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Dr WuMengYu talks 2020 Important Concepts in Venovenous ECMO

Kate Meng Yu Wu Kate Wu 1972 2018 KO www drwumengyu com

Hi Kate ECMO Venovenous ECMO workshop3627 gmail com

Concept 1 No more VILI

VV ECMO A R D S

Acute Respiratory Distress Syndrome Thompson BT Chambers RC Liu KD N Engl J Med 2017 Aug 10 377 6 562 572

ARDS ARDS Acute Respiratory Distress Syndrome ARDS 2012 Berlin definition ARDS X CT ARDS 7 PEEP Positive endrespiratory pressure 5

Mortality 45 Who will not survive while treated by MV alone

Berlin definition PF ratio PaO2 FiO2 ARDS 3 PF ratio 100 ARDS 50 50

Mechanical Ventilation is the first respiratory support for ARDS

The Principle of MV Open the Lung and Keep it Open Trans lung pressure No PEEP PEEP 12

1 open the lung and keep it open translung pressure PEEP translung pressure PEEP PEEP

PEEP ARDS dp dt PEEP 25 P1 50 P2 25 50 P2 P1 VP P2 P1 P1 PEEP

Open the Lung Need a warm up C dV dP Px P1 P2 15 Berne Levy Physiology 6th ed P434 P3

PEEP VP PX PEEP PX

2 peak inspiratory pressure PIP plateau pressure Pplt

MV driving pressure Ppt PEEP

pressure control mode PIP Pplt Pplt 30 Driving pressure Pplt PEEP Tidal volume VT driving pressure Compliance

driving pressure ARDS driving pressure driving pressure 13

VQ Mismatch 1 driving pressure FiO2 A R D S dependent part

Inhomogeneous Aerated Lung in ARDS VILI enhances V Q mismatch Dependent lower lobes Absorptive atelectasis Independent upper lobes Over Aerated 22

Ventilation V Perfusion P VQ match Q Perfusion

VQ Mismatch 2 ARDS 3 VQ mismatch dead space ventilation shunting

Dead space Ventilation Mosaic area Atelectasis 26 V Q Better VQ match V

ARDS VQ mismatch diastolic failure

Rationale of ARDS Deteriorating on MV Hypoxemia Hypotension Acute Cor Pulmonale AKI

VQ Mismatch ARDS FiO2 VQ mismatch

Lung Protective Ventilation Low tidal volume and higher PEEP

1 VQ Mismatch VQ mismatch Dead space ventilation VT Lung Protective ventilation LPV

The Rationale of LPV Dead space ventilation LPV recruited Conventional MVrecruited Shunting

2 LPV Baby lung driving pressure CT baby lung LPV VQ mismatch VT VQ mismatch

Extracorporeal membrane oxygenation ECMO

PF ratio 70

CGMH Linko VVECMO Protocol All cause

Concept 2 Competing pumps

vs

Venovenous ECMO Q0 venous blood Q1 ECMO oxygenated blood recirculated Q2 ECMO oxygenated blood not recirculated Q3 Mixed blood partially refreshed by ECMO Q4 Pulmonary oxygenated blood Arterial blood Q4 is the key for the speed to downgrade the setting of MV

VVECMO ECMO Pump pump ECMO pump Q3 Q3 VVECMO Q3 LPV

RA PA Ao The lungs still need to be Functional

Baby lung Q3 Q4 FiO2 FiO2

FiO2 ARDS driving pressure

Adjust Pump Flow Pumps Competition 3 2

VVECMO VVECMO PIP ECMO gas flow 1

PICCO ECMO pump flow ECMO pump ECMO PICCO pump flow Spo2 pump flow Spo2 PICCO 2 4 PRBC pump flow

Adjust Gas Flow Crosstalk between MV and ECMO 3 2 Reduce VILI Pressure first SPo2 90

ECMO Gas Flow Gas flow ECMO FiO2 100 FiO2 VVECMO LPV PIP 30 cmH2O PEEP 12 14 cm H2O FiO2 40 SaO2 90 PaO2 70mmHg PaCO2 30 40 mmHg

Factors Determining ECMO Gas Exchange Gas flow More CO2 washed out than Oxygenation in ECMO

10 gm dL ECMO CRRT ECMO CRRT ECMO CRRT CRRT

Recirculation ECMO flow recirculation ECMO 15 SVC

Venovenous Mode Prepulmonary Gas Exchange to Reduce VILI Mode for ARDS without shock

RV ECMO

VA VVA ECMO FiO2 PIP 30 cmH2O PEEP 12 14 cmH2O FiO2 60 40

Concept 3 Coagulopathy

Modest Anti coagulation aPTT 45 60 seconds

An Extreme Hypocoagulation This hypocoagulation state was reversed after 12 hours in patients without or with a mild TIC Wu MY et al Venovenous extracorporeal life support for posttraumatic respiratory distress syndrome in adults the risk of major hemorrhages Scand J Trauma Resusc Emerg Med 2014 Oct 2 22 56

2000 5000 aPTT aPTT 6 8 aPTT 40 50 aPTT 40 50 Protamine

Concept 4 Dry Lungs

Lung Water

Daily I O 63

I O negative volume control bolus ECMO blood flow ECMO blood flow

Concept 5 A Protocol

protocol

QR code

ARDS ARDS

ARDS 10 14 compliance PF ratio VQ mismatch PF ratio 70 200 baby lung ARDS

Increased pre ECMO MV duration Increased consumption of pulmonary compliance Increased driving pressure on respiratory support Increased hospital mortality rate after respiratory ECMO Survivors presentation

Take a rest but not in the end