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Home > ERCAST > What ECMO Does (and doesn't) Do. ERcast Lite Final Episode
Podcast: ERCAST
Episode:

What ECMO Does (and doesn't) Do. ERcast Lite Final Episode
Category: Religion & Spirituality
Duration: 00:34:47
Publish Date: 2020-06-08 03:30:00
Description:

In the swan song of ERcast Lite, we speak with Scott Weingart about the truths, misunderstandings, and physiology of ECMO.

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Pearls:

  • VV ECMO takes over lung function and is used for those with severe lung disease (ie. ARDS, pneumonia, severe asthma).
  • VA ECMO takes over the heart and lung. Ideal candidates are patients with massive PE or cardiogenic shock.
  • Intubated patients who you can’t oxygenate despite rapidly escalating PEEP and a high FiO2 should be considered for VV ECMO.  

 

There are 2 primary types of extracorporeal membrane oxygenation (ECMO):  veno-venous (VV) and veno-arterial (VA).

    • VV ECMO takes over lung function.
      • It drains blood from the IVC or SVC, sends it through a pump which delivers it to an oxygenator (a membrane which allows the influx of oxygen and removes CO2), and then pumps the oxygenated blood back into the right heart system (returning it to the IVC or SVC).

 

  • Useful for those with severe lung disease but decent heart function.

Examples:  pneumonia, ARDS, severe asthma with CO2 retention, immunologic lung diseases, cystic fibrosis awaiting lung transplant

    • Limited by its complications, cost, and logistical catastrophes.
  • VA ECMO takes over lung AND heart function.
    • It drains blood from the IVC/SVC, pumps it out and sends it to an oxygenator, and then returns the blood retrograde up the aorta so it can perfuse the abdominal viscera, brain, and possibly even the heart.

 

For patients with cardiogenic shock or massive PE.

  • Does not yield as much benefit for patients with septic shock or other vasodilatory states (unless they had a sepsis-induced cardiomyopathy).
  • Shares the same limitations as VV ECMO, with the addition that the physiology induced by the VA ECMO itself can be deleterious.

 

Which patients might benefit from transfer to an ECMO center?

    • The threshold for transfer depends in part on the capabilities at your institution for advanced ventilatory modalities (ie. airway pressure release ventilation, proning patients, nitric oxide). 
    • A large percentage of patients transferred for ECMO never end up receiving or needing it. However, they still greatly benefit from moving to a facility that has the ability to provide other nuanced critical care options.
    • In general, transfer young patients who are on very high vent settings and not getting better. 
      • At a community hospital with few vent resources, these patients should be transferred within hours. 
      • At bigger institutions, transfer within 48 hours. Often people wait too long (5-7 days) to initiate the transfer.
    •  
    •  

Use the ARDSnet Mechanical Ventilation Protocol and Murray Score to help decide if a patient would be a good VV ECMO candidate. 

    • The ARDSnet protocol is evidence-based and communicates where the patient is on their vent settings. It gives receiving centers a clean way to evaluate patients for potential transfer.
    • Patients should be
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