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EDITORIAL  
Year : 2011  |  Volume : 14  |  Issue : 1  |  Page : 1-2
ECMO - The way to go


Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bannerughatta Road, Bangalore, India

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Date of Web Publication31-Dec-2010
 

How to cite this article:
Chakravarthy M. ECMO - The way to go. Ann Card Anaesth 2011;14:1-2

How to cite this URL:
Chakravarthy M. ECMO - The way to go. Ann Card Anaesth [serial online] 2011 [cited 2021 Oct 20];14:1-2. Available from: https://www.annals.in/text.asp?2011/14/1/1/74391


Extracorporeal life support with circulatory support and membrane oxygenation is known as extracorporeal membrane oxygenation (ECMO). This technique appears to be a logical extension of the benefits of cardiopulmonary bypass. The lessons learned from the first 25 to 30 years of cardiopulmonary bypass gave the idea of potential to support reversible failing heart and/ or lung in critically ill adults and children. It was understood quickly that the early oxygenator devices such as the disc and the bubble oxygenator would not be beneficial for long-term support. It was the pioneering work of Clowes and Neville who built the first prototype of a membrane oxygenator using polyethylene sheets in the year 1955, which was successfully used in the experimental laboratory and convinced the world of the possibility of extended artificial oxygenation. [1] The concept was immediately adopted by the cardiac surgeons for extending the cardiopulmonary bypass time for carrying out their complicated surgeries. In the 1960s and 1970s, nine medical centers collaborated in a prospective randomized study to evaluate prolonged ECMO as a therapy for severe acute respiratory failure (ARF). Forty eight adult patients receiving conventional mechanical ventilation were compared to 42 patients receiving partial veno-arterial bypass in addition to mechanical ventilation. Just four patients in each group survived. The majority of patients died due to decreased compliance due to diffuse pulmonary inflammation, necrosis, and fibrosis. The authors concluded that ECMO can support respiratory gas exchange but did not increase the probability of long-term survival in patients with severe ARF. Despite these discouraging initial outcomes, the use of ECMO continued in assisting patients with reversible cardiorespiratory failure. Saving post-cardiac surgical patients and those with ARF continued to be reported as case reports and brief communications on a regular basis. Such reports appeared favoring ECMO support after congenital heart surgery, [2] during difficult interventions in congenital heart surgery [3] and acute respiratory failure in pediatric age group. [4] Over the next few years, the use of ECMO was extended to support a neonate with respiratory failure due to aspiration of meconium. [5] But over a decade, the type and number of neonates getting ECMO therapy changed. In two publications, based on the data of Extracorporeal Life Support Organization (ELSO) Registry, Roy and co-workers (reviewed the data of 12,175 neonates); and Fleming and co-workers (reviewed the data of 28, 171 neonates) showed interesting results. [6],[7] It was noted in the first of these two studies that the average number of neonatal patients reported from each site decreased from a peak of 18 in 1991 to 9 in 1997. This skew in the data disappeared when the neonates with congenital diaphragmatic hernia were removed from the data. But the total number of sites referring to ELSO increased from 58 in 1988 to 100 in 1993. In the second study, significant decrease in the mechanical failure during ECMO was reported. In the era up to early 2000, ECMO came to be accepted as a reasonable option to support an infant with failing respiratory gas exchange. Recently, a multicentric trial was conducted in the United Kingdom from July 2001 to August 2006 recruiting 180 patients from 70 centers. [8] The trial consisted of assessing conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR). Although smaller studies on similar topic were conducted earlier, the CESAR trial stands out as the modern trial using adult population with respiratory distress. Eligible patients were adults who had a Murray score [9] of 3.0 or higher, or uncompensated hypercapnea with a pH of less than 7.20 despite optimum conventional treatment. Similarly, ineligible patients were also identified. They showed that 63% of patients allocated to consideration for treatment by ECMO survived to six months without disability compared with 47% of those allocated to conventional management (relative risk 0· 69; 95% CI 0· 05-0·97, P=0· 03). The outcome of this trial encouraged the authors to suggest early institution of ECMO in patients with Murray score >3 and pH of <7.2 with reversible respiratory failure. In tandem with the CESAR trial, the global interest in ECMO to treat cardiac surgical patients seems to be increasing. In this issue of the Annals of cardiac anaesthesia, a retrospective study and a case report on ECMO [10],[11] have appeared. Further, an excellent recent review by Barlett and Gattinoni recently seems to provoke renewed interest on the topic. [12] Incidentally, Barlett is considered as the 'father of modern ECMO'. Considering the expanding indications for the use of ECMO, the authors believe that, time has come to define the inclusion and exclusion criteria for pediatric and adult patients who may require ECMO due to either pulmonary problems or cardiac problems. If this is not done, the outcome of ECMO use in these patients might appear distorted. If the clinicians lack the guidelines for the timing of commencement of ECMO, one might pose a moot question that the result in a particular unit might be due to incorrect timing. Premature commencement ECMO may be cited as the reason if the outcome is good and in contrast, delayed commencement among the patient subgroup is the reason where the outcome is unsatisfactory. The authors of one of the large studies published in the current issue of the 'Annals of cardiac anaesthesia' suggest that if ECMO support is used as an integrated ECMO-cardiopulmonary bypass circuit or if initiated early in the operating room after ascertaining completeness of surgical repair survival might improve. [10] It is important for us in the cardiac surgical and anesthesia team to define what 'early' is. These recent publications should draw the attention of cardiac surgeons, cardiac anesthesiologists and the extracorporeal technologists to set up a trial to explore the assessment of ECMO in cardiac surgical patients in similar lines to the CESAR trial. It is important to conduct such a trial to understand the potential benefits of ECMO in adult and pediatric cardiac surgical patients, define the end-points and to identify the factors modifying morbidity and mortality. Establishing protocols and prioritization of indications will not only standardize the outcome from all centres, but also allow future researchers to study the data from the registry. ELSO registry is a standing example of usefulness of such data. It may be worthwhile for the cardiac surgical team to emulate the pediatric colleagues in creating a registry on ECMO immediately.

