Extracorporeal Life Support: The ELSO Red Book

Red Book 5th Edition

ISBN 978-0-9656756-5-9

Editors

Thomas V. Brogan, M.D.

Laurance Lequier, M.D.

Roberto Lorusso, M.D., Ph.D.

Graeme MacLaren, M.D.

Giles Peek, M.D.

 

 

 

 

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Table of Contents

 

Dedication
Preface to the 5th Edition

 

I: Extracorporeal Life Support: General Principles

 

 

 

1. The History and Development of Extracorporeal Support

 

 

Extracorporeal Support: Earliest Beginnings
Global Spread of ECMO
Perseverance: Experience and Growing Indications in Adult ECMO
References

2. The History of ECMO: First Hand Accounts

The History of ECMO: First Hand Accounts
A Conversation with Dr. Robert H. Bartlett
A Conversation with Dr. Jay Zwischenberger

3. Evolution and History of Global ELSO

EuroELSO
Asia-Pacific ELSO
Latin American ELSO
South and West Asian ELSO
References

4. The Physiology of Extracorporeal Life Support

Cardiopulmonary Physiology
Cardiopulmonary Pathophysiology
Cardiopulmonary Pathophysiology during ECMO
The ECMO Circuit
Modes of Vascular Access and Perfusion
CO2 Removal
ECMO Management when the Native Lung is Recovering
Summary

5. The Circuit

Introduction
Historical Background
General Principles of Circuit Design
Blood Tubing Plasticizers
ECLS Circuit Components
Blood Pumps
Pulsatility
Roller Pumps
Roller Pump Servo Regulation
Centrifugal Blood Pumps
Centrifugal Pump Inlet Pressure Monitoring Techniques
Blood Pump Performance
Regulatory Status
Pump Related Complications
Commercial Centrifugal Pumps
Gas Exchange Devices
Commercial Gas Exchange Devices
Gas Exchanger Related Complications
Heat Exchange and Heat Regulation
Heat Exchanger Related Complications
Circuit Priming
Circuit Monitoring
Summary
References

6. Adverse Effects of ECLS: The Blood Biomaterial Interaction

Introduction
Normal Hemostasis
Activation of the Coagulation Pathway
Activation of the Fibrinolytic Pathway
Developmental Hemostasis
Coagulation Pathway Activation and Inflammatory Response
Activation of the Coagulation System during ECLS
Activation of the Innate Immune System
Endothelial Function in Hemostasis and Circuit Modifications
References

7. Anticoagulation and Disorders of Hemostasis

Introduction
Anticoagulation
Anticoagulation Monitoring
Anticoagulation Laboratory Schedule and Blood Product Replacement
Hemorrhagic and Thrombotic Complications
Conclusions
References

8. Transfusion Management during Extracorporeal Support

Blood Product Transfusion during Extracorporeal Support
Use of Coagulation Factor Replacement
References


II. Extracorporeal Life Support: Neonatal Respiratory Disease

9. Neonatal Respiratory Diseases

 

Introduction
Congenital Diaphragmatic Hernia (CDH)
Meconium Aspiration Syndrome (MAS)
Persistent Pulmonary Hypertension of the Newborn
Pneumonia/Sepsis
Surfactant Deficiency – Hyaline Membrane Disease
Surfactant Deficiency – Term Infants in Respiratory Failure
References

10. Congenital Diaphragmatic Hernia and ECMO

 

IntroductionDiagnosis
Management
Mechanical Ventilation
Inhaled Nitric Oxide
Sildenafil
Fetal Interventions
Management Adjuncts
ECMO
Summary
References

11. Indications and Contraindications in Neonates with Respiratory Failure

Introduction
Patient Selection Criteria
Indications
Contraindications
Weight <2 kg
Gestational Age <34 wks
Intracranial Hemorrhage
Irreversible Organ Damage
Chromosome Abnormalities
Pre-ECMO Ventilation Days
References

