Respiratory Medicine Series Editor: Sharon I.S. Rounds. Gregory A. Schmidt Editor. Extracorporeal Life Support for Adults

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1 Respiratory Medicine Series Editor: Sharon I.S. Rounds Gregory A. Schmidt Editor Extracorporeal Life Support for Adults

2 Respiratory Medicine Series Editor : Sharon I.S. Rounds More information about this series at

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4 Gregory A. Schmidt Editor Extracorporeal Life Support for Adults

5 Editor Gregory A. Schmidt, MD Division of Pulmonary Diseases, Critical Care, and Occupational Medicine Department of Internal Medicine University of Iowa Iowa City, IA, USA ISSN ISSN (electronic) Respiratory Medicine ISBN ISBN (ebook) DOI / Library of Congress Control Number: Springer New York Heidelberg Dordrecht London Springer Science+Business Media New York 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Humana Press is a brand of Springer Springer Science+Business Media LLC New York is part of Springer Science+Business Media (

6 To William R. Lynch, MD, who built and nurtured an outstanding program, exhibited remarkable vision in how to advance ECLS care, and opened my eyes to its new possibilities.

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8 Preface Extracorporeal life support (ECLS) consists of using an external gas-exchanging membrane to support oxygenation or carbon dioxide removal (or both), at times including circulatory assistance. ECLS has been used in severe hypoxemic respiratory failure (ARDS, pneumonia); diseases dominated by ventilatory failure such as status asthmaticus and COPD; cardiogenic shock; following cardiothoracic surgery complicated by circulatory or gas exchange failure; and as a bridge to lung transplant. Historically, ECLS has been used sparingly, often as a last resort, and in few centers with the requisite expertise. Three factors have combined to change this. First, technological improvements in membranes, pumps, circuits, and cannulas have led to more efficient and safer ECLS. Second, the CESAR trial has shown that, for adults with severe ARDS, referral to an ECLS center improves outcomes. Finally, the adverse consequences of conventional management of lung failure, including ventilator-induced lung injury, ICU-acquired weakness, and nosocomial infection, have become abundantly clear. Some of these may be ameliorated by using ECLS in preference to conventional care. As perceptions of the role of ECLS have evolved, more practitioners and more centers are developing ECLS capability or positioning themselves to offer ECLS. The aim of this book is to deliver a concise, evidence-based review of ECLS for adult disease. Adult medicine (rather than neonatal and pediatric disease, where ECLS has an established but limited role) represents the growth area for ECLS. Chapters are devoted to describing the complex physiology and technology; the evidence base in varied clinical conditions; how to obtain vascular access; daily management of the circuit and patient; guidance regarding the weaning and decannulation process; and recommendations for crisis management and rehabilitation related to ECLS. The text concludes with a fascinating historical review, showing just how far we ve come. This text has been written for practicing physicians, nurses, perfusion specialists, therapists, and critical care trainees who are considering whether to refer their patients for ECLS, debating whether to offer ECLS capability to their patients, or are already providing ECLS but seek a practical reference to best practices and updated information. It could never have been completed without the inspiration vii

9 viii Preface from my colleagues at Iowa who strive daily to save the sickest patients; the trainees whose curiosity makes us all want to know more; my contributors who are at the forefront of a truly challenging field; and our publisher at Springer-Link who pushed for this important book. Finally, I recognize all those who do the hard work: the nurses, perfusionists, and therapists who dedicate their lives to the critically ill. This is an exciting time, ripe with change and opportunity. We seek a path forward for the benefit of all our patients. Iowa City, IA, USA Gregory A. Schmidt, MD

10 Contents 1 Physiology of Extracorporeal Life Support (ECLS)... 1 Matthew J. Brain, Warwick W. Butt, and Graeme MacLaren 2 Hypoxemic Respiratory Failure: Evidence, Indications, and Exclusions Darryl Abrams, Matthew Bacchetta, and Daniel Brodie 3 Cardiogenic Shock: Evidence, Indications, and Exclusions Nicolas Bréchot and Alain Combes 4 ECCO 2 R in Obstructive Diseases: Evidence, Indications, and Exclusions Lorenzo Del Sorbo and V. Marco Ranieri 5 ECLS as a Bridge to Lung Transplantation Christian Kuehn 6 Modes of ECLS L. Keith Scott and Benjamin Schmidt 7 Vascular Access for ECLS Steven A. Conrad 8 Circuits, Membranes, and Pumps Bradley H. Rosen 9 Ventilator Management During ECLS Antonio Pesenti, Giacomo Bellani, Giacomo Grasselli, and Tommaso Mauri 10 Daily Care on ECLS Giles J. Peek 11 Crises During ECLS Cara L. Agerstrand, Linda B. Mongero, Darryl Abrams, Matthew Bacchetta, and Daniel Brodie ix

11 x Contents 12 Mobilization During ECLS Gregory A. Schmidt 13 ECMO Weaning and Decannulation Sundar Krishnan and Gregory A. Schmidt 14 The Story of ECLS: History and Future J. Ann Morris, Robert Pollock, Brittany A. Zwischenberger, Cherry Ballard-Croft, and Joseph B. Zwischenberger Index

