ECMO is a Team Sport
Between 2010 and 2017, the number of ECMO cases and centers nearly doubled according to the ELSO registry report published January 2018. Research has shown that patient outcomes (survival rate and complications) are closely related to the volume of cases at individual centers. In this retrospective, single-institution cohort study at Massachusetts General Hospital in Boston, the institution of a formal multidisciplinary ECMO team resulted in a 14.6% increase in survival to discharge. Prior to the establishment of the formal ECMO team, all adult patients that were cannulated for ECMO, either VV or VA, remained in the ICU that they originated in (CCU, SICU, CSICU, and MICU).
Following the establishment of the formal team, all adult VV ECMO patients received care in the MICU and all adult VA ECMO patients received care in the CSICU. This allowed specific protocols and guidelines to be established and managed in a comprehensive fashion. The formal team consisted of cardiac surgeons, cardiac anesthesiologists, intensivists, cardiologists, ICU nursing staff, perfusionists, respiratory therapists, nutritionists, physical and occupational therapists, and an ethics committee member.
ECMO truly is a ‘team sport’ and should be approached in this manner to improve clinical outcomes and team communication.
Way to go, MGH ECMO team!
Submitted by Jeliene LaRocque RRT-NPS, RRT-ACCS, ECMO Advantage Specialist
As extracorporeal modalities expand into nontraditional support of critically ill patients, the question of “Will Extracorporeal Modalities Replace Conventional Ventilators?” becomes a valid and interesting thought.
A recent article discussed ECCO2R as an Adjunct to Ventilation in ARDS. Extracorporeal CO2 removal, also referred to as respiratory dialysis, has demonstrated the feasibility of its use as an adjunct to ultra-lung protective ventilation (3-4 ml/kg IBW) in ARDS patients. At blood flows of 450 ml/min to 1000 ml/min, ECCO2R assists in the removal of CO2, thereby allowing the clinician to reduce excessive ventilator pressures that contribute to ventilator induced lung injury. The multicenter, international, randomized control trial SUPERNOVA denoted a 73% survival rate at 28 days and a 62% survival rate at hospital discharge for those enrolled. While consideration must be given to documented and potential serious adverse events associated with ECCO2R (brain hemorrhage, pneumothorax), it appears to be a viable adjunct therapy for the treatment of profound respiratory acidosis in ARDS patients. Full article can be found here.
Post submitted by: Jeliene LaRocque RRT-NPS, RRT-ACCS, ECMO Advantage Specialist
We are often faced with institutions trying to determine if it is worth developing a formal ECMO Program. Many institutions have been “doing ECMO” for many years but are now considering formalizing their program and processes. But the expense to do this could be significant. So is it worth the effort and expense? One could argue that if your outcomes are good the way you have always been doing it, then why change? Some institutions recognize that maybe their outcomes aren’t what they want them to be and are committed to improving those outcomes through formalizing their ECMO program.
So what is involved in “formalizing” an ECMO Program that makes such a difference? I would submit that there are several important factors that will significantly improve your ECMO patient care by formalizing your ECMO program. ELSO (Extracorporeal Life Support Organization) has published a set of guidelines that highlight how to create a formal ECMO program and achieve the benefit of a formal program. ECMO Advantage has assisted many institutions walk through the process of building a Formal ECMO Program. We have seen the many benefits from the result of the processes involved in creating a formal program to include:
- Formal hospital administration understanding and support for resources required for an ECMO program
- Formal development and acceptance of Inclusion/Exclusion Criteria
- Formal development and acceptance of ECMO Policies and Procedures
- Formal assignment of ECMO Leadership roles such as ECMO Medical Director(s), ECMO Coordinator(s), ECMO Specialists
- Development of a Multidisciplinary ECMO Team
- Formal ECMO Training for all healthcare professionals caring for the ECMO patient
Recently, I came across this article entitled The effect of multidisciplinary extracorporeal membrane oxygenation team on clinical outcomes in patients with severe acute respiratory failure published in the Annals of Intensive Care, Dec 2018. Na, S.J., Chung, C.R., Choi, H.J. et al. Ann. Intensive Care (2018) 8: 31. https://doi.org/10.1186/s13613-018-0375-9. The article reports a significant benefit in patient outcomes after formalizing their multidisciplinary ECMO team.
We would encourage institutions to take the time and effort to formalize their ECMO Program and allow their patients the Advantage of a formal program with formal structure and formal training as described in the ELSO Guidelines. ECMO Advantage would be honored to help your institution step through this process in a timely and cost-effective manner allowing your team the ability to offer your patients the ECMO Advantage. Contact us if we can be of assistance!
New GUIDELINES from a joint effort of the American Heart Association and American Thoracic Society specify the use of ECMO for Pulmonary Hypertension.
For many years ECMOlogists have utilized ECMO for Pulmonary Hypertension of both the newborn as well as pediatric patients. Some have utilized ECMO for Pulmonary Hypertension in adults as well. For the newborn with PPHN there has been fairly consistent use of ECMO. But the question of which patient and disease process to use ECMO for related to Pulmonary Hypertension can often lead to significant debate. This is especially true for the Diaphragmatic Hernia patient.
