Respiratory Medicine Series Editor: Sharon I.S Rounds Gregory A Schmidt Editor Extracorporeal Life Support for Adults Respiratory Medicine Series Editor : Sharon I.S Rounds More information about this series at http://www.springer.com/series/7665 Gregory A Schmidt Editor Extracorporeal Life Support for Adults Editor Gregory A Schmidt, MD Division of Pulmonary Diseases, Critical Care, and Occupational Medicine Department of Internal Medicine University of Iowa Iowa City, IA, USA ISSN 2197-7372 ISSN 2197-7380 (electronic) Respiratory Medicine ISBN 978-1-4939-3004-3 ISBN 978-1-4939-3005-0 (eBook) DOI 10.1007/978-1-4939-3005-0 Library of Congress Control Number: 2015950466 Springer New York Heidelberg Dordrecht London © Springer Science+Business Media New York 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Humana Press is a brand of Springer Springer Science+Business Media LLC New York is part of Springer Science+Business Media (www.springer.com) To William R Lynch, MD, who built and nurtured an outstanding program, exhibited remarkable vision in how to advance ECLS care, and opened my eyes to its new possibilities Preface Extracorporeal life support (ECLS) consists of using an external gas-exchanging membrane to support oxygenation or carbon dioxide removal (or both), at times including circulatory assistance ECLS has been used in severe hypoxemic respiratory failure (ARDS, pneumonia); diseases dominated by ventilatory failure such as status asthmaticus and COPD; cardiogenic shock; following cardiothoracic surgery complicated by circulatory or gas exchange failure; and as a bridge to lung transplant Historically, ECLS has been used sparingly, often as a last resort, and in few centers with the requisite expertise Three factors have combined to change this First, technological improvements in membranes, pumps, circuits, and cannulas have led to more efficient and safer ECLS Second, the CESAR trial has shown that, for adults with severe ARDS, referral to an ECLS center improves outcomes Finally, the adverse consequences of conventional management of lung failure, including ventilator-induced lung injury, ICU-acquired weakness, and nosocomial infection, have become abundantly clear Some of these may be ameliorated by using ECLS in preference to conventional care As perceptions of the role of ECLS have evolved, more practitioners and more centers are developing ECLS capability or positioning themselves to offer ECLS The aim of this book is to deliver a concise, evidence-based review of ECLS for adult disease Adult medicine (rather than neonatal and pediatric disease, where ECLS has an established but limited role) represents the growth area for ECLS Chapters are devoted to describing the complex physiology and technology; the evidence base in varied clinical conditions; how to obtain vascular access; daily management of the circuit and patient; guidance regarding the weaning and decannulation process; and recommendations for crisis management and rehabilitation related to ECLS The text concludes with a fascinating historical review, showing just how far we’ve come This text has been written for practicing physicians, nurses, perfusion specialists, therapists, and critical care trainees who are considering whether to refer their patients for ECLS, debating whether to offer ECLS capability to their patients, or are already providing ECLS but seek a practical reference to best practices and updated information It could never have been completed without the inspiration vii viii Preface from my colleagues at Iowa who strive daily to save the sickest patients; the trainees whose curiosity makes us all want to know more; my contributors who are at the forefront of a truly challenging field; and our publisher at Springer-Link who pushed for this important book Finally, I recognize all those who the hard work: the nurses, perfusionists, and therapists who dedicate their lives to the critically ill This is an exciting time, ripe with change and opportunity We seek a path