Update on Extracorporeal Membrane Oxygenation (ECMO)

Educational Objectives

The goal of this program is to improve the use of tranexamic acid in patients with extracorporeal membrane oxygenation. After hearing and assimilating this program, the clinician will be better able to:

1. Improve outcomes in patients receiving extracorporeal membrane oxygenation.
2. Select patients most likely to benefit from extracorporeal membrane oxygenation.
3. Employ massive transfusion protocols to optimize outcomes in patients with hemorrhage.

Summary

Extracorporeal Life Support Organization (ELSO) Registry report: found that with use of extracorporeal membrane oxygenation (ECMO), the survival rate in patients with adult respiratory failure was 60%; with cardiac failure, 44%; and with extracorporeal cardiopulmonary resuscitation (ECPR), 29%

Adult respiratory failure: the CESAR trial found that when ECMO-centered care was provided, the reduction in mortality rate was 31%; in the 2009 influenza A (H1N1) pandemic, ECMO was associated with a significantly lower hospital mortality rate; the 2017 acute respiratory distress syndrome (ARDS) clinical practice guidelines made no recommendation for ECMO in patients with severe ARDS; in treatment algorithms, ECMO is considered rescue therapy for severe hypoxemia (not for early treatment of ARDS)

2018 EOLIA trial: inclusion criteria — severe hypoxemia with a Pao2/fraction of inspired oxygen (PF) ratio <50 for >3 hr or a PF ratio <80 for >6 hr; these criteria are used by most ECMO centers for patients with respiratory failure (including trauma); management strategy — standardized in the ECMO and control arms; in the control arm, ECMO crossover was allowed for refractory hypoxemia; results — in the ECMO arm, the 60-day mortality rate was 35%; in the control arm, 46% (not statistically significant); in the control arm, crossover to ECMO occurred for refractory hypoxemia in 28%; in that patient group, the mortality rate was 57%; in the ECMO arm, the risk for treatment failure was significantly lower (relative risk was 0.62; reduction in mortality rate 38%); the study provides more definitive evidence for consideration of early use of ECMO for severe ARDS when the PF ratio is <80 (reflected in new treatment algorithms for severe ARDS)

Improved outcomes with ECMO: rates of survival to hospital discharge have significantly improved (38%-60% or higher); of >25,0000 cases of adult respiratory ECMO, the survival rate for extracorporeal life support was 69%, and the hospital survival rate was 60%; in patients with viral and aspiration pneumonia, the survival rate was higher

Venovenous (VV) ECMO cannulation strategy: the traditional 2-cannula approach using the right internal jugular vein (IJV) and right femoral vein has been replaced with use of a single dual-lumen (DL) cannula in the right IJV; this approach minimizes recirculation, but it requires fluoroscopy for insertion; the VV DL cannula allows much easier ambulation, early mobility, and early extubation; at the speaker’s institution, a jugular DL long-term ECMO catheter (Crescent) is used because of its superior flow characteristics and ease of insertion

Use of heparin: a bolus of heparin is required on ECMO implantation; the use of heparin can be minimized in trauma patients with traumatic brain injury or ongoing hemorrhage; if heparin is not infused after cannulation, high flows must be maintained to prevent clotting in the ECMO circuit

Treatment of patients receiving ECMO: keep the patient awake; promote early ambulation; allow spontaneous breathing; provide minimal or no anticoagulation (favors use of ECMO in trauma patients)

Trauma patients: a recent ELSO Registry review found that in adult trauma patients, overall rate of survival to hospital discharge was 61%; the majority of trauma patients (>88%) received ECMO for respiratory support; in patients requiring venoarterial (VA) ECMO for cardiac support, the hospital survival rate is 50%; for ECPR, 25%

Systematic review: hospital survival rate was ≈70%; VV ECMO for respiratory failure was most common; the leading cause of death was multiple organ failure; complications included bleeding and thrombosis (≈20% each)

Necrotizing pneumonia: not a contraindication for ECMO; as pulmonary compliance improves, prone positioning during ECMO can improve native lung function

Acute respiratory distress syndrome: some patients with severe ARDS require prolonged ECMO (overall survival rate is ≈45% compared with 60% to 70% for patients on short-term ECMO); recent analysis found that for patients with respiratory failure on ECMO for ≥14 days, the survival rate was 50%

Adult cardiac failure: a study found the hospital survival rate was 44%; optimal VA ECMO cannulation uses the percutaneous femoral approach; to avoid ischemia in the lower extremity, insert a distal perfusion cannula within 4 hr; with VA ECMO, early ambulation can be safely performed if the patient is an appropriate candidate and the cannulas are well-secured

ECPR for refractory cardiac arrest: a 2019 American Heart Association update recommends consideration of ECPR for selected patients as rescue therapy when conventional cardiopulmonary resuscitation (CPR) is failing; however, routine use is not recommended; France implemented prehospital ECPR because a key determinant of survival is duration of CPR before cannulation; according to a recent Paris Registry report, prehospital ECMO implantation for ECPR is associated with ≈3-fold higher survival rate

Septic shock: several case series and reports found that use of VA ECMO improves survival rate; in patients receiving maximal medical therapy, early ECMO improves outcomes

Readings

Combes A, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 2018; 378: 1965–1975; Eckman PM et al. Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Circulation. 2019;140. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.119.034512; Hilbert-Carius P et al. Pre-hospital CPR and early REBOA intrauma patients — results from the ABOTrauma Registry. World Journal of Emergency Surgery. 2020; https://wjes.biomedcentral.com/track/pdf/10.1186/s13017-020-00301-8.pdf; Pavlushkov E, Berman M, Valchanov K. Cannulation techniques for extracorporeal life support. Ann Transl Med. 2017;5:70; Peek GJ et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374:1351-63.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Napolitano was recorded at the 68th Annual Detroit Trauma Symposium, held online on November 4-6, 2020, and presented by the DMC Detroit Receiving Hospital and Wayne State University School of Medicine. For information about upcoming CME opportunities from the DMC Detroit Receiving Hospital and Wayne State University School of Medicine, please visit Detroittrauma.org. Audio Digest thanks the speakers and the DMC Detroit Receiving Hospital and Wayne State University School of Medicine for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS680802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.