ECMO in the Adult Patient
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ECMO in the Adult Patient
Alain Vuylsteke, BSc, MA, MD, FRCA, FFICM
Consultant in Intensive Care and Clinical Director
Papworth Hospital Cambridge, UK
Daniel Brodie, MD
Associate Professor of Medicine
Columbia University College of Physicians and Surgeons
New York-Presbyterian Hospital
New York, NY, USA
Alain Combes, MD, PhD
Professor of Intensive Care Medicine
University of Paris, Pierre et Marie Curie
Senior Intensivist at the Service de Réanimation Médicale Institut de
Cardiologie
Hôpital Pitié-Salpêtrière
Paris, France
Jo-anne Fowles, RGN
Lead ECMO Nurse
Papworth Hospital
Cambridge, UK
Giles Peek, MD, FRCS CTh, FFICM
Professor and Chief of Pediatric Cardiac Surgery
ECMO Director
The Children’s Hospital of Montefiore
New York, NY, USA
University Printing House, Cambridge CB2 8BS, United Kingdom
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Information on this title: www.cambridge.org/9781107681248
© Alain Vuylsteke, Daniel Brodie, Alain Combes, Jo-anne Fowles, Giles Peek 2017
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2017
Printed in the United Kingdom by TJ International Ltd, Padstow, Cornwall
A catalogue record for this publication is available from the British Library
ISBN 978-1-107-68124-8 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
CONTENTS
Note from the authors page vii
List of abbreviations viii
A patient testimony: I survived ECMO x
1 A brief history of ECMO 1
2 An ECMO service 9
3 The ECMO circuit 25
4 Monitoring the patient on ECMO 58
5 Case selection 68
6 Cannulation and decannulation 96
7 Coagulation, blood and ECMO 119
8 Management of the patient on veno-venous
ECMO: general principles 141
9 Management of the patient on veno-arterial
ECMO: general principles 153
10 Patient transfer 159
11 Liberation from ECMO 165
vi Contents
12 Specifics of intensive care management for
the patient on ECMO 171
13 Extracorporeal carbon dioxide removal or ECCO2R 197
14 ECMO to support organ donation 204
15 ECMO registries and research 207
Appendix: The future of ECMO 209
Index 210
NOTE FROM THE AUTHORS
This book is about ECMO in the adult patient. The adult patient
can be defined in many ways but we have arbitrarily chosen
someone older than 16 years and, more importantly in relation
to the discussed technology, heavier than 20 kg.
We would like to acknowledge the contributions of: Dr
Mindaugus Balciunas, UK; Dr Richard Porter, UK; Dr Mathieu
Schmidt, France; and Dr Martin Besser, UK.
ABBREVIATIONS
ACT activated coagulation time
AKI acute kidney injury
anti-Xa anti-factor Xa
APR activated prothrombin time ratio
aPTT activated prothrombin time
ARDS acute respiratory distress syndrome
CO2 carbon dioxide
CPR cardiopulmonary resuscitation
CT computed tomography
DCD donation after cardiac death
ECCO2R extracorporeal CO2 removal
ECMO extracorporeal membrane oxygenation
ECMONet International ECMO Network
eCPR extracorporeal cardiopulmonary resuscitation or
ECMO-assisted cardiopulmonary resuscitation
ELSO Extracorporeal Life Support Organization
FiO2 fraction of inspired oxygen
HbS sickle cell haemoglobin
HIT heparin-induced thrombocytopenia
HLA human leukocyte antigen
ICU intensive care unit
INR international normalized ratio
List of abbreviations ix
LMWH low-molecular-weight heparin
O2 oxygen
PaCO2 partial pressure of CO2 in the arterial blood
PaO2 partial pressure of O2 in arterial blood
PEEP positive end-expiratory pressure
RRT renal replacement therapy
A PATIENT TESTIMONY: I SURVIVED ECMO
It is somewhat challenging to define with precision what could
facilitate your journey to recovery, as there is no precedent in
your life. You are intensely searching for an invisible marker,
a destination you seek but cannot see on the horizon.