The new “First Guidelines Issued for Children” suggest use of ECMO for Pulmonary Hypertension in the diaphragmatic hernia patient with severe pulmonary hypertension that is not responding to medical therapy. The full text report also specifies use of ECMO for Pulmonary Hypertension in the newborn PPHN population. It also specifies use of NO for this patient population when their OI (Oxygen Index) reaches 25.
Oxygen Index can easily be calculated by using this formula.
FiO2 x MAP x 100
Take a few minutes to read through the entire full text report for a nice comprehensive review of the primary issues related to Pulmonary Hypertension in Children and how it differs from the issues seen in Adult patients.
ECMO Outcomes Updated Dec 2015
Are ECMO outcomes dependent on the number of ECMO patients supported at your institution? Does it really matter how many ECMO patients your program supports? Do patients suffer by being on ECMO at smaller ECMO programs? There have been a couple of publications recently suggesting that it does matter. A recent abstract I came across a few months ago has an interesting twist to it. The results summary would make it sound like there is significant benefit to a patient on ECMO if they are supported at a high volume center. But if you read the message carefully, you will see that there was NO SIGNIFICANT SURVIVAL BENEFIT for the pediatric age group for the period of study between 1989-2013. When broken down into relative data from the time period of 2008-2013, there was NO SIGNIFICANT SURVIVAL BENEFIT for the neonatal nor pediatric group. Only the Adult group was implicated in improved survival in “larger” ECMO programs (those who supported > 30 ECMO patients per year) compared to the smallest ECMO Programs (those supporting < 6 ECMO patients per year). It’s also interesting to note that they didn’t report on the Adult ECMO Programs supporting between 6 and 30 patients per year.
More recently an article was presented in Pediatric Critical Care Medicine:November 2015 – Volume 16 – Issue 9 – p 868–874 that looks specifically at Cardiac patients <16 years old supported with ECMO either before or after surgery. The conclusion from this group states: “We demonstrated no relationship between extracorporeal membrane oxygenation center volume and mortality. Further analyses are needed to evaluate this relationship.”
So what really makes the difference in the care that ECMO patients receive that allow them to survive to home?
The primary purpose of ECMO Advantage is to help raise the level of ECMO support to the absolute highest quality no matter how small or large your ECMO program is. Our primary objective is to help Hospitals develop ECMO Programs that have the proper structure, training, education, expertise and quality to safely and effectively support patients on ECMO and return them home to their families.
If your outcomes are not as good as they should be, contact us. We have a proven track record assisting both new and experienced ECMO programs develop into high quality programs with better then ELSO average survival to home.
Randy Bartilson, President of ECMO Advantage – Serving the ExtraCorporeal Community
A recent article in the Annals of Thoracic Surgery highlights successful support of Adult Myocarditis using VA ECMO. Use of Adult ECMO has significantly increased over the last few years. The benefits of using ECMO in various adult populations are still being proven.
This article provides a nice overview of successful use for this special diagnostic group.
Should new blood conservation practices impact ECMO management? Over the last few years we have seen multiple benefits from blood conservation measures across the OR and ICU environments. But should we employ these measures to ECMO management?
For many years, and still today, many ECMO order sets will direct caregivers to treat a HCT of < 40 or even 45 with PRBC’s. Some ECMO programs have lowered the treatment threshold to a HCT of 35. But how many of you would consider lowering that threshold to 30? 25? How about 21?
Ok, we all have sat through the lectures on ECMO Physiology and understand that one of our primary goals with ECMO is to deliver oxygen to the tissue and organs. And one of the key aspects of oxygen delivery is Hgb, right. So it makes perfect sense to pump the Hgb levels up to give us more “boxcars” to carry the oxygen more efficiently. And we have all seen that to be effective for many years. But what if adding those boxcars is actually contributing to the problems we have with coagulopathy, pulmonary edema, fluid shifts, ARDS, infection, compliment reaction? What if the additional transfusions are actually extending the time a patient needs to be on ECMO, or mechanically ventilated, or even decreasing their chance of survival?
This article in the Korean Journal of Critical Care Medicine provides a nice discussion of the potential for how blood conservation practices impact ECMO.
Is there a role for blood conservation practices in the management of ECMO patients? I would encourage each ECMO program to re-evaluate their standard ECMO orders sets and consider how blood conservation management practices impact their ECMO patient management.
In order to perform a valid apnea test it is generally accepted that the patient’s CO2 must rise above 60 mm Hg (or increase by 20 mmHg above baseline) with a correlating decrease in pH before the body has a chance to compensate metabolically. This can be challenging on ECMO, especially V-A ECMO.
The suggested way to accomplish this on VV ECMO is simply to turn down the ECMO Sweep flow until the CO2 rises to the desired level. The ventilator rate can also be turned down to 0 as applicable. This can often be obtained while still maintaining adequate oxygenation levels. VA ECMO can be a little more challenging as cardiac output and oxygenation may be more dependent upon the VA ECMO flow. In either VV or VA, if there is difficulty getting CO2 to rise without severely impacting oxygenation, then supplemental CO2 may be bled into the ECMO Sweep flow to drive the CO2 up while still maintaining adequate oxygenation to the patient.
The Apnea test on ECMO is a test that you never want to have to do, but it’s important to be able to achieve this assessment on ECMO when needed.