Extracorporeal Life Support and Extracorporeal Membrane Oxygenation

Extracorporeal life support (ECLS) are technologies that may be applied to support acute or chronic refractory cardiac and/or respiratory failure when conventional critical care cannot fulfill patient’s need. Examples of ECLS are mechanical cardiac support devices for bridge to recovery or transplant, or, as in ECMO, the addition of a gas exchanger to provide lung support or combined cardiorespiratory support. Our research group is led by Lars Mikael Broman.

The technology may be applied in situations with cardiopulmonary resuscitation, andlow flow support may be offered for carbon dioxide removal.

In all these methods, larger cannulae are implanted in larger vessels or the cardiac chambers of the patient. Hence, treatment carries high risk for bleeding, infection and embolization in the patient. Support may be offered in a wide range of time, from a few hours to months (prolonged ECMO).

Projects

Integrative human physiology and interaction with technologies used in extracorporeal life support (ECLS) 

The aims of this project are to increase understanding and to improve devices and methods for extracorporeal membrane oxygenation (ECMO) to reduce complications and improve outcome.

The focus is both on the macro and microscopic levels concerning the interaction of native and extracorporeal flow in the patient when ECMO is applied. Anticoagulation is regularly used in ECMO treatment to prevent clot formation. Clots in the circuit may halt perfusion or lead to thromboembolic events in the patient. Heparin is the most used anticoagulant (95% of centers worldwide). However, reducing the clot tendency increases the bleeding risk in the patient. Thus, in daily clinical practice there is a constant evaluation of the delicate balance between coagulation and anticoagulation. The most common severe adverse events are cerebral bleedings (ICH) or thromboembolic events (ischemic stroke). These are in many cases lethal. 

Both risk factors for ICH and ischemic stroke has been and is continued under investigation. We also evaluate biomarkers for earlier detection and platelet function is a field we aim to investigate. On the macroscopic level recirculation phenomena in venovenous ECMO is investigated both in a clinical perspective but also in ex-vivo models. Further, device flow characteristics are studied for increased knowledge to improve cannulae, connector and pump design for better treatment, i.e., reduced biotrauma and coagulation/inflammation activation in the patient. For this, resolution is increased, and we study each component’s influence on flow properties using several methods in collaboration with the Royal Institute of Technology (KTH), Department of Neuroscience, and ECMO centers abroad. Computer fluid dynamics (CFD), high speed filming, mathematical models and methods with fluorescent dies are used in several projects.

  • Cerebral bleeding and thromboembolic complications in ECMO patients
  • Feasibility of biomarkers for earlier detection of intracranial events in patients on extracorporeal membrane oxygenation
  • Recirculation in veno-venous (VV) extracorporeal membrane oxygenation (ECMO) in vivo and in ex-vivo ECMO flow simulation model
  • Ex-vivo investigations of ECMO components for improved clinical treatment
  • In-vitro study of the impact of left ventricular assist devices loading on mechanical performance

Clinical perspectives on septic syndromes, right ventricular failure and lung interaction, inflammation: the role for extracorporeal membrane oxygenation

 

Transport on extracorporeal membrane oxygenation

Sepsis is the most common diagnosis in adults and children submitted to intensive care worldwide. It is also the most common cause for death from infection, accounting for as many deaths in the U.S. as myocardial infarction.

At ECMO Centre Karolinska septic shock is the most common cause for ECMO in the adult and pediatric populations. In neonates ECMO is nowadays more or less acknowledged as standard of treatment in the most severe cases.

However, sepsis in adults and pediatric patients is still controversial in many centers but acceptance is slowly increasing. Patients above 65 years of age is even more questioned to be offered ECMO support, not only in sepsis but also for other less complex diagnoses, e.g. severe pneumonia, acute respiratory distress syndrome, etc. 

Before the H1N1 pandemic in 2009, more than 10% of all adult patients ever treated on ECMO had been treated at our center in Stockholm. Thus, ECMO Centre Karolinska is one of the most experienced units in the world in adult respiratory ECMO.

Besides prospective studies, retrospective investigations from our database on outcome and quality assurance are conducted regarding clinical perspectives but also concerning national and international inter/hospital transports on ECMO.