Meeting with some of the doctors, nurses and
physiotherapists who looked after me was a very unique and
special experience. Being able to put a face to the names I had
heard of so often started to anchor me in this part of my life
I could not access before. It also allowed me to say thank you in
person, a pivotal part of the healing process, because I was
physically there, unsupported by any machine and quite well
recovered in fact.
Although without any recollection of the hospital,
I suspected that I had probably ‘recorded’ many sounds of
intensive care without realizing it. This was confirmed when
I was able to hear an ECMO alarm: the reaction, although
slow coming, was strong. This is my only memory, my very
own, and I do hold it surprisingly dear. It is an oddly
reassuring sensation because it acts as the explanation, if not
the actual validation, of everything that has happened since.
It almost gives a logical meaning to the last 30 or so months
of my life.
A patient testimony: I survived ECMO xi
Even more noteworthy was the utterly inspired decision to
bring me to the bed of a lady undergoing ECMO. This was what
I very much needed but was too shy to ask for. I felt
overwhelmed and a bit amazed, but I was not frightened in any
way. It made me realize how far I had come.
It has proved to be a truly cathartic experience for me. It is
vastly important to encourage patients to return, because it is
a milestone not only in their journey of healing but in their
quest for acceptance too.
Someone told me once that I was brave; I do not think this is
true. You either sink or swim. I did not have a choice, that is all.
Strangely, it makes things simpler and therefore easier to get on
with.
I also believe that you never know what you are really
capable of until you are challenged to show it. If you never are,
you are blessed, truly.
If, however, the dice is cast the other way, there is still one
option left:
Fight back. It is worth it.
A PATIENT TESTIMONY: I SURVIVED ECMO
It is somewhat challenging to define with precision what could
facilitate your journey to recovery, as there is no precedent in
your life. You are intensely searching for an invisible marker,
a destination you seek but cannot see on the horizon.
Meeting with some of the doctors, nurses and
physiotherapists who looked after me was a very unique and
special experience. Being able to put a face to the names I had
heard of so often started to anchor me in this part of my life
I could not access before. It also allowed me to say thank you in
person, a pivotal part of the healing process, because I was
physically there, unsupported by any machine and quite well
recovered in fact.
Although without any recollection of the hospital,
I suspected that I had probably ‘recorded’ many sounds of
intensive care without realizing it. This was confirmed when
I was able to hear an ECMO alarm: the reaction, although
slow coming, was strong. This is my only memory, my very
own, and I do hold it surprisingly dear. It is an oddly
reassuring sensation because it acts as the explanation, if not
the actual validation, of everything that has happened since.
It almost gives a logical meaning to the last 30 or so months
of my life.
A patient testimony: I survived ECMO xi
Even more noteworthy was the utterly inspired decision to
bring me to the bed of a lady undergoing ECMO. This was what
I very much needed but was too shy to ask for. I felt
overwhelmed and a bit amazed, but I was not frightened in any
way. It made me realize how far I had come.
It has proved to be a truly cathartic experience for me. It is
vastly important to encourage patients to return, because it is
a milestone not only in their journey of healing but in their
quest for acceptance too.
Someone told me once that I was brave; I do not think this is
true. You either sink or swim. I did not have a choice, that is all.
Strangely, it makes things simpler and therefore easier to get on
with.
I also believe that you never know what you are really
capable of until you are challenged to show it. If you never are,
you are blessed, truly.
If, however, the dice is cast the other way, there is still one
option left:
Fight back. It is worth it.
Chapter 1
A brief history of ECMO
Starting point
Extracorporeal membrane oxygenation (ECMO) support is
a form of extracorporeal life support. ECMO is not a treatment
and does not correct the underlying pathological insult.
The technology is a direct extension from cardiopulmonary
bypass and the heart–lung machine used in cardiac surgery.
Extracorporeal life support technologies include other
devices, such as dialysis, continuous haemofiltration and
ventricular assist devices
Table 1.1 lists the main events that contributed to the
development of ECMO. Early attempts at mixing gas and blood
were hindered by thrombus (blood clot) formation.
