Introduction to ECMO:

What we need to know

Novik Budiwardhana
Harapan Kita Hospital, National Cardiovascular Center Jakarta
 Introduction
• Patients infected with COVID 19 leading to a significant increase in
hospital and intensive care unit (ICU) admissions globally. ICU
admissions are due to hypoxemic respiratory failure with up to 30-
88% of patients requiring invasive mechanical ventilation. ELSO
reported in the guideline a small proportion of these ventilated
patients fail to maximal conventional ventilation and may require
ECMO support
• Gov of Indonesia is willing to provide ECMO machine to COVID 19
referral hospital
Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency
Response. Jama. 2020
Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. Jama. 2020
Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV- 2 pneumonia in Wuhan, China: a single-centered, retrospective,
observational study. Lancet Respir Med. 2020.
Introduction
• The existence of ECMO machines will motivate us to apply this
sophisticated machine in effective ways
• Effective way means ECMO for COVID and nonCOVID
• NCCHK is one of ECMO center in Indonesia →VA ECMO there is a lot
to learn more about VV ECMO
Objectives
• To know the definition of ECMO and it’s positioning among the life
support devices
• To discuss the history and development of extracorporeal support
• To discuss pathophysiology during ECMO
• To discuss other pathophysiology we need to consider during ECMO
• To discuss ECMO time-out Planned ECMO
 Definition
• Extracorporeal membrane oxygenation
(ECMO), also known as extracorporeal life
support (ECLS), is an extracorporeal
technique of providing prolonged cardiac
and respiratory support to persons whose
heart and lungs are unable to provide an
adequate amount of gas exchange or
perfusion to sustain life.
ECMO and it’s positioning among other life
support measures

Oxygenation &Ventilation support

ECMO ULTIMATE LIFE
Circulatory support

SUPPORT?
IABP
Whenever
LVAD
CMV
other life
HFOV
Inotropes
PD NO
NO support has
CRRT failed?
 The History and development of ECMO
• The earliest beginnings
• 1693 Jean Baptise Denis experiments cross-transfusing the
blood of human to the lamb
• Benjamin Ward Richardson (1860) experiments using injected
oxygen and blood driven by a syringe to the right heart in an
animal model
• The innovation
• Sergei Brukhonenko etal (1920s) → autojector
• Dr Gibbon (1930s) -> first freestanding roller pump device of
extracorporeal support → ASD repair in 1953
• Surgeon C Walton Lillehei → innovator cardiopulmonary
bypass (1954)
“ During that long night, helplessly watching the
patient struggle for life as her blood became
darker…the idea naturally occurred to me that if it
were possible to remove continuously some of the
blue blood…put oxygen into that blood .. And then to
inject continuously the now-red blood back into the
patiet’s arteries, we might have saved her life”

-John Gibbon MD
 The History and development of ECMO
• The Development of ECMO
• Dr Robert H Bartlett the father of modern ECMO. In
1975 brought an ECMO oxygenator to the NICU
 Cardiopulmonary physiology

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 Cardiopulmonary pathophysiology

When the DO2 is less than twice the

VO2, oxygen supply is inadequate to
maintain aerobic metabolism and
anaerobic metabolism ensues, producing
lactic acid rather than CO2. A DO2:VO2
ratio less than 2:1 leads to supply-
dependency hypoxia and systemic
acidosis, with resultant organ failure

ECMO use

Bartlett R, Conrad SA. The physiology of extracorporeal life

support In: Brogan TV etal eds. The extracorporeal life support
the ELSO red book 5th ed. ISBN 978-0-9656756-5-9

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Pathophysiology during ECMO
• ECMO is used when heart or lung failure is so severe that DO2:VO2
less than 2:1 or when the intervention needed to keep DO2 twice
VO2 are inherently damaging
• ECMO is used whenever the pathophysiology is considered to be
reversible

3 Phases of ECMO
therapy
 How to Run ECMO A to Z

The Dual Circulation

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Why VV ECMO and Why VA ECMO?

Hypoxia or severe
hypercapnia
•VV ECMO

if the patient has

concomitant shock which
also necessitates ECLS for • VA ECMO
mechanical circulatory
support
VV ECMO
Drain blood from VEIN

One catheter dual lumen Two separate cannulas

Oxygenate and Remove CO2

Oxygenator Sweep gas

Return oxygenated blood via VEIN support gas exchange when lung can not be functioning well

Tip directly sit in RA and outflow facing directly TV RECIRCULATING ISSUE

VV ECMO
• Pathophysiology on VV ECMO
• “The sick” LUNGS can rest and ventilated with lung protective strategy
• NOT normal but adequate oxygenation by making sure adequate cardiac output.
• The mixing between ECMO blood and NATIVE blood
• Hemodynamic on VV ECMO
• VV ECMO does not alter hemodynamic
• RAP, LVEDP, BP and afterload unaffected
• Anticoagulant when on VV ECMO
• Minimal or no anticoagulant. But still coagulopathy can occur
• Less concern with fibrin clots post Oxyganator because it can be trapped by patient’s
LUNG
 VV ECMO goal