12 Contributors Darryl Abrams, MD Division of Pulmonary, Allergy and Critical Care, New York- Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA Cara L. Agerstrand, MD Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA Matthew Bacchetta, MD, MBA, MA Division of Thoracic Surgery, New York- Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA Cherry Ballard-Croft, PhD Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA Giacomo Bellani, MD, PhD Department of Health Sciences, University of Milano-Bicocca, Monza, Italy Department of Anesthesia and Critical Care, San Gerardo Hospital and Milano- Bicocca University, Monza, Italy Matthew J. Brain, MBBS (Hons), FRACP, FCICM, DDU School of Public Health and Preventive Medicine, Monash University, Malvern East, VIC, Australia The Alfred Intensive Care Unit, Melbourne, VIC, Australia Department of Medicine, Launceston General Hospital, Launceston, TAS, Australia Nicolas Bréchot, MD, PhD Service de Réanimation Médicale, Hospital Pitié Salpêtrière, Paris, France Daniel Brodie, MD Division of Pulmonary, Allergy and Critical Care, New York- Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA Warwick W. Butt, FRACP, FCICM ICU RCH, Department of Paediatrics UoM, Clinical Sciences Theme MCRI, Royal Children s Hospital, Melbourne, VIC, Australia Paediatric Intensive Care Unit, Parkville, VIC, Australia xi

13 xii Contributors Alain Combes, MD, PhD Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, ican, Institute of Cardiometabolism and Nutrition, Paris Cedex, France Steven A. Conrad, MD, PhD, MCCM, FCCP Department of Medicine, Emergency Medicine and Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA Lorenzo Del Sorbo, MD Dipartimento di Anestesiologia e Rianimazione, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Università di Torino, Torino, Italy Inter-departmental Division of Critical Care Medicine, University Health Network, University of Toronto, Toronto, ON, Canada Giacomo Grasselli, MD Department of Anesthesia and Critical Care, San Gerardo Hospital and Milano-Bicocca University, Monza, Italy Sundar Krishnan, MBBS Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Christian Kuehn, MD Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Privatdozent Dr. med., Hannover Medical School, Hannover, Germany Graeme MacLaren, MBBS, FRACP, FCICM, FRCP, FCCP, DipEcho ICU RCH, Department of Paediatrics UoM, Clinical Sciences Theme MCRI, Royal Children s Hospital, Melbourne, VIC, Australia Paediatric Intensive Care Unit, Parkville, VIC, Australia Cardiothoracic ICU, National University Hospital, Singapore, Singapore Tommaso Mauri, MD Department of Anesthesia and Critical Care, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy Linda B. Mongero, CCP, BS Department of Clinical Perfusion, New York Presbyterian-Columbia University Medical Center, Locust Valley, NY, USA J. Ann Morris, BS Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA Giles J. Peek, MD, FRCS CTh, FFICM Heartlink ECMO Centre, Glenfield Hospital, Leicester, UK Antonio Pesenti, MD Department of Health Sciences, University of Milano- Bicocca, Monza, Italy Department of Anesthesia and Critical Care, San Gerardo Hospital and Milano- Bicocca University, Monza, Italy Robert Pollock, BS Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA

14 Contributors xiii V. Marco Ranieri, MD Dipartimento di Anestesiologia e Medicina degli Stati Critici, Ospedale S. Giovanni Battista-Molinette, Università di Torino, Torino, Italy Dipartimento di Anestesiologia e Rianimazione, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Università di Torino, Torino, Italy Bradley H. Rosen, DO Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Benjamin Schmidt, MD Department of Surgery, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC, USA Gregory A. Schmidt, MD Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA L. Keith Scott, MD Department of Anesthesiology, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC, USA Brittany A. Zwischenberger, MD Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA Joseph B. Zwischenberger, MD Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA

15 Chapter 1 Physiology of Extracorporeal Life Support (ECLS) Matthew J. Brain, Warwick W. Butt, and Graeme MacLaren Introduction Extracorporeal life support (ECLS) and related implantable circulatory assistance devices describe several advancing technologies with broadening scope that are being increasingly incorporated into management of critically ill patients. ECLS may be provided in several configurations to support or replace cardiorespiratory function (Fig. 1.1). In veno-venous extracorporeal membrane oxygenation (VV-ECMO) the objective is to maintain systemic oxygen delivery by oxygenating venous blood returning to the right heart. In veno-arterial mode (VA-ECMO), M.J. Brain, MBBS (Hons), FRACP, FCICM, DDU (*) School of Public Health and Preventive Medicine, Monash University, Malvern East, VIC, Australia The Alfred Intensive Care Unit, Melbourne, VIC, Australia Department of Medicine, Launceston General Hospital, Charles St, Launceston, TAS 7250, Australia m.brain@iinet.net.au W.W. Butt, FRACP, FCICM ICU RCH, Department of Paediatrics UoM, Clinical Sciences Theme MCRI, Royal Children s Hospital, Melbourne, VIC, Australia Paediatric Intensive Care Unit, 50 Flemington Road, Parkville, VIC 3052, Australia Warwick.butt@rch.org.au G. MacLaren, MBBS, FRACP, FCICM, FRCP, FCCP, DipEcho ICU RCH, Department of Paediatrics UoM, Clinical Sciences Theme MCRI, Royal Children s Hospital, Melbourne, VIC, Australia Paediatric Intensive Care Unit, 50 Flemington Road, Parkville, VIC 3052, Australia Cardiothoracic ICU, National University Hospital, 5 Lower Kent Ridge Rd, Singapore , Singapore graeme_maclaren@nuhs.edu.sg Springer Science+Business Media New York 2016 G.A. Schmidt (ed.), Extracorporeal Life Support for Adults, Respiratory Medicine 16, DOI / _1 1