Success of an Expanding ECMO Program

A recent article in The Fresno Bee highlights the success of an expanding ECMO program at Valley Children’s Hospital in Fresno, CA.  Valley Children’s has been providing ECMO support for post-op cardiac surgery patients for some time, but have only expanded beyond that population recently.

The article quotes Valley Children’s ECMO Medical director,

 “It requires a lot of expertise to do this right,” Kallas said.”

Valley Children’s has been working very diligently over the last several months to methodically plan for the success of an expanding ECMO program to care for pulmonary ECMO patients in addition to the post-op cardiac patients.  The planning process involved looking to the ELSO guidelines to establish a solid foundation for the ECMO program structure as well as a solid plan for training new ECMO Specialists.  The article says,

“It’s taken a team of people to build the ECMO program at Valley Children’s, said Dr. Harry Kallas, medical director of the ECMO program. The hospital has contracted with an outside company, ECMO Advantage, for consultation to help build the program and train staff, he said.”

Read more here

We are very excited for the success Valley Children’s Hospital is having with their ECMO Program and especially excited for the high quality of care the patients they serve are now able to receive close to home.

 

ECMO Services Team Structure

ECMO services team structure at hospitals across the United States can be complex.  Many institutions starting new programs, growing programs, or needing to adjust their program operations are constantly seeking the best way to structure their ECMO teams to provide the safest, most efficient care to their patients.

ECMO Advantage established a survey in 2014 to evaluate different aspects of ECMO Services Team Structure.  We would like to present the same survey again in 2016 to evaluate how ECMO team structure may be changing with the advances in technology and the rapid expansion of ECMO programs across the United States.

If you would be willing to participate in the survey please complete the survey below.  If you would like to receive the summary results, please complete the last question of the survey with your contact information.  All individual survey results will be kept confidential so that no one will be able to trace an individual result back to an individual person or institution.

ECMO for Pulmonary Hypertension

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
———————
PaO2

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.

Prone Positioning on VV ECMO

Prolonged prone positioning on VV ECMO has recently been reported as beneficial by Levy et al in Annals of Intensive Care.  We presented another blog post in November 2015 related to Prone Positioning on ECMO.

Levy’s report does not show improved outcome directly, but unlike some other reports, he shows that by keeping the VV ECMO patient prone for 24 hours (rather than up to 12 hours as practiced by others) there is an improved ability to effect lung compliance allowing for safely increasing positive pressure ventilation that ultimately allows the patient to wean off of VV ECMO.

In the past, several studies indicated improved oxygenation during prone positioning on ECMO, but there was less indication that patients actually had better outcomes.  In addition, there has been a lot of concern regarding the risks involved in using prone positioning on ECMO.  There seems to be a growing body of evidence that would indicate there is benefit in prone positioning on ECMO that would lead to justified use.

Levy’s report also presents a very nice protocol for how they determine who needs prone positioning on VV ECMO, how to manage the VV ECMO, how to manage the ventilator, and how to wean the patient off of ECMO.

This article also states absence of serious adverse events providing some level of comfort in the safety factor involved in use of prone positioning on VV ECMO.

ECMO Outcomes Updated

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

Prophylactic Antibiotic Use on ECMO

Prophylactic antibiotic use on ECMO has historically been a very common practice.  Many institutions are still practicing prophylactic antibiotic use on ECMO but is it justified?

A review of the ELSO database published in PEDIATRIC CRITICAL CARE MEDICINE in May of 2011 highlighted an overall rate of 11.7% incidence of acquired infections on ECMO from 1998 to 2008.  It’s clear that infections acquired on ECMO are associated with longer ECMO runs, increased ICU stays, and decreased survival rates.  But how do we mitigate the risks of ECMO related to infections?

A recent abstract in ASAIO looked at the use of prophylactic antibiotic use on ECMO and found no evidence of benefit over treating on a case by case basis.  It was suggested that one reason there was no benefit may be because the causative organisms were so diverse that it would be difficult to determine a clear prophylactic strategy.

So as ECMOlogists, what do we do to mitigate the risk of infections acquired on ECMO?  ELSO set out to answer this very complex question in 2008.  The ELSO Task Force on Infectious Disease on ECMO: Diagnosis, Treatment and Prevention, submitted a SUMMARY report on their findings.  In that report they also state lack of evidence for routine prophylactic antibiotic use on ECMO. The summary report provides 8 pages of recommendations related to infection control on ECMO and is well worth a few minutes to review.

 

New 2015 ECPR Recommendations

New 2015 ECPR recommendations can be found buried in the 2015 American Heart Association guidelines for cardiopulmonary resuscitation.

The recommendations are broken down into 3 primary age groups; Neonatal, Pediatric, Adult. Then further distinguished by In Hospital Cardiac Arrest (IHCA) and Out-of-Hospital Cardiac Arrest (OHCA).

Overall general recommendations still state that there is insufficient evidence to recommend ROUTINE use of ECPR across the board.  However, use of ECPR in settings where the technology is readily available and can be rapidly implemented may be considered for “select cardiac arrest patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support.”

Interestingly, there was evidence of improved outcome for the Adult OHCA group.  According to the report, “The use of extracorporeal CPR (ECPR) may allow providers additional time to treat reversible underlying causes of cardiac arrest (eg, acute coronary artery occlusion, pulmonary embolism, refractory ventricular fibrillation, profound hypothermia, cardiac injury, myocarditis, cardiomyopathy, congestive heart failure, drug intoxication) or serve as a bridge for left ventricular assist device implantation or cardiac transplant.”  The evidence indicated improved neurologically intact survival rates for the Adult out-of-hospital cardiac arrest patients supported with ECPR compared to conventional CPR alone.   This may lead to an even more rapidly and wider expansion of the use of ECMO in Emergency Departments across the United States.

Full 2015 AHA Guidelines can be found in the November issue of CIRCULATION

Prone Positioning on ECMO

The recommendation of prone positioning on ECMO may put fear into the heart of the caregiver.  Thoughts of  inadvertent decannulation, extubation, excessive bleeding, kinked ECMO tubing…

A recent article in RESPIRATORY CARE provided a review of 7 prospective studies or case reports that revealed very few complications related to prone positioning on ECMO.  There were no reports of decannulation, inadvertent extubation, or chest tube dislodgment.  They also reported minimal bleeding from cannula site and no evidence of chest tube site bleeding were reported.

Hemodynamic instability was reported by two of the studies. But the episodes were reported as being short and reversible.

So next time someone suggests prone positioning on ECMO, take the time to carefully plan, gather adequate staff support, and approach the process with confidence that it can be done safely!

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