ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients
Journal
ASAIO journal (American Society for Artificial Internal Organs : 1992)
Journal Volume
67
Journal Issue
8
Date Issued
2021
Author(s)
Lorusso, Roberto
Shekar, Kiran
MacLaren, Graeme
Schmidt, Matthieu
Pellegrino, Vincent
Meyns, Bart
Haft, Jonathan
Vercaemst, Leen
Pappalardo, Federico
Bermudez, Christian
Belohlavek, Jan
Hou, Xiaotong
Boeken, Udo
Castillo, Roberto
Donker, Dirk W
Abrams, Darryl
Ranucci, Marco
Hryniewicz, Kasia
Chavez, Ivan
Abstract
Over the past decade, the use of extracorporeal membrane oxygenation (ECMO) has increased exponentially, from approximately 30–40 patients per year in the United States 20 years ago, to over 2,000 per year currently, and rising.1 The increased utilization of ECMO has resulted from improved cannulation techniques, including percutaneous approach, as well as advances in the technology of the pumps, oxygenators, and cannulas. Despite these features, however, choosing appropriate candidates and managing their daily care can be extremely challenging. What follows is an in-depth discussion of the indications for venoarterial (VA) ECMO in adult patients affected by cardiac disease, the manner of its application, the physiology underlying the care for these patients, and the assessment and treatment of complications, including ethical and organizational issues. More in-depth material and information are provided in the Extracorporeal Life Support Organization (ELSO) 5th Edition Red Book.2 Furthermore, the recent ELSO indications about ECLS and cannulation nomenclature will be followed in this guideline.3,4 Decision Making in Adult VA ECMO for Acute Cardiac Failure VA ECMO may support patients for days or weeks as a “bridge-to-decision” that includes weaning after recovery of cardiac function, transplantation, long-term mechanical circulatory support (MCS), and withdrawal in the case of futility. Dedicated documents for the use of VA ECMO in the setting of cardiac arrest and postcardiotomy in adult patients are addressed by additional ELSO guidelines and as joint society position paper (expert consensus of EACTS/ELSO/STS/AATS).5 Indications Specific physiologic goals, monitoring, and patient selection. Cardiogenic shock suitable for ECMO is generally characterized by systemic systolic pressure less than 90, urine output 3) (normal is 5, shock is 2): O2 delivery is arterial oxygen content (normal 20 ml/dl) times cardiac output (normal 30 dl/m2/min). In VA ECMO access, addressing the goal is easy because the cardiac output is the ECMO flow and the arterial hemoglobin saturation is 100%, so content is easily calculated, knowing the hemoglobin concentration (normal 15 g/dl). In VA ECMO, the drainage blood saturation (the SVO2) measures the DO2:VO2 ratio, and SVO2 is measured continuously. If the arterial saturation is 100% and the venous sat is 80%, the ratio is 5:1. So, adjusting flow and hemoglobin to maintain SVO2 over 66% assures that the goal of DO2/VO2 > 3 is met. Additional details are described in the Red Book chapter on physiology.2 Table 1. - Clinical Features of Cardiogenic Shock and Defined Contemporary Trials and Guidelines Clinical Trial/Guidelines Cardiogenic Shock Criteria SHOCK Trial (1999) • SBP 90 mm Hg• Evidence of end-organ damage (UO 15 mm Hg IABP-SOAP II (2012) • MAP 2 mmol/L) EHS-PCI (2012) • SBP 90 mm Hg• Evidence of end-organ damage and increased filling pressure ESC-HF Guidelines (2016) • SBP 30 min or supportive intervention to maintain SBP >90 mm Hg• Evidence of end-organ damage (AMS, UO null null null null null null null null null null null null null null Cardiac null null null null null null null null null null or null null null null null null or null or null null null null null null null null null null null null null null null null null 30 null null null null null null null null null null null null null null null null null null null null null of null null null with massive null null and null null are not null with the use of null null null are null to null null null null cannulation should be null null by null null with null null null null and null null the use of a null null null null will null the null of null null from null to null null may be an increased null for null null in the null null null the null null and the null null null null null null null to null null null Percutaneous null with null null may null null null null and null null when null to an null null null null of percutaneous null over null cannulation has not null shown and null null in this null are null null Furthermore, as the null of null of null is null null use of null null null or null for null and null is null null null null are null and may null in null than null of the null null Specific to the ECMO null A null null null of null ECMO null is null null null null the null especially in the null null null can null to failure null acute null null null the pump null null in null and null massive null null null null to ECMO is null after prolonged resuscitation null should null null in a null null ECMO null ECMO null null null null of null null of null null for null of null null null and null null null with null null null the null of null null null null are null in VA ECMO null in a null null null of the null null null null or null of null null null null null a null clinical null null Specific to VA ECMO null is null that VA ECMO null null null however, the null null is the null null in blood pressure null to the null flow in null to a null null null null null null null and, null null aortic valve null or null null null null VA ECMO flow should be null at the null null null null adequate null null and null null null null null null null null null null null however, null with increased null null myocardial null null null pulmonary null and null null in the left cardiac null at null ECMO null null on the null null null null null null a null when the null null is null by null null null null null of the null null null null null null null null blood when the null null and null is null severe null null null null damage to the heart and null can null to null null blood null null and saturation null be null from the null null If null of null null not null the null an additional null null to the null null null null may null null null null null and null can easily null null null will null the null of the null null null