Ebook Extracorporeal life support for adults: Part 2

(BQ) Part 2 book Extracorporeal life support for adults'' has contents: Circuits, membranes, and pumps; ventilator management during ECLS, daily care on ECLS, ECMO weaning and decannulation,... and other contents.

Chapter Vascular Access for ECLS Steven A Conrad Introduction Access to the central circulation to provide and maintain blood flow necessary for adequate gas exchange is one of the most essential aspects for successful extracorporeal support Inadequate extracorporeal flow can lead to failure to deliver sufficient support and limit any potential benefit of ECLS Cannulae and cannula insertion techniques are quite variable, and the choice will depend on the goals and mode of support, the size of the patient, size of the vessels, as well as institutional and logistical concerns Cannulas for Extracorporeal Support A variety of cannulae for peripheral vascular access are commercially available These cannulae differ with respect to the mode of insertion (percutaneous or surgical), blood flow direction (drainage or reinfusion), and wall reinforcement, as well as being available in various lengths and diameters to accommodate the choice of vessel Cannulae designed for percutaneous peripheral insertion have some minor feature differences from those intended for surgical placement The loading dilator that accompanies a percutaneous cannula has a long taper and central lumen to accommodate a guidewire, whereas the surgical cannula has a blunt dilator with a short tip and no central lumen The tip of a percutaneous cannula is designed to fit snugly S.A Conrad, MD, PhD, MCCM, FCCP (*) Department of Medicine, Emergency Medicine and Pediatrics, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71103-4228, USA e-mail: sconrad@lsuhsc.edu © 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_7 133 134 S.A Conrad against the loading dilator and is tapered to facilitate insertion through tissue, whereas this feature is optional in surgical cannulas Wire-reinforced cannulas contain a layer of metal spiral-wound wire embedded in the wall of the cannula This reinforcement allows the cannula to flex without kinking, resist flattening from external compression, and prevent collapse when negative pressures are applied to the lumen Since these complications can result in loss of extracorporeal support, reinforced cannulas are generally the preferred design Single-Lumen Design Cannulas with a single lumen are required for venoarterial and arteriovenous vascular access, and are an optional approach for venovenous access Two fundamental designs are manufactured, intended for drainage or for reinfusion (referred to as venous and arterial cannulas, respectively) The venous design is characterized by a greater length (up to approximately 50 cm), greater available diameter (up to 28 Fr), and a longer distal segment with multiple side holes to facilitate drainage The length allows insertion into more central veins such as the superior (SVC) or inferior vena cava (IVC) The arterial design is characterized by a shorter length and a shorter distal segment with a limited number of side holes, since deeper insertion is not required and flow is not dependent on side holes as is the venous design An excess number of side holes can increase the risk of hemolysis in arterial cannulas Recently introduced expandable, wire-reinforced cannulas that incorporate a distal segment of wall-free wire mesh (Smartcanula LLC, Switzerland) are available in some markets These cannulas expand to a larger diameter within the vessel to minimize flow resistance, and the distal mesh maintains vessel patency for improved drainage Dual-Lumen Design Cannulae that incorporate two lumens with two drainage and a single infusion port are a more recent design that has greatly facilitated the application of venovenous support for respiratory failure Although designed for percutaneous insertion, they can be placed surgically as well Three fundamental designs are available that have features to support different needs The cavo-atrial design [1, 2] (OriGen®, OriGen Biomedical) (Fig 7.1) is inserted via the internal jugular vein with the tip positioned in the low right atrium near the IVC ostium It has two drainage ports, one distal at the