ECMO for Endocrine Emergencies?

lightning storm

How many of you think ECMO for Endocrine Emergencies?  Have a patient with thyroid storm…think ECMO? Diabetic ketoacidosis…think ECMO?? Pheochromocytoma crisis…ECMO???

A recent report from  Chao, A. et al. Highlighting indication of extracorporeal membrane oxygenation in endocrine emergencies. Sci. Rep. 5, 13361; doi: 10.1038/srep13361 (2015).
discusses several cases of endocrine emergencies that have been successfully supported with ECMO.

This report identifies that endocrine emergencies can often present as other diseases such as acute myocardial infarction (AMI) or other causes of refractory shock.  If the cause of the shock can be quickly and accurately determined, then it seems there can be better chance of survival by treating the appropriate underlying disease process.thyroid storm pic

They concluded that “ECMO support can be clinically useful in endocrine emergencies. The screening of endocrine diseases should be considered during the resuscitation of patients with refractory circulatory shock.”

Endocrine diseases may not be at the top of your list for consideration when you have a patient crashing and needing ECMO.  But early recognition and treatment of endocrine emergencies is key to improved outcomes.

So next time you have a severe DKA or thyroid storm patient in cardiopulmonary collapse…maybe ECMO should be considered!

ECPR Improves Patient Survival

A recent article in the Journal of Thoracic and Cardiovascular Surgery states that ECPR improves patient survival from <20% to 30% with 100% full neurological recovery.

In addition, ECPR made successful organ donation possible for some of the patients that did not survive.
ECPR is the process of initiating ECMO for the purpose of or during the process of cardiopulmonary resuscitation.  There are still a significant number of ECMO centers that do not formally provide this service.  Reasons for not providing ECPR may include a general belief that it does not provide any or enough benefit to justify it’s use, or simply due to the fact that they do not have staff and equipment readily available to respond in the time frame required to make the procedure beneficial.

There have been other articles and reports from single institutions in the past that indicate up to a 55% survival with good neurological outcome in pediatric patients who were supported with ECMO during the course of CPR. In many of the most successful cases, total body hypothermia was used in conjunction with the ECMO support.  ELSO (Extracorporeal LIfe Support Organization) has published Guidelines for ECPR Cases.  Hypothermia is also a part of the ELSO recommendations.

Is ECPR a tool your ECMO Programs uses?

 

 

D-Dimer Monitoring for ECMO Coagulopathy Management…One More Piece of the Puzzle?

Could D-dimer monitoring for ECMO coagulation management be a critical piece of the puzzle? The ability to keep a circuit from clotting off  while at the same time not allowing the patient to bleed to death has been a battle in the extracorporeal world for many years.  In an  I listed my top 5 lab tests to assist with anticoagulation for ECMO patients.  D-dimer was not one of them.  But should it be?

This may encourage me to add it to the list as a critical piece of the puzzle.
Dornia, C., Philipp, A., Bauer, S., Stroszczynski, C., Schreyer, A. G., Müller, T., Koehl, G. E. and Lehle, K. (2015), D-dimers Are a Predictor of Clot Volume Inside Membrane Oxygenators During Extracorporeal Membrane Oxygenation. Artificial Organs. doi: 10.1111/aor.12460

The case for D-dimer monitoring is a tricky one.  This article mentions that increasing D-dimer in the face of unexplained causes could very well be due to clotting in the oxygenator.  It is important to rule out other causes.  D-dimer may significantly increase due to clots in the cannula, in a CRRT filter or CRRT device added into the ECMO circuit, pulmonary embolus, deep vein thrombosis, or other areas of bleeding that has formed a clot and begun to break down.  D-dimer is actually an indicator of clot degradation.  It’s a measure of the product that is produced when a clot breaks down.  D-dimer test is commonly used when pulmonary embolism or deep vein thrombosis is suspect.

In a recent ECMO case, a sharp rise in D-dimer essay was reported shortly after adding a CRRT system to the ECMO circuit.  It was noted that the CRRT lines were attached to the ECMO circuit using clave stop-cocks.  The clave stop-cocks were replaced with a high flow adaptor and the  D-dimer essays decreased markedly.  This highlights the need to rule out other explainable causes of increasing D-dimer before jumping to changing out the oxygenator.  But it also strengthens the case for monitoring D-dimer essays to shed light on problems in the ECMO circuit that may be fixed before creating complete “circuit DIC” type complications. It can also highlight undiagnosed bleeding problems within the patient.

Will D-dimer monitoring “fix” all our ECMO anticoagulation issues?  No.  But could it be an important part of the puzzle to help us see the whole picture as we care for our very complex ECMO patients?  It’s worth considering.

