01/06/2022

ECPR

Senior Consultant & ECMO Physician

Medica Superspecialty Hospital, Kolkata

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Chain of survival needs to be optimized

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Golden hour for ECPR

N=133 Wengenmayer et al. CriticCahleCnarYeS(.20C1C7M)2210:10587

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What ELSO tells us

AHA guidelines for CPR recommends consideration of ECMO to

aid CPR in patients who have an easily reversible event, have
had excellent CPR.

Contraindications: All contraindications to ECMO use should

apply to ECPR patients.

Futility: Unsuccessful CPR ( no return of spontaneous

circulation) for 5-30 minutes.

ECPR may be indicated on prolonged CPR if good perfusion and metabolic

support is documented.

Cannulation for ECPR

Central (for cardiac patients with recent sternotomy) or Peripheral vessel should be at discretion of
the surgical team.

Percutaneous cannulation is only recommended if access to the vessels exists prior to CPR, and
should only be performed providers who are skilled with vascular access.

Percutaneous cannulation can be performed in patients >15 kgs and in specialized areas such the
cardiac cath lab .

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ECPR TEAM

Management of out-of hospital

cardiac arrest patients with
extracorporeal cardiopulmonary
resuscitation in 2021.
Christopher Gaisendrees et al

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ECPR in HYPOTHERMIA

Multidisciplinary discussion should include patient's age,

comorbidities, time of no flow and/or low flow, presence of
severe trauma, or prearrest signs of asphyxia.

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Cannulation technique

OPEN

SEMI OPEN

PERCUTANEOUS

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Massive PE with recurrent cardiac arrest (failed

thrombolysis)

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Stuck mitral valve with cardiogenic shock

Periop MI in left main disease , Cardiac arrest in ITU

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Surgical Percutaneous Mixed

Surgeon +++ - -
Material +++ + -
Failure - + -
Bleeding - - +
Insertion +/- + -
time
Aviability - + +

How to run
, correct connection
Because ECPR required rapid cannulation and ECMO access

of the arterial and venous cannulae to the

corresponding limbs should be checked
Total body hypothermia should be included. Cooling should be achieved by applying ice to the head
during CPR and for 48 – 72 hours after ECMO cannulation.

Neurological exams and other imaging should be performed following discontinuation of

neuromuscular blocking agents after hemodynamic stability

Evaluation for LA hypertension should be undertaken soon after the patient is placed on ECMO and LA
decompression should be considered

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Limb ischemia

Femoral distal perfusion PTA distal perfusion

Progressive LV distension

No pulsatility Distended LV with no AV opening

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LV and Aortic valve thrombus

Management of LV distension
IABP Creation of large PFO

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Management of LV distension

Transseptal LA venting Mullen sheath through fem vein

Cerebral saturation with NIRS

Femoral VA-ECMO is a retrograde flow. Whether

the cerebral circulation is adequate or not
always remains a question.

The usual trend is to monitor clinically by

thorough neurological examination and sedation
break period.

It gives us the clue of adequacy of cerebral

perfusion

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SAVE J II Study
In this large cohort, data on the ECPR of 1644 patients with OHCA show
that the proportion of favorable neurological outcomes at hospital
discharge was 14.1%, survival rate at hospital discharge was 27.2%, and
complications were observed during ECPR in 32.7%.

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ECPR + Therapeutic Hypothermia

From this meta-analysis, we found that eCPR combined with
TH might be a more suitable CPR strategy for patients with
CA in improving survival and neurologic outcomes, and eCPR
with TH did not increase the risk of bleeding. Furthermore,
single-arm meta-analyses showed a plausible way of
temperature and occasion of TH.

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History

52 year male, smoker, type II DM

Presented with Acute inf wall MI to another hospital
Primary Angioplasty attempted but RCA origin could not be engaged
Meanwhie hypotensive, started on NORAD
PH 7.11 with cold peripheries

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History in Medica

Shifted to Medica with steep inotropes after 18 hrs of MI

Features of Cardiogenic Shock with AKI
Sudden bradycardia with hypotension
Intubated and Ventilated
Still hypotensive with Norad/Vasopressin/ Adrenaline
Lactic acidosis

ECHO finding

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ECHO finding

ECHO finding

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Femoro- femoral percutaneous VA ECMO

Flow / RPM

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NO to Limb ischemia
Femoral distal perfusion PTA distal perfusion

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Risk factors for critical limb ischemia in patients undergoing femoral cannulation for
venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory
approach?