inferior atrium and one proximately in the superior vena cava, with the reinfusion port in the mid right atrium directed at the tricuspid valve The proximity of the distal lumen to the reinfusion port allows some recirculation, but effective blood flow remains adequate Placement is somewhat easier than the bicaval design since the IVC does not have to be accessed Vascular Access for ECLS 135 Fig 7.1 A dual-lumen venous cannula, designed for drainage from the SVC and inferior right atrium with reinfusion into the mid right atrium (Reprinted with permission from OriGen Biomedical) The bicaval design (Avalon Elite®, Maquet) requires insertion via the internal jugular vein with the cannula traversing the right atrium and the tip positioned in the IVC [3, 4] (Fig 7.2) The drainage lumen extends the length of the cannula with drainage ports in both the IVC and SVC The reinfusion lumen is shorter, terminating in the right atrium with the reinfusion port directed toward the tricuspid valve This bicaval drainage design effectively separates the upper and lower venous systems and results in low recirculation with more effective blood flow The third design is similar to a hemodialysis catheter with a single proximal drainage lumen and a distal reinfusion lumen [5] This catheter is intended for lowflow extracorporeal circuits used for carbon dioxide removal (ECCO2R; Chap 4) If the cannula flow exceeds the insertion vessel flow, recirculation will limit effective flow, but placement in the internal jugular or femoral and iliac veins usually assures adequate blood flow Determinants of Cannula Blood Flow Blood flow through vascular cannulas is driven by the difference between the pressure at the hub of the cannula and the intravascular pressure at the tip of the cannula Although a cannula is cylindrical in shape, in which the relationship between flow and pressure is expected to be linear in the presence of laminar flow, the relationship is only approximately linear over a portion of the flow range (Fig 7.3) 136 S.A Conrad Fig 7.2 A dual-lumen venous cannula, designed for combined drainage from the IVC and SVC and reinfusion of blood into the right atrium for venovenous extracorporeal support Fig 7.3 Representative pressure-flow relationships for various size single-lumen cannulae The graph depicts the nonlinear relationship between flow and pressure due to a combination of laminar and disturbed/turbulent flow resulting from the complex geometry of the catheter The Hagen–Poisseulle equation for laminar flow, although not directly applicable to cannula flow, does illustrate the major determinants of blood flow ( Q ): DP × r Q = m ×L Vascular Access for ECLS 137 where ΔP is the pressure difference, r and L are the cannula radius and length, respectively, and μ is blood viscosity Maximizing blood flow involves use of the largest diameter cannulas that can be safely inserted, and keeping the length as short as possible The nonlinearity of actual pressure-flow curves most likely comes from the tip of the cannula, which includes side holes and a tapered tip, causing a departure from purely laminar flow Patient Preparation Determination of Vessel Size During surgical cannulation the vessel is exposed and cannula size selection can be made visually at the time of cannulation Determination of cannula diameter prior to percutaneous cannulation, however, requires imaging Without vessel sizing the use of too large a cannula can result in venous obstruction, failure to cannulate, or other complications such as vessel laceration or transection Too small a cannula can result in suboptimal blood flow and ineffective support Bedside ultrasound with a vascular transducer can provide high quality images of the cervical and femoral vessels Vessel size can be obtained by using the built-in measurement tools and converting to the French gauge system described by JosephFrédéric-Bent Charrière [6] used for sizing cannulas In the case of vessels with a circular shape, conversion of vessel diameter in mm to French size is accomplished with the following simple formula: Fr = D(mm ) ´ The chosen cannula size should be slightly smaller than the measured vessel to help assure successful placement and prevent complete obstruction of blood flow Infection Control Infection is