Ecmo: Extracorporeal Cardiopulmonary Support in Critical Care

Table of Contents

Dedication
Preface to the 4th Edition

I: Extracorporeal Life Support: An Overview

1 The History and Development of Extracorporeal Support
Biographical Beginnings: People
Propagation of ECMO
Perseverance: Adult ECMO Experience
References

2 Physiology of Extracorporeal Life Support
Physiology of Extracorporeal Life Support
Normal physiology
Pumps
Gas Exchange in Extracorporeal Life Support
Physiologic Principles in the Management of Extracorporeal Life Support
Managing the Patient on ECLS
Weaning and Decannulation
References

3 Cardiac Failure: Principles and Physiology
Introduction
Determinants of cardiac output
Compensated and Decompensated Cardiac Failure
Cardiac Function on ECMO
Summary
References

4 Acute Hypoxic Respiratory Failure in Children
Introduction
The Pathophysiology of Acute Lung Injury
Positive Pressure Ventilation and PEEP in the Management of ARDS
Ventilation Induced Lung Injury
Pulmonary Oxygen Toxicity
Epidemiology and Markers of Acute Lung Injury
The Development of a Lung Protective Ventilation Strategy
Algorithm for a Lung Protective Ventilation Strategy in ARF
Ventilation Strategy
Oxygenation Strategy
Alternative Ventilation Strategies for ARDS
High Frequency Ventilation
High Frequency Oscillatory Ventilation (HFOV)
Prone Position Ventilation
Adjuncts to Positive Pressure Ventilation
Inhaled Nitric Oxide (iNO)
NonInvasive Ventilation
Extra-Pulmonary Therapies in ARDS
Acute Hypoxic Respiratory Failure
Summary
References

5 Blood Biomaterial Surface Interaction During ECLS
Introduction
Normal Hemostasis
Coagulation Pathway Activation and Inflammatory Response
Activation of the Coagulation System during ECLS
References

6 The Registry of the Extracorporeal Life Support Organization
Introduction
History
Data Collection and Reporting
Implementation
Registry Data Summary
Summary
References

II: General Management and Outcomes

7 Preface to Sections II-V
Section II General Management and Outcomes:
Section III Patient Specific Management and Outcomes:
Section IV Other Uses for ECLS:
Section V Logistics and Legalities of ECLS:

8 The Circuit
Introduction
General principles of circuit design
Criteria for selecting circuit components
Circuit components
Pump types
Gas exchange devices
Commercial gas exchange devices
Circuit management
Refining circuit design: Simplicity and integrated systems
Summary: The circuit
References

9 Vascular Access for Extracorporeal Support
Introduction
Principles
Cannula Insertion for Neonatal ECLS
Cannula Insertion for Pediatric ECLS
Cannula Insertion for Adult ECLS
Transthoracic Cannulation
Cannulation Complications
References

10 Management of Blood Flow and Gas Exchange during ECLS
A Criteria for selecting circuit components
B Management during ECLS
C Ventilator management
References

11 Anticoagulation and Bleeding During ECLS
Anticoagulation
Clinical Consequences
Conclusions
References

12 Analgesia, Sedation, Neuromuscular Blockade, and Temperature Contro
Analgesia and Sedation
Pharmacology and ECLS
Indications for Sedation and Analgesia
Analgesia
Sedation
Neuromuscular Blockade
Delirium
Temperature Control
References

13 Renal Function and Renal Supportive Therapy during ECMO
Renal Function
Supporting Renal Function
Outcomes
Conclusions
References

14 Infections and ECMO
Epidemiology
Prophylaxis
Diagnosis of Infections while on ECMO
Surveillance
Discussion
References

15 Procedures on ECMO
Procedures Guidelines
Comments on Procedures on ECMO
Specific procedures
16 Weaning, Trialing and Futility
Weaning the Neonatal Patient
Trialing off ECMO
Futility
References

III: Patient Specific Management and Outcomes

17 Neonatal Respiratory ECLS
Introduction
Diseases Treated
Patient Selection Criteria
Contraindications
Modes of neonatal ECMO
ECMO details
Management during ECLS
Procedures
Complications
References

18 Congenital Diaphragmatic Hernia and ECMO
Introduction
Diagnosis
Management
ECMO
Summary
References

19 ECMO for Pediatric Respiratory Failure
Selection Criteria
Patient Population
Unique Patient Populations for ECLS Use:
ECLS in Sepsis
Contraindications
The Pediatric ECLS Circuit:
Patient Management
Complications
Weaning and Decannulation
Outcome and Followup
ECLS Termination
Summary
References