forward for the benefit of all our patients Iowa City, IA, USA Gregory A Schmidt, MD Contents Physiology of Extracorporeal Life Support (ECLS) Matthew J Brain, Warwick W Butt, and Graeme MacLaren Hypoxemic Respiratory Failure: Evidence, Indications, and Exclusions Darryl Abrams, Matthew Bacchetta, and Daniel Brodie Cardiogenic Shock: Evidence, Indications, and Exclusions Nicolas Bréchot and Alain Combes ECCO2R in Obstructive Diseases: Evidence, Indications, and Exclusions Lorenzo Del Sorbo and V Marco Ranieri 61 73 87 ECLS as a Bridge to Lung Transplantation 105 Christian Kuehn Modes of ECLS 117 L Keith Scott and Benjamin Schmidt Vascular Access for ECLS 133 Steven A Conrad Circuits, Membranes, and Pumps 147 Bradley H Rosen Ventilator Management During ECLS 163 Antonio Pesenti, Giacomo Bellani, Giacomo Grasselli, and Tommaso Mauri 10 Daily Care on ECLS 181 Giles J Peek 11 Crises During ECLS 193 Cara L Agerstrand, Linda B Mongero, Darryl Abrams, Matthew Bacchetta, and Daniel Brodie ix 14 The Story of ECLS: History and Future 255 References Gibbon Jr JH, Miller BJ, Dobell AR, Engell HC, Voigt GB The closure of interventricular septal defects in dogs during open cardiotomy with the maintenance of the cardiorespiratory functions by a pump-oxygenator J Thorac Surg 1954;28(3):235–40 Gille JP, Bagniewski AM Ten years of use of extracorporeal membrane oxygenation (ECMO) in the treatment of acute respiratory insufficiency (ARI) Trans Am Soc Artif Intern Organs 1976;22:102–9 Gaffney AM, Wildhirt SM, Griffin MJ, Annich GM, Radomski MW Extracorporeal life support BMJ 2010;341:c5317 Dalton HJ, Butt WW Extracorporeal life support: an update of Rogers’ Textbook of Pediatric Intensive Care Pediatr Crit Care Med 2012;13(4):461–71 Froelich C Pediatric ECMO: old dog or new trick? 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2005 p 1–27 86 Kanto WP, Shapiro MB The development of prolonged extracorporeal circulation In: Zwishcenberger JB, Steinhron RH, Bartlett RH, editors ECMO: Extracorporeal cardiopulmonary support in critical care 2nd ed Extracorporeal Life Support Organization; 2000 87 Morris AH, Wallace CJ, Menlove RL, Clemmer TP, Orme Jr JF, Weaver LK, et al Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome Am J Respir Crit Care Med 1994;149(2 Pt 1): 295–305 14 The Story of ECLS: History and Future 259 88 Zwischenberger JB, Lynch JE Will CESAR answer the adult ECMO debate? Lancet 2009;374:1307–8 89 Sadahiro T, Oda S, Nakamura M, Watanabe E, Abe R, Nakada TA, et al Trends in and perspectives on extracorporeal membrane oxygenation for severe adult respiratory failure Gen Thorac Cardiovasc Surg 2012;60:192–201 90 Flörchinger B, Philipp A, Klose A, Hilker M, Kobuch R, Rupprecht L, et al Pumpless extracorporeal lung assist: a 10-year institutional experience Ann Thorac Surg 2008;86(2):410– discussion 417 91 Kolla S, Awad SS, Rich PB, Schreiner RJ, Hirsch RB, Bartlett RH Extracorporeal life support for 100 adult patients with severe respiratory failure Ann Surg 1997;226:544–64 discussion 65–66 92 Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial Lancet 2009;374:1351–63 93 Ketoconazole for early treatment of acute lung injury and acute respiratory distress syndrome: a randomized controlled trial The ARDS Network JAMA 2000;283(15): 1995–2002 94 Eisner MD, Thompson T, Hudson LD, Luce JM, Hayden D, Schoenfeld D, et al Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung injury and the acute respiratory distress syndrome Am J Respir Crit Care Med 2001;164(2): 231–6 95 Davies A, Jones D, Balley M, Beca J, Bellomo R, Blackwell N, et al Extracorporeal membrane oxygenation for 2009 Influenza A (H1N1) acute respiratory distress syndrome JAMA 2009;302:1888–95 96 Freed DH, Henzler D, White CW, Fowler R, Zarychanski R, Hutchison J, et al Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada Can J Anaesth 2010;57:240–7 97 Roch A, Lepaul-Ercole R, Grisoli D, Bessereau J, Brissy O, Castanier M, et al Extracorporeal membrane oxygenation for severe influenza A (H1N1) acute