1. Extracorporeal Life Support (ECLS)
Anupol Panitchote, MD.
Division of Critical Care Medicine, Department of Medicine
Faculty of Medicine, Khon Kaen university, Thailand

2. ปอดจริง ปอดเทียม
Oxygenator

3. หัวใจจริง หัวใจเทียม
Blood pump

4. VA ECMO (venoarterial)
Cardiopulmonary failure: for instance
Acute myocarditis
Cardiogenic shock
ECMO CPR
Drainage at venous site: femoral vein
Return at arterial site: femoral artery

5. VV ECMO (venovenous) Pulmonary failure: for instance
ARDS
Drainage at venous site: femoral vein
Return at venous site: internal jugular vein

6. VA ECMO

7. VV ECMO

8. Compare natural lung VS membrane lung
Natural lung (NL)
Membrane lung (ML)
Exchange surface (m2)
150 4
Interface (m)
1-3
10-30
Surface blood volume ratio (cm-1)
300 30

10. VV access via double lumens
Recirculation
VV access via double lumens

11. Oxygenation during VV ECMO
Recirculation
Shunt

12. 𝑉𝑂2𝑀𝐿=𝐵𝐹×(𝐶𝑜𝑢𝑡𝑂2−𝐶𝑖𝑛𝑂2)
𝑉𝑂2𝑁𝐿=𝐶𝑂×(𝐶𝑎𝑂2−𝐶𝑣𝑚𝑖𝑥𝑂2)
𝑉𝑂2𝑇𝑜𝑡=𝑉𝑂2𝑀𝐿+𝑉𝑂2𝑁𝐿
Factors affect to VO2ML
Intrinsic properties of ML
FiO2 in sweep gases
Recirculation
ECMO blood flow

13. Factors affect to SvmixO2
SvO2 that leaving tissues
BF/CO
Recirculation

14. Severity of lung disease (shunt) Ventilator set up (FiO2) Cannula size
Factors affect to VO2NL
Severity of lung disease (shunt)
Ventilator set up (FiO2)
Cannula size
FiO2

15. Oxygenation during VA ECMO
Mixing blood b/t ECMO flow and blood pass heart and lungs
Hypoxic
Harlequin syndrome
VA access via femoral vessels

16. CO2 removal during ECMO Easier than oxygenation
CO2 clearance is more efficient than oxygen delivery
Lower ECMO blood flow
Sweep gas flow determine CO2 removal

17. Hemodynamics during VV ECMO
Hemodynamically neutral support

18. Hemodynamics during VA ECMO
Extracorporeal pump works in parallel with patient’s heart
Different arterial cannulation sites have some advantages and disadvantages

19. General hemodynamic changes
Loss of arterial flow pulsatility (flat arterial line)
Patient’s circulation is fully supported
Pulsatile > non-pulsatile
Pulsatility is the index of LV ejection
Reduction of preload: divert blood to ECMO circuit
Resting RV
Coronary arteries were perfused by deoxygenated blood
Increase in LV afterload
LV distension

20. Indication for Respiratory ECMO
Hypoxemic respiratory failure
50% mortality risk: PaO2/FiO2 < 150 on FiO2 > 90% and/or Murray score 2-3
80% mortality risk: PaO2/FiO2 < 100 on FiO2 > 90% and/or Murray score 3-4
CO2 retention despite of high Pplat (>30 cmH2O)
Severe air leak syndromes
Need for intubation in a patient on lung transplant list
Immediate cardiac or respiratory collapse.

21. Contraindications for Respiratory ECMO
MV at high settings ≥ 7 days (FiO2 > 0.9, Pplat > 30)
Major pharmacologic immunosuppression (ANC < 400)
CNS hemorrhage
Non recoverable co-mobidity such as terminal malignancy
Underlying diseases: Charlson score ≥ 7
Current condition: SOFA ≥ 18 (w/ GCS), ≥ 16 (w/o GCS)

22. Indication for ECMO in adult cardiac failure
Inadequate tissue perfusion despite adequate intravascular volume
Shock persists despite volume administration, inotropes and vasopressors and IABP
Typical causes: Acute MI, myocarditis, Peripartum cardiomyopathy, decompensated chronic heart failure, post cardiotomy shock
Septic shock is an indication in some centers

23. Complications Circuit related complications
Blood clots in circuits and thromboembolism
Gas embolism
Circuit fractures
Plasma leak
Patient related complications
Vascular complication: perforation, dissection, fistula, aneurysm
Leg ischemia: VA femoral a. cannulation
Bleeding, coagulopathy, ICH
Cardiac complications: tamponade, LV distension, pneumothorax

26. Q & A