12. ECLS Cannulation for Neonates with Respiratory Failure

Setup
VV- or VA- ECMO?
Choice of Cannula and Vessel
Cannulation Technique
Post Cannulation Imaging
References

13. Congenital Comorbidities among Respiratory Neonatal ECLS Patients

Background
Congenital Anomalies
Malignancies
Infections
Neurologic
Inborn Errors of Metabolism
Genetic Abnormalities
Prematurity
Conclusion
References

14. Medical Management of the Neonate with Respiratory Failure on ECLS

Fluids, Electrolytes, and Nutrition
Respiratory
Cardiovascular
Infection
ECMO Circuit Considerations in the Neonatal Patient
Hematologic
Neurologic System
Summary
References

15. Nursing Management of the Neonate with Respiratory Failure

Nurse or Technician?
Background
Respiratory
Prone Positioning on ECMO
Ventilator-Associated Pneumonia (VAP)
Sedation
Cardiovascular
Neurological
Fluid Balance–Renal/Elimination
Gastrointestinal (GI) Concerns and Nutrition
Hematological Management/Bleeding
Bleeding and Anticoagulation Management
Hygiene and Skin Care
Family Support
Conclusion
References

16. Weaning & Decannulation of Neonates with Respiratory Failure on ECLS

Weaning
Special Circumstances
Neonatal ECMO Trial off
Decannulation
References

17. Outcomes, Complications, & Followup of Neonates with Respiratory Failure

Introduction
Early Survival Outcomes
Late Survival Outcomes
Complications with Impact on Long-term Outcomes
Long-term Medical Outcomes
Long-term Neurodevelopmental Outcomes
Outcomes in Congenital Diaphragmatic Hernia
Recommendations for Long-term Followup
References


III. Extracorporeal Life Support: Pediatric Respiratory Disease

18. Pediatric Respiratory Diseases Predisposing to ECLS

Epidemiology of ECLS for Respiratory Support
Acute Respiratory Failure
Status Asthmaticus
The Immunocompromised
Mediastinal Masses
Pulmonary Hemorrhage
Perioperative Support for Airway Surgery
Severe Air Leak
ECLS for Bridge to Lung Transplant and Preoperative Rehabilitation
Burns
Respiratory Support of Patients with Congenital Heart Disease
Prolonged Respiratory ECLS
Summary
References

19. Indications & Contraindications in Children with Respiratory Failure

Introduction
Indications
Contraindications
An Approach to an Unknown Cause of Respiratory Failure
Summary
References

20. ECLS Cannulation for Children with Respiratory Failure

Introduction
Preferred Routes
Technique
Complications
References

21. Comorbidities among Pediatric Patients with Respiratory Failure

Epidemiology
General Considerations
Pediatric Respiratory Failure-Risk Factors for In-Hospital Mortality
Coexisting Conditions
Genetic Abnormalities
Complications and Therapies
Hospital Volume
Prediction of Mortality Risk Prior to ECLS Initiation
Conclusion
References

22. Management of the Pediatric Respiratory Failure Patient on ECMO

Introduction
Patient Management
Extubation on ECMO
Diagnostic Tools in ECMO
Other Interventions
Complications
Followup
Conclusion
References

23. Nursing Management of the Child with Respiratory Failure on ECLS

Introduction
Daily Assessment
Daily Patient Care
Wound Care
Daily Activities
Conclusion
References

24. Weaning and Decannulation of Children with Respiratory Failure on ECLS

Strategies for Withdrawal of ECLS Support
Withdrawal of ECLS Support as Palliative Withdrawal of Care
Weaning Support and Trialing
Technique for Decannulation of Patients on Venovenous ECLS
Continuing Venous Access after Decannulation
Approaches to Inadvertent Decannulation
References

