A Comprehensive Review of Extra Corporeal Membrane Oxygenation: The Lifeline in Critical Moments

Extracorporeal membrane oxygenation (ECMO) has evolved into a pivotal intervention in critical care, offering a lifeline for patients facing severe respiratory or cardiac failure. This review provides a comprehensive exploration of ECMO, spanning its definition and historical background to its contemporary advancements and ongoing impact in critical care. The versatility of ECMO in addressing diverse critical conditions, careful patient selection criteria, and the nuanced management of complications are discussed. Advances in technology, including miniaturization, novel circuit designs, and the integration of remote monitoring, showcase the evolving landscape of ECMO. The review underscores the ongoing impact of ECMO in improving survival rates, enhancing mobility, and enabling remote expertise. As a symbol of hope and innovation, ECMO's lifesaving potential is evident in its ability to navigate the complexities of critical care and redefine the boundaries of life support interventions.

Neurological outcomes and quality of life in post-cardiac arrest patients with return of spontaneous circulation supported by ECMO: A retrospective case series

Post-cardiac arrest brain injury constitutes a significant contributor to morbidity and mortality, leading to cognitive impairment and subsequent disability. Individuals within this patient cohort grapple with uncertainty regarding the potential advantages of extracorporeal life support (ECMO) cannulation. This study elucidates the neurological outcomes and quality of life of post-cardiac arrest patients who attained spontaneous circulation and underwent ECMO cannulation. This is a retrospective case study within a local context, the research involved 32 patients who received ECMO support following an intrahospital cardiac arrest with return of spontaneous circulation (ROSC). An additional 32 patients experienced cardiac arrest with ROSC before undergoing cannulation. The average age was 41 years, with the primary causes of cardiac arrest identified as acute coronary syndrome (46.8%), pulmonary thromboembolism (21.88%), and hypoxemia (18.7%). The most prevalent arrest rhythm was asystole (37.5%), followed by ventricular fibrillation (34.4%). The mean SOFA score was 7 points (IQR 6.5-9), APACHE II score was 12 (IQR 9-16), RESP score was -1 (IQR -1 to -4) in cases of respiratory ECMO, and SAVE score was -3 (IQR -5 to 2) in cases of cardiac ECMO. Overall survival was 71%, and at 6 months, the Barthel score was 75 points, modified Rankin score was 2, cerebral performance categories score was 1, and the SF-12 had an average score of 30. Notably, there were no significant associations between the time, cause, or rhythm of cardiac arrest and neurological outcomes. Importantly, cardiac arrest is not a contraindication for ECMO cannulation. A meticulous assessment of candidates who have achieved spontaneous circulation after cardiac arrest, considering the absence of early signs of poor neurological prognosis, is crucial in patient selection. Larger prospective studies are warranted to validate and extend these findings.

Intracannula Thrombus Formation Associated With Dual Lumen ProtekDuo Cannula in Extracorporeal Membrane Oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) is used in cases of severe respiratory failure refractory to medical management. Use of ECMO is increasing, along with new cannulation strategies including oxygenated right ventricular assist devices (oxy-RVADs). Multiple dual lumen cannulas are now available, which increase the potential for patient mobility and decrease the number of vascular access sites. However, dual lumen, single cannula flow can be limited by adequate inflow, requiring the need for an additional inflow cannula to meet patient demands. This cannula configuration may result in differential flows in the inflow and outflow limbs and altered flow dynamics, increasing the risk of intracannula thrombus. We describe a series of four patients treated with oxy-RVAD for COVID-19-associated respiratory failure complicated by dual lumen ProtekDuo intracannula thrombus.

Extracorporeal Membrane Oxygenation (ECMO): A Lifeline for Pregnant and Postpartum Women

