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Extracorporeal Life Support in the Emergency Department

Written by Clay Smith

What Is ECLS?

Extracorporeal life support (ECLS, aka ECMO) in its simplest form is taking out a patient’s blood, sending it through a pump and membrane to oxygenate and remove CO2, and putting it back in. There are two main types: veno-venous (V-V) and veno-arterial (V-A).

  • V-V is most common and is used for inability to oxygenate despite maximal ventilator settings in the absence of cardiovascular collapse. In V-V, blood is sucked out of a femoral vein (FV) or internal jugular vein (IJ), sent through the pump to a membrane to remove CO2 and add oxygen, and returned to the right atrium (RA). It is returning oxygenated blood to the RA since the lungs aren’t working. There are single cannula systems via the IJ with a proximal port in the RA and distal in the IVC. Flow rate is up to 6L/min.

  • V-A is used for situations with poor perfusion and need for circulatory support. In V-A, a FV cannula sucks blood out, into the pump, to the membrane for oxygenation and removal of CO2, and returns it to the femoral artery (FA). It can provide up to 10L/min flow.

  • There is also a hybrid model, V-AV for severely compromised cardiac and pulmonary function. With these, blood is sucked out of the IVC, oxygenated, and pumped back to both the RA (for oxygenation) and FA (for circulatory support).

Newer cannulas, better pumps, and miniaturized ECLS devices, have made this heroic procedure more accessible and feasible for use in the ED.

From http://dx.doi.org/10.1155/2016/1094296. Not shown is V-AV.

From http://dx.doi.org/10.1155/2016/1094296. Not shown is V-AV.
From http://dx.doi.org/10.1155/2016/1094296. Not shown is V-AV.

Why Do ECLS?

It should be used in conditions causing cardiac or pulmonary failure that are reversible. It can buy time for diagnostics or procedures. ECLS is estimated to be appropriate in about 2.5 patients per 10,000 ED visits.

ECLS is useful as a temporary bridge for potentially reversible conditions for which a definitive fix is available or possible. Survival with good neurological outcome is better in select patients than those with standard CPR.

V-A ECLS

  • Arrest needing PCI

  • MI with shock

  • Aortic dissection with tamponade

  • Sepsis related cardiac dysfunction

  • Hypothermia with refractory VT

  • Bridge to damage control surgery/procedure

  • PE with CV collapse

  • Other refractory shock or arrest

  • Cardiodepressant overdose

V-V ECLS

  • Respiratory failure

  • Drowning

  • Amniotic fluid/fat embolism

  • Air embolism

V-AV ECLS

  • Cardiogenic shock with severely compromised lung function, i.e. pumonary edema/ARDS

Contraindications

  • Prolonged or unwitnessed arrest with brain injury

  • Other end stage illness or condition incompatible with life

  • Intracranial bleed or irreversible brain injury

  • Uncontrolled hemorrhage

  • Advanced age (relative contraindication)

  • Anatomic issues with cannula sites

Who’s Involved?

This requires a team of nurses, RTs, and physicians with specialized training in ECLS and the ability to troubleshoot and manage sudden circuit failure.

What Could Possibly Go Wrong?

These are quoted directly from the cited article, Table 2.

Cannulation-related

  • Failure to complete cannulation

  • Major vessel perforation or dissection

  • Cannulation of the wrong vessel

  • Pseudoaneurysm

  • Retroperitoneal hemorrhage

  • Cannula malposition or migration

  • Distal limb ischemia

  • Accidental decannulation

  • Cannula clotting

Circuit-related

  • Hemolysis

  • Pump or oxygenator malfunction or failure

  • Inadequate drainage

Hemorrhagic

  • Cannula site bleeding

  • Intracerebral hemorrhage

  • Retroperitoneal hemorrhage

  • Gastrointestinal hemorrhage

  • Pulmonary hemorrhage

  • Systemic fibrinolysis and coagulopathy

Other

  • Thromboembolism (arterial or venous)

  • Hypoperfusion (end-organ injury including multiple organ failure)

  • LV distension and pulmonary edema (VA support)

  • Cannula site infection

  • Cannula-related bloodstream infection

Logistics for Transport

  • Trained ECLS team members

  • Backup circuit components pre-primed

  • Back up batteries/fully charged power sources

  • Secure all cannulas

  • Transport pack: “clamps, scissors, gloves, fluids, hand ventilation bag, monitor, ventilator, small procedure tray, chest tubes”

  • Full O2 tank(s)

  • Emergency drugs, IV pumps

Another Spoonful

Source

Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation. 2018 Dec;133:108-117. doi: 10.1016/j.resuscitation.2018.10.014. Epub 2018 Oct 15.

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