Macau Society of Emergency and Critical Care Medicine

Macau Society of Emergency and Critical Care Medicine Inaugural Ceremony cum Scientific Meeting Applications of 2011 Extracorporeal Membrane Oxygenation (ECMO) Dr. Yan Wing Wa Chief of Service (ICU), Pamela Youde Nethersole Eastern Hospital, HKSAR Chairman, Hong Kong Society of Critical Care Medicine Chairman, Specialty Board of Critical Care Medicine, HKCP 23 July 2011

2 nd September 3

Types of ECMO V-V ECMO V-A ECMO Bad lung good Heart Good lung Bad heart Bad lung Bad heart V-V X X V-A peripheral X (not required) V-A Central

System console Set Up Oxygenator Return cannula Centrifugal pump Access cannula Warmer Air/O 2 blender

Access cannula Return cannula

Principles of ECMO n Temporary support the failed lung n n n Buy time for the lung to recover n n n Not suitable for irreversible lung failure Less suitable for the lung condition required long time to heal (complication risk > benefit) Keep patient alive Create an optimal condition for the lung to heal Avoid complications related to ECMO

Indications n Principles n n n Reversible life threatening disease n Un-response to conventional therapy At the discretion of the critical care / intensive care team Absence of contraindication

Contraindications n Vary between different institutions n In general n n n Progressive & Non-recoverable diseases Terminal diseases Contraindication to anticoagulation

Complications of ECMO n n n n n Vessel damage during insertion Unidentified heart failure Bleeding Circuit thrombosis Oxygenator failure Haemolysis Air embolism Circuit rupture Infection Access recirculation

CESAR Study Conventional ventilation or ECMO for Severe Adult Respiratory failure Lancet 2009, 374: 1351 -63 Single ECMO centre at Glenfield Hospital, UK n Survival without severe disability (confined to bed, or unable to dress/wash oneself) by 6 months n ECMO: 57 in 90 patients (63%) n Conventional ventilation: 41 in 87 patients (47%) n Relative risk reduction in favour of ECMO n 0. 69 (0. 05– 0. 97; P = 0. 03) n NNT to save one life without severe disability is 6

ECMO for 2009 Influenza A(H 1 N 1) Acute Respiratory Distress Syndrome The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators JAMA. 2009; 302(17): 1888 -1895. Published online October 12, 2009(doi: 10. 1001/jama. 2009. 1535) n n n During winter 2009 (1 June 2009 to 31 August 2009), Australia & New Zealand ICUs 68(34%) required ECMO out of 133 patients with IPPV For patients given ECMO n 48/68 (71%) survived ICU n n 32/68 (47%) survived hospital 16/68 (24%) still in hospital 6/68 (9%) still in ICU 14/68 (21%) died

Indications for VV-ECMO n n Potentially reversible and life-threatening respiratory failure unresponsive to optimum conventional ventilation and therapy. Severe respiratory failure was defined in the CESAR trial as: n n Murray score* ≥ 3. 0; or Uncompensated hypercapnia with p. H ≤ 7. 20

Hong Kong Med J 2010; 16: 447 -54

Pandemic Influenza H 1 N 1 in Hong Kong

Summary of Cases n May 1, 2009 to Feb 28, 2010. 3 ICUs

Hong Kong ECMO referral centres n Pamela Youde Nethersole Eastern Hospital n Prince of Wales Hospital n Queen Elizabeth Hospital n Queen Mary Hospital

Reasons for ECMO (PYNEH) n VV-ECMO n n n n n Influenza A H 1 N 1 pandemic: Human metapneumovirus: 1 Mycoplasma pneumoniae: 1 Pneumococcus: Streptococcus constellatus: 1 Pseudomonas areuginosa: 1 Unknown: 2 Paraquat poisoning: 1 14 1 VA-ECMO n Viral myocarditis: 1

ECMO in PYNEH ICU n n Male/Female: Age distribution n n n 15 -25: 26 -35: 36 -45: 46 -55: 56 -60: >60: 1 3 1 8 7 3 12 / 11

Referrals n n n n PYNEH: Canossa Hospital ICU: 2 KWH ICU: 1 NDH ICU: POH ICU: RH ICU: TMH ICU: 3 14 1 1 1

1 1 3 1 1 2 11 PYNEH Other Hong Kong N

ECMO and RRT

Duration of ECMO n n n n 4 days: 3 5 days: 4 6 days: 7 7 days: 3 8 days: 1 10 days: 16 days: 24 days: 1 1 2

Outcome n Died: n n n 2 (8. 7%) Paraquat poisoning (100 ml 24% paraquat) Viral myocarditis (VA-ECMO) Home: Rehab hospital: Still in ICU: 18 1 2

Severe Myocarditis n n n F/15, good past health Pulseless VT & Vf requiring repeated defibrillation & CPR (total duration: 162 mins) VA-ECMO started (procedure time: 110 mins)

Upon admission to ward

During CPR and ECMO cannulae

Backflow cannula to right superficial femoral artery was inserted by surgeon at bedside