• No alteration of hemodynamic
• Pa O2 45-80 mmHg
• SpO2 60% - 90% as long as
adequate systemic oxygen
delivery is achieved
• Hgb 13-15, HCT : 40
• pH 7,35-7,45
• PCO2 35-45
• DO2: VO2 > 2
• Echo: The right ventricle
echocardiographic assessment
in the ECMO patients with
acute respiratory distress
syndrome (ARDS) plays a key
role to reduce complications
and to improve the outcome

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VA ECMO
Draining blood from the VEIN

TWO separate cannulae

Oxygenate / Remove CO2

Return blood in artery VIA AORTA

FLOW oxygenated blood to perfuse Unload the heart by reducing preload

Source of illustration https://youtu.be/OOjKEPTKSpg
VA ECMO

• Pathophysiology on VA ECMO

• No risk of recirculation issue as happen in VV ECMO

• MIXING CLOUD Phenomenon:
• We should maintaining normal ventilation. Failing lungs = Hypoxemia
• Mixing between retrograde ECMO flow and native blood flow at somewhere between
ascending Ao and renal artery
• Right Radial artery + pulse oxy at right hand → monitor pulse pressor
• NON Pulsatile Flow: Most of all flow from ECMO
• Decrease pulse pressure or flat art-line
 VA ECMO goal
• Pulse pressure at least 10
• Pa O2 60-80 mmHg
• Hgb 13-15, HCT : 40
• SVO2 65-70%
• pH 7,35-7,45
• PCO2 35-45
• DO2:VO2 = 3:1
• Echo: Monitoring during ECMO must
fundamentally focus on the systolic
function of the left ventricle. The
systolic function is evaluated with
conventional parameters such as the
size of the left ventricle (LV), ejection
fraction (EF), mitral regurgitation dP/dt,
and aortic velocity time integral (VTI)

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 VA & VV – ECMO

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 How to Run ECMO A to Z

ECMO flow and it’s functions (P1, P2 and P3)

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 Circuit related monitoring
Venous line/ inlet pressure is
measured prepump and
monitored for excessive
negative pressure, which can
lead to vessel or right atrial
damage, as well as cavitation
and resulting hemolysis. The
venous pressure also reflects
circuit volume status. Pressure
depends on patient volume
status, circuit length, cannula
position, and FR size. If a
bladder is present, the venous
pressure may be obtained
from an access site on the
bladder.

Larissa Yalon, BSN, RN, CCRN,

Kenneth A. Schenkman, MD, PhD.
ECLS Safety and Other Monitoring
Devices. In: Brogan TV etal. Ed
ECMO Specialist training manual
4th Edition

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 Circuit related monitoring

Post oxygenator/arterial line

pressure is measured after the
oxygenator and is a function of
the pump speed, the tubing
resistance,
cannula and the arterial
pressure of the patient. An
obstructed or kinked arterial
line will lead to an increased
pressure. If this pressure
exceeds 400 mmHg, the risk of
circuit interruption and
hemolysis increases.

Larissa Yalon, BSN, RN, CCRN,

Kenneth A. Schenkman, MD,
PhD. ECLS Safety and Other
Monitoring Devices. In: Brogan
TV etal. Ed ECMO Specialist
training manual 4th Edition

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 Circuit related monitoring

Pre-oxygenator/internal
pressure is measured at the inlet
to the oxygenator and is used in
correlation with the post-
oxygenator pressure to diagnose
oxygenator issues. If an outflow
problem exists, both the pre-
and post-oxygenator pressures
rise together. An independent
increase in pre-oxygenator
pressure is an indicator of
oxygenator clot formation or
flow disruption within the
oxygenator housing.

Larissa Yalon, BSN, RN,

CCRN, Kenneth A.
Schenkman, MD, PhD. ECLS
Safety and Other
Monitoring Devices. In:
Brogan TV etal. Ed ECMO
Specialist training manual 4th
Edition
Instalasi Pendidikan dan Pelatihan– RS Jantung dan Pembuluh Darah Harapan Kita
 How to Run ECMO A to Z

ECMO circuit monitoring

Pressures

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 WHAT IS “ UN LOADING “

UN LOADING is defined as the reduction of total

mechanical power expenditure (Pressure Volume
Area – Heart Rate) of the Ventricle which correlates
with reductions in MYOCARDIAL OXYGEN
CONSUMPTION and HEMODYNAMIC FORCES that
lead to Ventricle remodeling

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 TIME
48-72 hrs

Chirine Mossadegh, RN Adult Cardiac ECLS: Patient Management. In Brogan TV etal. Ed ECMO
Specialist training manual 4th Edition
 How to Run ECMO A to Z

ECMO-Pump Flow

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 Other pathophysiology we need to consider during ECMO

Diunduh dari: https://www.stepwards.com/?page_id=866#ACTIVATED_PARTIAL_THROMBOPLASTIN_TIME_aPTTPARTIAL_THROMBOPLASTIN_TIME_PTT

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Other pathophysiology we need to consider during ECMO

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 Other pathophysiology we need to consider during ECMO

• ECMO does not cure the disease

• Deep understanding of pathophysiology and natural history

of the disease is important

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 We need to know about ECMO organization and
protocols
• International standards under ELSO
• In house ECMO protocols in the hospital

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 Summary

• The knowledge of the pathophysiology of underlying disease and

cardiopulmonary pathophysiology during ECMO is a essential for each
of the ECMO team
• The knowledge of the ECMO circuit and it’s troubleshooting requires
enrichment from time to time through ECMO runs practice

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