Extracorporeal life support

Description:
This book covers up-to-date knowledge of extracorporeal life support/ membrane oxygenation (ECLS/ECMO), which is performed as one special procedure that takes over the work of the lungs when they are too sick to properly support the body. ECLS has been recognized as one primary rescue strategy when the conventional treatments cannot reverse the process of cardiac dysfunction or respiratory dysfunction. During the recent years, ECLS has also been utilized as the bridge during peioperative organ transplantation, emergency cardiopulmonary resuscitation, and chronic assistant devices such as left ventricular assist device.
This book summarizes the major characteristics of technique, current status of implication and topics of development. Physiology and mechanism of ECLS is defined in the initial part of the book. Type and primary characteristics of ECLS, including instrument materials and monitoring methods are further introduced. Methods of cannulation, characteristics of patients and key-point of management during pediatric ECLS are included. ECLS has been recognized as one kind of novel CPR procedures, transport of ECLS, treatment of various complications with preventive strategy are demonstrated. Recent hot topics of ECLS and training perspective are also discussed.

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Preface

Extracorporeal life support (ECLS), which is previously named as “extracorporeal membrane oxygenation” (ECMO) by many practitioners, has emerged to describe the entire family of extracorporeal support modalities for long-term support and has been popularized widely and applied in various fields since the twenty-first century. The ECLS member units reported by Extracorporeal Life Support Organization (ELSO) Annual Reports have also increased year by year. In particular, the outbreak of SARS and COVID-19 has praised ECLS as a “magic tool” to control the epidemic. However, the clinical outcomes of patients using ECLS have not improved substantially in the past few decades. This has a lot to do with the type of basic primary diseases of patients, but it is also directly related to the timing of assistance, the selection of ECLS methods, the screening of implantation sites, the reasonable management during ECLS, prevention of various complications, and the timely removal of ECLS.

In the past, most practitioners engaged in ECLS refer to The ELSO red book for management of ECLS. Many pilots of ECLS have propagated and promoted the professional development of ECLS with establishment and update of the ELSO database, compilation of ELSO red book, introduction of recommendations or guidelines. However, the emergence of new ECLS consumables, especially the emergence of new ECLS indications and the adapted population, requires professionals to reassess ECLS. Many clinical problems still need specific practitioners to report and communicate information with them, rather than covering up some iatrogenic errors and decision-making bias. With the continuous progress of other medical specialties, many patients and their relatives have higher requirements and expectations for such patients, urging us to re-examine the protocol of treatment, therapeutic strategies, and treatment concept of such critically ill patients. The development of multidisciplinary consultations helps to optimize the adjustment of treatment during ECLS. Therefore, we have organized domestic and some foreign experts to update the relevant content of this field. We hope that the publication of this work can provide the basic theoretical model of ECLS for front-line practitioners, and certain reference for the treatment of critically ill patients.

Although all our three chief editors are from China and English is not our native language, the current world is a diversified world, and the geographical boundaries cannot block the communication and cooperation of such professionals. We hope that this work can become a form of academic exchange in ECLS.

