Biomarkers, Genomics, Physiology in Critically Ill and ECMO Patients (IGNITE)

Patients in end-stage cardiac failure and/or respiratory failure may be started on a rescue therapy known as Extracorporeal Membrane Oxygenation (ECMO). One of the major clinical questions is how to manage the ventilator when patients are on ECMO therapy. Ventilator Induced Lung Injury (VILI) can result from aggressive ventilation of the lung during critical illness. VILI and lung injury such as Acute Respiratory Distress Syndrome (ARDS) can further increase the total body inflammation and stress, this is known as biotrauma. Biotrauma is one of the mechanisms that causes multi-organ failure in critically ill patients. One advantage of ECMO is the ability to greatly reduce the use of the ventilator and thus VILI by taking control of the patient's oxygenation and acid-base status. By minimizing VILI during ECMO we can reduce biotrauma and thus multi-organ failure. Since the optimal ventilator settings for ECMO patients are not known, we plan to study the impact of different ventilator settings during ECMO on patient's physiology and biomarkers of inflammation and injury.

Acute Respiratory Distress Syndrome, Cardiac Failure, Extracorporeal Membrane Oxygenation Complication, Respiratory Failure, Renal Failure, Critical Illness, Pulmonary Disease

The patients ventilator driving pressure will be decreased (as tolerated by the patient) for 2 hours while on extracorporeal membrane oxygenation (ECMO) support.

The patient starts at a ventilator driving pressure of 10-15 cm of H2O as per guidelines for patients on ECMO with ARDS. The driving pressure is then decreased as tolerated for two hours to evaluate the effects on pulmonary, cardiac, and inflammatory biomarkers.

sRAGE is a marker of systemic inflammation and acute lung injury, previously used in studies of ECMO and ARDS.

Inclusion Criteria Patient currently on ECMO (Veno-Venous or Venous-Arterial or Venous-Arterial-Venous) Patient that is a potential ECMO candidate. Exclusion Criteria History of Lung or Cardiac Transplantation Patient is not committed to full support Treating clinician refusal, or unwillingness to commit to controlled ventilation for at least 4-6 hours (if patient is mechanically ventilated) Inability to get informed consent from the patient or surrogate.