not an uncommon risk during prolonged extracorporeal support [7] Since extracorporeal support may be required for periods of weeks, steps to prevent infection are warranted, and strict attention to skin asepsis is mandatory during cannulation Full surgical skin preparation can be accomplished with both aqueous and alcohol-based chlorhexidine solutions, and should be applied according to the manufacturer’s recommendations For example, with aqueous-based % chlorhexidine, a scrub, allowing the skin to dry, then repeating the scrub is the recommended technique Peri-procedural prophylaxis with intravenous antibiotics can be considered for patients who are not receiving antibiotics, and with choice of antibiotic and schedule 138 S.A Conrad provided according to the institutions guidelines Continuation of prophylactic antibiotics for the duration of ECLS support, other than required for treatment of underlying infection, is not recommended [8] Following insertion, strict aseptic technique for prevention of cannula-associated infection is mandatory Since patients on ECLS may be fully dependent on support for weeks, simple redressing and observation for development of infection should be replaced with an active approach Our approach is to perform a surgical scrub of the site with aqueous % chlorhexidine every 24 h Insertion Technique Three techniques for cannula insertion are commonplace Historically, all cannulations were performed by surgeons using an open surgical technique While some vessels still require an open approach, surgical cannulation in most cases has been replaced with percutaneous cannulation, and performed by surgeons, interventionalists, intensivists, and emergency physicians Percutaneous Percutaneous cannulation has been used successfully for venovenous support [9], and is preferred since it is associated with a lower incidence of cannulation-site bleeding and infection It also is non-obstructive, allowing blood flow around the cannula It can be used for arterial (other than carotid) as well as venous access The same Seldinger technique used for smaller vascular access catheters is used for ECLS cannulae, but with multiple dilators of no more than Fr difference in size (typically 12, 16, 20, 24, 28, and 30–32 Fr) with the largest size approximately equal to the size of the cannula to be inserted Prior to insertion, vessel size is determined with ultrasound and an appropriate size cannula is chosen Under adequate sedation a neuromuscular blocker is administered to prevent respiratory effort Under aseptic conditions and following infiltration of a local anesthetic, the vessel is identified with ultrasound and an approach is chosen to avoid injury to neighboring vessels, since vessels may overlie each other The access needle is inserted using ultrasound to guide it into the center of the vessel, and a 035″ to 038″ guidewire is advanced Fluoroscopy is invaluable for preventing guidewire misadventures during advancement, and recommended for the bicaval dual-lumen cannula to assure placement of the wire across the atrium Following placement of the guidewire, a skin incision is made just large enough to admit the cannula The tract is then dilated sequentially to the target size The cannula is placed over its tapered loading dilator, and advanced into position Using a tubing clamp to control back-bleeding, the guidewire and dilator are removed, and Vascular Access for ECLS 139 the cannula flushed with heparinized saline (2 units/mL) to maintain patency until attached to the ECLS circuit and extracorporeal circulation has begun The cannula is sutured to prevent decannulation, taking care to avoid crimping the cannula or providing a pivot point for cannula kinking Percutaneous cannulation of the femoral artery may result in inadequate distal perfusion and the development lower limb ischemia This can be managed by percutaneous placement of a retrograde arterial cannula (6–8 Fr), or surgical cannulation of the posterior tibial artery to assure adequate perfusion of the limb Semi-open A variation of percutaneous cannulation preferred by some surgeons is a technique which combines percutaneous skin and vessel insertion under direct visualization through an incision over the vessel entry point Following sedation and neuromuscular