null null and null with null null are null to null null null on null and null to be null by null of null arterial blood null after null null of ECMO null including null of null and null null null null null null is null for percutaneous null In the null of null null null null is null null null should be null null in null of null ECMO flow and null null null null at the arterial or venous cannulation null may null null and after ECMO null The null of a null null null null null to the null null null should be considered in the null of null oxygenation and refractory null null null null null null and null should be null null null at ECMO null should be also null to null null null and null null null null VA ECMO VA ECMO weaning should be considered when patients null null null cardiac null null the null for null null null support to maintain an adequate pulse pressure null mm Hg null mean arterial pressure null of null mm null and null null sat at null null of VA ECMO null null null should be null null null of null pump flow and weaning null null null weaning null is null and null to null biventricular function, null of null null as well as null null null is a null of cardiac output. null null null be null in this null to null null null null and cardiac output with the VA ECMO null null null null VA ECMO flow is null null by 500 ml null null null null are null after null null of no support null null or null at null of 1 null of null null null ECMO flow null to null null of the null null and null null heart null may not be null null when null of the ECMO null or null null is null null null null Trial null is a weaning null that can be null The arterial flow null is null and 1 L of flow is null to the null null and null null null venous null In null with the null null null this null null for null assessment of null null null weaning is null null the null null are null MAP > null mm null null null > null null null null null null null null systolic null null null null null null mm null and null null null null null on null null of null inotropes or null null null inotropes and null are null as null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null a null weaning null null should null null to null null null that are associated with ECMO null null null are null to null from VA ECMO support null null days null be considered for temporary null support to null null null for null recovery as null as null systolic null is null null null null with null null null null systolic null before VA ECMO null null be considered for null null null or heart null null for null null should be null on the null null Society for null and null null guidelines null is null null null null null null null of neurologic null multiorgan null null age, null null null or null cancer as contraindications to durable null support and heart transplantation and null null to these null is null null null null null with null of care in patients null are not candidates for null null null is null to null with a null null and withdrawal of null null involvement of null care null should be considered in null patients null with VA ECMO to assist with null of null the null of null and null null null null for ECMO null null and decision null for venoarterial extracorporeal membrane oxygenation null and null null in patients with cardiogenic shock. null null null null CI, cardiac index; null null venous pressure; null null null null null null LVAD, left ventricular assist device; null null left ventricular null null null null null MAP, mean arterial blood pressure; null null null null VA null venoarterial extracorporeal life null VA ECMO weaning should be considered when patients null null null in the null of null ECLS null including MAP > null mm null null null > null null null null null null null null systolic null null null null null null mm null and null null null null null on null null null null null null null null Trial null or a null null null the arterial and venous null null null null assessment with null or null ELSO null support null ECMO null a null of null that null ethical null by null of its null to null null null null null as a null for null The ECMO null null null the null to null null and null null null null null the use of ECMO in a null that not null null life null also null null null null the ethical null null its use null to null the patient and null or null null null the null null and null null The null and the null The null of null is generally null because the situations in null ECMO is null are null null null that the null for null null null null null null null null null null after its null The null null null be null null of this and null null null null of ECMO support and null of appropriate null care should null null null in situations where ECMO is unlikely to be null null null of null or supportive care null null null or null null null may be of null null in null these null null and null null support to null null null null are null null for null null null decision null The ECMO null null null the ECMO null can null as a null of null in null about the utilization of ECMO for null null null null null of null and null null null by a null null can null null of null null null null the null null null of null the null to null and null of ECMO should be null The Society In null null ECLS is not a null null to or null null the null null with the null null of null null the null of ECMO to support patients is null in null clinical null the evidence to support its use is null null null to this is the null of its null null in null null null null and the null on null null null to null with the null of null of null null ECMO has null null to be null and null in null clinical null null null the null of ECMO, decision null should null the null of myocardial null and, null null the null of bridging to durable MCS or null null null of the null should null a discussion of the null the null of bridging to null null and null null be a null null of support should recovery not null in null with the patient’s null null ECMO null null in the care of these patients should be null in null null on null this null null of a null null null with null null null should be null for null null to null null null and null null be null of the ECMO null null We null null null null null null null null and the ELSO null null for null in the
SDGs
Type
journal article