20 Pediatric Cardiac Extracorporeal Life Support
Introduction
Technical Aspects
Indications and Outcomes
ECMO in Patients With Functionally Univentricular Circulation
Outcome and Risk Factors for Death
Conclusions
References

21 Adult Respiratory ECMO
Introduction
Evidence base
Case Selection
Transport
Cannulation
Circuit design
Treatment Protocols
The ECMO Specialist and Nursing Care
Results
Conclusion
References

22 Adult Cardiac Support
Introduction
Options for Temporary Mechanical Circulatory Support
Weaning
Results
Summary
References

23 Extracorporeal Cardiopulmonary Resuscitation: ECPR
Definition
Patient Selection
Technical Issues
Outcomes
Future Directions
References

IV: Other Uses for ECLS

24 Ventricular Assist Devices in Children
Introduction
Types of Ventricular Assist Devices
ECMO to Bridge Children to Cardiac Transplantation
ECMO versus VAD as Initial Device for Bridge to Transplantation
Transition of ECMO patients to VAD
Ventricular Assist Device Use in Single Ventricle Patients
Ventricular Assist Device Anticoagulation
Conclusion
References

25 Plasmapheresis
Introduction
Historical Perspective
Physiology
Apheresis Procedure
Selected Indications for Plasmapheresis
Apheresis in the ECMO patient
Specific humoral considerations of Therapeutic Apheresis
Care of the apheresis patient
Complications
References

26 Artificial Lung
Introduction
History of Artificial Lung Development
Design and Application of an Artificial Lung
Applications for an Artificial Lung
References

27 Extracorporeal Support Assisted Organ Donation
Introduction
Rapid Recovery for procuring organs of Donors after Cardiac Death (DCD)
ECS assisted DCD technique
ECS of Maastricht type III DCD
EDCD compared to RR
Outcome of organs transplanted from ECS assisted DCD
ECS of Maastricht type I and II DCD
ECS assist for brain dead donors
Laboratory Experience
Future Directions
Conclusion
References

28 Sepsis and ECMO
Introduction
Indications
Contraindications
Cannulation
Management on ECMO
Outcomes
Conclusions
References

29 Extracorporeal Life Support Pre and Post Lung Transplantation
Abstract
Introduction
ECLS Pre-Lung Transplantation
Modes of ECLS–Configuration of Device
Hypercapnic Respiratory Failure
Hypoxemic Respiratory Failure
Hypoxemic Respiratory Failure and Hemodynamic Compromise
Pulmonary Hypertension and Right Ventricular Failure
Patient Management
Outcomes
Perioperative ECLS
ECLS Post Lung Transplantation
Conclusions
References

30 Cardiac Catheterization Procedures for ECMO Patients
Introduction
Left Heart Decompression on ECMO
ECMO to Support High Risk Cardiac Catheterization Procedures
Summary
References

31 The Future of Extracorporeal Life Support
References

V: Logistics and Legalitites of ECLS

32 Regionalization and Triage
Which centers should provide ECMO?
The benefits of regionalization
Volume-outcome benefits
Regionalized systems of care
Recommendation
Triage of patients for ECMO
References

33 Transport of the ECMO Patient: From Concept to Implementation
Introduction
History of inter-hospital ECMO transport
Logistics of inter-hospital transport
Effects of altitude on membrane gas exchange
Recognition and management of in-transport emergencies
Military ECMO transport and lessons from combat casualty care
Results of inter-hospital transport
Intra-hospital transport
Conclusions
Disclaimer
Acknowledgment
References

34 ECMO Administrative and Training Issues, and Sustaining Quality
Introduction
Essential Hospital Support Components
ECMO Team Organization
Educational Process
Maintaining Competency Standards
Summary
References

35 Economics of ECLS
Introduction
Costs
Charges and reimbursement
Intangible costs and benefits of ECMO
Is it worth it?
References

36 Regulatory and Legal Aspects of ECLS
Introduction
Summary of the statutory authority of the FDA for medical devices
Device classification
Regulatory approval process
Regulatory processes for marketing ECLS devices
Issues with ECLS devices
Implications of using an ECLS device off-label
Is ECLS/ECMO FDA approved?
The legal process
Civil liability
Informed consent
The rules of research
Legal implications as ECMO develops
Conclusion
References

37 ECMO Ethics in the Twenty-first Century
Introduction
Two Typical ECMO scenarios
Best interest standard
Substituted judgment
Emotions
ECMO and futility
Defining time-limited trials
Palliative care
Conclusions
References

Glossary