25. Outcomes, Complications, & Followup of Children with Respiratory Failure

Introduction
Outcomes
Long-term Outcomes
ECMO Complications
References


IV. Extracorporeal Life Support: Neonatal and Pediatric Cardiac Disease

26. Neonatal and Pediatric Cardiovascular Diseases Predisposing to ECLS

Introduction
Indications and Outcomes
ECMO in Patients with Functionally Univentricular Circulation
Outcome and Risk Factors for Death
Conclusions
References

27. Extracorporeal Cardiopulmonary Resuscitation in Children

Introduction
ECPR Definition
ECMO for Failed CPR
ECPR Utilization and Epidemiology
Survival to Hospital Discharge after ECPR
Patient Selection for ECPR
Duration of CPR and ECPR Outcomes
Neurologic Injury in ECPR
ECPR in Specific Populations
ECMO Equipment and Organizing an ECPR Team
Long-term Outcomes Following ECPR
Summary
References

28. ECMO for Adults with Congenital Heart Disease

Introduction
Specific Cardiac Defects Requiring ECMO
Indications for ECMO Support in ACHD
Management Strategies
Tips/Pitfalls for ECMO in Patients with Previous Sternotomies
Results and Outcomes Following ECMO for ACHD
References

29. Indications and Contraindications in Children with Cardiovascular Disease

Preoperative Stabilization
Perioperative Support
Mechanical Support beyond the Perioperative Period
Low Cardiac Output Syndrome
Bridge to Transplantation
Posttransplantation Support
Procedural Support
ECPR
Respiratory Support
Contraindications
References

30. Neonatal/Pediatric Cardiac Cannulation

Neonatal/Pediatric Cardiac Cannulation
Neck Cannulation
Transthoracic Cannulation
Venting
Not Venting
Troubleshooting
Conclusion
References

31. Comorbidities and Outcomes in Pediatric Patients for Cardiac Disease

Background
Preexisting Comorbidities
Acquired Comorbidities
Summary
References

32. Medical Management of Neonates & Children with Cardiovascular Disease

Introduction
Utilization of Cardiovascular ECLS
Management of Common Issues for the Cardiac ECLS Patient
Cardiovascular Assessment and Monitoring
Ventilator Management
Inotrope/Vasoactive Medications
Other Organ System Considerations Specific to the Cardiac ECLS Patient
Psychological Support
Conclusion

33. Nursing Management of Children with Cardiovascular Disease

Introduction
Nursing Assessment
Cardiac Anatomy Considerations
Respiratory Considerations
Prevention of Infection
Neurologic Considerations
Rehabilitation
Integumentary Considerations
Nursing Roles in Rapid Deployment
Family Support
Reference

34. Weaning Pediatric Cardiac ECMO

Introduction
When to Attempt Weaning
Predictors of Successful Weaning
Weaning Trial
Speed of Weaning
Optimizing for Decannulation
Decannulation
Failure to Wean
Conclusion
References

35. Outcomes/Complications/Followup of Children with Cardiovascular Disease

Introduction
Early Survival Outcomes
Single Ventricle Patients
Heart Failure and Transplantation
Longer-term Survival
Early Neurological Outcome
Longer-term Neurodevelopmental Outcome
Long-term Quality of Life (QOL)
Followup
Conclusions
References


V. Extracorporeal Life Support: Adult Respiratory Disease

36. Adult Respiratory Diseases Predisposing to ECLS

Introduction
Initial Diagnostic and Management Approaches to Respiratory Disease
Imaging and Acute Respiratory Distress Syndrome (ARDS)
Gas Exchange
Hemodynamic Stabilization and Echocardiography in Acute Hypoxemia
Immunosuppressed Hosts
Imitators of ARDS
Open Lung Biopsy
Summary
References

37. Indications & Contraindications in Adults with Respiratory Failure

Introduction
ECLS for Rescue from Refractory Hypoxemia
ECLS for Rescue from Refractory Hypercapnia
ECLS for Rescue from Ventilator-Induced Lung Injury
ECLS Consideration in Patients with Potentially Reversible Diseases
Potential ECLS Contraindications
Conclusions
References