blockade, skin preparation and anesthetic infiltration, an incision is made over the expected vessel entry point, and dissection is carried out to visually expose the vessel A needle puncture is made distally to the incision, and a tract is created as for percutaneous insertion Access into the vessel is performed visually The subcutaneous tissue and skin are closed Vessel ligation and incision are avoided, and the skin can be closed without the cannula exiting through the incision, reducing bleeding complications Open Surgical The preferred technique for cervical cannulation when carotid arterial access is required is the open surgical technique (Fig 7.4) Following sedation, neuromuscular blockade, and skin preparation, an incision is made perpendicular to the axis of the vessel, and carried down to expose the cervical vessels The cannula can be sized by visual comparison with vessel size The vessels are freed from surrounding tissue, and ligatures are placed proximal and distal to control bleeding An arteriotomy (or venotomy) is made, and the cannula with its blunt-tipped loading dilator is inserted into the vessel while loosening the proximal ligature to admit the cannula Following insertion to the proper depth, the ligatures are secured, typically with pledgets to prevent vessel injury, as vessel repair may be performed at decannulation The subcutaneous tissue and skin are closed around the cannulae, taking care to securely close the skin around the cannulae The above description is generic, and variations are numerous, subject to the surgeon’s preferences and experience If open cannulation is performed on the femoral artery which, unlike the carotid, has no collateral circulation, then a smaller retrograde perfusion catheter is placed 140 S.A Conrad Fig 7.4 Technique of surgical cannulation of the cervical vessels for extracorporeal life support The technique for the femoral vessels is similar (Used with permission from [11]) to prevent limb ischemia An alternative approach to arterial cannulation for the femoral or subclavian artery is to attach an end-to-side vascular graft to the artery, and cannulate the graft This allows use of a large cannula for optimal blood flow and avoids obstruction and distal ischemia The graft approach may also be more suitable for long-term venoarterial support Cannulation Configurations The foremost decision regarding vascular access is the mode of support, which dictates the cannulation configuration Extracorporeal life support for both respiratory and cardiac failure was historically performed using only a venoarterial (VA) Vascular Access for ECLS 141 configuration While still the preferred configuration for cardiac failure, other configurations have been developed that are more suitable for other types of support Venoarterial The venoarterial configuration drains blood from the central venous circulation and returns it to the arterial circulation The cervical approach is used in neonates and infants, in whom femoral vessels are small, and since they have adequate collateral circulation of the cerebral vessels following ligation of the carotid artery The arterial cannula is placed into the carotid artery and advanced to the proximal innominate artery The venous cannula is placed into the internal jugular vein and advanced into the right atrium This configuration supplies oxygenated blood to the proximal aorta, but coronary and right upper extremity blood may be poorly saturated if pulmonary failure is present and the left ventricle is ejecting (Chap 6) Venoarterial cannulation may be performed using the femoral vessels This configuration is suitable if the native lungs can provide adequate saturation of blood, since in the presence of cardiac ejection, the upper half of the body is supplied by the native heart and lungs and the lower half by the extracorporeal circuit Venovenous Venovenous cannulation was introduced later than venoarterial, and is suitable for respiratory failure with adequate native cardiovascular function (Chap 6) It provides oxygenated blood into the venous system and uses the native heart for oxygen delivery, making oxygenated blood available to all tissues, including the myocardium Cannulae for venovenous support may be placed percutaneously or surgically The venovenous