Extracorporeal Membrane Oxygenation (ECMO) and Extracorporeal CO2 Removal (ECCO2R)
Extracorporeal membrane oxygenation (ECMO) should be considered in cases of severe hypoxemia usually related to severe acute respiratory distress syndrome (ARDS) of many etiologies. ECMO replaces pulmonary function, allows ultra-protective mechanical vent
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Eric T. Chang and Lena M. Napolitano
Case Presentation A 34 year old male presented to the outside hospital with a 2 day history of shortness of breath, chest pain, and syncope while walking. He had yellow sputum, a saturation of 85 % on room air, and a RLL infiltrate on CXR (Fig. 82.1). Blood cultures were negative. He was started on levofloxacin and only required 2 L of O2 via nasal cannula. The next day, he had worsening shortness of breath and rapidly increasing oxygen requirements. He was intubated and started on vancomycin and piperacillin/tazobactam. CT showed bilateral lower lobe consolidation and enlarged mediastinal lymph nodes. His ABG with FiO2 1.0 and PEEP 18 cm H2O was 7.45/44/65. He was transferred to a quaternary care center. Oseltamivir and azithromycin were added. Influenza A PCR test returned positive. Neuromuscular blockade, recruitment maneuvers, proning, and inhaled nitric oxide as rescue strategies for severe hypoxemia improved his oxygenation initially, but PaO2 then worsened to
45 and CXR demonstrated worsening bilateral infiltrates (Fig. 82.2). He also developed hypotension requiring multiple vasopressors and CRRT was initiated for acute anuric kidney injury. Question What intervention would you consider next? Answer Extracorporeal membrane oxygenation (ECMO) evaluation This patient has severe ARDS (paO2/FiO2 ratio 30 cm H2O), severe air leak syndromes, a need for intubation in a patient on the lung transplant list, and immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care). ECMO survival in adults with severe respiratory failure has significantly improved. The ELSO registry report from 1986 to 2006 included 1473 patients with severe respiratory failure treated with ECMO and 50 % survived to hospital discharge [4]. In the most recent study of adult
Fig. 82.5 Optimal position of the bicaval dual-lumen cannula with de-oxygenated blood outflow to ECMO circuit and oxygenated blood inflow to right atrium via medial infusion port
E.T. Chang and L.M. Napolitano
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Acute respiratory distress syndrome The berlin definition ECMO
Increasing intensity of intervention
Fig. 82.6 Treatment and Rescue Strategies in ARDS (Definition Task Force ARDS [1])
Inhaled NO HFVO Prone Positioning Lower tidal volume/Pplat + ECCO2R? Neuromuscular blockade Higher PEEP NIV Low-moderate PEEP Low tidal volume ventilation Mild ARDS 300
250
Servere ARDS
Moderate ARDS 200
150
PaO2/FiO2
100
50
0
Table 82.1 Murray Score for consideration of ECMO Parameter/score PaO2/FiO2 (On 100 % Oxygen) CXR PEEP (cmH2O) Compliance (ml/ cmH2O)
0 ≥300 mmHg ≥40 kPa Normal ≤5 ≥80
1 2 225–299 175–224 30–40 23–30 1 point per quadrant infiltrated 6–8 9–11 60–79 40–59
3 100–174 13–23
4 30 cm H2O) for 7 days or more (Lower likelihood of recovery if >5 days on the ventilator at these settings) 2. Major pharmacologic immunosuppression (absolute neutrophil count 95 %. If the SaO2 is stable on these settings, a trial off ECMO can be done by clamping the sweep gas while on lung protec
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