. 2006. Technical data brochure

Duke Adult ECMO 2007

Duke Adult ECMO 2007


Cannulation Strategies 

VV 

RIJ(23F Fr) )t to RFV(19F Fr) 

RFV (long 21 Fr) to RIJ (or LIJ) 

percutaneous eous approach when possible 

“lowest flow to achieve highest arterial sat %” 

requires native cardiac output 

VA 

RIJ to RCA (or LCA or Axillary) 

FV to FA 

RA to Ao 

avoid total bypass of lungs 

danger of emboli 

need to vent heart in asystole

Adult ECMO Management 

“Gentilation” (FiO 2 < 40%, Press 30/20 torr, rate 6/min, 

PEEP 5-10 torr) 

Venous O 2 sats 80-90%, arterial O 2 sats 80-95% 

Anticoagulation 160-180180 sec, 120-150 150 sec if bleeding 

Hct > 30% VA, > 35% VV 

Plt > 75,000/mm 3 , > 100,000 if bleeding 

PTT > 50-70 sec, Fib > 100-200 mg/dL 

Bridge, oxygenator management 

Urine output 100-300 ml/hr, hemofiltration 

Infection prevention


Termination of ECMO 

Improvement in lung compliance, ABG’s, Chest X-Ray 

Extensive hemorrhage (12 L/day for 1 day, 6 L/day for 2 days) 

Uncontrolled ET blood loss (> 200 ml/hr for > 3 hr) 

Time on support 

Indicators of reversibility of ARDS unclear 

Futility – ethical and legal problems

Duke Adult ECMO Experience 12/94-12/0912/09 

Venous-Arterial 

Venous-Venous 

V-A 

V-V 

Respiratory 28 37 

Cardiac 71 0 

Total 97 37

Duke Adult ECMO 12/94 – 12/09 

Diagnosis 

Total 

Redo-CAB 

5 

Lung Tx 54 Heart-Lung 

2 

VAD 12 CABG 6 

CPR 23 Heart Tx 7 

PE 2 PVR 4 

ARDS 8 Viral CM 3 

Ao Dissect 4 Other 4

Duke Adult ECMO 


Cases 

27 

24 

21 

18 

15 

12 

9 

6 

3 

0 

1993 

1994 

1995 

1996 

1997 

1998 

1999 

2000 

2001 

2002 

2003 

2004 

2005 

2006 

2007 

2008 

2009 

Year 

Each ECMO requires 24/7 coverage and removes 3 call personnel 

each day to staff. Each ECMO lasts an average of 4-6 days.

Improved Results Treating Lung Allograft Failure With 

Venovenous Extracorporeal Membrane Oxygenation 

Methods: 512 patients underwent lung transplantation from 

April 1992 to July 2004. 23 (4.5%) patients required ECMO 

2° PGF unresponsive to conventional treatment. 15 (65%) 

treated with VA ECMO, while 8 (35%) underwent VV 

ECMO. 

Results: 8/15 (53%) of VA were successfully weaned from 

ECMO. Only 1 long term survivor. 8/8 (100%) of VV were 

successfully weaned from ECMO, with 7/8 (88%) surviving 

> 30 days. 

Hartwig et al 

Ann of Thor Surg 

2005; 80: 1872-8080

Improved Results Treating Lung Allograft Failure With 

Venovenous Extracorporeal Membrane Oxygenation 

Complications 

Renal failure (ARF) 16 

Neurologic catastrophes 8 

Sepsis 5 

Hemorrhage 10 

VA ECMO recipients incurrred 30/39 

complications. Most complications for VV 

ECMO involved ARF, but by discharge, 

mean creatinine was 0.9. 

Hartwig et al 

Ann of Thor Surg 

2005; 80: 1872-8080

Lung Transplant Survival 

N = 12 

V V ECMO (updated) 

58% 

V V ECMO 

N = 8 

88% 

V A ECMO 

7% 

N = 15 

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ECMO Support After Percutaneous Coronary 

Intervention For Acute Myocardial Infarction 

PCI has evolved as an important treatment for patients who present with 

AMI associated with cardiogenic shock. 