respiratory distress syndrome: a prospective observational comparative study Intensive Care Med 2010;36:1899–905 98 Pappalardo F, Pieri M, Greco T, Patroniti N, Pesenti A, Arcadipane A, et al Predicting mortality risk in patients undergoing venovenous ECMO for ARDS due to influenza A (H1N1) pneumonia: the ECMO net score Intensive Care Med 2013;39:275–81 99 Bartlett RH Esperanza: presidential address Trans Am Soc Artif Intern Organs 1985;31(1): 723–6 100 Mortensen JD Extracorporeal membrane oxygenation for pulmonary assist in patients with ART Chest 1975;67(1):29–30 101 Bartlett RH, Andrews AF, Toomasian JM, Haiduc NJ, Gazzaniga AB Extracorporeal membrane oxygenation for newborn respiratory failure: forty-five cases Surgery 1982;92(2): 425–33 102 Ware JH Investigating therapies of potentially great benefit: ECMO Statist Sci 1989;4(4):298–306 103 Bartlett RH, Roloff DW, Cornell RG, Andrews AF, Dillon PW, Zwischenberger JB Extracorporeal circulation in neonatal respiratory failure: a prospective randomized study Pediatrics 1985;76:479–87 104 O’Rourke PP, Crone RK, Vacanti JP, Ware JH, Lillehei CW, Parad RB, et al Extracorporeal membrane oxygenation and conventional medical therapy in neonates with persistent pulmonary hypertension of the newborn: a prospective randomized study Pediatrics 1989;84: 957–63 105 UK Collaborative ECMO Trial Group UK collaborative randomized trial of neonatal extracorporeal membrane oxygenation Lancet 1996;348(9020):75–82 106 Bartlett RH, Harken DE Instrumentation for cardiopulmonary bypass—past, present, and future Med Instrum 1976;10(2):119–24 260 J.A Morris et al 107 Bartlett RH Extracorporeal life support: history and new directions ASAIO J 2005; 51(5):87–9 108 Friedman DF, Montenegro LM Extracorporeal membrane oxygenation and cardiopulmonary bypass In: Handbook of pediatric transfusion medicine; 2004 p 181–9 109 Green TP, Timmons OD, Fackler JC, Moler FW, Thompson AE, Sweeney MF The impact of extracorporeal membrane oxygenation on survival in pediatric patients with acute respiratory failure Pediatric Critical Care Study Group Crit Care Med 1996;24(2):323–9 110 Moler FW, Custer JR, Bartlett RH, Palmisano JM, Akingbola O, Taylor RP, et al Extracorporeal life support for severe pediatric respiratory failure: an updated experience 1991–1993 J Pediatr 1994;124(6):875–80 111 Kreider M, Hadjiliadis D, Kotloff RM Candidate selection, timing of listing, and choice of procedure for lung transplantation Clin Chest Med 2011;32(2):199–211 112 Singer JP, Blanc PD, Hoopes C, Golden JA, Koff JL, Leard LE, et al The impact of pretransplant mechanical ventilation on short- and long-term survival after lung transplantation Am J Transplant 2011;11(10):2197–204 113 Diaz-Guzman E, Davenport DL, Zwischenberger JB, Hoopes CW Lung function and ECMO after lung transplantation Ann Thorac Surg 2012;94:686–94 114 Cypel M, Keshavjee S Extracorporeal life support as a bridge to lung transplantation Clin Chest Med 2011;32:245–51 Index A Activated clotting time (ACT), 185, 189 Acute hypercapnic respiratory failure, 36, 95, 96 Acute myocardial infarction, 75 Acute myocarditis, 76–77 Acute respiratory distress syndrome (ARDS), 202, 206 CESAR, 246 Cilley test, 224 conventional therapies, 245–246 ECCO2R, 175, 176 ECMO support, 224 extracorporeal CO2 removal, 245 HFOV, 171 iNO, 170 lung function, 224–225 mechanical ventilation early ECMO phase, 166 lung recruitment and lung rest, 166–167 venoarterial (VA) mode, 167–168 prone positioning, 169, 170 randomized ECMO trial, 245 RNs and RRTs, 245 treatment protocol, 245 VA-ECMO support, 224–225 VV ECMO treatment, 246 weaning ECLS, 226 Adenosine triphosphate (ATP) molecules, Aerobic and anaerobic metabolism, 3, Airway pressure release ventilation (APRV), 172 Ambulatory, 214–215 APRV See Airway pressure release ventilation (APRV) ARDS See Acute respiratory distress syndrome (ARDS) Arteriovenous carbon dioxide removal (AVCO2R) configuration, pumpless system, 128, 129 mathematical simulation, 128 pH and PaCO2, 128, 129 ASD See