Table of contents :
Preface
Introduction of Chief Editor, Feilong Hei
The Main Academic Title
Scientific Research and Clinical Achievements
Introduction of Chief Editor, Yulong Guan
The Main Academic Title
Scientific Research and Clinical Achievements
Scientific Achievements
Scientific Training
Scientific Monographs
Scientific Papers
Introduction of Chief Editor, Kun Yu
The Main Academic Title
Scientific Research and Clinical Achievements
Contents
1: Physiology of Extracorporeal Life Support
Cardiovascular Physiology
Heart
Vasculature
Blood
Blood Composition
Transportation of O2 in Blood
Transportation of CO2 in Blood
Cardiovascular Pathophysiology
ECMO Circuit and Circuit Physiology
Blood Pumps
Roller Pumps
Rotary Pumps
Interaction Between Centrifugal Pump and Patient
Gas Exchange Device: Artificial Oxygenator
Blood Oxygenation in Oxygenator
CO2 Removal in Oxygenator
Other Functions of Oxygenator
Cannulas
Tubing and Connectors
Mechanism of Cardiorespiratory Support
Physiology of VA-ECMO
Hemodynamic Effects of VA-ECMO
Gas Exchange in VA-ECMO
Advantages and Disadvantages of VA-ECMO
Physiology of VV-ECMO
Hemodynamic Effects of VV-ECMO
Oxygenation in VV-ECMO
CO2 Removal in VV-ECMO
Recirculation During VV-ECMO
Advantages and Disadvantages of VV-ECMO
VA-ECMO vs. VV-ECMO
Pharmacokinetics During ECMO
Pumpless Extracorporeal Lung Assist (pECLA)
Summary
References
2: Equipment and Devices of Extracorporeal Life Support
Blood Pump
Centrifugal Pump Physics
Components of a Centrifugal Pump
Commercial Centrifugal Pumps
Membrane Oxygenator
Commercial Gas Exchange Devices
ECLS Tubing
General Principles of Circuit Design
Surface Coating Technology
Heat Exchanger/Heater-Cooler Device
Medicare Monitoring During ECLS
Hemoglobin Saturation Measurement
Anticoagulation Monitoring
Circuit Pressures
Colloid Osmotic Pressure
Plasma Free Hemoglobin
Temperature Monitoring
References
3: Types of Extracorporeal Life Support and Evolution of Extracorporeal Oxygenators
The Retrospective Glance on the Historical Development of ECLS/ECMO and Extracorporeal Oxygenators
Evolution of Extracorporeal Oxygenator and Its Use in Extracorporeal Life Support
Development of High-Performance Extracorporeal Oxygenators for ECMO Use—High Gas Exchange Efficiency, Low Flow Resistance, and Plasma Leak-Tight Oxygenator
Extracorporeal Membrane Oxygenation (ECMO)
Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) Mode
VV Configurations and Cannulation Strategies
Special Consideration: Right Ventricular Failure During ARDS and VV ECMO
Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) Mode
VA Configuration and Cannulation Strategies
Venovenous-Arterial (VV-A) ECMO, Alternative Configuration of Peripheral VA Mode and Cannulation Strategies
Veno-Veno-Arterial (V-VA) ECMO, a “Hybrid” Mode Configuration in North-South or Harlequin Syndrome or Differential Hypoxia
Conclusion
References
4: Cannulation and Decannulation of Extracorporeal Life Support
Cannulation Sites
Femoral Artery
Axillary Artery
Carotid Artery
Ascending Aorta
Femoral Vein
Right Internal Jugular Vein
Subclavian Vein
Right Atrium
Cannula Selection
Single-Lumen Cannula
Dual-Lumen Cannula
Methods and Techniques of Cannulation
Surgical Cannulation
Femoral Vessel Cannulation
Neck Vessel Cannulation
Axillary Artery Cannulation
Central-VA ECMO Cannulation
Percutaneous Cannulation
Pre-Procedure Preparation
Peri-Procedure
Post-Procedure
Semi-Percutaneous Cannulation
Decannulation
Decannulation of Arterial Cannula
Decannulation of Venous Cannula
Left Ventricular Venting
Surgical Venting
Sternotomy
Mini-Thoracotomy
Percutaneous Venting
Transseptal Venting
Transpulmonary Venting
Transaortic Venting
References
5: Anticoagulation During Extracorporeal Life Support
Hemostatic Alterations
Anticoagulation
Unfractionated Heparin
Direct Thrombin Inhibitors
Antiplatelet Agents
Anticoagulation Monitoring
ACT
aPTT
Anti-Factor Xa Assay
Thromboelastography/Thromboelastometry-Guided Algorithm
