Transplantologiya 2014

Table 2. Veno-venous ECMO use in the period from 2007 to 2014.

Diagnosis	Number of patients	Sex, male/female	Age, years	ECMO days	Number of survivors, (%)
Pneumonia, sepsis	214	135/79	51 ± 15	13 ± 11	138 (64%)
Extrapulmonary sepsis	96	69/27	51 ± 18	8 ± 6	47 (49%)
Multisystem trauma	44	40/4	32 ± 15	6 ± 3	29 (72%)
Other (heart and lung transplantation)	39	20/19	51 ± 16	17 ± 14	20 (51%)

The decision to use the ECMO in a patient is generally taken by a team of doctors that consists of a critical care physician, the attending physician from the pertinent department, and a clinical perfusionist (responsible for a heart-lung machine operation). They discuss a probable course and specific features of the disease, the prognosis, and a potential benefit from ECMO. Should indications to ECMO exist, the doctors make their choice regarding its type, consider the way of the circuit setup and the site of cannula placement. As a rule, in veno-arterial ECMO the cannulas are preferably placed in the femoral vein and artery. A veno-venous access in patients under ECMO treatment was provided by the placement of one cannula via femoral vein into the inferior vena cava, and the other cannula was placed via the internal jugular vein into the superior vena cava. The exceptions were the cases of intraoperative central connection circuit while making cardiac surgery and lung transplantation. We also watched a practical use of the Avalon Elite bicaval dual lumen cannula which was placed in the internal jugular vein and allowed the deoxygenated blood to drain from the inferior vena cava (IVC) and the superior vena cava (SVC); and the oxygenated blood to return from the external pump to the right atrium directed toward the tricuspid valve.

The foreign clinical experience implies the allocation of a 24-hour cardiovascular perfusion service having specialists who, besides providing a heart-lung machine management during cardiac surgery, participate in the initiation of ECMO and in a subsequent management and monitoring care of the patient on ECMO. The ECMO specialists are responsible for the equipment preparation, the circuit installation, the set-up and management of monitoring devices. The ECMO equipment with pertinent oxygenators and centrifugal pump heads used in the clinic are from the following manufacturers: Stockert, Maquet and Medos.

The central venous access is achieved by cardiovascular surgeons; the peripheral access is the responsibility of the intensive care physicians. ECMO daily monitoring and management is carried out by the physicians and ECMO specialists of the 24-hour duty service. Besides monitoring the standard parameters of hemodynamics, breathing, and electrolyte balance, a special attention, as a rule, is paid to measuring the plasma lactate level, oxygen transmembrane arterial-venous gradient in the ECMO circuit, and activated clotting time. A routine blood sampling is as frequent as 4 times a day, at least. The criteria of a successful and correct ECMO include: the improvement of lactate level over time, return to normal of arterio-venous oxygen difference and other homeostasis parameters, as well as reduced requirements in inotropic support. In some patients, normothermia was maintained using a thermoregulatory device (Hypotherm). ECMO treatment duration varied ranging from 3 to 23 days, as we observed. Weaning from ECMO in the clinic is undertaken by a stepwise approach considering the ECMO method used and the goals to achieve by using it. As a whole, the tactics of weaning off the veno-arterial ECMO is similar to that of weaning from a cardiopulmonary bypass during cardiac surgery.

Currently ECMO is the only method that warrants a cardiopulmonary life support for a long time that is essential, for example, for heart and lung transplantation, for a life support in a complicated course of H1N1 virus influenza, in case of a developed acute respiratory distress syndrome (ARDS), in cardiac arrest refractory to resuscitation, as well as for patient's transportation to a specialized clinic anywhere in the world. Currently ECMO is the only method to improve a survival prognosis in patients with severely complicated cardiac and/or pulmonary conditions.

The Sklifosovsky Clinical and Research Institute for Emergency Medicine is the leading medical institution in Moscow to provide a specialized care for the patients with severe poytrauma, cardiac pathology, as well as to perform organ transplants. Implementation of ECMO method in the clinical practice may significantly improve the surgical and conservative treatment outcomes in severely ill or traumatized patients.

References

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