Extracorporeal membrane oxygenation (ECMO) is a life-saving technology that temporarily supports the heart and lungs in critical care situations. This review article examines the role of ECMO as a lifeline for pregnant and postpartum women facing severe maternal and fetal conditions. The review begins with an overview of the physiology and pathophysiology of ECMO, including its procedure and how it supports cardiopulmonary function. Unique considerations specific to pregnant and postpartum women, such as physiological changes during pregnancy, risks and complications associated with ECMO, and the need to balance maternal and fetal considerations, are discussed. The indications for ECMO in this population are explored, including common maternal indications such as cardiogenic shock, acute respiratory distress syndrome (ARDS), pulmonary embolism, and eclampsia, as well as fetal indications such as fetal distress, hypoxic-ischemic encephalopathy (HIE), and twin-to-twin transfusion syndrome (TTTS). The challenges and considerations in ECMO for pregnant and postpartum women, including ethical considerations and the decision-making process, are highlighted. The review further explores the multidisciplinary care and collaborative approach required, emphasizing the importance of a specialized ECMO team and collaboration between obstetricians, neonatologists, cardiologists, and other specialists. Additionally, patient selection, pre-ECMO assessment, and planning strategies are discussed. The review evaluates existing literature and studies on ECMO in pregnant and postpartum women, analyzing survival rates and maternal and fetal outcomes and comparing different ECMO modalities and strategies. Future directions and research opportunities are presented, including emerging technologies, areas for further research and clinical trials, and improved patient selection and management strategies. The conclusion emphasizes the importance of ECMO as a lifeline for pregnant and postpartum women and the potential impact on maternal and fetal health. The review highlights the need for ongoing research and advancements in ECMO to optimize outcomes and improve care for this unique and vulnerable patient population.

Extracorporeal Membrane Oxygenation for Neonates With Congenital Diaphragmatic Hernia: Prevalence of Seizures and Outcomes

OBJECTIVES

We aimed to determine the prevalence of electrographic seizures and associated odds of adverse outcomes of electrographic seizures in neonates with congenital diaphragmatic hernia (CDH) receiving extracorporeal membrane oxygenation (ECMO).

DESIGN

Retrospective, descriptive case series.

SETTING

Neonatal ICU (NICU) in a quaternary care institution.

PATIENTS

All neonates with CDH receiving ECMO undergoing continuous electroencephalographic monitoring (CEEG) and follow-up between January 2012 and December 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All eligible neonates with CDH receiving ECMO underwent CEEG (n = 75). Electrographic seizures occurred in 14 of 75 (19%): they were exclusively electrographic-only in nine of 14, both electrographic-only and electroclinical in three of 14, and electroclinical only in two of 14. Two neonates developed status epilepticus. We identified an association between presence of seizures, rather than not, and longer duration of initial session of CEEG monitoring (55.7 hr [48.2-87.3 hr] vs 48.0 hr [43.0-48.3 hr]; p = 0.001). We also found an association between presence of seizures, rather than not, and greater odds of use of a second CEEG monitoring (12/14 vs 21/61; odds ratio [OR], 11.43 [95% CI, 2.34-55.90; p = 0.0026). Most neonates with seizures (10/14), experienced their onset of seizures more than 96 hours after the start of ECMO. Overall, the presence of electrographic seizures, compared with not, was associated with lower odds of survival to NICU discharge (4/14 vs 49/61; OR 0.10 [95% CI 0.03 to 0.37], p = 0.0006). Also, the presence of seizures-rather than not-was associated with greater odds of a composite of death and all abnormal outcomes on follow-up (13/14 vs 26/61; OR, 17.5; 95% CI, 2.15-142.39; p = 0.0074).

CONCLUSIONS

Nearly one in five neonates with CDH receiving ECMO developed seizures during the ECMO course. Seizures were predominantly electrographic-only and when present were associated with great odds of adverse outcomes. The current study provides evidence to support standardized CEEG in this population.

Comparative Propensity Matched Outcomes in Severe COVID-19 Respiratory Failure-Extracorporeal Membrane Oxygenation or Maximum Ventilation Alone

OBJECTIVE

Does extracorporeal membrane oxygenation (ECMO) improve outcomes in ECMO-eligible patients with COVID-19 respiratory failure compared to maximum ventilation alone (MVA)?

SUMMARY BACKGROUND DATA

ECMO is beneficial in severe cases of respiratory failure when mechanical ventilation is inadequate. Outcomes for ECMO-eligible COVID-19 patients on MVA have not been reported. Consequently, a direct comparison between COVID-19 patients on ECMO and those on MVA has not been established.

METHODS

A total of 3406 COVID-19 patients treated at two major medical centers in Chicago were studied. One hundred ninety-five required maximum ventilatory support, and met ECMO eligibility criteria. Eighty ECMO patients were propensity matched to an equal number of MVA patients using detailed demographic, physiological, and comorbidity data. Primary outcome was survival and disposition at discharge.