 
   References Top

1.Clowes GH Jr, Neville WE. Further development of a blood oxygenator dependent upon the diffusion of gases through plastic membranes. Trans Am Soc Artif Intern Organs 1957;3:52-8.   Back to cited text no. 1
    
2.Aharon AS, Drinkwater DC Jr, Churchwell KB, Quisling SV, Reddy VS, Taylor M, et al. Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions. Ann Thorac Surg 2001;72:2095-101.   Back to cited text no. 2
[PUBMED]    
3.Carmichael TB, Walsh EP, Roth SJ. Anticipatory use of venoarterial extracorporeal membrane oxygenation for a high-risk interventional cardiac procedure. Respir Care 2002;47:1002-6.   Back to cited text no. 3
[PUBMED]    
4.Green TP, Moler FW, Goodman DM. Probability of survival after prolonged extracorporeal membrane oxygenation in pediatric patients with acute respiratory failure. Extracorporeal Life Support Organization. Crit Care Med 1995;23:1132-9.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Kugelman A, Gangitano E, Taschuk R, Garza R, Riskin A, McEvoy C, et al. Extracorporeal membrane oxygenation in infants with meconium aspiration syndrome: a decade of experience with venovenous ECMO. J Pediatr Surg 2005;40:1082-9.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Roy BJ, Rycus P, Conrad SA, Clark RH. The changing demographics of neonatal extracorporeal membrane oxygenation patients reported to the Extracorporeal Life Support Organization (ELSO) Registry. Pediatrics 2000;106:1334-8.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Fleming GM, Gurney JG, Donohue JE, Remenapp RT, Annich GM. Mechanical component failures in 28,171 neonatal and pediatric extracorporeal membrane oxygenation courses from 1987 to 2006. Pediatr Crit Care Med 2009;10:439-44.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-63.   Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988;138:720-3.  Back to cited text no. 9
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10.Chauhan S, Malik M, Malik V, Chauhan Y, Kiran U, Bisoi AK. Extra corporeal membrane oxygenation after pediatric cardiac surgery: A 10 year experience. Ann Card Anaesth 2011;14:19-24.   Back to cited text no. 10
  Medknow Journal  
11.Malik V, Pandey A, Chauhan S, Airan B. Use of extracorporeal membrane oxygenator support to salvage an infant with anomalous left coronary artery from pulmonary artery. Ann Card Anaesth 2011;14:51-4.  Back to cited text no. 11
  Medknow Journal  
12.Bartlett RH, Gattinoni L. Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. Minerva Anestesiol 2010;76:534-40.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Murali Chakravarthy
Department of Anesthesia, Critical Care and Pain Relief, Fortis hospitals, Bannerughatta Road, Bangalore 560078
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.74391

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