38. ECLS Cannulation for Adults with Respiratory Failure

Introduction
Cannulation Decision Making for Adult Respiratory Failure
Technical Aspects of Cannulation for Adult Respiratory Failure
References

39. Comorbidities among ECLS Patients with Respiratory Failure

Introduction
Comorbidities and Patient Outcome from ECLS
Comorbidities Identified in Adult VV-ECLS
Impact of Comorbidities on Outcome in Non-ECLS Adults
Specific Common Comorbidities and Their Interaction with ECLS
Summary
References

40. Medical Management of the Adult with Respiratory Failure on ECLS

Introduction
Ventilatory Support
Prone Positioning
Bronchoscopy
Airway Hemorrhage
Tracheostomy
Awake Extubation
Cardiovascular Support: Vasopressors and Inotropes
Right Heart Failure
Venoarterial Support
Arrhythmias
Sedation Management
Delirium
Intracerebral Hemorrhage
Renal Support
Nutrition
Endocrine Support
Hematological Abnormalities
Infection as the Indication for Respiratory ECLS Support
Infection Complicating ECLS Support
Conclusion
References

41. Nursing Care of the Adult Respiratory ECLS Patient

Introduction
ECLS Specific Nursing Care
Checklists and Preventative Care
Cannula Care
ECLS Circuit Observations and Monitoring of Circuit Function
Console Settings, Safety, and Responses
Renal Replacement
Emergency Responses
General Nursing Care of the ECLS Patient
Neurological Assessment and Sedation Practice (and Awake ECLS)
Patient Moves and Pressure Area Care
Prevention of Bleeding
Hygiene and Infection Prevention
Nutrition
Bowel Management
Staff Support
Role Allocation
References

42. Weaning and Decannulation of Adults with Respiratory Failure on ECLS

Introduction
VV-ECLS Physiology
Initiation of VV-ECLS
Maintaining VV-ECLS
Recirculation
Weaning VV-ECLS
Liberation and Decannulation
Other Modes of Support
The Patient Who Cannot be Weaned
Conclusion
References

43. Outcomes and Complications of Adult Respiratory ECLS

Short-term Outcome of ARDS Patients on VV-ECLS
Long-term Outcomes after ECLS for Severe ARDS
Main ECLS Related Complications and Their Impact on Outcome
Mortality Risk Factors and Outcome Prediction for ECLS Candidates
Volume-Outcome Effect and ECLS Activity Organization
Conclusion
References


VI. Extracorporeal Life Support: Adult Cardiac Disease

44. Adult Cardiovascular Defects, Diseases, and Procedures

Acute Myocardial Infarction
Postcardiotomy
Acute Myocarditis
Acute Pulmonary Embolism
Cardiogenic Shock in Other (Rare) Non Surgery-Related Etiologies
Cardiocirculatory Support or Bailout Assistance
Preoperative Support
Acutely Decompensated Chronic Cardiomyopathy
Conclusions
References

45. Extracorporeal Cardiopulmonary Resuscitation

Introduction
Definition of ECPR
Organizational Issues Related to ECPR Implementation
Facilities and Equipment Appropriate for ECPR
The Ideal ECPR Patient
ECPR Cannulation Technique
Optimal Cannula Diameter
Reperfusion Technique and Initial ECLS Flow Setting
Complications during Implantation and Initial Launching
Rhythm Analysis, Conversion of Ventricle Fibrillation
Postresuscitation Care Monitoring
Studies on ECPR in IHCA
Studies on ECPR in OHCA
Studies on ECPR in the Pediatric Population
ECPR as a Stepwise Approach to Refractory CA
Weaning from ECLS after ECPR
Ethical Issues in ECPR
Future
References