RESULTS

Seventy-one percent of patients were decannulated from ECMO. Mechanical ventilation was discontinued in 75% ECMO and 16% MVA patients. Twenty-five percent of patients in the ECMO arm expired, 21% while on ECMO, compared with 74% in the MVA cohort. Mortality was significantly lower across all age and BMI groups in the ECMO arm. Sixty-eight percent ECMO and 26% MVA patients were discharged from the hospital. Fewer ECMO patients required long-term rehabilitation. Major complications such as septic shock, ventilator associated pneumonia, inotropic requirements, acute liver and kidney injuries are less frequent among ECMO patients.

CONCLUSIONS

ECMO-eligible patients with severe COVID-19 respiratory failure demonstrate a 3-fold improvement in survival with ECMO. They are also in a better physical state at discharge and have lower overall complication rates. As such, strong consideration should be given for ECMO when mechanical ventilatory support alone becomes insufficient in treating COVID-19 respiratory failure.

Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation as the Initial Presentation of Anti-neutrophillic Cytoplasmic Auto-antibody Positive Vasculitis

Acute respiratory distress syndrome (ARDS) is a life-threatening inflammatory state of lung injury that can require acute interventions including mechanical ventilation as well as emergent veno-venous extracorporeal membrane oxygenation (VV-ECMO) for management. Etiologies of ARDS are not clearly discernible in certain cases and can vary from sepsis, pneumonia, trauma and intoxication. Anti-nuclear cytoplasmic auto-antibody (ANCA)-associated vasculitis (AAV) is a group of several conditions that can have pulmonary complications including ARDS. We present a case where the primary manifestation of myeloperoxidase (MPO)-ANCA positive vasculitis was ARDS, in order to highlight the importance of investigating rare vasculitides as the underlying cause of ARDS and the importance of ECMO as an early life-saving intervention for the management of ARDS.

Venovenous Extracorporeal Membrane Oxygenation Therapy in Adults

Extracorporeal membrane oxygenation (ECMO) therapy is used as supportive therapy for patients with respiratory failure, cardiac failure, and cardiopulmonary failure. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is one subtype used for respiratory failure as a supportive treatment for critically ill patients. The principle behind it is that the membrane lung (oxygenator) is placed sequentially with the normal lungs rather than in parallel like with cardiopulmonary bypass, therefore, the lungs do not have to work as hard to oxygenate the blood. Then using a drainage cannula, blood is drained from the right atrium (RA) and after going through the membrane lung, the newly oxygenated blood is returned back to the RA. Because of this, there is enough systemic oxygen delivery to manage metabolism and preserve the airway even at lower tidal volume ventilation settings. With ventilator settings placed at lower tidal volume, there is less risk of barotrauma. This is a review article discussing VV-ECMO therapy with adult patients. It will also go into detail regarding its indications, contraindications, configurations, patient assessment, vascular access, and complications.

Applied Uses of Extracorporeal Membrane Oxygenation Therapy

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

First successful combination of extracorporeal membrane oxygenation (ECMO) with video-assisted thoracic surgery (VATS) of pulmonary bullae resection in the management of refractory pneumothorax in a critically ill patient with H7N9 pneumonia and acute respiratory distress syndrome: A case report

RATIONALE

At present, data regarding refractory pneumothorax treated with video-assisted thoracic surgery (VATS) in combination with extracorporeal membrane oxygenation (ECMO) in critically ill patients with H7N9 pneumonia have never been reported.

PATIENT CONCERNS

A laboratory-confirmed case of human infection with avian influenza A (H7N9) virus was treated in our hospital. Acute respiratory distress syndrome (ARDS) developed and the patient was oxygenated via veno-venous ECMO due to the failure of mechanical ventilation. Unfortunately, a right refractory pneumothorax occurred. Despite treatment with pleural drainage and select bronchial occlusion, the patient still failed to improve.

DIAGNOSIS

Fatal H7N9 pneumonia complicated with severe ARDS, pulmonary bullae, and refractory pneumothorax.

INTERVENTIONS

Successful combination of ECMO with VATS of pulmonary bullae resection was performed and pneumothorax was cured.

OUTCOMES

One week after the operation, ECMO was removed. However, the patient finally developed multiorgan failure (MOF) complicated by refractory hypoxemia due to progressive lung fibrosis and died 36 days after admission.