Atrial septal defect (ASD) Assisted mode, ventilation, 172 Asthma AVCO2R, 128 hospital and intensive care unit, 96 MV, progressive hypercapnia, 98 near-fatal asthma refractory, 99 respiratory system mechanics, 98, 99 severe respiratory acidosis, 98 treatment, 96 Atrial septal defect (ASD), 234, 237 AVCO2R See Arteriovenous carbon dioxide removal (AVCO2R) Axial flow pumps, 42 B Barotrauma, 174, 175 Bernoulli equation, 45 Blood flow for gas transfer Bernoulli equation, 50 conservation of energy, ECMO circuit, 50–52 membrane oxygenator, 48 oxygenator as resistor, 49–50 Reynolds number, 51 laminar flow, resistance to, 46–47 Reynolds number, 47–48 turbulent flow, 47 © Springer Science+Business Media New York 2016 G.A Schmidt (ed.), Extracorporeal Life Support for Adults, Respiratory Medicine 16, DOI 10.1007/978-1-4939-3005-0 261 262 Blood pump positive displacement pumps, 41 roller pumps, 41 velocity pumps, 42 Bohr effect, 19 Bridge to transplant (BTT) age and co-morbidities, 109 bridge to recovery, 110 chronic bronchiolitis, 108 mechanical ventilation, 109, 111–112 organ donation, 110 physical therapy, 215 pulmonary fibrosis, 108 pulmonary hypertension, 111 sarcoidosis, 108 BTT See Bridge to transplant (BTT) C Cannulation, vascular access bleeding, 144 configurations arteriovenous, 142 low-flow venovenous, 142 transthoracic, 142–143 venoarterial, 141 veno-arterio-venous, 142 venovenous, 141 decannulation, 143 extracorporeal support (see Extracorporeal support, cannulation) inadequate flow, 144–145 infection, 145 insertion technique open surgical, 139–140 percutaneous, 138–139 semi-open, 139 limb ischemia, 144 patient preparation infection control, 137–138 vessel size, 137 recirculation, 143 vascular injury, 144 Carbon dioxide partial pressure blood pump, types, 41, 42 ECCO2R, 36–40 extracorporeal blood path, 41 Carbon dioxide transport arteriovenous, 34–35 carbamino carriage, 34–35 carbonic anhydrase, 34 hydrogen ion concentration, effect, 32–34 in solution, 31–32 Carbonic anhydrase, 34 Index Cardiopulmonary bypass (CPB) ASD, 234 autogenous lungs, 237 canine experimentation models, 237 congenital heart defects, 234 cross-circulation method, 237 Gibbon’s heart-lung machine model, 234, 236 human donors’ lungs, 237 John Gibbon, 234, 236 lung transplantation, 113 magnitude, 236 pulmonary edema, 237 timeline, ECMO development, 234, 235 Cardiorespiratory function, 1–2 Cardiotoxic drug intoxication, 77 Cellular metabolism aerobic and anaerobic metabolism, glycolysis, 3–5 CESAR See Conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR ) Chronic obstructive pulmonary disease (COPD) alveolar hyperinflation, 93 dynamic lung hyperinflation, 96 endotracheal intubation, 95 exacerbation, 93 femoral artery pseudoaneurysm, 95 heparin-induced thrombocytopenia, 95 hypercapnic respiratory failure, 96 indications, exclusions and goals, 96, 97 invasive strategies, respiratory support, 94 ventilator-induced diaphragmatic dysfunction, 94 Circuit air blood and fibrin, 194–195 cardiotomy reservoir, 195 cavitation, 194 diagnosis and management, 196–197 pre-oxygenator, 194 tubing, 195 Circuit crises circuit air, 194–197 heat exchanger, 200 inadvertent decannulation, 200–201 oxygenator failure, 199 pump failure, 199–200 thrombosis, 197–198 tubing rupture/cannula fracture, 200 Circuits air entrainment and gas embolism, 148 antibiotics, sedatives and analgesics, 149 artery and vein, 150 Index blood flow, 151 cannulas and tubing, 152 cellular deposition, 149 centrifugal pump, 150 complex circuit design, 148 compliance chamber, 152 components and connectors, 148 dual-lumen cannulas, 150 heat exchanger and heater-cooler, 158–159 inflow and outflow cannulas, 151 length and complexity, 149 medications and anticoagulant agents, 151 membrane oxygenators, 154–157 outflow cannula, 150 polymethylpentene (PMP) oxygenators, 149 ports, 151 pressure, 151 priming, 149–150 pumps, 152–154 renal replacement therapy, 147, 148 spectrophotometric sensors, 151 surface coatings, 158 ultrasound probes, 151 Coefficient