Tim Kaufeld, Eric Beckmann, Fabio Ius et al

First Published February 8, 2019, Perfusion

We were able to identify the absence of distal limb perfusion as an independent risk factor for the
development of critical distal limb ischemia during femoral venoarterial extracorporeal membrane
oxygenation treatment. The application of a distal limb perfusion should be considered as a mandatory
approach in the context of femoral venoarterial extracorporeal membrane oxygenation treatment
regardless of the implantation technique

Checking distal perfusion

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Checking the flow in distal limb

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Adequacy of
Tissue Perfusion

SVO2/ Urine
Lactate
ScVO2 output

TARGET ACT 180-200

APTT 1.5- 2 times

Day 3

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North-south syndrome

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Ensure adequate gas exchange

The net systemic arterial oxygen content = native
cardiac output + the output of the ECMO circuit

As patients recover , the upper body

receives blood flow from the native
circulation.

Right hand and right ear Spo2 monitoring

Harlequin phenomenon

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Day 6 of ECMO on Milrinone and touch of NORAD

Weaning from VA ECMO

According ELSO guidelines, hepatic function should have recovered prior
to any attempt to wean patients from ECMO, irrespective of the findings
of cardiac assessment .

It is unusual to attempt weaning in the first 72 hours after VA ECMO implantation because
damaged organs need time to recover except poisoning.

The mean duration of support was at least of 3.3 ± 2.9 days and was even 8.0 ± 6.0 days in
one study . This time period is also necessary to allow the recovery of a potentially
“stunned” myocardium.

Not necessary to wait for the recovery of renal function (can take weeks )

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Weaning from VA

Compatible MAP>60
for Pulsatile arterial PaO2/ Fio2 > 200
myocardial waveform
recovery LACTATE < 2

Start LVEF >20%,

Aortic VTI >12
weanin TAPSE >12

Put a bridge before weaning VA

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Weaning – ECHO and Hemodynamics

ECHO
Aortic VTI
LVEF
TAPSE

The ECMO flow is dropped in 0.3-0.5l/min increments for five minutes at

a time. The flows are reduced to 1-1.5L/min but no less.

Hemodynamics
MAP
HR
CVP / PAP
SpO2

Regular checking of Aortic VTI

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Predicting success
The measurements below are predictive of success on decannulation:

Aortic VTI (>10cm)

TDSa mitral annulus (>6cms-1)
The percentage of patients with refractory cardiogenic shock who are
LVEF (>20-25%)
successfully weaned from ECMO varies from 31% to 76%.

However, 20–65% of patients weaned from ECMO do not reach

survival
At an ECMOto discharge
circuit . 1 L/min the MAP drops to 40 mmHg and the CVP rises to 20
blood flow of
mmHg. The oxygen saturations also drop to 80%. As a result you decide to abandon the
weaning trial.

Decannulation
The patient should be decannulated as soon as is feasible.

Femoral arterial cannulae (whether inserted

percutaneously or open) and femoral venous cannulae
inserted via surgical cut down approach are usually
removed surgically. .

A low dose inotrope may be restarted prior to decannulation (if not on any) in case cardiac output is still
inadequate post decannulation.

If there is significant pulmonary dysfunction the patient

may need to be transitioned from VA ECMO to VV ECMO.

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Rehab anf follow up

SPREAD AWARENESS TO DOCTORS AND COMMON PEOPLE

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Follow-up till Facebook

Take Home Message

• When
• Starting after 20 min of CPR with AED
• Goal to be in 60 min after CA on ECPR
• Can be prolonged if neuroprotection or signs of life

• HOW:
• Selected patient
• Mixed or percutaneous…used what you know !
• Prehospital ECPR: good results need to be confirmed

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