configuration was introduced to extracorporeal support using two single-lumen cannulae, one placed into the femoral vein and advanced to the intrahepatic inferior vena cava for drainage, and the second placed into the internal jugular vein and advanced to the superior cavo-atrial junction An alternative configuration to gain better flow and reduce recirculation was to introduce three cannulae, two for drainage placed at the superior cavo-atrial junction and distal IVC respectively, and one for return placed near the inferior cavo-atrial junction A major advance in venovenous support was the introduction of the dual-lumen venovenous cannula Developed initially for neonates and infants, cannula are now available for adult and pediatric patients These cannulae have a single shaft, incorporating a drainage lumen with ports in the SVC and IVC (or low right atrium) and a reinfusion lumen with a port in the mid-right atrium Recirculation rates with these cannulae are lower than with the single-lumen configurations, and are negligible with the bicaval design 142 S.A Conrad Veno-arterio-venous A variation of the venovenous technique is a veno-arterio-venous (VAV) hybrid mode, which drains from the venous system and returns to both the venous and arterial systems (Chap 6) This configuration can provide partial cardiac support as well as oxygenation, and is suitable for patients with respiratory failure who have a sustained reduction in cardiac function, or cardiac failure who develop respiratory failure, such as pulmonary edema Low-Flow Venovenous Venovenous support can target carbon dioxide removal (extracorporeal carbon dioxide removal, ECCO2R) to support lung-protective ventilation in patients for whom oxygenation can be adequately provided through mechanical ventilation (Chaps and 6) A venovenous configuration using smaller single-lumen cannulae or a dual-lumen cannula with low blood flow (1–1.5 L/min) can effectively provide significant CO2 removal Commercial systems are emerging which use an integrated pump and oxygenator and 15–16 Fr dual-lumen catheter, similar in design to a hemodialysis catheter, placed in the jugular or femoral vein Arteriovenous Another approach to extracorporeal carbon dioxide removal is arteriovenous carbon dioxide removal (AVCO2R), sometimes termed interventional lung assist (iLA) This configuration involves cannulation of the femoral vessels with a small arterial cannula (12–14 Fr), and a 16–18 Fr venous cannula, attached to an oxygenator using short tubing The patient’s arterial blood pressure provides the gradient for blood flow, avoiding the need for a pump The major disadvantage is the need for arterial access, but with smaller cannulae the risk of arterial complications is low It is likely that the new generation of dedicated ECCO2R devices will replace the arteriovenous configuration, just as continuous venovenous hemofiltration (CVVH) has largely replaced continuous arteriovenous hemofiltration (CAVH) Transthoracic Although much more invasive, direct cannulation of the right atrium and aortic root through a sternotomy remains an important approach to vascular access The most common use is support of post-cardiotomy failure to wean from cardiopulmonary 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? Pediatric Grand Rounds Gibbon Jr JH Application of a mechanical heart and lung apparatus to cardiac surgery Minn Med 1954;37(3):171–85 Cohen M, Lillehei CW A quantitative study of the azygos factor during vena caval occlusion in the dog Surg Gynecol Obstet 1954;98(2):225–32 Dennis C A heart-lung machine for open-heart operations How it came about ASAIO Trans 1989;35(4):767–77 Lillehei CW Controlled cross circulation for direct-vision intracardiac surgery; correction of ventricular septal defects, atrioventricularis communis, and tetralogy of Fallot Postgrad Med 1955;17(5):388–96 10 Kurusz M May 6, 1953: the untold story ASAIO J 2012;58(1):2–5 11 Warden HE, Dewall RA, Read RC, Aust JB, Cohen M, Varco RL, et al Total cardiac by-pass utilizing continuous perfusion from reservoir of oxygenated blood Proc Soc Exp Biol Med 1955;90(1):246–50 12 Fazel S, Williams WG, Goldman BS Thinned blood, monkey lungs, and the cold heart J Card Surg 2004;19(3):275–8 13 Gibbon Jr JH An oxygenator with large surface area to