Thursday, January 26, 2012

ECMO as a Bridge to Lung Transplantation

See end of article for ECMO explained.

“As waiting times for donor organs continue to increase, so does the need for bridging strategies for patients with end-stage lung disease awaiting transplantation,” said Doctor Marius M. Hoeper. “Our study shows that ECMO support in awake and non-intubated patients may be an alternative to intubation and mechanical ventilation, and may result in better survival.”

In the retrospective, single-centre study of consecutive lung transplantation candidates with terminal respiratory or cardiopulmonary failure, 26 patients received awake ECMO and 34 control patients received conventional mechanical ventilation (MV) as a bridge to transplant. Median duration of ECMO support was 9 days (range 1-45) and median duration of MV was 15 days (range 1-71). Veno-arterial ECMO was used primarily in patients with right ventricular failure and/or profound hypoxemia while the veno-venous approach was used primarily in patients exhibiting hypoxemic and/or hypercapnic respiratory failure but stable hemodynamics.

Of 26 patients in the ECMO group, six (23 per cent) died before a donor organ became available, compared with 10 of 34 (29 per cent) patients in the MV group. Among the patients who reached transplantation, the survival rate at six months post-transplantation was significantly (p=.02) higher in the awake ECMO group (80 per cent) compared with the MV group (50 per cent). The six-month survival rate among awake ECMO patients who required secondary intubation dropped to 43 per cent. Awake ECMO patents required significantly (p=.04) shorter postoperative mechanical ventilation and showed a trend towards shorter postoperative hospital stays.

ECMO-related complications included a fatal cardiac arrest after insertion of the venous ECMO cannulae in one patient. Intubation and mechanical ventilation was required 1-7 days after ECMO insertion in six patients. Blood transfusions due to bleeding complications were needed in eight patients. Of five patients who developed a sepsis-like syndrome, one recovered.

“Ours is the largest series of patients who underwent awake ECMO as a bridge to lung transplantation,” said Doctor Thomas Fuehner. “In addition to the possibility that this approach may improve survival, one of the main benefits of using awake ECMO is the avoidance of the complications associated with general anaesthesia, intubation, and long-term ventilation.”

The study had a few limitations, including the small number of patients included and the retrospective nature of the analyses. “Awake ECMO may be an effective bridging strategy for lung transplantation candidates,” said Hoeper. “This strategy, however, remains investigational and must be studied further to improve its safety and efficacy and examine how to tailor its use for specific patient populations.”
Source: American Thoracic Society

ECMO explained
In intensive care medicine, extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique of providing both cardiac and respiratory support oxygen to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function. Initial cannulation of a patient receiving ECMO is performed by a surgeon and maintenance of the patient is the responsibility of the ECMO Specialist and gives 24/7 monitoring care during the duration of the ECMO treatment.

An ECMO machine is similar to a heart-lung machine. To initiate ECMO, cannulae are placed in large blood vessels to provide access to the patient's blood. Anticoagulant drugs, usually heparin, are given to prevent blood clotting. The ECMO machine continuously pumps blood from the patient through a membrane oxygenator that imitates the gas exchange process of the lungs, i.e. it removes carbon dioxide and adds oxygen. Oxygenated blood is then returned to the patient.
Source: Wikipedia

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