Uncommon Life Saving Indications for ECLS (Trauma, Hypothermia, Airway Obstruction)

Size: px

Start display at page:

Download "Uncommon Life Saving Indications for ECLS (Trauma, Hypothermia, Airway Obstruction)"

Christopher Cameron
6 years ago
Views:

1 Uncommon Life Saving Indications for ECLS (Trauma, Hypothermia, Airway Obstruction) Matthew Bacchetta, MD Director of Adult ECMO Surgical Director The Pulmonary Hypertension Comprehensive Care Center Columbia University

2 Trauma & ECMO Simple Guidelines Follow standard ATLS recommendations Do not deviate from Standard of Care to accommodate ECMO ECMO will accommodate Trauma Leave vascular access points open whenever possible Don t put in needless or redundant lines into potential cannulation sites

3 ECMO Support Following Trauma Indications & Contraindications Michaels et al. J Trauma, Infect & Crit Care 1999

4 ECMO Support Following Trauma Standard Patient Management Michaels et al. J Trauma, Infect & Crit Care 1999

5 ECMO Support Following Trauma Patient Injuries Michaels et al. J Trauma, Infect & Crit Care 1999

6 ECMO Support Following Trauma Patient Characteristics & Outcomes Michaels et al. J Trauma, Infect & Crit Care 1999

7 Michaels et al. J Trauma, Infect & Crit Care 1999 ECMO Support Following Trauma Respiratory Variables Early intervention better survival Vent days inflection point: 7 days

8 Michaels et al. J Trauma, Infect & Crit Care 1999 ECMO Support Following Trauma Effects of Early vs. Late Intervention Late = 7.2 days

9 Possible Contraindications? Active bleeding within the cranium Abdominal compartment syndrome from hemorrhage Limb ischemia Transport involved Aero MedEvac

10 Traumatic Brain Injury 18 M ped struck ISS = 27 Parieto-occipital epidural Ventricular drain & bolt Day #4 ARDS PaO2 = 42 CO2 ICP crisis 20 M ejected from truck ISS = 33 B/l temporal contusions, frontal, cerebral edema B/l ventricular drains Day #4 ARDS PaO2/FiO2 = 30 Biscotti et al. Perfusion 2014

11 TBI Cases Biscotti et al. Perfusion 2014

12 Traumatic Brain Injury ECMO 31Fr Avalon Anticoagulation PTT protocol: sec Median PTT = 47 sec Day 11 following commands Day 13 ECMO removed Walked out of hospital ECMO 31Fr Avalon Anticoagulation PTT protocol: sec Median PTT = 51 sec Cooled - hypothermia ECMO for 6 days Complete neurologic recovery Biscotti et al. Perfusion 2014

13 Lessons for TBI ARDS develops in 20 30% of TBI patients Independent predictor of poor outcome Holland et al. J Trauma 2003 Be prepared Lung protective strategies Permissive hypercapnia CO2 ICP crisis High PEEP PEEP Cerebral perfusion pressure ECMO CO 2 & O 2 Selective Use

14 Glenfield Experience The Brief Summary 20 of 28 survivors PaO2/FiO2 = 62 Murray score = 3.1 Relatively young patients Blunt trauma Conclusions Severe but potentially treatable trauma patients with ARDS/ALI should be considered for ECMO Only simple bedside procedures are possible Avoid invasive procedures (orthopedic ORIFs) Multi-disciplinary team approach offers patients their best chance for survival Smith et al. 2006

15 ECMO for Tracheobronchial Trauma Case report 32 month girl with a tracheobronchial burst injury after being crushed by a van. Placed on VA ECMO Right thoracotomy with primary repair POD# 2 Switch from VA to VV ECMO Weaned off ECMO POD#4 Conclusions ECMO is an important supportive modality for tracheobronchial trauma Ballouhey et al. Eur J Cardiothoracic Surg 2012

16 Regensburg Experience Retrospective summary of a 10 year experience with PECLA & ECMO 52 patients Age: 32 ± 14 years MVA: 73% Blast injury: 17% Other: 10% Severity of illness ISS: 58.9 ± 10.5 LIS: 3.3 ± 0.1 Reid et al. Crit Care 2013

17 Regensburg Experience Time to support: 5.2 ± 7.7 days Duration of support: 6.9 ± 3.6 days Transport: 48% Surgical procedures while on ECLS: 31% No major complications Cannulation issues: 15% (ischemia or bleeding) Reid et al. Crit Care 2013

18 Regensburg Experience Outcomes Survival: 79% Predicted ISS survival: 59% Conclusions: ECLS represents a good treatment option for trauma patients with lung injury Interdisciplinary teams are essential to improved outcomes Reid et al. Crit Care 2013

19 Transportable ECLS of Combat Casualties Bein et al. J Traum Acute Care Surg 2012

20 Transportable ECLS of Combat Casualties Major points to note: Improvements in ABG ph PaO2/FiO2 PaCO2 Improvements in Vent Parameters: Tidal volume Plateau Pressures Bein et al. J Traum Acute Care Surg 2012

