Extracorporeal membrane oxygenation (ECMO) in adults
- Robert Bartlett, MD
Robert Bartlett, MD
- Professor Emeritus
- University of Michigan Health Systems
Mechanical cardiopulmonary support is most often applied intraoperatively to facilitate cardiac surgery (ie, cardiopulmonary bypass). However, cardiopulmonary support can also be delivered in a more prolonged fashion in an intensive care unit, although it is less common.
Prolonged cardiopulmonary support is called extracorporeal membrane oxygenation (ECMO), extracorporeal life support, or extracorporeal lung assist. There are two types of ECMO – venoarterial (VA) and venovenous (VV). Both provide respiratory support, but only VA ECMO provides hemodynamic support.
The impact of ECMO on clinical outcomes as well as patient selection, technical aspects, and complications will be reviewed here. Only adult applications are discussed. Extensive information about indications, complications, and outcome is available from the web site of the Extracorporeal Life Support Organization .
Survival — The survival of patients undergoing ECMO can be categorized according to the indication for the ECMO: severe acute respiratory failure or cardiac failure.
Acute respiratory failure — Multiple studies have evaluated the effect of ECMO on mortality in patients with severe acute respiratory failure [2-14]. After two poorly designed randomized trials of ECMO in the 1970s, all nine subsequent controlled trials show a significant survival benefit to ECMO compared with conventional care in neonates (five trials), children (one trial), and adults (three trials) . ECMO is the only life support system in acute fatal illness which has been studied in controlled trials compared with conventional care.
- The Registry of the Extracorporeal Life Support Organization. www.elso.org (Accessed on October 09, 2015).
- Hemmila MR, Rowe SA, Boules TN, et al. Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg 2004; 240:595.
- Peek GJ, Moore HM, Moore N, et al. Extracorporeal membrane oxygenation for adult respiratory failure. Chest 1997; 112:759.
- Lewandowski K, Rossaint R, Pappert D, et al. High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation. Intensive Care Med 1997; 23:819.
- Ullrich R, Lorber C, Röder G, et al. Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS. Anesthesiology 1999; 91:1577.
- Rich PB, Awad SS, Kolla S, et al. An approach to the treatment of severe adult respiratory failure. J Crit Care 1998; 13:26.
- Kolla S, Awad SS, Rich PB, et al. Extracorporeal life support for 100 adult patients with severe respiratory failure. Ann Surg 1997; 226:544.
- Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D, et al. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA 2009; 302:1888.
- Brogan TV, Thiagarajan RR, Rycus PT, et al. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 2009; 35:2105.
- Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306:1659.
- Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374:1351.
- Pham T, Combes A, Rozé H, et al. Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2013; 187:276.
- Bartlett RH. Clinical Research in Acute Fatal Illness: Lessons From Extracorporeal Membrane Oxygenation. J Intensive Care Med 2016; 31:456.
- Posluszny J, Rycus PT, Bartlett RH, et al. Outcome of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) ECMO. Ann Surg 2016; 263:573.
- Trudzinski FC, Kaestner F, Schäfers HJ, et al. Outcome of Patients with Interstitial Lung Disease Treated with Extracorporeal Membrane Oxygenation for Acute Respiratory Failure. Am J Respir Crit Care Med 2016; 193:527.
- Younger JG, Schreiner RJ, Swaniker F, et al. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med 1999; 6:700.
- Massetti M, Tasle M, Le Page O, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005; 79:178.
- Smedira NG, Blackstone EH. Postcardiotomy mechanical support: risk factors and outcomes. Ann Thorac Surg 2001; 71:S60.
- Kelly RB, Porter PA, Meier AH, et al. Duration of cardiopulmonary resuscitation before extracorporeal rescue: how long is not long enough? ASAIO J 2005; 51:665.
- Combes A, Leprince P, Luyt CE, et al. Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med 2008; 36:1404.
- Pagani FD, Aaronson KD, Swaniker F, Bartlett RH. The use of extracorporeal life support in adult patients with primary cardiac failure as a bridge to implantable left ventricular assist device. Ann Thorac Surg 2001; 71:S77.
- Kagawa E, Dote K, Kato M, et al. Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 2012; 126:1605.
- Bednarczyk JM, White CW, Ducas RA, et al. Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: a Canadian observational experience. Resuscitation 2014; 85:1713.
- Chang CH, Chen HC, Caffrey JL, et al. Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults: A Nationwide Cohort Study. Circulation 2016; 133:2423.
- Shin TG, Choi JH, Jo IJ, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med 2011; 39:1.
- Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008; 372:554.
- Ortega-Deballon I, Hornby L, Shemie SD, et al. Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes. Resuscitation 2016; 101:12.
- ELSO guidelines for ECMO centers (updated February 2005) http://www.elso.med.umich.edu/guide.htm (Accessed on June 19, 2007).
- Tsai HC, Chang CH, Tsai FC, et al. Acute Respiratory Distress Syndrome With and Without Extracorporeal Membrane Oxygenation: A Score Matched Study. Ann Thorac Surg 2015; 100:458.