LESSONS

Although the patient died of MOF triggered by severe lung fibrosis at last, the successful treatment of refractory pneumothorax by combination of ECMO with VATS is encouraging. Thus, when refractory pneumothorax in a patient with severe pulmonary dysfunction fails to improve through routine therapy, the treatment of pneumothorax by VATS based on ECMO support can be considered as a feasible selection.

Shunting of Oxygenated Blood to the Venous System in the Avalon® Cannula on Venovenous Extracorporeal Membrane Oxygenation with High-frequency Oscillatory Ventilation

High-frequency oscillatory ventilation (HFOV) may assist in the prevention of volutrauma for high-risk patients with acute respiratory distress syndrome (ARDS) during venovenous extracorporeal membrane oxygenation (VV ECMO). In combined VV ECMO and HFOV, we noted that increased intrathoracic pressure contributed to shunt formation in the dual-lumen Avalon® cannula (Maquet, Rastatt, Germany).

A 51-year-old female with ARDS secondary to aspiration pneumonia was placed on VV ECMO using a single Avalon cannula. By ECMO Day 16, she became unable to ventilate due to elevated peak airway pressures, even with low tidal volume ventilation and an otherwise stable VV ECMO course. HFOV was introduced to minimize ventilator-induced lung injury. Shortly after HFOV started, the patient desaturated, and consequently, the fraction of inspired oxygen (FiO₂) was increased to 100%. We noted that a flash of bright red, oxygenated blood was flowing retrograde in the Avalon cannula at the same rate as the beat of the oscillator, while the patient's ECMO flow rate, arterial blood gas, and blood pressure all remained stable. The ECMO flow was increased above 5.5 L/min and the resolution of the retrograde shunt through the Avalon cannula was immediately observed. 

Concurrent use of HFOV with VV ECMO using an Avalon cannula may result in a shunt that becomes visible with arterial O₂ saturations nearing 100%. Due to pressure differences between the venous and arterial lumens of the Avalon cannula, increasing the ECMO flow rate appeared to decrease this shunting effect caused by elevated intrathoracic pressure.

Electrographic Seizures in Children and Neonates Undergoing Extracorporeal Membrane Oxygenation

OBJECTIVE

We aimed to determine the prevalence and risk factors for electrographic seizures in neonates and children requiring extracorporeal membrane oxygenation support.

DESIGN

Prospective quality improvement project.

SETTING

Quaternary care pediatric institution.

PATIENTS

Consistent with American Clinical Neurophysiology Society electroencephalographic monitoring recommendations, neonates and children requiring extracorporeal membrane oxygenation support underwent clinically indicated electroencephalographic monitoring.

INTERVENTIONS

We performed a 2-year quality improvement study from July 2013 to June 2015 evaluating electrographic seizure prevalence and risk factors.

MAIN RESULTS

Ninety-nine of 112 patients (88%) requiring extracorporeal membrane oxygenation support underwent electroencephalographic monitoring. Electrographic seizures occurred in 18 patients (18%), of whom 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively electrographic-only seizures. Electrographic seizures were more common in patients with low cardiac output syndrome (p = 0.03). Patients with electrographic seizures were more likely to die prior to discharge (72% vs 30%; p = 0.01) and have unfavorable outcomes (54% vs 17%; p = 0.004) than those without electrographic seizures.

CONCLUSIONS

Electrographic seizures occurred in 18% of neonates and children requiring extracorporeal membrane oxygenation support, often constituted electrographic status epilepticus, and were often electrographic-only thereby requiring electroencephalographic monitoring for identification. Low cardiac output syndrome was associated with an increased risk for electrographic seizures. Electrographic seizures were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether electrographic seizures identification and management improves outcomes.

A Pregnant Woman with Acute Massive Pulmonary Embolism

A 30-year-old pregnant woman who suffered from massive pulmonary embolism presented in an unstable hemodynamic status. Angiojet catheter embolectomy and extracorporeal membrane oxygenation (ECMO) were performed, which caused the patient's condition to improve. Use of ECMO was continued during the weaning program, but the patient died of intracranial hemorrhage, a complication of ECMO.

KEY WORDS

Angiojet; Extracorporeal membrane oxygenation (ECMO); Pregnancy; Pulmonary embolism; Thromboectomy.