  • Infectious disease follow-up of ECMO patients with septic syndromes
  • Adrenal cortical response during Extracorporeal membrane oxygenation in children and adults admitted to Intensive Care.
  • Extracorporeal membrane oxygenation in different ages> neonatal, pediatric, adult, and the elderly.
  • Refractory septic shock in adults with septic cardiac failure 
  • Conversion from venovenous to venoarterial extracorporeal membrane oxygenation in adults.
  • The role of lung blood flow on the prognosis in severe pulmonary failure and extracorporeal membrane oxygenation.

Group members

Lars Mikael Broman

Group leader, Senior Consultant Intensivist and Anesthetist, ECMO specialist ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden

Lars Falk

Doctoral student

Francesco Fiusco

Doctoral student

Linne Flow, BioMEx, Royal institute of Technology (KTH)

Urban Fläring

Affiliated to research

Björn Frenckner

Professor (Pediatric surgery)

Gabriel Fuchs

Doctoral student

Jan Hultman

Associate Professor, supervisor

Julienne Lemètayer

Doctoral student

Linne Flow, BioMEx, Royal institute of Technology (KTH)

Mattias Lindfors

Doctoral student

Carmen Mesas Burgos

Affiliated to research

Ivan Kohn

Lisa Prahl Wittberg

Associate Professor

Federico Rorro

Doctoral student

Linne Flow, BioMEx, Royal institute of Technology (KTH)

Eddie Weitzberg

Professor, co-supervisor

Financial support

  • Vetenskapsrådet
  • The Royal Institute of Technology (KTH)
  • Stockholm City Council

Selected publications

International Survey on Extracorporeal Membrane Oxygenation Transport.
Broman LM, Dirnberger DR, Malfertheiner MV, Aokage T, Morberg P, Næsheim T, Pappalardo F, Di Nardo M, Preston T, Burrell AJC, Daly I, Harvey C, Mason P, Philipp A, Bartlett RH, Lynch W, Belliato M, Taccone FS
ASAIO J 2020 02;66(2):214-225

Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study.
Lunz D, Calabrò L, Belliato M, Contri E, Broman LM, Scandroglio AM, Patricio D, Malfertheiner M, Creteur J, Philipp A, Taccone FS, Pappalardo F. 
Intensive Care Med. 2020 Feb 12. doi: 10.1007/s00134-020-05926-6. [Epub ahead of print]

Serial S100B Sampling Detects Intracranial Lesion Development in Patients on Extracorporeal Membrane Oxygenation.
Fletcher-Sandersjöö A, Lindblad C, Thelin EP, Bartek J, Sallisalmi M, Elmi-Terander A, Svensson M, Bellander BM, Broman LM
Front Neurol 2019 ;10():512

Extracorporeal Membrane Oxygenation for Septic Shock.
Falk L, Hultman J, Broman LM
Crit Care Med 2019 08;47(8):1097-1105

The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support - a position paper of the Extracorporeal Life Support Organization.
Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Bembea MM, Barbaro RP, Diaz R, Grazioli L, Pellegrino V, Mendonca MH, Brodie D, Fan E, Bartlett RH, McMullan MM, Conrad SA
Crit Care 2019 Feb;23(1):36

Flow-induced platelet activation in components of the extracorporeal membrane oxygenation circuit.
Fuchs G, Berg N, Broman LM, Prahl Wittberg L
Sci Rep 2018 09;8(1):13985

The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization.
Conrad SA, Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Grazioli L, Barbaro RP, McMullan DM, Pellegrino V, Brodie D, Bembea MM, Fan E, Mendonca M, Diaz R, Bartlett RH
Am J Respir Crit Care Med 2018 08;198(4):447-451

A Single-Center Experience of 900 Interhospital Transports on Extracorporeal Membrane Oxygenation.
Fletcher-Sandersjöö A, Frenckner B, Broman M
Ann Thorac Surg 2019 01;107(1):119-127

Extracorporeal CO2 removal (ECCO2R) in critically ill patients: A systematic review.
Taccone FS, Malfertheiner MV, Ferrari F, Di Nardo M, Swol J, Broman LM, Vercaemst L, Barrett N, Pappalardo F, Belohlavek J, Mueller T, Lorusso R, Belliato M. 
Minerva Anestesiol. 2017: 83(7), 762-772. 

The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation.
Broman LM, Holzgraefe B, Palmér K, Frenckner B
Crit Care 2015 Jul;19():278

    Contact

    Lars Mikael Broman

    Affiliated to research