46. General Considerations for VA-ECMO Implantation

Peripheral VA-ECMO is Fast and Easy to Implant
Peripheral VA-ECMO is Efficient as a Circulatory Support Device
ECMO is Cost Effective
ECMO Does Not Unload the Left Ventricle
ECMO Decreases the Transpulmonary Flow
ECMO is Associated with a High Rate of Complications
ECMO Requires the Patient to Stay in Bed
ECMO and Hemodynamic Criteria
ECMO and Neurological Status
ECMO and Cardiac Arrest
ECMO vs. Other Short-Term Circulatory Support Devices
VA-ECMO and Contraindications
Conclusion
References

47. Cannulation for ECMO in Adult Patients with Cardiac Failure

Peripheral Cannulation
References

48. Adult Cardiac ECLS Acute Complication and Comorbidity Management

Introduction
Acute Complications during ECLS
Multimorbidity Patients
Summary
References

49. Medical Management of the Adult with Cardiovascular Disease

Introduction
General ICU Management
Monitoring of the ECMO Circuit
Daily Echocardiography Monitoring
Management of Pulmonary Edema under VA-ECMO
Blood and Coagulation Issues
Cannula Site Related Complications
Nosocomial Infections
Drug Pharmacokinetics
Weaning from VA-ECMO
Conclusion
References

50. Nursing Management of Adults with Cardiovascular Disease

Introduction
Management of the ECMO Device
Preventing Complications
Adopting the Specifics of ECLS to Patient Regular Monitoring
References

51. The Weaning Process and Decannulation in Adult Cardiac Patients

Weaning
Echocardiography in the Weaning Process
Decannulation
VA-ECMO Decannulation
Emergent ECMO Decannulation
Conclusion
References

52. Neurologic and Pulmonary Complications

Introduction
Factors Determining Neurologic Outcome
Incidence of Neurologic Injury
Factors and Incidence of Pulmonary Complications
Return to Work Expectations and Quality of Life
Conclusion
References


VII. Extracorporeal Life Support: Special Indications

53. Pregnancy and Extracorporeal Life Support

Physiological Changes During Pregnancy
Adult Respiratory Distress Syndrome (ARDS) in Pregnancy
Severe Cardiac Disease in Pregnancy
Special Considerations for ECMO Therapy during Pregnancy
Complications of ECMO
Specific Complications of Pregnancy to Consider during ECMO
Experience with ECMO in the Puerperium Period
References

54. Trauma and Extracorporeal Life Support

Introduction
Indications for ECLS in Trauma Patients
Conclusions
References

55. Transport of the Patient Supported with ECMO

Inter-Hospital Transport
Special Transport Situations
Conclusion
References

56. ECMO for Septic Shock

Introduction
Indications
Contraindications
Cannulation Strategies
Central Cannulation
Management on ECMO
Outcomes
Conclusions
References

57. Extracorporeal Life Support for Severe Cardiotoxic Drug Poisoning

Introduction
ECLS for Poisoning-induced Cardiovascular Failure
Venovenous ECLS for Poisoning-induced Respiratory Failure
Conclusion
References

58. ECMO as Bridge to Lung Transplantation

Introduction
Cannula Configurations
Patient Selection and Timing of ECMO Initiation
Patient Management Strategies
ECMO Use in the Intraoperative and Posttransplantation Settings
Outcomes of ECMO as BTT
Limitations to Bridge to Transplant
Conclusions
References

59. ECLS in Heart Transplantation

Introduction
Pretransplant ECMO
ECLS after Heart Transplantation
References

60. Immunodeficiency and ECLS

Introduction
Support in Pediatric and Adult Patients with Solid Organ and Blood Cancer
ECLS Utilization in Patients with Malignancy
Indications, Contraindications and Specific Considerations
ECLS in Patients Treated with Hematopoietic Stem Cell Transplant (HSCT)
Technical Considerations
Use of ECLS to Manage Respiratory Failure after HSCT
Use of ECLS to Manage Heart Failure after HSCT
Vascular Access
Management of Coagulation after HSCT
ECLS in Adult Human Immunodeficiency Virus (HIV) Patients
ECLS in Patients with PJP: the South Africa Experience
ECLS Candidate Selection for HIV+/PJP+
Antiretroviral Drugs (ARVs) and ECLS
ECLS in Adult and Pediatric Autoimmune Diseases
References