Volume ratio J Lab Clin Med 1939;24:1192–8 14 Miller BJ, Gibbon JH, Fineburg C An improved mechanical heart and lung apparatus; its use during open cardiotomy in experimental animals Med Clin North Am 1953;1:1603–24 15 Jones RE, Donald DE, Swan JC, Harshbarger HG, Kirklin JW, Wood EH Apparatus of the Gibbon type for mechanical bypass of the heart and lungs; preliminary report Proc Staff Meet Mayo Clin 1955;30:105–13 16 Kirklin JW, Dushane JW, Patrick RT, Donald DE, Terry Jr HR, Burchell HB et al Intracardiac surgery with the aid of a mechanical pump-oxygenator system (gibbon type): report of eight cases Proc Staff Meet Mayo Clin 1955;30(10):201–6 17 Kirklin JW, Donald DE, Harshbarger HG, Hetzel PS, Patrick RT, Swan HJ, et al Studies in extracorporeal circulation I Applicability of Gibbon-type pumpoxygenator to human intracardiac surgery: 40 cases Ann Surg 1956;144:2–8 18 Dennis C Perspective in review One group’s struggle with development of a pumpoxygenator Trans Am Soc Artif Intern Organs 1985;31:1–11 19 Stoney WS Evolution of cardiopulmonary bypass Circulation 2009;119:2844–53 20 Kirklin JW, Donald DE, Harshbarger HG, Hetzel PS, Patrick RT, Swan HJ Studies in extracorporeal circulation I Applicability of Gibbon-type pump-oxygenator to human intracardiac surgery: 40 cases Ann Surg 1956;144(1):2–8 21 Kirklin JW Open-heart surgery at the Mayo Clinic The 25th anniversary Mayo Clin Proc 1980;55(5):339–41 22 DeWall RA, Najafi H, Roden T A hard-shell temperature-controlling disposable blood oxygenator Use in clinical open-heart surgery JAMA 1966;197(13):1065–8 23 Dewall RA, Gott VL, Lillehei CW, Read RC, Varco RL, Warden HE Total body perfusion for open cardiotomy utilizing the bubble oxygenator; physiologic responses in man J Thorac Surg 1956;32(5):591–603 256 J.A Morris et al 24 Clarke Jr LC, Gollan F, Gupta VB The oxygenation of blood by gas dispersion Science 1950;111(2874):85–7 25 DeWall RA, Bentley DJ, Hirose M, Battung V, Najafi H, Roden T A temperature controlling (omnithermic) disposable bubble oxygenator for total body perfusion Dis Chest 1966;49(2): 207–11 26 Lillehei CW A personalized history of extracorporeal circulation Trans Am Soc Artif Intern Organs 1982;28:5–16 27 Gott VL, Dewall RA, Paneth M, Zuhdi MN, Weirich W, Varco RI, Lillehei CW A selfcontained disposable oxygenator of plastic sheet for intracardiac surgery Thorax 1957;12:1–9 28 Gott VL, Sellers RD, Dewall RA, Varco RL, Lillehei CW A disposable unitized plastic sheet oxygenator for open heart surgery Dis Chest 1957;32(6):615–25 29 Naef AP The story of thoracic surgery Toronto: Hogrefe and Huber; 1990 30 Cross ES, Berne RM, Hirose Y Evaluation of a rotating disc type oxygenator Proc Soc Exp Biol Med 1956;93:210–4 31 Osborn JJ, Bramson ML, Gerbode F A rotating disc blood oxygenator and integral heat exchanger of improved inherent efficiency J Thorac Cardiovasc Surg 1960;39:427–37 32 Melrose DG, Bramson ML, Osborn JJ, Gerbode F The membrane oxygenator; some aspects of oxygen and carbon dioxide transport across polyethylene film Lancet 1958;1:1050–1 33 Cross FS, Berne RM, Hirose Y, Jones RD, Kay EB Description and evaluation of a rotating disc type reservoir-oxygenator Surg Forum 1957;7:274–8 34 Kolff WJ, Effler DB, Groves LK, Peereboom G, Moraca PP Disposable membrane oxygenator (heart-lung machine) and its use in experimental surgery Cleve Clin Q 1956;23: 69–97 35 Zuhdi N, McCollough B, Carey J, Krieger C, Greer A Hypothermic perfusion for open-heart surgical procedures Report on the use of a heart-lung machine primed with five per cent dextrose in water inducing hemodilution J Int Coll Surg 1961;35:319–26 36 Zuhdi N, McCollough B, Carey J, Greer A Double-belical reservoir heart-lung machine designed for hypothermic perfusion; primed with per cent glucose in water; inducing hemodilution Arch Surg 1961;82:320–5 37 Dewall RA, Lillehei CW Simplified total body perfusion Reduced flows, moderate hypothermia, and hemodilution JAMA 1962;179:430–4 38 Dewall RA, Lillehei RC, Sellers RD Hemodilution perfusions for open-heart surgery Use of five per cent dextrose in water for the priming volume N Engl J Med 1962;266:1078–84 39 Kolff WJ, Baltzer R The artificial coil lung Trans Am Soc Artif Intern Organs 1955; 1:39–42 40 Clowes Jr GHA, Hopkins AL, Kolobow T Oxygen diffusion