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Usage of Adult ECMO in Critically Ill

INTRODUCTION: In the last several decades, it is increasing number of extracorporeal membrane oxygenation (ECMO) therapy in critically ill. From the beginnings, ECMO usage was primary method of life saving in children population for the post partum respiratory problems. In the eighties and nineties, this method expanded and became the life-threatening method in adult medicine. At the beginning of adult era, point was to manage difficult respiratory problems, and later, when technology improved, started to use as the combination of respiratory, and mostly as the circulatory support in the critically ill, today generally known as the extracorporeal life support (ELS).

OBJECTIVE: In this study, it is analyzed indications, usage and outcome of veno-arterial or veno-venous extracorporeal membrane oxygenation (V-A/V-V ECMO) in Department of Cardiovascular Anesthesiology and Cardiac Intensive Medicine Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava Zagreb.

METHODS: Patients’ data were collected from the CardioBase software during period of five years. It has been analyzed: demographic data, clinical data, indications for ECMO implantation, duration of ECMO and outcome.

RESULTS: In period from the beginning of 2011 to the end of 2016, in Department were performed 28 ECMO devices. As the primary circulatory support, in 26 patients (93%) V-A ECMO was established, and in two of them, V-A ECMO converted in V-V ECMO. These two patients, in the meantime, received other types of mechanical support for heart function and remained only respiratory support. In two patients, V-V ECMO primary implanted due to respiratory dysfunction and/or ARDS. Indications for V-A ECMO in 26 patients were: postcardiotomy low cardiac output syndrome (LCOS) in 23 (88%), of which, in three patients (13%) had primary graft failure after heart transplantation. In 19 patients, V-A ECMO implanted in operating room as the emergency procedure, and in remaining 4 in the ICU as the consequence of late heart failure. In three patients (11%) of all 26 with V-A ECMO implanted preoperatively due to hemodynamic instability and/or acute heart failure. Of all patients, 17 (60%) died – eight in operating room, and nine in ICU within several days (range 1-7 days). Of survived patients, except two patients on V-V ECMO, 7 of them successfully weaned from V-A ECMO, and in remaining 4, long-term mechanical support implanted. Patients on V-V ECMO successfully weaned from machine, and discharged on the hospital ward.

DISSCUSION: At the beginning of adult era, point was to manage difficult respiratory problems, and later, when technology improved, started to use as the combination of respiratory, and mostly as the circulatory support in the critically ill. In this overview, it has been shown mostly emergency usage of V-A ECMO in single Department. Most of those patients had postcardiotomy LCOS, in which implantation was life-saving measure. That because, high mortality rate is not surprising. Some of these patients, also died of complications produced of combination of ECMO usage and surgery, primary of uncontrolled bleeding. Few of those patients were in bad condition before surgery, and their early postoperative course was complicated with multiply organ dysfunction, which led to the bad outcome. Last couple of years, indications for ECMO usage is expanded, then usage for primary graft failure after heart transplantation, in combination with inotropic medications, shown good results. Furthermore, in patients with preoperative heart failure, or with complications of invasive diagnostic procedures, ECMO establishment give the chance for bridging to emergency surgery, implantation of long-term mechanically support or, finally, heart transplantation. However, no matter that, ECMO could be use for life-threatening conditions, this method is only “buying” the time and definitive decision and plan for patients’ treatment must exist.


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