VIII. ECLS: Procedures and Adjunctive Extracorporeal Therapies

61. Procedures on ECLS

Introduction
Decision Threshold-Three Questions
General Principals
General Measures
ECMO Circuit Related Procedures
Diagnostic Procedures
Surgical Procedures General
Trauma and Burn Patients
Specific Surgical Procedures in Respiratory ECMO
Specific Surgical Procedures in Cardiac ECLS
Conclusion

62. Extracorporeal Elimination

Acute Kidney Injury (AKI) during ECLS
Apheresis during ECLS
References

63. Extracorporeal Carbon Dioxide Removal

Introduction
Considerations for ECCO2R
Contraindications and Limitations
Physiological Targets
Circuit Configurations
Anticoagulation Strategy and Impact of Low Extracorporeal Blood Flow
Management Considerations in the Event of Circuit Failure
Weaning ECCO2R
Conclusion
References

64. Other Forms of Extracorporeal Cardiovascular Support

Introduction
Intraaortic Balloon Pump
IMPELLA
Levitronix CentriMag
Anticoagulation
Right Ventricular Failure
Mobilization
Weaning
References


IX. Extracorporeal Life Support: Organization

65. Implementing an ECLS Program

Identify the ECMO Service
Identify Your Customer
Identify the Employees and Equipment Needed
Develop the Key Processes
Mistake-Proof the Processes
Develop Measures, Improvement Goals and Controls
Continuously Improving and Sustaining a Program
References

66. Centralization and Regionalization of ECLS Resources

Background
Relationship of Centralization to ECMO
The ECMO Center
Outlying Centers and Critical Care Transport
ECMO Transport
Summary
References

67. Education and Training

Introduction
Educational Process
Establishing ECMO Competency
ECMO Training Program
ECMO Training Course Curriculum
Didactic (Classroom) Course
Training Labs
Water Drills
Animal Lab
High Fidelity Simulation
ELSO ECMO Training Course
Maintaining Competency Standards
Maintaining ECMO Competency
Summary
References
Addendum 67-1

68. Quality of Care in Extracorporeal Life Support

Introduction
Summarizing the Evidence for Interventions to Improve Outcomes
Identify Local Barriers to Implementation of Changes
Performance Measurement
Implementation of the Interventions
Data Collection and Measuring Quality
Quality in Small vs. Large ECLS Programs
New Technology
Summary
References

69. The Economics of ECMO

Introduction
Fundamental Considerations
Measuring the Overall Cost of ECMO
International Models of ECMO Finance
The Future of ECMO
References

70. The Ethics of ECLS

Introduction
Expanding Utilizations of ECLS: Application and Resource Allocation
Complex Medical Decision Making in ECLS: Starting and Stopping ECLS
Research in ECLS: Ethical Challenges and Controversy
Practical Considerations
Conclusion
References

71. Strategies for Medication Management in ECLS

Introduction
Pharmacokinetics
Pharmacokinetic Changes in Critical Illness and ECLS
Experience and Recommendations Based on Medication Class
General Dosing Strategy
References

72. The Registry of the Extracorporeal Life Support Organization

Registry Data Collection
Registry Reports
Current Registry Data Summary
Neonatal Trends
Pediatric Trends
Adult Trends
Cardiac Trends
Summary
References

Glossary
Appendix 1: Pediatric ECLS Cannula Characteristics
Appendix 2: Adult ECLS Cannula Characteristics (Edwards)
Appendix 3: Adult ECLS Cannula Characteristics (Medtronic)
Appendix 4: Adult ECLS Cannula Characteristics (Maquet)
Appendix 5: Adult ECLS Cannula Characteristics (Sorin)
Appendix 6: Adult ECLS Cannula Characteristics (Medos)
Appendix 7: Double Lumen ECLS Cannula Characteristics
Index