hospital authority convention 2015 ecmo/ ecco2r + ultra ... · cannulation risk similar to renal...

Hospital Authority Convention 2015

ECMO/

ECCO2R + Ultra-protective Lung Ventilation

Dr. Yan Wing Wa

Department of Intensive Care

Pamela Youde Nethersole Eastern Hospital

19 May 2015

1

2

Scope

Two forms of ECMO

ECMO - high flow

Extracorporeal CO2 Removal (ECCO2R) - low flow

Roles in management of ARDS?

Types ECCO2R available

Acute respiratory distress syndrome (ARDS)

Injured lung need rest till recovery but

Injured lung need to maintain adequate O2 saturation

More severe injury need more vent. pressures, PEEP,

FiO2

More ventilator induced lung injury

Oxygen toxicity

Vicious cycle

Protective Lung Ventilation (PLV)

Tidal volume

6ml/kg vs. 12ml/kg

Anesthesiology 2009;111:826-35

Ultra-Protective Lung Ventilation

2 Forms of ECMO

Extracorporeal membrane oxygenation (ECMO)

High flow (4 – 6 L/min)

Both oxygenation & CO2 removal

Extracorporeal CO2 removal (ECCO2R)

Low flow (0.5 to 1 L/min)

Only CO2 removal

7

Extracorporeal flow needed F

low

ml/m

in

10

100

1000

10000

CRRT IHD

ECMO

ECCO2R

Physiology Of O2 delivery

O2 consumption ~ 240 ml/min

Amount of O2 added to the

blood via ECMO ~ 40-60 ml/L

1.34 * Hb * (SoutO2 – SinO2)

4 – 6 L/min blood flow is

needed

Physiology of CO2 removal

CO2 generation ~ 200 ml/min

Amount of CO2 stored in blood

~ 500 ml/L

Achieved adequate CO2

removal with < 1L/min

9

ECCO2R

Gattinoni L,et al. Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal : an experimental study. Anesth Analg 1978, 57:470-477

Randomized Control Trials

Fitzgerald M et al. ECCO2R for patients with acute respiratory failure secondary to the ARDS: a

systematic review. Critical Care 2014,18:222

Outlook of ECCO2R

No definitive conclusions can be drawn at this stage for ARDS Sample sizes too small

Negative RCT

No mortality benefit

Do have improvements in PaCO2, lower tidal volume, plateau pressure, +/-ventilator-free day

Possible other roles COPD failing NIV

Status asthmaticus

Bridge to lung transplant

Complications Cannulation risk similar to renal replacement therapy

Circuit thrombosis, bleeding

Trial Indication Type Number of subjects Estimated End

SUPERNOVA

ARDS Pilot-to-

Pivotal

Ultraprotective

ventilation in Moderate

to Severe ARDS

Prospective, ESICM-led Single-arm Pilot 100

Pivotal 2,050

Q3 2019

REST ARDS

Pilot-to-Pivotal

Ultraprotective

ventilation in Moderate

to Severe ARDS

Prospective, UK funded, consortium-led Single-arm Pilot 40

Pivotal 1,120

Q4 2019

Singapore ARDS

Pilot

Ultraprotective

ventilation and

recruitment in Moderate

to Severe ARDS

Prospective, Investigator-Initiated Pilot

RCT

50 (25/25) Q1 2016

HAVAnA Trial

(The

Netherlands)

Effects of induced

hyperthermia with

novatherm and iLA-

activve minilung in

Moderate ARDS

Prospective, Feasibility Study 30 Not yet recruiting

ALung ARDS

Feasibility

Ultraprotective

ventilation in Moderate

to Severe ARDS

Prospective, Investigator- Initiated

Feasibility Study

15 Q4 2014

PARSA Trial

(France)

Pulmonary and renal

support for adult

patients experiencing

both ARDS and acute

renal failure

Prospective, Single-arm Feasibility Study 10 Recruiting

Clinical Trials (ARDS)

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Types & Devices for ECCO2R

Arteriovenous CO2 Removal (AVCO2R)

Pumpless Extracorporeal Lung Assist (PECLA)

Venovenous CO2 Removal (VVCO2R)

Decap/Decap-Smart

Hemolung

iLA Activve

Typical VV-ECMO set up

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AVCO2R or PECLA

iLA Membrane Ventilator, Novalung, GmbH, Germany

18

AVCO2R or PECLA

Novalung: interventional Lung Assist (iLA) membrane ventilator

Hemodynamic should be stable, with MAP >60mmHg

Flowmeter monitoring is needed

Risk of distal limb ischemia

Indications

UPLV for ARDS

Status asthmaticus

Bridge to lung transplantation

19

20

Hemodec, Salerno, Italy

Allow CO2 removal + Renal Replacement Therapy

Successful trials in adults and children

*Terragni PP, Gattinoni L, Ranieri VM et al: Tidal volume lower than 6 ml/kg enhances lung protection: role of

extracorporeal carbon dioxide removal. Anesthesiology 2009, 111:826-835

21

Alung Technologies, Pittsburgh, USA

22

Venovenous CO2 Removal

Move gradually to VV-ECMO

Typical VV-ECMO circuit

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Jugular vein

Femoral vein

Membrane

lung

Circuit pump

Oxygen

25

Thank you.