1、uEXTRA CORPOREAL MEMBRANE OXGENATIONuPROVIDES PROLONGED RESPIRATORY AND CARDIAC SUPPORTuDOES NOT TREAT UNDERLYING PATHOLOGYuALLOWS SUPPORT WHILST DISEASE RESOLVES OR REVERSESuONLY APPROPRIATE IF UNDERLYING PATHOLOGY IS POTENTIALLY REVERSIBLEuAspiration pneumoniauARDS traumauARDS sepsisuARDS obstetri
2、cuPneumonia viral bacterial atypicaluPancreatitisuDrowninguBurns-smoke inhalationuPulmonary embolusuTricyclic Antidepressant ODuViral myocarditisuPost CPB failure to weanuCapillary leakuHyaline membranesuSurfactant depletionuCollapse/consolidationuVQ mismatchuReduced complianceuNeutrophil infiltrati
3、on and cytokine release u1916-MACLEAN-HEPARIN(JH)u1930-JOHN GIBBON-FIRST INVESTIGATION INTO ECLSu1944-KOLFF AND BERK-BLOOD OXYGENATION IN CELLOPHANE CHAMBERS OF ARTIFICIAL KIDNEYu1950-EARLY DEVELOPEMENTS OF CPBu1956-CLOWES-INVENTED MENBRANE OXGENATORu1957-KAMMERMEYER-INVENTED SILICONE-MEMBRANE LUNGD
4、r&Mrs Gibbon with their CPB machineu1960-EXPERIMENTS INTO PROLONGED CPBu1972-HILL-FIRST ADULT ECMO-AORTIC RUPTUREu1975-BARTLETT-FIRST SUCCESSFUL NEONATAL ECMO u1986-USA 18 CENTRES ECMOu1986-GATTINONI-50%SURVIVAL IN ADULT ECCO2Ru1989-ELSO REGISTRYu2001-120 CENTRES WORLD WIDEuNeonatal 40 cases per yea
5、ruPaediatric 20 cases per yearuAdult 40 cases per yearuCardiac(v.small number)NO RESERVOIR;BLADDER SERVOREGULATOR NO CENTRIFUGAL PUMP(haemolysis)NO MICROPROUS OXYGENATOR VENO-VENOUS PREFERRED WITH ADEQUATE CARDIAC FUNCTION NORMOTHERMIA HEPARIN ACT 160-200 NOT 500+NO ARTERIAL FILTER NOT HAEMODILUTED
6、HB 14g/dl;HCT 40 NO AUTOTRANSFUSIONuVeno-venous(v=28Fr;a=21 to 28Fr)uVeno-arterialuPercutaneousuOpenuSemi-SeldingeruDouble lumenuSingle lumen21F percutaneous return cannula in adult Rt femoral veinuPulmonary vasodilation(corr.Of hypoxia and acidosisuMyocardial oxygenationuMaintained pulmonary blood
7、flowuMinimally invasiveuNot affected by PDAuMore difficultuSlower stabilisationuNo circulatory supportuRe-circulationuEasy to useuCirculatory supportuInstant stabilisationuHuge experienceuRight heart offloaded and resteduCarotid ligationuJugular ligationuRaised LV afterloaduReduced pulmonary blood f
8、lowuHypoxic coronary perfusionuStun-high LV afterloaduDuctuFIO2-0.3uPEEP 10cm H20uPEAK INSPIRATORY PRESSURE 20cm H2OuRATE 5-10/minuTHEREFORE REDUCE:BAROTRAUMA VOLUTRAUMA OXYGEN TOXICITY MYOCARDIAL DEPRESSIONuMULTIPLE TRANSFUSIONuHYPOALBUMINAEMIC-SEPSIS,DILUTIONuCAPILLARY LEAK SYDROMEuRENAL FAILURE-S
9、EPSISuFLUID OVERLOAD FROM CIRCUIT PRIMEuDIURESIS TO DRY WEIGHTvDOPAMINEvFRUSEMIDE INFUSIONvAMINOPHYLLINEv40%CVVHFuPercutaneous Veno-venous Cannulation.uLow range heparinisation;ACT 160-200uLung Rest(20/10,RR10,FIO2 30%).uNormothermia.uDiuresis to dry weight.uHb 14g/dl.uNIH Adult ECMO Trial Zapol et
10、al JAMA 242:2193-96,1979uPCIRV vs ECCO2R Morris et al,Am J Respir Crit Care Med 1994;149:295-305.uZapol,:(NIH Trial)(VA ECMO+ventilation and ventilation only)Severe ARF.A Randomized Prospective Study.JAMA 1979:242:2193-6)u90 patients,9 US centres,1974-77uSurvival 20,Peak 45-55 cmH2)uFrequent severe