Anticoagulation Management During ECLS
Bleeding
Thrombosis
Conclusions
References
6: Management of Pediatric Extracorporeal Life Support
Overview and History
Centrifugal Pump Takes the Place of Roller Pump
Hollow Fiber Oxygenator Takes the Place of Silicon Membrane Oxygenator
Cannula
Circuit and Coating Technique
Outcomes
Indications
Respiratory Failure
Cardiac Support
Perioperation Support of Heart
Nonstructural Heart Disease
Cannulation Strategies
VA ECMO
Neck Cannulation
Central Cannulation
Groin Cannulation
VV ECMO
Decannulation
ECMO Circuit Priming
Initiation of ECMO
Selection of Cannula
ECMO Flow
ICU Management and Assessment of Support
Ventilation
Hypoxia
Cardiac Output
Fluid Management and Nutrition
Sedation
Anticoagulation
Key Points in Management
Systemic and Local Hypoxia
Left Heart Decompression
VA ECMO for Single Ventricle
Special Situations
Cannulation Site Care
Hypertension
Infection
Bleeding and Thrombosis
Weaning from ECMO
References
7: Management of Adult Extracorporeal Life Support
Monitoring
Monitoring of ECLS Equipment
Blood Flow Rate and Pump Rotation Speed
Sweep Gas Flow
Gas Exchange of Oxygenator
Pressure Monitoring in the Circuits
Water Tank Temperature
Thrombus in the Circuits
Patient’s Monitoring
Hemodynamic Parameters
Respiratory System
Nervous System
Gastrointestinal System
Renal Function
Blood System
Respiratory and Circulatory Management
VV ECLS
Target Values
Ventilator Management
ECLS Blood Flow and Sweep Gas Flow
Hemodynamics
Patient Position
VA ECLS
Target Values Control
Respiratory Management
Hemodynamics
Blood Management
Hematocrit
Destruction of Red Blood Cells
Anticoagulation During Extracorporeal Life Support
Kidney Function and Electrolytes
Kidney Function
Blood Gas Parameters and Electrolytes
Management of Edema and Fluids
The Mechanisms of Edema During ECLS
Fluid Management During ECLS
Central Nervous System
Assessment of Central Nervous System During ECLS
Central Nervous System Protective Measures During ECLS
Gastrointestinal Tract Management and Nutritional Support
Parenteral Nutrition
Enteral Nutrition
Nutritional Assessment
Analgesia and Sedation
Evaluation and Goals
Commonly Used Drugs
Conscious ECLS
Temperature Management
Vascular Complications
Blood Vessel Damage
Limb Ischemia
Infection and Antibiotics
Urinary Tract Infection
Pulmonary Infections
Intravascular Infection Caused by Indwelling Catheter
Wound Infection
Intestinal Infection
Fungal Infection
Discontinuation of ECLS
Requirements for ECLS Discontinuation
Testing Before Discontinuation
VV ECLS
VA ECLS
Repeat ECLS Assistance
Termination of Ineffective ECLS
References
8: Extracorporeal Life Support During Cardiac Arrest
Selection of ECPR Patients
No Flow Time and Low Flow Time
Age
CPR Quality: EtCO2
Ventilator Setting
Strategies of Cannulation
Management
Complications
Neurological Outcome
References
9: Adverse Events and Complications of Extracorporeal Life Support
Categories of Complications and the Cumulative Incidence
Mechanical Adverse Events
Pump Failure
Symptoms
Causes
Solution
Low Flow/Cutting Off
Symptoms
Causes
Solution
Air in Circuit
Symptoms
Causes
Solution
Oxygenator Failure
Symptoms
Causes
Solution
Thrombosis
Symptoms
Causes
Solution
Tubing Rupture
Symptoms
Causes
Solution
Others
Cannulation-Related Complications
Clinical Manifestations
Causes
Solution
Hematologic Disorders
Thrombosis
Incidence
Clinical Manifestations
Mechanisms
Management of Thrombosis
Bleeding
Definition and Incidence
Clinical Manifestations
Mechanism
Prevention and Management
Neurologic Injury
Clinical Manifestations
Incidence
Risk Factors
Mechanism
ICH
AIS
Hypoxic Ischemic Encephalopathy
Seizures
Prognosis
Prevention
Management
Circulatory Complications
LV Dilation Complications
Harlequin Syndrome
Pulmonary Complication
Clinical Manifestations
Causes
Solution
Acute Kidney Injury
Definitions of ECMO-Associated Kidney Injury
Risk Factors
Pathophysiology of ECMO-Associated Kidney Injury
Prevention and Management
