Similar to the heart-lung bypass machine used in open heart surgery, extracorporeal membrane oxygenation (ECMO) is an advanced life-support device that pumps and oxygenates a patient’s blood outside the body, permitting the heart and lungs to rest.
Contents
Introduction
Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), is an extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life.
Derivative of cardiopulmonary bypass (provides shorter-term support with arrested native circulation)
ECMO circuit sketch | Jürgen Schaub – CC BY-SA 2.0 de, https://commons.wikimedia.org/w/index.php?curid=8756034
ECMO circuit components and flow. Flow through the ECMO circuit starts with the venous drainage cannula (1), which is propelled forward by the pressure gradient generated by the centrifugal pump head (2). The blood passes through the oxygenator (3) and then returns to the patient in the outflow tubing back into the right atrium (VV) or femoral artery (VA) (4). Gas exchange is regulated by the amount of countercurrent “sweep” gas flowing through the oxygenator (5) and the blood is warmed by the thermoregulator attached to the circuit (6). Flow, hemoglobin, hematocrit and venous saturation can be continuously monitored by ultrasonic meters attached to the circuit (7 and 8) | Mosier, J. M., Kelsey, M., Raz, Y., Gunnerson, K. J., Meyer, R., Hypes, C. D., … Spaite, D. W. (2015). Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions. Critical Care, 19(1), 431. https://doi.org/10.1186/s13054-015-1155-7
History
ECLS was initially developed in the 1950s by John Gibbon as a means of oxygenating blood via a membrane oxygenator during prolonged operations on cardiopulmonary bypass.
Professor John Heysham Gibbon, Jr., AB, MD, (1903 – 1973) was an American surgeon best known for inventing the heart–lung machine and performing subsequent open heart surgeries which revolutionized heart surgery in the twentieth century.
Dr Gibbon and his wife Mary “Maly” Gibbon with the newer version of the heart–lung machine (IBM II). This was the second and more refined model that Dr Gibbon used on his first patients.
May 6, 1953: The Bavolek operation. Drs Gibbon (left) and Frank Allbritten (right) performing the first successful open heart surgery to close an atrial septal defect in Cecilia Bavolek.
Dr. Gibbon and former patient Cecelia Bavolek pose before the Plexiglas-covered “lung” ten years after the landmark operation, 1963.
Types
Veno-arterial ECMO (VA-ECMO):
Facilitates gas exchange
Provides haemodynamic support (blood pumped from venous to arterial side)
Veno-venous (VV-ECMO):
Facilitates gas exchange (blood removed from venous side and pumped back)
Does not provide haemodynamic support
Arterio-venous ECMO (AV-ECMO):
Facilitates gas exchange (by using the patient’s own arterial pressure to pump the blood from arterial to venous side)
Veno-arterial (VA) ECMO for cardiac or respiratory failure featuring right internal jugular vein drainage and right carotid artery infusion | Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, Extracorporeal Life Support Organization, Ann Arbor 2005. – ECMO: Extracorporeal Cardiopulmonary Support in critical care, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=18864580
Veno-venous (VV) ECMO for respiratory failure featuring right common femoral vein drainage and right internal jugular vein infusion | Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, Extracorporeal Life Support Organization, Ann Arbor 2005. – ECMO: Extracorporeal Cardiopulmonary Support in critical care, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=18864581
Indications
VA-ECMO
VV-ECMO
Weaning from cardiopulmonary bypass after cardiac surgery
Any potentially reversible acute respiratory failure
Bridge to cardiac transplantation
ARDS. Associated with pneumonia (viral or bacterial)
Acute myocarditis
Failed lung transplant graft
Intractable arrhythmia
Trauma (pulmonary contusion)
Post-cardiac arrest (as part of Advance Life Support)
Respiratory therapist Michelle Sirra takes a blood sample from a 3-day-old patient in preparation for transfer to an Extracorporeal Membrane Oxygenation unit on Friday, July 21, in San Juan, Puerto Rico. An ECMO team comprised Air Force and Army medical specialists from the Wilford Hall Medical Center at Lackland Air Force Base, Texas, flew to Puerto Rico to transport Stuart to San Antonio for more advanced care. Ms. Sirra is a respiratory therapist in the neonatal intensive care unit at the Hospital Auxilio Mutuo in San Juan. | U.S. Air Force photo/Staff Sgt. Matthew Rosine
Patient with acute respiratory distress syndrome treated with “awake extracorporeal membrane oxygenation (ECMO)”. The patient was not intubated and was breathing spontaneously. The ECMO device can be seen at the foot end of the bed. The ECMO cannulas were inserted in the left femoral vein and the right internal jugular vein. | Wiesner, O., Hadem, J., Sommer, W., Kühn, C., Welte, T., & Hoeper, M. M. (2012). Extracorporeal membrane oxygenation in a nonintubated patient with acute respiratory distress syndrome. European Respiratory Journal, 40(5), 1296 LP-1298. https://doi.org/10.1183/09031936.00076912
Veno-venous cannulation for ARDS. This chest X-ray demonstrates severe airspace disease in a patient with ARDS. The dual-lumen ECMO cannula (arrows) can be seen passing through the internal jugular vein, superior vena cava, and terminating in the inferior vena cava at the level of the hepatic vein | Mosier, J. M., Kelsey, M., Raz, Y., Gunnerson, K. J., Meyer, R., Hypes, C. D., … Spaite, D. W. (2015). Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions. Critical Care, 19(1), 431. https://doi.org/10.1186/s13054-015-1155-7
