extracorporeal methods

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Slide 1:

1 welcome

Extracorporeal Membrane Oxygenation.:

Extracorporeal Membrane Oxygenation. Amalnath John First year m.pharm 2

Introduction:

Introduction ECMO is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful. ECMO is essentially a modification of the cardiopulmonary bypass circuit which is used routinely in cardiac surgery. It is used as temporary support, usually awaiting recovery of organs. 3

Dynamics of ECMO:

Dynamics of ECMO Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium, Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta. 4

Basic mechanics:

Basic mechanics Blood is drained from the right atrium Blood is warmed and oxygenated Excess CO 2 is removed Oxygenated blood is returned to the aorta (or for VV ECMO into the right atrium) ECMO blood mixes with blood ejected from the left ventricle 5

How ECMO Works…:

How ECMO Works… 6

Indications for ECMO:

Indications for ECMO Divided into two type Cardiac Failure Respiratory Failure 7

Indications – Cardiac Failure:

Indications – Cardiac Failure Post-heart transplant usually due to primary graft failure Severe cardiac failure due to almost any other cause Decompensated cardiomyopathy Myocarditis Acute coronary syndrome with cardiogenic shock Profound cardiac depression due to drug overdose or sepsis 8

Indications – Respiratory Failure:

Indications – Respiratory Failure Adult respiratory distress syndrome (ARDS) Pneumonia Trauma Primary graft failure following lung transplantation. ECMO is also used for neonatal and pediatric respiratory support. 9

ECMO Criteria Guidelines:

ECMO Criteria Guidelines Birth weight > 2.0 kg Potentially reversible lung, cardiac disease Normal cranial ultrasound No significant coagulopathy or uncontrollable hemorrhage No major cardiac malformation 10

ECMO Contraindications :

ECMO Contraindications Mechanical ventilation > 14 days in duration ?CLD Intracranial hemorrhage Uncontrolled bleeding 11

Configurations for ECMO:

Configurations for ECMO ECMO can be inserted in 2 configurations: Veno-venous Veno-arterial 12

VA ECMO:

VA ECMO Veno-arterial (VA) configuration Blood being drained from the venous system and returned to the arterial system. Provides both cardiac and respiratory support. Achieved by either peripheral or central cannulation 13

VA ECMO:

VA ECMO Used for both respiratory failure and cardiac failure 14

VV ECMO:

VV ECMO Veno -Venous (VV) configuration Provides oxygenation Blood being drained from venous system and returned to venous system. Only provides respiratory support Achieved by peripheral cannulation , usually of both femoral veins. 15

VV ECMO:

VV ECMO Used primarily for respiratory failure Indirectly improved cardiac function 16

Complications of ECMO:

Complications of ECMO Bleeding/ Hemolysis Coagulopathy Thrombocytopenia Non-pulsatile perfusion to end organs Kidneys Splanchnic circulation seems to be particularly susceptible GI bleeding, ulceration and perforation Liver impairment 17

Complications of ECMO:

Complications of ECMO Mechanical Complications Tubing rupture Pump malfunction Cannula related problems Local complications: Leg ischemia Particularly at peripheral insertion site of VA Air embolism/Thromboembolism Neurological: Intracerebral bleeds Largely associated with sepsis Manifest as seizures or brain death 18

VenoArterial vs. VenoVenous ECMO-Benefits :

VenoArterial vs. VenoVenous ECMO-Benefits VA ECMO Cardiac and respiratory support VV ECMO Preserves normal physiologic pulsatility Decrease for ischemic lung injury Avoids ligation of carotid artery May decrease risk of neurologic injury Blood entering cerebral arterial tree is less highly oxygenated and under less pressure 19

VenoArterial vs. VenoVenous ECMO-Disadvantages:

VenoArterial vs. VenoVenous ECMO-Disadvantages VA ECMO Ligation of carotid artery Lack of normal pulsatility VV ECMO Decline in renal function during first 48 hours Requirement of two site cannulation for larger patients No direct circulatory support 20

Common Cannulation Sites:

Common Cannulation Sites VA Right Internal Jugular Vein Right Common Carotid VV internal Jugular Vein alone 21

Central ECMO Cannulation:

Central ECMO Cannulation 22

ECMO Neck Cannulas:

ECMO Neck Cannulas 23

ECMO Chest Cannulation:

ECMO Chest Cannulation 24

Peripheral ECMO Cannulation:

Peripheral ECMO Cannulation 25

CARDIO PULMONARY BYPASS :

CARDIO PULMONARY BYPASS 26

Slide 27:

Technique that temporarily takes over function of heart and lungs during surgery, maintaining the circulation of blood. The CPB pump is commonly known as “ heart-lung machine ” 27

AIM OF CPB:

AIM OF CPB To provide a non-beating & Bloodless Heart with blood flow temporarily diverted to an Extracorporeal Circuit that functionally replaces the Heart & the Lung 28

Heart-Lung Machine:

Heart-Lung Machine 29

Cardiopulmonary Bypass:

Cardiopulmonary Bypass 30

Scheme of CPB Circuit:

Scheme of CPB Circuit Pump Oxygenator Heat exchanger Reservoir Filter Sucker & vent Cardioplegic solution delivery system 31

Pumps:

Pumps Sigmamotor pump Roller pump Centrifugal pump 32

Oxygenator:

Oxygenator Solid disc oxygenator Screen oxygenator Solid disc with rotation screens Bubble oxygenator Membrane oxygenator 33

Filtration :

Filtration Screen-type filters : have pores in the medium that are of a particular size. The depth filters : contain a medium through which the blood flows. This large wet surface blocks many particles and thus prevents them from being carried in the fluid stream; they are retained on the internal medium surface by adsorptive forces . 34

uses:

uses Coronary artery bypass surgery Cardiac valve repair, Septal defect repair, Transplantation, Repair of aneurysms. 35

Differences between ECMO & CPB:

Differences between ECMO & CPB ECMO provides long term support (3~10 ) days. CPB Provides short term support( upto 7/8 hours). Usually cardiopleagics are added to CPB circuit. 36

Slide 37:

37 Plasmapheresis

What is Plasmapheresis:

What is Plasmapheresis Plasmapheresis involves withdrawal of venous blood, separation of plasma from blood cells, and reinfusion of cells plus autologous plasma or another replacement solution. Plasma and blood cells are separated by centrifugation or membrane filtration. 38

Aim:

Aim Plasmapheresis is to take out causative substances of the disease, especially high molecular weight substances , and to supply normal plasma component 39

Slide 40:

Plasma exchange 40

Slide 41:

Centrifugal Separation 41

Slide 42:

Membrane Separation 42

Indication of plasmapheresis Category 1: Standard acceptable therapy:

Indication of plasmapheresis Category 1: Standard acceptable therapy Chronic idiopathic demyelinating polyneuropathy (CIDP), cryoglobulinemia, Goodpasture’s syndrome, Guillain-Barre syndrome, myasthenia gravis, post transfusion purpura, 43

Indication of plasmapheresis Category 2: Sufficient evidence to suggest efficacy usually as adjunctive therapy:

Indication of plasmapheresis Category 2: Sufficient evidence to suggest efficacy usually as adjunctive therapy ABO incompatible organ transplant, bullous pemphigoid, drug overdose and poisoning (protein bound), 44

Small vs. Large Volume Exchange:

Small vs. Large Volume Exchange 1.0 plasma volume exchange: minimizes time required for each procedure but may need more frequent procedures. 2.0 – 3.0 plasma volume exchange: greater initial diminution of pathologic substance but requiring considerably more time to perform the procedure.

The most frequent complication :

The most frequent complication Hypocalcemia Infusion CaCl 2 : 2% 20 c.c/hr Hypokalemia Add potassium Anaphylactic reactions Hypothermia 46

Mechanical Removal of Antibodies:

Mechanical Removal of Antibodies When antibody is rapidly and massively decreased by plasmapheresis, antibody synthesis increases rapidly. This rebound response complicates treatment of autoimmune diseases. It is usually combined with immune suppressive therapy. 47

Replacement Fluid:

Replacement Fluid Fresh frozen plasma – TTP, liver failure, patients with coagulopathy, immediate post surgery. Cryopoor plasma – TTP 5% albumin – Most cases. 48

Exchange Transfusion:

Exchange Transfusion 49

Slide 50:

This procedure, used most commonly to treat severe unconjugated hyperbilirubinemia, removes the infant’s circulating blood and replaces it with donor blood. The amount of blood exchanged is expressed as multiples of the infant’s blood volume The procedure is done in small increments/cycles. 50

Exchange transfusion.:

Exchange transfusion. 51

Slide 52:

Exchange transfusion may be indicated for correction of severe anaemia, removal of antibody-coated red blood cells in haemolytic disease, removal of excessive unconjugated bilirubin, toxin removal, neutropenia associated with sepsis 52

Types of Exchange Transfusion:

Types of Exchange Transfusion Simple 2-Volume Exchange Exchanging 2x the infant’s blood volume Isovolumetric 2-Volume Exchange Exchanging 2x the volume Infusing and withdrawing blood at the same time through two separate ports Partial Exchange (<2 volumes) Exchanging < 2x the patient’s volume Usually used for Severe Anemia or Polycythemia 53

Catheters used.:

Catheters used. Generally umbilical venous catheters(UVC) and umbilical artery catheters (UAC) used. 54

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55

Indications:

Indications Major Hyperbilirubinemia Hemolytic Disease of the Newborn Rh incompatibility ABO incompatibility Other blood group incompatibilities Severe Anemia Polycythemia Other Sepsis DIC Metabolic acidosis Severe fluid/electroyte imbalances 56

Blood:

Blood Homologous blood Cytomegalovirus seronegative and leukodepleted Sickle negative Irradiated 57

Blood:

Blood Preferable to use blood or plasma collected in citrate phosphate dextrose (CPD) < 72hrs old However in newborns with severe asphyxia or hydrops fetalis blood that is < 24 hrs old is preferable. 58

references:

references www.assets.cambridge.org en.wikipedia.org emedicine.medscape.com books.google.com wisegeek.com lane.stanford.edu nlm.nih.gov 59

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