Backflo w cannula to superfici al femoral artery Photos showing backflow cannulae & ECMO + CVVH circuit Before After

Day SBP MAP DBP NIBP Temp HR RR ICP 1 2 3 4 5 6 7 8 9 10 11

Day 6 Return of sinus rhythm

Weaning of VA ECMO n n Trial of ECMO weaning on Day 7 ECMO flow reduced, noradrenaline and dobutamine infusion increased to facilitate weaning Ventilator support and anticoagulation increased Successfully weaned off ECMO and decannulated on Day 8 (ECMO duration: 7 days)

CT brain on Day 10 Certified brain death on Day 11

Likely Future Indications for ECMO in Hong Kong ICUs n VV-ECMO n n More wide spread use, may extend to bacterial pneumonia besides viral pneumonitis VA-ECMO n n Poisoning with profound cardiac suppression Viral myocarditis Peri-cardiac operation in cardiothoracic centres Extracorporeal-Cardiopulmonary resuscitation (e. CPR)

e-CPR n Experience in Taipei Veteran General Hospital n n Structured Considered for CPR >10 mins Determined within 10 mins Onsite setup in another 10 mins (i. e. e. CPR setup within 30 mins) n n n A primed ECMO circuit is available at all times Early recognition of complications and aggressive management The doctor setting up the circuit would be responsible

Lancet 2008; 372: 554 -61

Crit Care Med 2011; 39: Epub

Conclusion n n ECMO is Life saving and should be provided to indicated patients (Overseas & Hong Kong experience) It is feasibel to start ECMO service n n Department & Hospital determination We are most happy to share with you our experience

Acknowledgement n PYNEH hospital top management n n n 任燕珍醫生 Dr Loretta Yam, CCE, HKEC (until 30 April 2011) 劉楚釗醫生Dr CC Lau, CCE, HKEC (since 1 May 2011) PYNEH ICU doctors n n n n n 陳勁松 Dr Chan King Chung, Kenny, AC 劉俊穎 Dr Lau Chun Wing, Arthur, AC 林倩雯 Dr Lam Sin Man, Grace, AC 沈海平 Dr Shum Hoi Ping, AC 胡曉琳 Dr Wu Hiu Lam, RS 梁玉華 Dr Leung Yuk Wah, Natalie, RS 關明哲 Dr Kwan Ming Chit, Arthur, RS 譚靄欣 Dr Tam Oi Yan, Jackie, RT 張莉莉 Dr Chang Li Li, Lily, RT 張詠詩 Dr Cheung Wing Sze, Emily, RT

Acknowledgements (2) n PYNEH ICU nurses n n n n n n Chung, Hing-yee RN, n Wong, Pui-yan Pauline, RN , Chan, Shuk Ching, Christine, DOM, n Yeung, Chau-kwan RN, n Wong, Wickon RN, Kwok, Lai-ping Nora, WM, So, Hang-mui, NS, n Po, Pui-chun RN, n Chin, Sau-wai RN, Lau, Lan, NO, n Chan, Yim-yu RN, n Tong, Wing-yam RN, Lui, Kam-cheung, NO, n Wong, Hoi-lee RN, n Wong, Chun-fai RN, Chan, Shiu-kee Danny, NO, n Liu, Yan-chi Kylie RN, n Wang, Mei-kei RN, Kwan, Yuen-fan Eva, NO, n Chun, Yuen-kwan Emily RN, n Yiu, Man-ching RN, Lau, Yuk-yin, APN, n Liu, Sing-kwan Benjamin RN, n Ng, Sze-wah RN, Fok, See-kee, APN, n Cheung, Yin-pui Shirley RN, n Cheung, Wah-ling RN, Lee, Chun-heung, APN, n Chau, Hau-yan RN, n Wong, Ka-po RN, Chiu, Mei-chun, APN, n Mok, Chi-man RN, n Yeung, Kai-jone RN, Lo, Wan-Po Joanna, APN, Ng, Ching-ping, APN, n Leung, Ka-yue RN, n Au, Pui-man RN, Li, Siu-chun, RN, n Wong, Sze-ting RN, n Lam, Yin-yu RN, Lui, Wai-king RN, n Ip, Tsui-yuk Joey RN, n Hon, Hiu-shan RN, Chan, Siu-cheung RN, n Luk, Wai-Ha Veronica RN, n Mak, Hiu Yan RN, Tang, Wai-yan RN, n Lai, Siu-cheong RN, n Chow, Pik-ki RN, Wong, Wo-ming RN, n Chang, Lai-fan RN, n Wong, Hoi-ching RN, Yeung, Mei-wa RN, n Mui, Sze-yuen Kevin RN, n Yu, Hoi-lam RN, Tam, Yuen-fan RN, n Wong, Tang-tat RN, n Chan, Peggy RN, Cheung, Wai-han RN, n Hung, Pui-yan RN, n Ho, Yin-ting Stephanie RN, Chan, Yuet-king RN, Fung, Mei-lan RN, n Wong, Hoi-yan RN, n Wong, Chui-ying Caroline RN

Thank you for your attention. This presentation file can be downloaded at our Society website www. hksccm. org