of ultrafiltration, 16–17 Colour flow Doppler techniques, 45–46 Complications BTT, 109, 110 cannulation, 143–145 catastrophic, 215 ECCO2R, 89, 94–96 ECMO, 80 hemorrhagic, 201 HFOV, 171 LV distension, 125 postcardiotomy, 77 prone positioning, 169–170 vessel laceration/transection, 137 Constrained vortex pumps, 42 Continuous venovenous hemofiltration (CVVH), 142, 183, 185, 188–189 Conventional medical therapy (CMT), 235, 249 Conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR ), 65, 66, 202, 212, 246 COPD See Chronic obstructive pulmonary disease (COPD) CPB See Cardiopulmonary bypass (CPB) CVVH See Continuous venovenous hemofiltration (CVVH) 263 D Decannulation gas exchange, 229–230 inadvertent, 200–201 respiratory function, ventilator, 230 trialing-off, 229 and weaning (see Weaning and liberation, ECMO) Diffusion of gas molecules into liquid phase biophysics of membrane oxygenation, 12–13 concentration of gases in solutions, 10–11 Fick’s Law of Diffusion, 12 porous media, 13 respiratory gases in solution, solubility of, 11–12 transport of gases blood pressure and systemic vascular resistance, 14 effect of turbulence and haematocrit, 16–17 Fick’s Law, 13 Henry’s Law, 13 membrane exposure time, 14 relative flow direction, 15 Double-lumen cannula (DLC), 244, 251 E ECCO2-R See Extracorporeal carbon dioxide removal (ECCO2-R) ECLS configuration, VAV See Veno-arteriovenous (VAV) ECLS ECLS crises bleeding and transfusions adverse events, 202 anticoagulation, 202, 203 bronchoscopy, 203 diagnosis and management, 204–205 hemoglobin, 202–203 hemorrhagic complications, 201 patient management, 202 thrombocytopenia, 203 thrombosis, 203 circuit air, 194–197 heat exchanger, 200 hemolysis, 203, 205 inadvertent decannulation, 200–201 oxygenator failure, 199 pump failure, 199–200 refractory hypoxemia, 206–207 shock, 207 264 ECLS crises (cont.) thrombosis, 197–198 tubing rupture/cannula fracture, 200 ECLS emergencies circuit-related, 194–201 patient-related, 201–207 ECMO See Extracorporeal membrane oxygenation (ECMO) ECMO configuration See Types of ECMO ECMO hybrids See Veno-arterio-venous (VAV) ECLS ECPR See Extracorporeal cardiopulmonary resuscitation (ECPR) ELSO See Extracorporeal Life Support Organization (ELSO) ELSO registry charter meeting, 252–253 number of active ECLS centers, 252, 253 overall patient outcomes, 254 Erythrocyte metabolism, 7–8 EVLP See Ex-vivo lung perfusion (EVLP) Extracorporeal carbon dioxide removal (ECCO2-R) acute severe asthma, 96–99 and alveolar oxygen concentrations, 39–40 ARDS, 88, 245 arteriovenous (AV) bypass, 88 asthma, 90 blood flow rates, 63 requirements, 36–37 clinical indications and exclusion criteria, 90 configurations, 88, 89 COPD, 90 integration with pulmonary oxygenation, 38 Pubmed, 87, 88 pumpless arteriovenous, 157 recirculation, 37–38 technological progress and marketing, 88 trinsic-PEEP, 90 ventilation strategies, 38–39 Extracorporeal cardiopulmonary resuscitation (ECPR) application, 244 and ECMO, 75–76 VA cardiopulmonary bypass, 244 Extracorporeal gas exchange, 14, 87, 89, 164, 175–176 Extracorporeal life support (ECLS) ACT, 185 blood film, 237–238 cerebral vasoconstriction, 184 clinical improvement, 190 connector joining, 182 Index CPB (see Cardiopulmonary bypass (CPB)) DeWall-Lillehei bubble oxygenator, 238 direct-contact extracorporeal oxygenators, 239 disease, 233 drainage cannula, 181 ECMO, 233 excessive pressure, 183 feeding and gastrointestinal tract, 188 hard-shell device, 239 heart, 188 hematology, anticoagulation and transfusion, 189–190 hemodilution, 239 hypotension, 184 inhaled prostacyclin/nitric oxide, 184 inlet pressure, 184 kidneys, 188–189 lung management, 186–187 lung transplantation, 105–114 management phase, 185 Mayo-Gibbon pump oxygenator, 238 metal film oxygenator, 237 morbidity and mortality, 239 oxygenator, 183 polymethylpentene membranes, 183 pressure-controlled ventilation, 184 pump, 182 robust communication, 181 rotating disc oxygenator, 239 sedation, 187 Sigma motor pump, 238 single and double-lumen