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Stefonknee's Sissy I Group

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Gabriel Peterson
Gabriel Peterson

ECMO-Extracorporeal Life Support In Adults ((NEW))

Importance: The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice.

ECMO-Extracorporeal Life Support in Adults

Observations: Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice.

Conclusions and relevance: The role of extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.

Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.

The goal of ECLS is to support gas exchange and systemic metabolic demands by providing oxygen delivery to the tissues. The degree of support provided for native heart or lung function is in large part dependent on blood flow (as well as patient hemoglobin, inlet hemoglobin saturation, and the properties of the membrane lung). Table 1 details the differences in cardiac and pulmonary effects of VA- versus VV-ECMO. When primary cardiac support is the goal, drainage of blood from the patient to the circuit results in decreased right and left heart filling pressures, reduction in pulmonary blood flow, cardiac unloading, and an improvement in end-organ perfusion. In VA-ECMO, because left ventricular afterload is increased by (usually) retrograde aortic flow, additional interventions may be required to prevent or relieve left ventricular overdistension in certain settings. Targeted flow rates in adults for VA- (and VV-) ECMO are usually 60 to 80 ml/kg/min. During cardiac support, mixed venous oxygen saturation is monitored from the venous drainage limb, and flow rates are adjusted to maintain adequate oxygen delivery.

ECMO may be used to help people who are very ill with conditions of the heart and lungs, or who are waiting for or recovering from a heart transplant. It may be an option when other life support measures haven't worked. ECMO does not treat or cure a disease, but can help you when your body temporarily can't provide your tissues with enough oxygen.

ECMO is used when life support is needed after surgery, or when you are very ill and your heart or lungs need help so that you can heal. Your doctor will decide when it may be helpful. If you need ECMO, your doctor and trained respiratory therapists will prepare you.

Evolution of extracorporeal life support (ECLS) technology has added a new dimension to the intensive care management of acute cardiac and/or respiratory failure in adult patients who fail conventional treatment. ECLS also complements cardiac surgical and cardiology procedures, implantation of long-term mechanical cardiac assist devices, heart and lung transplantation and cardiopulmonary resuscitation. Available ECLS therapies provide a range of options to the multidisciplinary teams who are involved in the time-critical care of these complex patients. While venovenous extracorporeal membrane oxygenation (ECMO) can provide complete respiratory support, extracorporeal carbon dioxide removal facilitates protective lung ventilation and provides only partial respiratory support. Mechanical circulatory support with venoarterial (VA) ECMO employed in a traditional central/peripheral fashion or in a temporary ventricular assist device configuration may stabilise patients with decompensated cardiac failure who have evidence of end-organ dysfunction, allowing time for recovery, decision-making, and bridging to implantation of a long-term mechanical circulatory support device and occasionally heart transplantation. In highly selected patients with combined severe cardiac and respiratory failure, advanced ECLS can be provided with central VA ECMO, peripheral VA ECMO with timely transition to venovenous ECMO or VA-venous ECMO upon myocardial recovery to avoid upper body hypoxia or by addition of an oxygenator to the temporary ventricular assist device circuit. This article summarises the available ECLS options and provides insights into the principles and practice of these techniques. One should emphasise that, as is common with many emerging therapies, their optimal use is currently not backed by quality evidence. This deficiency needs to be addressed to ensure that the full potential of ECLS can be achieved.

Extracorporeal life support (ECLS) is a therapeutic option increasingly used in the management of patients with cardiorespiratory failure that is refractory to maximal conventional treatment [1, 2]. This support may facilitate therapeutic intervention, bridge to recovery, bridge to a long-term support device, heart or lung transplantation, or bridge to palliation. Despite the renewed interest in ECLS technology following the 2009 H1N1 influenza pandemic [3], there is a lack of definitive evidence regarding its routine application. Current ECLS equipment has evolved to allow a plethora of perfusion strategies enabling tailored temporary support for patients and the ability to transition between configurations. A number of factors limit more frequent utilisation. These factors include challenges in patient selection, choice of an appropriate strategy, technical aspects of initiation and maintenance, and minimising complications [4].

For patients with predominant cardiac failure with preserved pulmonary function, the available MCS devices provide several options (Table 2). Central VA ECMO has been traditionally applied as a bridge to recovery in patients who fail to wean from cardiopulmonary bypass after cardiac surgery (Figure 2). Central VA ECMO outside this setting in adults is uncommon. Femoral VA ECMO (Figure 2) is more commonly used in adults requiring urgent cardiac support because it can be achieved rapidly and a sternotomy is avoided. One of the major limitations of peripheral femoro-femoral VA ECMO is left ventricular (LV) afterload mismatch and inadequate LV decompression/venting. This limitation is particularly so in patients with very low native cardiac output states and severe mitral valve regurgitation, and may result in severe hydrostatic pulmonary oedema in some patients. Although some centres use an intra-aortic balloon pump in conjunction with peripheral VA ECMO to reduce LV afterload and pulmonary congestion, no definitive data exist to support routine use.

Abstract: The article reviews cannulation strategy for different modes of extracorporeal life support. Technical aspects, pitfalls and complications are discussed for central and peripheral extracorporeal membrane oxygenation (VA, VV, VAV, VVA), biventricular assist device support and extracorporeal CO2 removal.

Using extracorporeal membrane oxygenation (ECMO) to provide advanced life support in adult trauma patients remains a controversial issue now. The study was aimed at identifying the independent predictors of hospital mortality in adult trauma patients receiving ECMO for advanced cardiopulmonary dysfunctions.

33952 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed). 041b061a72


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