• ECMO
    • Technology derived from CPB and allows gas exchange outside the body
      • The gas exchanger is more efficient at CO₂ removal than O₂ addition
      • Newer models have less resistance to flow and cause less traumatic to blood flowing through
      • CESAR trial
        Link:www.frcamindmaps.org/trials.html
        • Patients transferred to a centre with ECMO had better outcomes
    • Indications
      • VA ECMO
        • Weaning from CPB
        • Bridge to cardiac transplant
        • Myocarditis
        • Intractable arrhythmias
        • PAH (after pulmonary endarterectomy)
      • VV ECMO
        • Acute respiratory failure
        • ARDS due to pneumonia
        • Failed lung transplant graft
        • Pulmonary contusion
        • PE (if good cardiac function)
    • Contraindications
      • Irreversible organ damage
      • Multi organ failure
      • Not a candidate for transplant
      • Severe aortic regurgitation or dissection are CI for VA ECMO
    • Complications
      • Labile BP
        • Initially volume expansion is required then a rapid reduction in inotropes may be needed due to lower intrathoracic pressures
      • Circuit related
        • Infection
        • Bleeding from cannula sites
        • Circuit failure
        • Disconnection
        • Thromboembolism
      • Coagulation related
        • Haemorrhage
          • Local
          • Intracranial
        • HIT due to heparin anticoagulation
          • ACT is commonly at 1.5x normal
        • Thrombocytopenia
    • Types
      • An external pump pushes blood through a membrane before returning via a warmer
        • Veno-venous (VV) ECMO
          • Facilitates gas exchange but doesn't provide haemodynamic support
          • Used if cardiac function is preserved
          • Can use dual or single cannula methods
        • Veno-arterial (VA) ECMO
          • Allows gas exchange and haemodynamic support
          • Drainage is usually via the IVC or R atrium
          • Return is to the aorta (CENTRAL ECMO - surgically placed) or the femoral artery (PERIPHERAL ECMO - surgically or percutaneously placed)
          • Part or all of the blood bypasses the heart
          • Reduces cardiac work and O₂ consumption
      • Arterio-venous (AV) ECMO
        • Uses cannula in the femoral artery
        • Uses patient's own arterial pressure to drive blood from arterial to venous side (no pump used)
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/early/2011/12/20/bjaceaccp.mkr056.full.pdf