Extracorporeal membrane oxygenation: beneficial strategy for lung transplant recipients

The role of extracorporeal membrane oxygenation (ECMO) as a therapeutic strategy has been very well documented for over a decade now with consistently positive remarks. The aim of the present study was analyzing the outcome of ECMO application in our lung transplant program, especially the feasibility and safety of our ECMO approach. Therefore, we retrospectively analyzed the data of 15 patients recipients requiring ECMO support. We analyzed clinical data, complications, and survival of the lung-transplanted population that needed ECMO support at our institution from 2006-2009. During that period, 19 applications of ECMO were done on 15 adult patients with the following indications: primary graft dysfunction (10 patients), "bridge to transplantation" (five), pulmonary hypertension (three), and severe acute respiratory distress syndrome (one). At 28 days, the overall survival was 93% (14 of 15 patients) and 12 of these patients (80%) survived at least 6 months. Complications included acute renal insufficiency with temporary need of renal replacement therapy (53%), bleeding (33%), critical illness polyneuropathy (66%), and reversible thrombocytopenia (73%). Based on the evaluation of the patients in this analysis, ECMO seems to be a safe therapeutic approach in lung transplant recipients with severe respiratory failure directly after transplantation.

Novel multi-functional life support system

Concepts of cardiopulmonary support (CPS), extracorporeal membrane oxygenation (ECMO), and ventricular support (VS) have been thoroughly studied and refined. These perfusion adjuncts often require multiple devices, skill sets, and significant financial burden to purchase, maintain, deploy, and use. We describe a novel system that is rapidly deployable, user-friendly, portable, safe, and economical. Over a 1-year period we have used a multi-functional life support system (MLS) in the cardiac catheterization laboratory, cardiovascular intensive care unit, and cardiac surgical suites. Further, we have conducted multiple transports within the hospital and one to an alternate facility. Applications have included ECMO, cardiopulmonary resuscitation-supported cardiogenic shock, high risk percutaneous coronary intervention (PCI), valvuloplasty, right ventricular assist device transition to ECMO post cardiotomy, left ventricular assist device transition to ECMO, ventricular septal defect closure, and ECMO transition to conventional cardiopulmonary bypass (CPB). Duration of support has ranged from approximately 39 minutes to several days.

KEYWORDS

extracorporeal membrane oxygenation (ECMO), percutaneous ventricular assist device, cardiopulmonary support, portable cardiopulmonary life support, ventricular assist.

Use of thromboelastograph and factor VII for the treatment of postoperative bleeding in a pediatric patient on ECMO after cardiac surgery

This report describes a case of possibly fatal bleeding treated successfully with an "overdose" of recombinant factor VII (rFVII; Novo7). A 3.5-year-old boy had surgery for aortic stenosis and aortic arch repair and was placed on extracorporeal membrane oxygenation (ECMO) after a prolonged cardiopulmonary bypass time (CPB); there was subsequent failure to wean from CPB because of right ventricular failure. Subsequently, a severe coagulopathy developed, and despite large volume transfusions with blood and blood products, this was unresolved. Thromboelastograph (TEG) measurements were obtained, and on the advice of the Hematology Department, Novo7 (recommended dose: 15-30 microg/kg) was administered at a dose of 200 microg/kg because of the severity of the bleeding. TEG was repeated, and a further dose of Novo7 was administered at 500 microg/kg; a further TEG after 15 minutes showed normalization, and the remaining bleeding was treated surgically. The patient was weaned from ECMO 48 hours later and was subsequently discharged home with no further problems. Novo7 in an "overdose" can apparently correct major coagulopathy even in patients on ECMO support with no dire effects on the ECMO circuit or the patient in a life-threatening scenario.

Capgras syndrome: a clinical manifestation of watershed cerebral infarct complicating the use of extracorporeal membrane oxygenation

Ischaemic cerebral accidents are frequent following extracorporeal membrane oxygenation (ECMO), especially after fixing the reinjection cannula in the right primitive carotid artery, which leads to an interruption in downstream flow. We describe a rare and unusual symptom of cerebral ischaemic accident that is known as Capgras syndrome. This feature is interesting because it may be documented by computed tomography (CT) scan and particular electroencephalography signals. It appears that our observation represents the first documented case of Capgras syndrome complicating ECMO. This incident emphasizes the potential hazards associated with right common artery ligature for venoarterial extracorporeal membrane oxygenation (VAECMO). In addition, it shows that this psychiatric symptom (that has been interpreted psychodynamically for many years) can have an organic basis, which should be studied.