cannulae, 184 sweep gas flow and FIO2 selector, 183 transparent film dressing, 181–182 venoarterial (VA), 182 veno-arterio-venous (VAV), 185 venous compliance chamber, 182 venovenous (VV), 185 water heater function, 183 Extracorporeal Life Support Organization (ELSO), 193, 201 Extracorporeal membrane oxygenation (ECMO) acute myocardial infarction, 75 for acute myocarditis, 76–77 acute respiratory failure, 163 advantages, 73 ARDS (see Acute respiratory distress syndrome (ARDS)) avoidance of intubation, 173 cavitation, 52 complications, 80 configurations, conservation of energy, 50–51 Index decannulation, 229–230 disconnection, 173 and drug intoxication, 77 and ECPR, 75–76 flow management, 227 flow regurgitation, 52 and heart transplantation, 77–78 high airway pressures and high tidal volumes, 164 LVAD implantation, 78 and massive pulmonary embolism, 79 microporous devices, 242 nonmicroporous devices, 242–243 occlusion of flow path, 51–52 outcomes after VA-ECMO, 80–81 oxygenation, 164–165 patient and disease-specific issues configurations and cannulation strategies, 74 retrieval units, 74–75 VA-ECMO indication, 74 PECOR, 174–176 PGD, 252 postcardiotomy cardiogenic shock, 77 and profound hypothermia, 79 refractory septic shock, 79 termination of ECLS, 230–231 VA ECMO, 243–244 VV ECMO, 244 Extracorporeal support, cannulation blood flow, 135–137 dual-lumen bicaval design (Avalon Elite®, Maquet), 134, 135 cavo-atrial design (OriGen®, OriGen Biomedical), 134 hemodialysis catheter, 135 percutaneous cannula, 133–134 single lumen design, 134 wire-reinforced cannulas, 134 Ex-vivo lung perfusion (EVLP), 113 F “Flashing the cannulae”, 228 Frank-Starling mechanism, 56 G Glycolysis ATP molecules, glycogen storage, 3–4 intracellular metabolism, TCA cycle, 265 H Haemoglobin arterial oxygen saturations, 27 oxygen affinity, 19 venous oxygen saturation, 28 Haldane effect, 19 Heart transplantation, 77–78 Heat exchanger, 200 Hemolysis, 202, 205 Hemorrhage, 201, 202 Henry’s Law, 11 Heparin-induced thrombocytopenia (HIT), 158, 189, 196–198 High-frequency oscillatory ventilation (HFOV), 170–171 HIT See Heparin-induced thrombocytopenia (HIT) Hydrogen ion concentration, 32–34 Hypercapnic acidosis, 39 Hypovolemia, 155 Hypoxemia, 208–209 I IABP See Intra-aortic balloon pump (IABP) iLA See Interventional lung assist (iLA) Inadvertent decannulation, 200–201 Interventional lung assist (iLA), 107 Intra-aortic balloon pump (IABP), 125, 128 L LAS system See Lung allocation scoring (LAS) system Left ventricular assist devices (LVAD), 2, 53–54 Left ventricular end diastolic pressure (LVEDP), 56–57 Liberation, 218 See also Weaning and liberation, ECMO Limb ischemia, 144 Lung allocation scoring (LAS) system, 250 Lung transplantation bleeding, hemolysis and infection, 105 bridge to decision, 111 BTT (see Bridge to transplant (BTT)) centrifugal pumps, 106 complications, 110 diseases, 250 DLC, 251 iLA, 107 intraoperative VA-ECLS, 112 intubation, 110 LAS system, 250–251 mechanical ventilation, 106, 111–112 266 Lung transplantation (cont.) mobilization, 110 organ preservation, 113–114 oxygen exchange, 106 physical therapy and potentially ambulation, 251–252 postoperative ECLS, 112–113 post-traumatic ARDS, 106 primary diagnosis, 109 pulmonary failure, 111 pulmonary hypertension, 111 right heart problems, 109 right ventricular failure, 111 technical complications, 105 technical developments, 106 VA-ECLS, 108 VV-ECLS, 107–108 VV ECMO, 250 LVAD See Left ventricular assist devices (LVAD) M Massive pulmonary embolism, 79 Mayo-Gibbon pump oxygenator, 238 Mechanical ventilation, ARDS early ECMO phase, 166 lung recruitment and lung rest, 166–167 venoarterial (VA) mode, 167–168 Membrane exposure time, 14 Membrane oxygenation biophysics, 12–13 extra-capillary flow, heat loss, 10 hollow fibre oxygenators, 8–9 Membrane oxygenators blood and gas phases, 154 carbon dioxide transfer, 155 circuit pressures, 155, 156 delta pressure, 156 extra-capillary blood flows, 154 oxygen transfer, 154–155 plasma leak, 154, 157–158 