Surgical revascularization not ideal treatment option due to established 

infarct and iatrogenic coagulopathy. 

Surgical LVAD not an ideal choice since LV recovery is difficult to 

predict and inadequate time to evaluate patient. 

Methods: Study period from June 2008 to September 2009. Nine 

consecutive patients treated with ECMO following PCI. 

Summary: Emergency ECMO may be used as a bridge to further clinical 

treatments. Can be rapidly established and achieves hemodynamic 

stability and normalization of end organ perfusion with no major 

complications. 

Piacentino et al 

submitted to JACC 2010

ECMO in Post PCI Shock 









Methods 

UK-based multicenter trial. 180 adults randomized to receive 

conventional ventilation or referred for ECMO. Eligible patients 

18-65 yr. Usual exclusion criteria. 

Results 

68 (75%) actually received ECMO. 63% (57/90) survived ECMO 

to 6 months without disability compared to 47% (41/87) with CVM. 

p=0.03 

Referral to ECMO treatment led to gain of .03 quality-adjusted-life 

years at 6 mo follow-up. 

Peek et al 

Lancet 2009 

Oct:374; 1351-63

Swine Flu H1N1 

H1N1 Differs from “Typical” ARDS 

Incidence of alveolar 

obstruction/peripheral airway disease 

Extremely rapid progression of 

hypoxemia 

Incidence of secondary bacterial 

infection 

More refractory to “standard” therapies 

Predilection for healthy teens/young 

adults

In the recent Australia/New Zealand outbreak, 201 

patients with confirmed or suspected H1N1 were 

treated in 15 ECMO centers. 68 patients who 

failed conventional measures were placed on 

ECMO, with a 79% recovery/survival at time of 

reporting. 

ANZ ECMO ECMO Influenza Investigators 

JAMA Vol 302 No. 17, Nov 4, 2009

Duke H1N1 Experience e Fall 2009 

62% 75% 76% 94% 

Norfolk et al, Crit Care Med, submitted.

Response se to demand d for additional ECMO capacity 

c

Duke ECMO Program 10/09 

• Multidisciplinary leadership meetings 

• Decision i to move forward 

– 8 wks to formally launch an adult respiratory 

ECMO program in the MICU 

– Expand from 3 to an 8 bed center (not incl adult 

CT unit) 

• Physician, administrative and financial support 

• Equipment-need need to design a simple, less expensive, 

less labor intensive system 

• Personnel – training and education

Duke ECMO lite 2009

A New Miniaturized System for Extracorporeal 

Membrane Oxygenation in Adult Respiratory Failure 

Mthd Methods: 60 consecutive patients t (Apr 2006-Dec 2008) with life 

threatening respiratory failure. Utilization of a “new” 

miniaturized veno-venous venous device. 

Results: Rapid increase of PaO 2 /FiO 2 from 64 (48-86)torr 86)torr to 120 

(84-171) torr 

Decrease of PaCO 2 from 63 (50-80) torr to 33(29-39) 39) torr 

(p

Alternative pumps for adult ECMO 

Thoratec Levatronics VAD 

CardiacAssist Inc 

Tandem Heart VAD

Successful Treatment of Peripartum 

Cardiomyopathy y With Extracorporeal Membrane 

e 

Oxygenation 

• 24 yr female developed HF within 4 months of delivery of 

child. 

• Intubation, ti inotropic i support, IABP 

• Use of ECMO with Quadrox D (Bioline) and CentriMag 

centrifugal pump, coated tubing, coated cannulae 

• 11 days of support, successfully weaned. 

• Discharged one month later with EF of 30%, 5 month 

follow-up; RV normal size, EF 47% 

Palanzo et al 

Perfusion 2009; 24: 75-7979

Avalon Dual Lumen Cannula 

Sizes 13, 16, 19, 20, 23, 27, 31 Fr


Summary 

Limited clinical experience 

Resource intensive 

Equipment/circuit improvements 

Rapid deployment preparedness 

Expanding applications 

Role for the perfusionist

Questions?

Adult ECMO - Perfusion.com

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