11、bleeding complications(leading to discontinuation of ECCO2R in 7/19 cases)BOTH TRIALS HAVE LITTLE RELEVANCE TO CURRENT ECMO REGIMENSPaO2/FIO2 65mmhgMurray Score=3.4DiagnosisNSurvival%Survival.Pneumonia261973%ARDS201365%Other4125%Total503366%uLFPPV with ECCO2R in severe acute respiratory failure,Gatt
12、inoni L et al,JAMA 1986 256;7:881-6(50%survival)uECLS for 100 adult patients with severe respiratory failure.PaO2/FiO2=55mmHg Kolla S et al,Ann Surg 1997;226:544-64(survival 54%)uConventional patients 8/28 Survived (28.5%)uECMO patients39/57 Survived(68.4%)up=0.001uSome centres in the US and Europe
13、have been quite successful at providing ECMO for severe adult respiratory failure (Ann Arbor,Michigan,Berlin,Marburg,Munich,Glenfield Hospital,Leicester etc.)uECMO has become standard treatment for severe Neonatal Respiratory Failure and Persistent Pulmonary Hypertension of the NewbornuMichigan-66%u
14、Leicester-80%uBerlin-77%uVienna-80%uHF JET VENTILATION-Romand 1995uHF OSCILLATING-Moller 1995uINHALED NITIC OXIDE-Gerlach 1993uNEBULISED PROSTACYCLIN-Zwissler 1996uPCIRV-Morris 1994uPERMISSIVE HYPERCAPNOEA-Gentilello 1995(91%n=11,survival in trauma pts)uPRONE VENTILATION-Stoller 1990;Pappert 1994uLI
15、QUID VENTILATION-still experimentaluHickling,Walsh,Henderson,Jackson:Low mortality rate in adult respiratory distress syndrome using low-volume,pressure limited ventilation with permissive hypercapnia:A prospective study.Crit Care Med1994,22:1568-78u74%survival(=40 of 53 patients with severe ARDS,ie
16、.Murray Lung Injury score 2.5,paO2/FiO2 13,Vt 6 ml/kg(360-390 ml),pressure limited ventilation with peak pressure 30 cmH2O,permissive hypercapnoeauThe ARDS Network:Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and ARDS.NEJM 4 May 2000;342:1301-
17、8u861 patients in 10 US university centres ALI/ARDS,ie.paO2/FiO2 300 mmHg,80%200,mean 136 u69%survival and less ventilator days with 6ml/kg tidal volume(mean paO2/FiO2 u60%survival with 12 ml/kg Vtu 22%mortality difference,P=0.007uNo data on subgroup with paO2/FiO2 100)uUS:NIH ARDSnet database:70%uU
18、K:uIntensive Care National Audit&Research Centre(ICNARC):62%(1506 patients with paO2/FiO2 24hrsu1426 patients from 25 centres(USA11;Europe 14)uOverall survival 55%uSurvival only 33%in hypoxic and hypercarbic pts ie more like ECMO ptsuAge 65 yearsuReasonable long term outlookuNo contraindication to a
19、nticoagulationuIPPV 3.0hypercapnoea pH 7.20aged 18-65 yearsduration of high pressure and high FIO2 ventilation 7 daysno contra-indication to limited heparinisationno contra-indication to continuation of active treatmentAssuming a 10%risk of severe disability among survivors in both trial armsa=0.05(
20、2 sided test)b=0.2Sample size of 120 patients in each group would be required to detect a reduction in the rate of primary outcome from 73%to 55%u“.Any treatment which relies on the patients lungs to provide gas exchange”uCan include any treatment modality thought appropriate by patients intensivist