through plastic films Trans Am Soc Artif Intern Organs 1955;1:23–4 41 Clowes Jr GH, Hopkins AL, Neville WE An artificial lung dependent upon diffusion of oxygen and carbon dioxide through plastic membranes J Thorac Surg 1956;32:630–7 42 Clowes Jr GH, Neville WE Further development of a blood oxygenator dependent upon the diffusion of gases through plastic membranes Trans Am Soc Artif Intern Organs 1957;3:52–8 43 Kammermeyer K Silicone rubber as a selective barrier Ind Eng Chem 1957;49:1685–6 44 Burns N Production of a silicone rubber film for the membrane lung Biomed Eng 1969;4:356–9 45 Iwahashi H, Yuri K, Nose Y Development of the oxygenator: past, present, and future J Artif Organs 2004;7:111–20 46 Peirce 2nd EC A modification of the Clowes membrane lung J Thorac Cardiovasc Surg 1960;39:438–48 47 Kolobow T, Bowman RL Construction and evaluation of an alveolar membrane artificial heart-lung Trans Am Soc Artif Intern Organs 1963;9:238–43 48 Bramson ML, Osborn JJ, Main FB, et al A new disposable membrane oxygenator with integral heat exchange J Thorac Cardiovasc Surg 1965;50:391–400 14 The Story of ECLS: History and Future 257 49 Landé AJ, Dos SJ, Carlson RG, et al A new membrane oxygenator-dialyzer Surg Clin North Am 1967;47(6):1461–70 50 Day SW, Crystal DK, Wagner CL, Kranz JM Properties of synthetic membranes in extracorporeal circuits Am J Surg 1967;114(2):314–9 51 Marx TI, Snyder WE, St John AD, Moeller CE Diffusion of oxygen into a film of whole blood J Appl Physiol 1960;15:1123–9 52 Bodell BR, Head JM, Head LR, Formolo AJ, Head JR A capillary membrane oxygenator J Thoracic Cardiovasc Surg 1963;46:639–50 53 Wilson R, Shepley DJ, Llewellyn-Thomas E A membrane oxygenator with a low priming volume for extra-corporeal circuit Can J Surg 1965;8:309–11 54 Dorson Jr W, Baker E, Hull H A shell and tube oxygenator Trans Am Soc Artif Intern Organs 1968;14:242–9 55 Peirce 2nd EC, Dibelius NR The membrane lung: studies with a new high permeability copolymer membrane Trans Am Soc Artif Intern Organs 1968;14:220–6 56 Kolobow T, Zapol W, Pierce JE, Keeley AF, Replogle RL, Haller A Partial extracorporeal gas exchange in alert newborn lambs with a membrane artificial lung perfused via an A-V shunt for periods up to 96 hours Trans Am Soc Artif Intern Organs 1968;14:328–34 57 Bartlett RH, Isherwood J, Moss RA, Olszewski WL, Polet H, Drinker PA A toroidal flow membrane oxygenator: four day partial bypass in dogs Surg Forum 1969;20:152–3 58 Bartlett RH, Drinker PA, Burns NE, et al The toroidal membrane oxygenator: design, performance, and prolonged bypass testing of a clinical model Trans Am Soc Artif Intern Organs 1972;18:369–74 59 McCaughan JS, Weeder R, Schuder JC, Blakemore WS Evaluation of new nonwettable macroporous membranes with high permeability coefficients for possible use in a membrane oxygenator J Thorac Cardiovasc Surg 1960;40:574–81 60 Lim MW The history of extracorporeal oxygenators Anaesthesia 2006;61(10):984–95 61 Mortensen JD An intravenacaval blood gas exchange (IVCBGE) device A preliminary report ASAIO Trans 1987;33(3):570–3 62 Cox Jr CS, Zwischenberger JB, Traber DL, Traber LD, Haque AK, Herndon DN Use of an intravascular oxygenator/carbon dioxide removal device in an ovine smoke inhalation injury model ASAIO Trans 1991;37(3):M411–3 63 Kaushik M, Wojewodzka-Zelezniakowicz M, Cruz DN, Ferrer-Nadal A, Teixeira C, Iglesias E, et al Extracorporeal carbon dioxide removal: the future of lung support lies in the history Blood Purif 2012;34(2):94–106 doi:10.1159/000341904 Epub 2012 Oct 24 64 Zwischenberger JB, Tao W, Bidani A Intravascular membrane oxygenator and carbon dioxide removal devices: a review of performance and improvements ASAIO J 1999; 45(1):41–6 65 Peek GJ, Killer HM, Reeves R, Sosnowski AW, Firmin RK Early experience with a polymethyl pentene oxygenator for adult extracorporeal life support ASAIO J 2002;48(5): 480–2 66 Toomasian JM, Schreiner RJ, Meyer DE, Schmidt ME, Hagan SE, Griffith GW, et al A polymethylpentene fiber gas exchanger for long-term extracorporeal life support ASAIO J 2005;51(4):390–7 67 Motomura T, Maeda T, Kawahito S, Takano T, Nonaka K, Linneweber J, et al Development of silicone rubber hollow fiber membrane oxygenator for ECMO Artif Organs 2003;27(11): 1050–3 68 Bartlett RH The development of prolonged