 

Moving ECMO from “Last Ditch Effort” to ECMO as Mode of Support to Improve Quality of Life

As with almost everything in healthcare, weighing the benefits of a therapy or support vs. the adverse effects of that therapy or support can result in widely variable opinions.  I think most involved in ECMO support would agree that historically, many institutions too often use ECMO as a “last ditch effort”.  Often we hear doctors tell families, “If we don’t put your loved on on ECMO now, they will die.”  Or, “This is their only chance of surviving.”  Or, “We have done everything we can do. The only other thing we have to try is ECMO.”   And admittedly there is a subset of patients where this may be the case.However, I’d like to encourage you to consider that ECMO/ECLS should be more readily considered as a frontline life support modality initiated early in a disease process for the purpose of improving quality of life outcomes rather than just to attempt to save a life.

I recently came across this pair of opposing view editorials in the March 2015 edition of Intensive Care Medicine.

Continue reading “Moving ECMO from “Last Ditch Effort” to ECMO as Mode of Support to Improve Quality of Life”

ECMO Outcomes

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. The most recent abstract I came across 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
 

Perforation During ECMO Cannulation

Perforation During ECMO Cannulation is a known risk that must be mitigated.

A Recent publication in the Journal of Cardiac Surgery from the Children’s Hospital of Philadelphia describes the importance of using echocardiography in placement of the Avalon Elite Bicaval Dual Lumen Cannula in neonates for VV ECMO. The authors share some very important points in their conclusion:

  • “Fluid shifts are frequent after initiation of ECMO and are a common cause of systemic hypotension and impaired venous return to the pump, events that typically respond to fluid boluses. Because a slow developing cardiac tamponade causes the same signs and also responds (initially) to fluid boluses, it is somewhat difficult to clinically distinguish between the two at the early stages of development.”
  • “As illustrated by our report, the echocardiography at the time of cannulation may fail to detect minor cardiovascular injuries.”
  • “Because of this and the known potential risk of cardiovascular perforation, we believe that it is critical to perform routine surveillance echocardiography within the first hours after Avalon Elite cannula placement, and to have a low threshold to repeat the study if the venous return to the pump becomes impaired at any time.”

 

Cardiovascular Perforation During Placement of an Avalon Elitew Bicaval Dual Lumen ECMO Cannula in a Newborn by Matias E. Czerwonko, M.D., Maria V. Fraga, M.D., David J. Goldberg, M.D., Holly L. Hedrick, and Pablo Laje, M.D Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA doi: 10.1111/jocs.12507 (J Card Surg 2014;XX:1–3)

Synopisis: The Authors present the case of a 19-day-old term male newborn with profound respiratory failure secondary to adenovirus that met criteria for VV-ECMO. The cannulation was done at the bedside in the Neonatal Intensive Care Unit under direct transthoracic echocardiographic guidance. The right IJV was dissected and the lumen accessed with the 18-gauge needle provided by the manufacturer. The 0.038‘‘ guidewire provided by the manufacturer was threaded toward the IVC under live echocardiographic guidance. The IVC was markedly collapsed. Despite multiple maneuvers, the guidewire could not reach the IVC. We kept the guidewire in the right atrium (RA) and threaded the cannula with the introducer. Once the cannula and introducer reached the RA, the guidewire was retrieved. After multiple maneuvers under direct echocardiography, the tip of the introducer reached the IVC and the cannula was threaded forward. At the end of the procedure the cannula was properly placed, full ECMO flow was achieved without delay, and no recirculation was observed. Over the course of the following hours, the patient’s mean arterial blood pressure gradually decreased. This was attributed to fluid shifts, as it responded to fluid boluses. Venous return to the pump became intermittently impaired. Eight hours postcannulation, the patient went into asystolic arrest. The ECMO circuit was clamped immediately and resuscitation maneuvers initiated. An echocardiogram done within minutes of the arrest showed cardiac tamponade and the heart in asystole. A subxyphoid pericardial window was done; however, the heart remained in asystole. The patient expired 40minutes after the cardiac arrest. The autopsy revealed a pinhole perforation at the posterior aspect of the intrapericardial segment of the IVC. Additionally, the autopsy revealed alveolar hemorrhage and severe acute bronchopneumonia.

The efficacy of a bicaval ECMO cannula is dependent upon precise placement. In newborns, this represents a challenge because minimal cannula movements can result in suboptimal positioning. The use of transthoracic echocardiography is critical at the time of placement to ensure that: (i) the guidewire reaches the IVC; (ii) the distal port of the cannula remains in the lumen of the IVC once the guidewire is retrieved; and (iii) the infusion port is precisely facing the tricuspid valve. Not using any form of imaging guidance is likely to result in malposition of the cannula. Newborns with profound respiratory failure are usually on high-pressure ventilating settings, which can produce overexpansion of the lungs, collapse of the right atrium, mediastinal shift, and distortion of the IVC/RA junction. Placing the guidewire into the IVC can be challenging in newborns, even with the aid of echocardiography.

Figure 1. Echocardiographic view of the right atrium/inferior vena cava at the time of cannula placement. The suprahepatic veins are seen. The interior vena cava is collapsed.