PMP and polypropylene hollow-fiber membranes, 154 PMP oxygenators, 155–157 polypropylene hollow-fiber, 157 rated flow, 157 secondary flows, 154 thrombosis, 156 Metabolism aerobic and anaerobic, 3–5, 12 cellular, 3–5 Index erythrocyte, 7–8 in stressed state, 6–7 Mobilization ambulatory, 214–215 barriers, 215–216 early, 213–214 health costs of immobility, 212–213 myopathy and weakness, 213 team and methods ambulation, 219 caregivers, 217 complexity, 217–218 cycle ergometry, 219 physical activity, 218–219 responsibilities, 218 technological advances, 211–212 weaning, 214 Modes of ECLS AVCO2R, 128–129 VA, 117, 118, 122–125 VAV, 126–128 VV, 118–122 N Neonatal acute respiratory distress syndrome arterial pO2, 246, 247 CMT, 249 Esperanza’s lung function, 247, 248 “play-the-winner” strategy, 248–249 PPHN, 248 randomized clinical trial, 248 O Obstructive diseases acute severe asthma, 96–99 ARDS, 88 COPD, 93–96 dynamic alveolar hyperinflation, 90 exclusions, 99–100 expiratory flow-limitation, 90 extracorporeal life support strategies, 87 NIV, 90 pathophysiological mechanisms, 90–92 respiratory acidosis, 90 Organ care system (OCS), 113–114 Osmotic diuresis, Outcome assessment, after VA-ECMO, 80–81 Oxygenator failure, 199 Oxygen carriage cardiac output, arterial saturations, 23–25 effect of oxygen carrying capacity, 26 haemoglobin oxygen affinity, 17–19 267 Index mixed-venous saturation, 26, 29 oxygen-haemoglobin dissociation curve, 19–23 recirculation, 28 venous oxyhaemoglobin saturation, 30 VO2 and cardiac output, 26 VV-ECMO, 27–28, 30 Oxygen-haemoglobin dissociation curve, 18 oxygen partial pressures, 20–21 right-shifted curve, 20 VV-ECMO and oxygen transport, 21–23 Oxygen transport, 17 Oxyhemoglobin saturation, 30 P Partial extracorporeal CO2 removal (PECOR) barotrauma, 174, 175 bilateral pleurectomy, 174 clinical application, 174 ventilatory control, 174–176 Passive oxygenation, 39 Patent ductus arteriosus (PDA), 237 Patient crises bleeding and transfusions adverse events, 202 anticoagulation, 202, 203 bronchoscopy, 203 diagnosis and management, 204–205 hemoglobin, 201–203 hemorrhagic complications, 201 patient management, 202 thrombocytopenia, 203 thrombosis, 203 hemolysis, 203, 205 refractory hypoxemia, 206–207 shock, 207 Patient-ventilator interaction, 172 PECOR See Partial extracorporeal CO2 removal (PECOR) Pediatric acute respiratory distress syndrome, 249–250 PEEP See Positive end-expiratory pressure (PEEP) Persistent pulmonary hypertension of the newborn (PPHN), 248 Physical therapy, mobilization ambulation, 214, 215 bridge-to-transplant, 215 intubation, 213 resources, ICU, 217 Positive end-expiratory pressure (PEEP) airway pressures, 166 ECCO2R, 174 levels, 167 ventilation, 38–39, 167, 168 VILI, 169 Postcardiotomy cardiogenic shock, 77 Primary graft dysfunction (PGD), 252 Profound hypothermia, 79 Pulmonary hypertension, 39 Pumps centrifugal, 153–154 failure, 199–200 roller head, 153 velocity (see Velocity pumps) R Rapoport-Luebering shunt, Registered nurses (RNs), 245 Registered respiratory therapists (RRTs), 245 Rehabilitation, 214, 216 Renal replacement therapy (RRT), 151 Respiratory quotient (RQ), 5–6 Respiratory system compliance (Crs), 172 Reynolds number, 47–48 Right ventricular assist devices (RVAD), RNs See Registered nurses (RNs) RRT See Renal replacement therapy (RRT) RRTs See Registered respiratory therapists (RRTs) RVAD See Right ventricular assist devices (RVAD) S Septic shock, 79 Shock, 207 Silicone rubber membrane lungs (SRML) alveolar membrane, 240 extracapillary orientation, 241 gas exchange, 240–241 helical tube arrangement, 241 hemodialysis machine design, 240 heparin, 242 hypobaric oxygenation, 241 incorporate hydrophobic materials, 240 intracapillary orientation, 241 limitations, 239 O2 and CO2, 240 SRML See Silicone rubber membrane lungs (SRML) Systematic review, 99, 150 Systemic inflammatory response syndrome (SIRS), 268 T TCA See Tricarboxylic acid (TCA) cycle Termination, ECLS ARDS, 230 critical care, 230 treatment goals, 231 