- Ferguson ND, Fan E, Camporota L, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012; 38:1573.
- Braune S, Sieweke A, Brettner F, et al. The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study. Intensive Care Med 2016; 42:1437.
- Ouweneel DM, Schotborgh JV, Limpens J, et al. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med 2016; 42:1922.
- Schmidt M, Tachon G, Devilliers C, et al. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 2013; 39:838.
- Wang D, Zhou X, Liu X, et al. Wang-Zwische double lumen cannula-toward a percutaneous and ambulatory paracorporeal artificial lung. ASAIO J 2008; 54:606.
- Madershahian N, Nagib R, Wippermann J, et al. A simple technique of distal limb perfusion during prolonged femoro-femoral cannulation. J Card Surg 2006; 21:168.
- Navia JL, Atik FA, Beyer EA, Ruda Vega P. Extracorporeal membrane oxygenation with right axillary artery perfusion. Ann Thorac Surg 2005; 79:2163.
- Spinelli E, Bartlett RH. Anemia and Transfusion in Critical Care: Physiology and Management. J Intensive Care Med 2016; 31:295.
- Mazzeffi M, Greenwood J, Tanaka K, et al. Bleeding, Transfusion, and Mortality on Extracorporeal Life Support: ECLS Working Group on Thrombosis and Hemostasis. Ann Thorac Surg 2016; 101:682.
- Wilson JM, Bower LK, Fackler JC, et al. Aminocaproic acid decreases the incidence of intracranial hemorrhage and other hemorrhagic complications of ECMO. J Pediatr Surg 1993; 28:536.
- Biswas AK, Lewis L, Sommerauer JF. Aprotinin in the management of life-threatening bleeding during extracorporeal life support. Perfusion 2000; 15:211.
- Peek, G, Wittenstein, et al. Management of bleeding during ECLS. In: ECMO in Critical Care, Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, JB (Eds), Extracorporeal life support organization, Ann Arbor 2005.
- Bui JD, Despotis GD, Trulock EP, et al. Fatal thrombosis after administration of activated prothrombin complex concentrates in a patient supported by extracorporeal membrane oxygenation who had received activated recombinant factor VII. J Thorac Cardiovasc Surg 2002; 124:852.
- Wittenstein B, Ng C, Ravn H, Goldman A. Recombinant factor VII for severe bleeding during extracorporeal membrane oxygenation following open heart surgery. Pediatr Crit Care Med 2005; 6:473.
- Anselmi A, Guinet P, Ruggieri VG, et al. Safety of recombinant factor VIIa in patients under extracorporeal membrane oxygenation. Eur J Cardiothorac Surg 2016; 49:78.
- Mateen FJ, Muralidharan R, Shinohara RT, et al. Neurological injury in adults treated with extracorporeal membrane oxygenation. Arch Neurol 2011; 68:1543.
- Cornell T, Wyrick P, Fleming G, et al. A case series describing the use of argatroban in patients on extracorporeal circulation. ASAIO J 2007; 53:460.
- Thiele H, Sick P, Boudriot E, et al. Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J 2005; 26:1276.
- Peek GJ, Killer HM, Reeves R, et al. Early experience with a polymethyl pentene oxygenator for adult extracorporeal life support. ASAIO J 2002; 48:480.
- Toomasian JM, Schreiner RJ, Meyer DE, et al. A polymethylpentene fiber gas exchanger for long-term extracorporeal life support. ASAIO J 2005; 51:390.
- Khoshbin E, Roberts N, Harvey C, et al. Poly-methyl pentene oxygenators have improved gas exchange capability and reduced transfusion requirements in adult extracorporeal membrane oxygenation. ASAIO J 2005; 51:281.
- Malfertheiner MV, Philipp A, Lubnow M, et al. Hemostatic Changes During Extracorporeal Membrane Oxygenation: A Prospective Randomized Clinical Trial Comparing Three Different Extracorporeal Membrane Oxygenation Systems. Crit Care Med 2016; 44:747.
- Hoshi H, Shinshi T, Takatani S. Third-generation blood pumps with mechanical noncontact magnetic bearings. Artif Organs 2006; 30:324.
- Lawson DS, Ing R, Cheifetz IM, et al. Hemolytic characteristics of three commercially available centrifugal blood pumps. Pediatr Crit Care Med 2005; 6:573.
- Zhang H, Annich GM, Miskulin J, et al. Nitric oxide releasing silicone rubbers with improved blood compatibility: preparation, characterization, and in vivo evaluation. Biomaterials 2002; 23:1485.
- Bharat A, Pham DT, Prasad SM. Ambulatory Extracorporeal Membrane Oxygenation: A Surgical Innovation for Adult Respiratory Distress Syndrome. JAMA Surg 2016; 151:478.
- - Acute respiratory failure
- - Cardiac failure
- PATIENT SELECTION
- Relative contraindications
- - Cannulation
- - Titration
- - Special considerations
- Weaning from ECMO
- Heparin-induced thrombocytopenia
- VA ECMO-specific complications
- SUMMARY AND RECOMMENDATIONS