The discovery of heparin at the start of the 20th century
circumvented this obstacle. Various devices to allow mixing of
gas and blood were developed, with the bubble oxygenator
probably the most recognized. In this system, the gas literally
bubbled up in the blood. Great attention to the size of the
bubbles and the circuit design with traps allowed this to happen
without the air bubbles being entrained into the patient’s
bloodstream and causing an air embolism. The mixing of gas and
blood caused multiple disruptions to the blood homeostasis and
2 Chapter 1: A brief history of ECMO
Table 1.1 Milestones in the history of ECMO support
Year Event
1635–1703 Robert Hooke conceptualizes the notion of an oxygenator.
1869 Ludwig and Schmidt attempt to oxygenate blood by shaking
together defibrinated blood with air in a balloon.
1882 von Schröder of Strasburg uses a bubble oxygenator to oxygenate
an isolated kidney.
1882 Frey and Gruber describe the first ‘two-dimensional’, direct-contact
extracorporeal oxygenator, which exposed a thin film of blood
to air in an inclined cylinder, which was rotated by an electric
motor.
1916 Discovery of heparin when Jay Maclean demonstrates that
a phosphatide extracted from canine heart muscle prevents
coagulation of the blood.
1929 First whole-body extracorporeal perfusion of a dog by
Brukhonenko and Tchetchuline.
1930s Gibbon and Kirkland further develop the concept of the
oxygenator.
1948 Bjork describes the rotating disc oxygenator.
1952 All-glass bubble oxygenator by Clarke, Gollan and Gupta.
1953 First successful human intracardiac operation under direct vision
using a mechanical extracorporeal pump oxygenator.
1955 Kirklin and colleagues at the Mayo Clinic further developed the
Gibbon-type stationary screen oxygenator into
the Mayo–Gibbon pump oxygenator apparatus, and made it
available for commercial use.
1955 Lillehei and colleagues then begin to use the DeWall bubble
oxygenator clinically.
1958 Clowes, Hopkins and Neville use 25 m2 of permeable ethylcellulose
(soon replaced by the mechanically stronger
polytetrafluoroethylene or Teflon) in multiple sandwiched layers
to form the first clinical membrane oxygenator.
1972 Hill reports the first adult survivor on ECMO.
1972 Editorial in the New England Journal of Medicine by Zapol: ‘Buying
time with artificial lungs’.
Chapter 1: A brief history of ECMO 3
Table 1.1 (cont.)
Year Event
1976 Bartlett reports the successful use of ECMO on an abandoned
newborn nicknamed Esperanza by the nursing staff.
1978 Kolobow and Gattinoni describe using extracorporeal circulation
to remove carbon dioxide, allowing a potential decrease in
ventilation harm.
1979 Publication of a randomized controlled trial in adult patients with
acute respiratory distress syndrome (ARDS) by the National
Heart, Lung and Blood Institute: disappointing results with 10%
survival in either group.
1989 Founding of the Extracorporeal Life Support Organization (ELSO).
2009 H1N1 influenza pandemic and data relating to clinical success with
ECMO are widely disseminated, including in the lay press.
2009 ‘Efficacy and economic assessment of conventional ventilatory
support versus extracorporeal membrane oxygenation for severe
adult respiratory failure (CESAR): a multicentre randomized
controlled trial’, published in The Lancet.
2011 The National Health Service (England) commission a national
respiratory ECMO service.
2014 Publication of ‘Position paper for the organization of
extracorporeal membrane oxygenation programs for acute
respiratory failure in adult patients’ in the American Journal of
Respiratory and Critical Care Medicine.
limited the duration of exchange. Interposing a semi-permeable
membrane between the air and the blood was a key
development that allowed longer periods of support.
The birth of ECMO can be traced back to 1929 in Russia with
the first successful reported extracorporeal perfusion of a dog.
In humans, the first successful cardiopulmonary bypass was
performed in 1953 by Gibbon.