21、,eg prone,NO,HFOVuLow(6ml/kg)tidal volume strategy(as in ARDSnet trial)and PIP 40 cmH2O recommended,but not mandatoryuNot standardized(no consensus)u(Analogous to UK Neonatal ECMO trial)uPrimary:death or severe disability at six monthsuSecondary:-Nature and duration of ventilation and other organ sy
22、stem support-Length of ICU and hospital stay-Blood product use-Cost/cost effectiveness to health and social services,patients and their families (by methods adopted from neonatal ECMO trial)uBristol Royal InfirmaryuSt James LeedsuRoyal Liverpool University Hospitals(3)uUniversity of WalesCardiffuSou
23、th Manchester uRoyal Infirmary,EdinburghuMorriston,SwanseauNorth Devon District uGloucester RoyaluWalsgraveuQueen Elizabeth,GatesheaduRoyal ChesterfielduDerby Royal InfirmaryuDerby City uMilton Keynes General uCrosshouse,KilmarnockuPilgrim,BostonuCheltenham uQueens,Burton-on TrentuLlandough,Penarthu
24、MacclesfielduNorth Staffordshire,Stoke-on-TrentuWrexham MaeloruWest SuffolkuChase Farm,EnfielduECMO with lung rest is a rational treatment.uSurvival with conventional treatment remains poor in most centres.uOnly an RCT can determine the best treatment.Ventilation with lower tidal volumes for acute l
25、ung injury and the acute respiratory distress syndromeThe Acute Respiratory Distress Syndrome NetworkN Engl J Med 2000;342:1301-8u6ml/Kg(PIP30)vs.12ml/Kg(PIP50)u861 patientsuAge 51+17 vs.52+18uPaO2/FIO2 138+64 vs.134+58RESULTSuTV 6.2+0.8 vs.11.8+0.8 ml/kguPIP 25+6 vs.33+8 cm/H2OuMortality 31.0%vs.39
26、.8%(p=0.007)uDays without organ failure also lower(p=0.006)Ventilation with lower tidal volumes for acute lung injury and the acute respiratory distress syndromeThe Acute Respiratory Distress Syndrome NetworkN Engl J Med 2000;342:1301-8Adult ECMO,PATIENT STATUS AT REFERRAL.uPaO2/FIO2 65mmhguMurray S
27、core=3.4uTime Vent=76.5 hrsuTime on 100%O2=14 hrs.uPAP=39.6 cmH2O.uPEEP=10 cmH2O.uMV=12.6 L/min.uMAP=82 mmHg.uMPAP=29 mmHg.uCVP=12 mmHg.uPAWP=12 mmHg.uCO=127 ml/kg/min.uUO=1.4 ml/kg/hr.uAge=30.1 yrs.uWt=71.9 Kg.uHb=10.8 Kg.uMedian length of stay of adult ECMO pts is 14 days(range 0-41days).ELSO reco
28、mmend 2:1 specialist to patient ratiouDaily cost for conventional care for severe respiratory failure is 1500-2300(Sheffield Health care costing system)uTotal cost per case 27000-63000u40 pediatric cardiacu10 adult cardiacAdult Cardiac ECLSDIAGNOSESuPost op MVRuPulmonary Emboli(2)uLoefflers syndrome
29、uCABG(2)uViral MyocarditisuPericardectomyuseptic shock post removal of infected pacing wire/vegative massuPost infarct VSDCardiac ECLS at GlenfielduBetween July 1991 and Sept 1998u505 patients received ECMOu152 adult respiratoryu182 neonatal respiratoryu121 pediatric respiratoryAdult Cardiac ECLSu10 patients,5 surviveduage 39.6(19)uRun time 188(220)hoursuPaO2/FIO2=81(20)mmHgCESAR