21 Transportable ECLS of Combat Casualties Cannulation 4 of 10 in the war zone Management Local center of expertise in Germany, i.e. Regensburg Outcomes Survival: 90% Conclusions: ECLS represents a means to safely transport casualties with severe lung injuries out of a war zone Cannulation can be performed safely in a war zone Partnership with centers of expertise can extend care provided to soldiers in a war zone; advance the concept of multidisciplinary teams Bein et al. 2012

22 Transports An Added Complexity Aero-Medical Evacuation Ground Transport

23 Ground vs Air Ground Steady state partial pressures Unless you are driving over mountain ranges Air Partial pressures are dynamic, i.e. a function of the altitude Higher altitude is more efficient for planes Device flow can shift when taking off and landing cc per minute

24 Physiologic Stresses of Flight and Extended Travel Distance Decreased partial pressure of oxygen Know your rated cabin pressure Barometric pressure changes Thermal changes: patients can lose heat quickly Decreased humidity increased fluid requirements Noise: difficult to communicate; disturbing to the patient

25 PaO 2 of 100 at sea level equates to a PaO 2 of 60 at 10,000 feet Partial Pressure (mm Hg) Increased risk of hypoxemia with lung injury Relatively stable CO Altitude (feet) Alveolar PaO2 Alveolar PaCO2

26 Oxygenator Function Declines at Altitude Boyle s Law and Dalton s Law (partial pressure O2 available) Real life example courtesy of LTC Eric Osborn Sea level ABG post oxygenator 7.43/44/290 Patient 7.39/52/ ft ABG post oxygenator 7.42/49/119 3am Patient 7.36/61/39 Iowa City 700ft ABG post oxygenator 7.44/36/ am Patient SVO2 68%, O2 Sat 82% Example courtesy of LTC Eric Osborn (US Army)

1 st DoD Adult ECLS in CONUS (SAMMC to Columbia U.

27 1 st DoD Adult ECLS in CONUS (SAMMC to Columbia U.) 16 JAN 2013 Dr. Bacchetta (Columbia U.) during transport. Surgical procedure at 28k ft (pulling back the L IJ cannula to improve flow. (LTC Jeremy Cannon & Matt Bacchetta) Our current transport equipment/supply inventory = 9 Pelican cases + 3 Boxes

28 Equipment & Personnel: Military

29 C-17 CCATT Flight with ECMO Transport

30 Extreme Transport Modes

31 MedEvac - Blackhawk Limited space Noise distraction Vibration Electrical limitations

32 Battlefield Challenges Limited supplies Harsh environment Lack of brick and mortar structures Dirty operating rooms Unpredictable MedEvacs

33 Blast Lung

34 ECMO in the Austere Environment Far Forward Position in Afghanistan: 2011

35 Equipment & Personnel: Civilian Pilot

36 Equipment: Civilian Go Bag and Emergency Supply Bag Ambulance Transport

37 Lessons Learned: Cannulation for Field Transport Simple is always better than complex Select what meets physiologic needs Remember Aero MedEvac can further compromise O 2 levels Durable to withstand transition zones Bed to stretcher Stretcher to ambulance/aircraft Ambulance/aircraft to ambulance/aircraft Tail-to-tail transfer Ambulance to ICU Stretcher to ICU bed

38 Lessons Learned: Accommodations in Management Protocols Anticoagulation Dose Patient size Extent of injuries, e.g. active bleeding, head trauma Coagulation status, e.g. DIC, massive transfusion Bolus dosages: 0 5,000 units of heparin Liberal use of anti-fibrinolytics, e.g. aminocaproic acid, especially during procedures Avoid Factor VII

39 Summary Trauma first, ECMO Second Follow basic ATLS protocols Complete basic damage control procedures Preferably before the need for ECLS Open abdomen with a VAC dressing is not defeat Prudent trauma management, especially with a patient on ECMO May need to consider External fixation to ORIF for orthopedic injuries Possibly better hemorrhage control Consider delay in fixation until off ECMO

40 Summary Initiate therapy early He who hesitates loses a patient Maintain liberal use of antifibrinolytic medications during procedures Adopt low dose heparin/anticoagulation protocols Keep vascular access points open/available for cannulation

41 Summary Primary contraindication Active CNS bleeding Relative contraindication Ongoing bleeding Decision hinders on Extent of bleeding Likelihood of obtaining control Blast Lung Injuries are ripe for consideration of ECMO support Youth matters

excellence in care Procedure Management of patients with difficult oxygenation. For Review Aug 2015

excellence in care Procedure Management of patients with difficult oxygenation. For Review Aug 2015 Difficult Oxygenation HELI.CLI.12 Purpose This procedure describes the processes and procedures for a lung protective strategy in the mechanical ventilation of patients that are difficult to oxygenate