withdrawal of life-sustaining device, 231 Thrombosis, 197–198 Total parenteral nutrition (TPN), 188 Transplant team See Lung transplantation Trialing-off, 225 decannulation, 229 VA-ECMO, 228 VV-ECMO, 228–229 Tricarboxylic acid (TCA) cycle, Turbulence and haematocrit gas exchange membrane, 16 resistances to diffusive transport, 16 ultrafiltration of plasma water, 16–17 Types of ECMO VA ECMO, 243–244 VV ECMO, 244 U Ultrafiltration rate, 17 United Network of Organ Sharing (UNOS), 250 V VADs See Ventricular assist devices (VADs) VA ECLS See Venoarterial (VA) ECLS Vascular access See Cannulation, vascular access VAV ECLS See Veno-arterio-venous (VAV) ECLS Velocity pumps systemic circulation thrombus formation, 58 VADs, 53–54 VA-ECMO, 55–56 ventricular preload vs device preload, 56–58 types axial flow pumps, 42 centrifugal constrained vortex pumps, 42 monitoring pump output, 42 Venoarterial (VA) ECLS advantages, 117, 118, 125 antegrade perfusion catheter, 122, 125 blood pressures, 125 circulatory effect, 123 IABP, 125 intraoperative, 112 Index ischemia-reperfusion damage, 112–113 local anesthesia, 108 neonates and infants, 122, 123 older children and adults, 122, 125 oxygenation and carbon dioxide elimination, 122–123 pulmonary hypertension, 108, 110, 111 respiration and circulation, 122 right-sided heart failure, 109 stroke, 123, 125 Veno-arterial ECMO (VA-ECMO) differential cyanosis, 55–56 flow reversal, 55 valvular incompetence, 56 Veno-arterio-venous (VAV) ECLS cardiac dysfunction, 128 configuration, 126–127 IABP, 128 partially occlusive clamp, 127 Venous oxyhaemoglobin saturation, 30 Venovenous (VV) ECLS, 107–108 advantages, 117, 118, 121–122 dual-lumen cannulation, 119–120 inferior (IVC) and superior (SVC) vena cavae, 118–119 physiological implications, 120–121 Veno-venous ECMO (VV-ECMO) arterial oxygen saturations, 27 oxygenation, 30 and oxygen transport access configurations, 22 anaerobic metabolism, 23 arterial (SaO2) and venous oxygen saturations (SvO2), 23–25 cardiac output, 21–22 ECMO circuit, 22 mixing blood streams, 23 oxyhaemoglobin dissociation curve, 23 venous haemoglobin oxygen saturation, 23 physiology, 30 recirculation, 28 venous saturations, 27, 28 Ventilator-induced lung injury (VILI) ARDS, 175 description, 164 prevention, 166 prone positioning, 169, 170 Ventilator management ARDS (see Acute respiratory distress syndrome (ARDS)) assisted mode, 172 avoidance of intubation, ECMO, 173 disconnection, 173–174 269 Index gas exchange carbon dioxide (CO2), 165 oxygenation, 164–165 PECOR, 174–176 rescue therapies, hypoxemia HFOV, 171 inhaled NO (iNO), 170 pneumothoraces, 171 prone positioning, 168–170 Ventricular assist devices (VADs), 53–54 Ventricular preload vs device preload Frank-Starling mechanism, 56 inflow cannula, 57 LVEDP, 56–57 mitral inflow restriction, 58 right ventricular function and pulmonary haemodynamics, 58 Ventricular septal defect (VSD), 237 VILI See Ventilator-induced lung injury (VILI) Viscoelasticity fluid and conduit, 44–46 relative viscosity of blood, 43–44 viscous friction, 44 vortex centrifugal pumps, 43 VSD See Ventricular septal defect (VSD) VV ECLS See Venovenous (VV) ECLS W Weaning and liberation, ECMO, 94, 96, 110, 172, 214 anticoagulation management, 228 cardiopulmonary assessment, 228–229 ECMO flow management, 227–228 oxygenator sweep gas flow management, 227 in ventilated ARDS patient, 226 ventilator management, 225–227 ... may be ameliorated by using ECLS in preference to conventional care As perceptions of the role of ECLS have evolved, more practitioners and more centers are developing ECLS capability or positioning... themselves to offer ECLS The aim of this book is to deliver a concise, evidence-based review of ECLS for adult disease Adult medicine (rather than neonatal and pediatric disease, where ECLS has an established... are considering whether to refer their patients for ECLS, debating whether to offer ECLS capability to their patients, or are already providing ECLS but seek a practical reference to best practices