Vascular Complications
Limb Ischemia
Prevalence and Definition
Mechanism
Prevention
Treatment
Vessel Damage
Clinical Manifestations
Etiological Factor
Prevention
Treatment
Infection
Clinical Manifestations
Risk Factors
Etiology of Infection
Preventive Practices
Hemolysis
Diagnosis and Clinical Manifestations
Mechanisms
Patient-Related Factors
Circuit-Related Factors
ECMO Set-Up and Management Factors
Management and Prevention
References
10: Transport of the Patients Supported with Extracorporeal Life Support
Intra-Hospital Transport of Patients Supported with ECLS
Purpose of Transport
Preparation of Personnel and Equipment
Transport Points
Inter-Hospital Transport
Indications for Inter-Hospital ECLS Transport
Transport Logistics
Transfer Modes
Personnel Preparation
Transport Equipment
Management of Inter-Hospital ECLS Transport
Assessment of Patient
Lay Out a Scheme
Patient Transport
Monitoring in ECLS Transfer
Treatment and Care in ECLS Transfer
Complications Associated with Transport
References
11: Extracorporeal Life Support During Perioperative Transplantation
ECLS During Perioperative Heart Transplantation
ECLS Prior to Heart Transplant
Inclusion Criteria of ECLS Prior to Heart Transplant
Current State of ECLS as a BTT in Adult Candidates
ECLS as a BTT Before Pediatric Heart Transplantation
ECLS as Post-Transplant Support
Definition and Classification of PGD After Heart Transplant
Advantage of ECLS for PGD
Current State of ECLS for PGD
Outlook of ECLS During Perioperative Heart Transplantation
ECLS During Perioperative Lung Transplantation
ECLS as a Bridge to Lung Transplant
Advantage of ECLS as a Bridge to Lung Transplant
Recommendations on the Use of ECLS in Bridge to Lung Transplant
Factors That Affect Post-Transplant Survival in Patients on ECLS Support
Current State of ECLS as a Bridge to Lung Transplant
The Protocol of Implementation of ECLS as a BTT
ECLS During Lung Transplantation
Management of Ventilation and Oxygenation
Transfusion and Anticoagulation
Weaning from ECLS
ECLS Following Lung Transplantation
Clinical Experience
Indications
Time of Initiation
Technical Aspects
Outcomes of ECLS After Lung Transplantation
Outlook of ECLS During Perioperative Lung Transplantation
ECLS During Donor Storage
Organ-Preservation ECLS in DBD Donor
ECPR and Organ Donors
ECLS for Abdominal Organ Protection from Donors After Circulatory Death
Ethical Dilemmas of ECLS in Organ Donors
References
12: Topics of Extracorporeal Life Support
Novel ECLS Instruments
Animal Experiments with Newly Developed ECLS System
Clinical Experiments with Newly Developed ECLS System
The Timing of ECLS Initiation
Patient Selection and Timing for rECLS Support
Bridge to Recovery
Bridge to Transplant
Patient Selection and Timing for cECLS Support
Bridge to Recovery
Bridge to Transplant or Mechanical Circulatory Support
Extracorporeal Cardiopulmonary Resuscitation
The Timing of ECLS Termination
Weaning from VA ECLS
Hemodynamics
Respiratory Criteria
End-Organ Recovery Criteria
Flow Reduction
Echocardiographic Assessment
Weaning from VV ECLS
ECLS During Treatment of COVID-19
When ECLS Is Used for COVID-19 Patients
What Patients Are the Highest Priority?
What Patients Should Be Excluded?
ECLS During Donor Reconditioning of Lung Transplantation
Patient Selection for ECLS
ECLS and Protection During Reperfusion
Combination of Mechanical Assistance with ECLS
New Indications of ECLS in the Future
References
13: Extracorporeal Life Support Training
Teaching Theory
Cognitive Domain
Psychomotor Domain (Technical Skills)
Psychomotor Domain (Behavioral Skills)
Affective Domain
Training of ECLS Team
Training Content
Acquiring Competency
Didactic Course
Water Drills
Animal Lab
High-Fidelity Simulation
Verifying ECLS Competency
Evaluation Ability
Maintaining Competency
Credentialing
Ethics Training
Ethical Dilemmas
Ethics Content
Skills for Managing Ethical Dilemmas
ECLS Training in China Mainland
Future Perspectives
References