Blood Conservation Practices Impact ECMO

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.

Apnea Test on ECMO

A group in Poland has published a nice summary regarding how to perform an apnea test on ECMO. This discussion has also come up on eclsnet over the years.

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.

ECMO for Endocrine Emergencies?

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!

Ambulatory ECMO Saves Money

Can Ambulatory ECMO save your program money?

A recent article in Respiratory Care indicates Ambulatory ECMO saves money. According to the abstract, a single center produced a 73% reduction in post lung transplant ICU cost and a 22% reduction in overall hospital cost.

Walking ECMO patients is becoming more and more popular as cost savings and improved outcomes are being reported. But how do you safely ambulate a patient on ECMO? Which patients do you chose to ambulate? Do you have policies and procedures in place to ambulate the appropriate ECMO patients? Do you have the right tools to help you safely ambulate ECMO patients? Has your institution properly trained staff to safely ambulate ECMO patients?

There are a couple of companies marketing devices to help improve the ease and safety of ambulation for the ICU patient. Livengood is one.

Clinical Advantage Group ecls cart is another. I am sure there are others out there. As the experiences ambulating ECMO patients increase I am sure we will hear more about this. If your program is ambulating ECMO patients please share your experiences!

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?

Successful Use of the CARDIOHELP system for Neonates

The ECMO Advantage team has completed successful use of the CARDIOHELP system for neonates. After several months of planning, training, reconfiguring circuit, and waiting, the ECMO Advantage team has finally had the opportunity to manage three patients with Maquet’s CARDIOHELP. For the two neonatal patients, we used a modified 1/4 inch circuit adapted to the standard 3/8 inch CARDIOHELP circuit. There were no circuit complications noted in any of the runs.

For the last couple of years as the transition from roller head to centrifugal systems has been underway, there has been some hesitancy by some neonatal ECMO programs to switch due to the general lack of a “neonatal or pediatric” centrifugal circuits.

Several of the individuals that make up the ECMO Advantage Specialist team have had extensive experience with the CARDIOHELP. But this was the first time an ECMO Advantage client that our team supported has used the CARDIOHELP on infants. There of course have been other ECMO programs that have used the CARDIOHELP on neonatal patients. I would encourage them to publish their use so that others can have some insight into this particular application.

Will ExtraCorporeal Support Replace the Ventilator?

Will extracorporeal support replace the ventilator? Traditional ECMO has focused on providing life support for the sickest of the sick once conventional ventilation methods are maximized. But what about using minimally invasive or smaller extracorporeal systems to provide support that would prevent patients from needing to be intubated? Or what if extracorporeal support was used to wean very sick patients off of the ventilator. Is is feasible that we advance the safety and efficacy of extracorporeal support to significantly reduce or even eliminate the need for invasive positive pressure ventilation?

Sklar et al recently published in Intensive Care Medicine June 2015 an abstract indicating the possibility of beneficial use of extracorporeal support for selective patients to either assist in weaning patients off of the ventilator or preventing them from needing invasive positive pressure ventilation. Their abstract also points out that complications of extracorporeal support where not benign.

A company called Alung Technologies has been perfecting a device what they refer to as The Hemolung® RAS to provide Respiratory Dialysis®. As stated on their web site…”A simple, minimally invasive approach to extracorporeal CO2 removal for patients with acute hypercapnic respiratory failure.” Hemolung is not yet FDA approved for open use in the United States. But it has been used in over 75 hospitals in at least 19 countries. It has reportedly been used at least twice in the United States under the FDA’s emergency use regulation.

So maybe the question “Will extracorporeal support replace the ventilator?” isn’t as far fetched as one might think.

Ventilator Management on ECMO

Ventilator Management on ECMO has been a debatable topic for many years. There have been many approaches to managing the sick lung without ECMO support that still create a lot of debate. But when you add in the complexities of the ECMO system and support processes it becomes even more difficult to find consensus on the best way to adjust ventilator settings. A small percentage of ECMO Centers have begun actually extubating patients on ECMO. Some centers manage the ventilator the same as if the patient were not on ECMO. Some centers perform tracheostomy, some just leave an endotracheal tube in even for prolonged ECMO runs that may last for weeks or months.

A recent article found in Europe PubMed Central entitled International survey on the management of mechanical ventilation during extracorporeal membrane oxygenation in adults with severe respiratory failure. highlights the wide variety of thoughts and practices across the globe.

ELSO (Extracorporeal Life Support Organization) has long recommended “rest” ventilator settings while on ECMO. The ELSO H1N1 Specific Supplements to the ELSO General Guidelines during the H1N1 crisis was to:

keep plateau pressures under 25
adjust FiO2 to under 40%
allow SaO2 in the 70’s and 80’s on VV patients
keep hematocrit in normal range to aid with oxygen delivery
early tracheostomy
minimize sedation
perform frequent bronchoscope
consider HFOV at low settings (MAP of 12-14 cmH2O) to help with lung recruitment

The recommendations go on to suggest there is no benefit in attempting recruitment maneuvers until there is some sign of some native gas exchange and aeration on x-ray noted in lung fields. In addition, they mention that some have reported surfactant, prone positioning, fluorocarbon lavage, and percussive ventilation to be beneficial in some patients.

I’m a fan of this approach. I’m a believer in the concept of rest ventilator settings even in the face of complete and total whiteout of the lungs and then allowing TIME for the lungs to begin to recover before forcing recruitment procedures. But there are a lot of smart clinicians out there that take other approaches and have good success as well.

How does your center manage the ventilator on ECMO patients?

“ECMO for ARDS in pediatric and adult trauma patients”…UPDATE FROM SEECMO

ECMO for ARDS in pediatric and adult trauma patients?

Yes – even with CHI (Closed Head Injury) !

ECMO is being used in these patients with great results. As we are all aware, ARDS is a known complication in trauma patients due to both injury and the results of aggressive resuscitation efforts. Even with attentive measures including gentle ventilation (such as low TV) and close monitoring of amounts and types of fluids given, patients frequently develop ARDS. Speakers presented cases of initiating ECMO on these patients, generally at least 48 hours following initial injury. Close attention is paid to bleeding and fibrinolysis. It was suggested to reduce heparin doses managed by maintaining anti Xa goal of 0.1-0.2 and being proactive with the use of Amicar both as a bolus prior to cannulation and a drip for the first 24-48 hours.For management of these patients, the main focus is Rest and Patience. Decrease patient vent settings to rest settings once ECMO flow is achieved.

Be patient with these patients. We, as medical professionals, feel we need to be actively providing treatment for patients that are this ill but we have to remember WE ARE! We have them on ECMO!

And last but not least, no recruitment measures. These measures are causing more damage to already damaged and inflamed lungs.

Other treatments being preformed are daily bronchoscopy for wash outs and evaluation, decreased sedation to allow for accurate neuro exams as well as monitor for seizures and alertness. Head CT is performed after 48 hours for evaluation of new or old bleeding.

Many centers are having great outcomes on pediatric and adult trauma patients with ARDS.

As reported by Amanda Smith RN, ECMO Advantage Specialist