ECMO System ExtraCorporeal Membrane Oxygenation ECMO System l

ECMO System Extra-Corporeal Membrane Oxygenation “體外循環生命支持系統”

ECMO System l. Extra-Corporeal Membrane Oxygenation l俗稱“葉克膜” l體外循環膜式換氧系統 l又稱“體外循環生命支持系統” (Extra-Corporeal Life Support ) l密閉式體外循環系統

Applications and Management of ECMO • I. Neonatal ECMO Indications: Respiratory failure secondary to 1. Meconium aspiration syndrome 2. Congenital diaphragmatic hernia 3. Sepsis 4. Hyaline membrane disease 5. Primary pulmonary hypertension 6. Persistent fetal circulation 7. Postcardiotomy cardiac failure

Applications and Management of ECMO • II. Pediatric ECMO Indications: 1. ARDS 2. Acute respiratory failure, non-ARDS

Applications and Management of ECMO • III. Adult ECMO Indications: 1. ARDS 2. Pneumonia (bacterial, viral, aspiration) 3. Postlung transplant graft dysfunction 4. Postpneumonectomy pulmonary edema Relative Contraindications: 1. Septic shock 2. Severe fixed pulmonary hypertension mean pulmonary artery pressure (MPAP)>45 mm. Hg 3. Acute or chronic irreversible myocardial dysfunction 4. Immunosuppression 5. Central nervous system injury or malfunction

Applications and Management of ECMO • IV. Cardiac ECMO Indications: 1. Postcardiotomy support 2. Acute myocardial failure/myocarditis 3. Bridge to cardiac transplantation or left ventricular assist device(LVAD)

Applications and Management of ECMO • Exclusion Criteria: 1. Correct diagnosis uncertain 2. Unrepaired congenital cardiac defects 3. CNS damage 4. Malignancies 5. Irreversible end-organ damage(lungs, kidneys, liver) 6. Postoperative patient with uncontrolled hemorrhage

ECMO System 1. V-V mode 插管部位: V-V Mode ( Venovenous bypass mode ) 頸靜脈右心房腹股靜脈下腔靜脈適應症： l成人呼吸窘迫症( l. Gas ARDS ) flow: 10 L/min, Fi. O 2: 100%

Modes of ECMO B. VV (Venovenous) ECMO 1. Advantages a. Safety: avoids cannulation and ligation of carotid artery b. Less risk of systemic embolization c. Maintenance of adequate blood flow to lungs, may decrease risk of ischemic injury

Modes of ECMO B. VV (Venovenous) ECMO 1. Disadvantages a. Does not provide circulatory support b. Lower oxygen level achievable, may not be adequate oxygen delivery in larger patients c. Two sites of cannulation sometimes necessary for adequate flow d. Potential for volume overload, as decreased renal function common during initial 48 hours of starting VV ECMO e. Recirculation: major disadvantage of VV ECMO

Mode of ECMO: 插管部位: l成人: 2. V-A mode V-A bypass mode 腹股靜脈右心房腹股動脈體循環 Advantege: 1. Both lung & heart support 2. Higher Pa. O 2 Gas flow: blood flow: 1: 1 Fi. O 2 100% (視Pa. O 2)

Modes of ECMO • A. VA (Venoarterial ) ECMO 1. Advantages: a. Full cardiorespiratory support allowing maximum rest for pulmonary and cardiac systems. Ability to offer support in situations of full cardiovascular collapse b. Maximize perfusion pressure to end organs 2. Disadvantages: a. Need to sacrifice carotid artery in neonates b. Potential for neurologic injury from vessel ligation or systemic embolization

抗凝劑的使用 • Heparin Dose: 25000 u/250 c. c. N/S to keep ACT level(by Dr. order) = 160”~200”

Weaning 1. Lung recovery: (1) clear CXR (2) improve compliance (3) Pa. O 2 , Pa. CO 2 (4) peak airway pressure

Weaning 2. Heart recovery: (1) Sv. O 2 (2) pulse pressure (3) echocariography VV system: stop gas flow & keep blood flow in ECMO VA system: decrease flow to 10% C. O

Complication 1. Bleeding: surgical site bleeding, thrombocytopenia 2. hemolysis 3. Neurologic: ICH or seizures 4. Pneumothorax, hemothorax, tension pneumothorax, cariac tamponade 5. Renal failure: BUN, Creatinine H/D or CAVHD & CVVHD

Complication 6. Tubing rupture or disconnet 7. Oxygenator failure 8. Pump failure 9. Heat exchanger malfunction 10. Air in circuit, air embolism 11. Cannula problem 12. Infection, sepsis 13. Cadiac stun: IABP support