Get ready for ECMO

• Veno-venous ECMO for acute severe respiratory failure
• Veno-arterial ECMO for acute severe cardiac failure*

*plus some other cool stuff like ventricular assist devices

• Really great advice on ITU management of patients with acute cardiac or respiratory failure, even if your patient isn't a candidate for retrieval.

If your patient has a reversible life-threatening respiratory failure that would benefit from giving the lungs a complete rest, then maybe, if:

• They have decent enough cardiac function
• They're hypercapnoeic with a pH <7.2
• They have a Murray score of 3 or more

If your patient is satisfying the above criteria, and none of the following are present:

• Severe heart failure or cardiogenic shock not managed with medical therapy
• Severe chronic pulmonary hypertension
• Ongoing cardiac arrest

...Then give them a call.

They might say that VV-ECMO isn't indicated in the case of:

• More than 7 days of ventilation with plateau pressures over 30cmH2O and FiO2 80%
• Severe immunosuppression
• More than 30 min of CPR with no documented neurological recovery
• BMI less than 18

But it's still worth a call, if only for advice.

If your patient has severe but potentially reversible, refractory cardiogenic shock, where ECMO would be a bridge to a more definitive treatment, then potentially, if:

• They need to have no absolute contraindications to a heart transplant
• Lacte is >3 between 1 and 12 hours after starting inotropes
• Persistent cardiac index <2.2
• End organ dysfunction due to cardiogenic shock
• LVEF <30% or aortic velocity time integral <8-12 cm/sec

Absolute contraindications to VA-ECMO

• Any contraindication to heart transplant
• Aortic dissection or peripheral arterial disease that means cannulation not possible
• Uncontrolled major haemorrhage
• Known CVA within 6 month
• More than 30 mins of CPR at time of cannulation

• Chronic medical condition with a life expectancy of less than 12 months
• Progressive heart or lung disease not suitable for transplant
• Chronic severe pulmonary hypertension
• Advanced cancer
• Graft vs Host disease
• Unwitnessed cardiac arrest
• Bone marrow transplant if within last 9 months

• FBC
• Electrolytes and creatinine
• LFT
• Lactate (ABG)
• CRP
• Clotting
• Fibrinogen
• CXR
• ECG
• Echo if possible
• Relevant microbiology results

• A theatre with anaesthetist and scrub nurse - you're going to need to coordinate with CEPOD to avoid pausing CEPOD unnecessarily
• A half-decent ultrasound machine
• 2 large and 1 small empty surgical trolleys
• A radiolucent table - usually with the head at the foot end of the table with it fully traversed to the feet so that you can X-ray all the way from groin up to chest
• A friendly radiographer with a C-arm - they'll also need special IV contrast
• Lots of lead gowns and thyroid shields
• Four units crossmatched blood
• Platelets if less than 100
• FFP if INR or APPTr is more than 1.5
• Good bilateral IV access or central lines (avoid the groin where possible, but don't remove lines that are already in - the ECMO team occasionally rewire them)
• Radial arterial line

• The ECMO team should have had a decent handover from whoever made the referral from ITU, but if you're the CEPOD anaesthetist helping out, it's a good idea to clarify the patient's history in your own mind, so that you can answer questions during the procedure
• The patient is probably already intubated on ITU, and therefore this whole procedure is probably being done via a consent form 4
• It is imperative that the family or next of kin are aware of the plan and what's going on
• The ECMO team will consent the patient's family where possible and appropriate, but it certainly shouldn't be the first time that they're hearing about it
• If you can have the family ready in the relatives' room when the ECMO team arrive, this will speed things along remarkably

• Have a fresh bag of Hartmann's or Plasmalyte or equivalent on a blood giving set ready to go
• Noradrenaline, propofol, fentanyl, rocuronium and any other active infusions should be made up and ready to go
• Make sure all the relevant notes and images have been sent to the receiving hospital
• An offer of food and drink before they set off always goes down well, even if it's just tea and NHS issue bourbons!