Take home points:

  • “Fluid shifts are frequent after initiation of ECMO and are a common cause of systemic hypotension and impaired venous return to the pump, events that typically respond to fluid boluses. Because a slow developing cardiac tamponade causes the same signs and also responds (initially) to fluid boluses, it is somewhat difficult to clinically distinguish between the two at the early stages of development.”
  • “As illustrated by our report, the echocardiography at the time of cannulation may fail to detect minor cardiovascular injuries.”
  • “Because of this and the known potential risk of cardiovascular perforation, we believe that it is critical to perform routine surveillance echocardiography within the first hours after Avalon Elite1 cannula placement, and to have a low threshold to repeat the study if the venous return to the pump becomes impaired at any time.”

 

 

ECLS Cannulation Technical Updates

The discussions about ECLS cannulation may involve many different issues. Who may cannulate in your institution? This publication offers data to say that it may be done safely and efficaciously with imaging support by intensivists in an ICU environment. Percutaneous Cannulation for Extracorporeal Membrane Oxygenation by Intensivists: A Retrospective Single-Institution Case Series

Conrad, Steven A. MD, PhD, MCCM; Grier, Laurie R. MD, FCCM; Scott, L. Keith MD, FCCM; Green, Rebecca MD; Jordan, Mary RN, MSN. The authors describe their experience with “One hundred ninety cannulations with cannula sizes from size 12 to 31F were performed by four intensivists in 100 subjects. Twenty-three were arterial (12-16F) and 167 were venous (12-31F). “They list the use of imaging guidance for their patients including pre-insertion ultrasound, fluoroscopy, and the use of ultrasound guidance during insertion of the cannulas. The authors conclude that “Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists can be performed with a high rate of success and a low rate of complications when accompanied by imaging support. “How do you cannulate? The typical thought process is that “bigger is better”. Perhaps with arterial access, that may not hold true. This paper describe their experience with two groups of patients: one with varying larger sizes of arterial cannulas and the second using the 15fr arterial cannula. They report clinical success and a decrease in bleeding occurrence in the group using the smaller size return cannula. Feasibility of Smaller Arterial Cannulas in Veno-arterial Extracorporeal Membrane Oxygenation

Hiroo Takayama, MD, PhD; Elissa Landes, MD; Lauren Truby, BS; Kevin Fujita, BS; Ajay J. Kirtane, MD, SM; Linda Mongero, CCP; Melana Yuzefpolskaya, MD; Paolo C. Colombo, MD; Ulrich P. Jorde, MD; Paul A. Kurlanski, MD; Koji Takeda, MD, PhD; Yoshifumi Naka, MD, PhD  Article Review by: M. Heard

Recirculation During Veno-Venous Extra-Corporeal Membrane Oxygenation – A Simulation Study

Speaking of Simulation – it is also useful in the investigation of situations that are not easily defined in patients.

Broman M1, Frenckner B, Bjällmark A, Broomé M.
Veno-venous ECMO is indicated in reversible life-threatening respiratory failure without life-threatening circulatory failure. Recirculation of oxygenated blood in the ECMO circuit decreases efficiency of patient oxygen delivery but is difficult to measure. We seek to identify and quantify some of the factors responsible for recirculation in a simulation model and compare with clinical data.

RBC Transfusion in Pediatric Patients Supported with Extracorporeal Membrane Oxygenation: Is There an Impact on Tissue Oxygenation?

Richard T. MD1; Irby, Katherine MD1; Ward, Rebekah M. BS1; Tang, Xinyu PhD1; McKamie, Wes RRT, CCP2; Prodhan, Parthak MD1; Corwin, Howard L. MD3

This article captures a unique aspect to the old question: What is the ‘right’ level to maintain a patient’s hemoglobin?

As clinicians, we can be our own worst enemy. This center quantified their blood testing at 75mL/kg, and after removing the factor of circuit blood priming, cardiac patients were transfused 529 mL/kg and non-cardiac patients were transfused 74 mL/kg.

Most importantly, the authors report the affect of the RBC transfusions on tissue oxygenation as measured by an SvO2 or cerebral near-infrared spectroscopy.

“Most transfusions resulted in no significant change in either SvO2 or cerebral near-infrared spectroscopy. Only 5% of transfusions administered (31/617) resulted in an increase in SvO2 of more than 5%, whereas an increase in cerebral near-infrared spectroscopy of more than 5 was only observed in 9% of transfusions (53/617). Most transfusions (73%) were administered at a time when the pretransfusion SvO2 was more than 70%.”

The authors conclude that:

1. “In the majority of events, RBC transfusion did not significantly alter global tissue oxygenation, as assessed by changes in SvO2 and cerebral near-infrared spectroscopy.”
2. “Most transfusions were administered at a time at which the patient did not appear to be oxygen delivery dependent according to global measures of tissue oxygenation.”

An unstated conclusion may be inferred as well. The amount of blood testing that is performed on ECMO is the major contributor to the need for RBC transfusion. Can we, as clinicians, decrease the amount of testing? Can we rely on non-invasive monitoring? Has your center reviewed its testing protocols lately?

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