extracorporeal circulation In: Zwischenberger JB, Steinhorn RH, Bartlett RH, editors ECMO: extracorporeal cardiopulmonary support in critical care Michigan, Ann Arbor: Extracorporeal Life Support Organization; Ann Arbor, Michigan, 2000 69 Crawford D, Harvey B A review of extracorporeal membrane oxygenation in the UK Nurs Child Young People 2012;24(8):18–22 258 J.A Morris et al 70 Anderson 3rd HL, Otsu T, Chapman RA, Barlett RH Venovenous extracorporeal life support in neonates using a double lumen catheter ASAIO Trans 1989;35(3):650–3 71 Otsu T, Merz SI, Hultquist KA, Attorri RJ, Anderson 3rd HL, Scheffler DE, et al Laboratory evaluation of a double lumen catheter for venovenous neonatal ECMO ASAIO Trans 1989;35(3):647–50 72 Wang D, Zhou X, Liu X, Sidor B, Lynch J, Zwischenberger JB Wang-Zwische double lumen cannula-toward a percutaneous and ambulatory paracorporeal artificial lung ASAIO J 2008;54(6):606–11 73 Rais-Bahrami K, Walton DM, Sell JE, Rivera O, Mikesell GT, Short BL Improved oxygenation with reduced recirculation during venovenous ECMO: comparison of two catheters Perfusion 2002;17(6):415–9 74 Garcia JP, Iacono A, Kon ZN, Griffith BP Ambulatory extracorporeal membrane oxygenation: a new approach for bridge-to-lung transplantation J Thorac Cardiovasc Surg 2010; 139:e137–9 75 Reeb J, Falcoz PE, Santelmo N, Massard G Double lumen bi-cava cannula for veno-venous extracorporeal membrane oxygenation as bridge to lung transplantation in non-intubated patient Interact Cardiovasc Thorac Surg 2012;14:125–7 76 Garcia JP, Kon ZN, Wu Z, Iacnon AT, McCormick B, Griffith BP Ambulatory veno-venous extracorporeal membrane oxygenation: innovation and pitfalls J Thorac Cardiovasc Surg 2011;142(4):755–61 77 Hayes Jr D, Kukreja J, Tobias JD, Ballard HO, Hoopes CW Ambulatory venovenous extracorporeal respiratory support as a bridge for cystic fibrosis patients to emergent kung transplantation J Cyst Fibros 2012;11(1):40–5 78 Bellezzo JM, Shinar Z, Davis DP, Jaski BE, Chillcott S, Stahovich M, et al Emergency physician-initiated extracorporeal cardiopulmonary resuscitation Resuscitation 2012;83(8): 966–70 79 Hoopes CW, Kukreja J, Golden J, Davenport DL, Diaz-Guzman E, Zwischenberger JB Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation J Thorac Cardiovasc Surg 2013;145(3):862–7 discussion 867–8 80 Diaz-Guzman E, Hoopes CW, Zwischenberger JB The evolution of extracorporeal life support as a bridge to lung transplantation ASAIO J 2013;59(1):3–10 81 Iglesias M, Jungebluth P, Petit C, Matute MP, Rovira I, Martínez E, et al Extracorporeal lung membrane provides better lung protection than conventional treatment for severe postpneumonectomy noncardiogenic acute respiratory distress syndrome J Thorac Cardiovasc Surg 2008;135:1362–71 82 Meyer A, Struber M, Fischer S Advances in extracorporeal ventilation Anesthesiol Clin 2008;26:381–91 83 Hill JD, O’Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, et al Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome) Use of the Bramson membrane lung N Engl J Med 1972;286:629–34 84 Zapol WM, Snider MT, Hill JD, Fallat RJ, Edmunds LH, Morris AH, et al Extracorporeal membrane oxygenation in severe acute respiratory failure A randomized prospective study JAMA 1979;242(20):2193–6 85 Zwischenberger JB, Bartlett RH Extracorporeal life support: an overview In: Van Meurs K, Lally KP, Peek G, Zwischenberger JB, editors ECMO extracorporeal cardiopulmonary support in critical care 3rd ed Ann Arbor: Extracorporeal Life Support Organization; 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 ... adults Pediatr Crit Care Med 20 11; 12( 3) :27 7–81 Extracorporeal Life Support Organization Task Force on Infections Infection control and extracorporeal life support 20 10 http://elso.org/downloads/resources/committees/infectiousdisease-and-antibiotic/Infection-Control-and -Extracorporeal- Life- Support. pdf... and Clinics, 20 0 Hawkins Drive, Iowa City, IA 522 42, USA e-mail: bradley-rosen@uiowa.edu © Springer Science+Business Media New York 20 16 G.A Schmidt (ed.), Extracorporeal Life Support for Adults,... closed chest extrathoracic cannulation for cardiopulmonary bypass and extracorporeal life support: methods, indications, and outcomes Postgrad Med J 20 06; 82( 967): 323 –31 Chapter Circuits, Membranes,