E-CPR: The Next Frontier in Extracorporeal Life Support?

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Extracorporeal Membrane Oxygenation used in the face of cardiac and/or respiratory arrest is not new. However, as ECLS systems become smaller, easier to use and widely available, the expansion of the therapy is inevitable. The challenge will be to decide when and where to initiate E-CPR.The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital in Melbourne, Australia. Their experience was recently published in Resuscitation. The CHEER Trial

The results of the study are encouraging as compared to previously published reports. However, caution must be undertaken by centers that read the article and decide that their center should have an E-CPR program. The authors very carefully describe the use of mechanical chest compressions (Autopulse™) and iced saline lavage as well as the use of a team of expert physicians and nurses trained in ECMO. They also comment on the duration of time to place on ECMO as being a significant factor in survival. Their protocol involved emergency services provided in the field to assure that the protocol was started as soon as possible. The authors also describe preventive management of lower limb ischemia with placement of a backflow cannula.

Their results are encouraging for both outside hospital cardiac arrest and in hospital cardiac arrest patients, and by all accounts should be considered when decisions about starting an E-CPR program are being made. Nevertheless, purchasing an ECLS blood pump and having the initiative is not enough. The significant factor that most institutions fail to consider is the staff. If the team is not adequately trained and experienced, the availability of E-CPR may not contribute to increased survival for their patients.

Training physicians to insert cannulas and ECMO Specialists to initiate and manage the ECLS system is not an easy task. If the team is new to ECMO as a therapy, the groundwork doesn’t even exist yet for building these new skills upon.

Additionally, the increased burden on resources with initiating an E-CPR program can be overwhelming. Most ECMO centers have a limited number of ECLS Systems and staff who are trained to care for these patients. How do you offer a new service to a high-risk population and assure that you are not depriving other populations of the service? How many patients code in your institution on a daily basis? Do you offer E-CPR to every one? Institutions need to have in place appropriate protocols and procedures for patient selection and use of ECMO in all populations.

E-CPR is a valuable tool. It most definitely will save lives. Assure that your team is approaching this ‘new frontier’ with wisdom and the education to give your patients the best possible outcomes.

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.

 

ECMO and Consent: The Importance of Communication

Consent and Disclosure in Pediatric Heart Surgery

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The trust that families give healthcare workers is immense. To break that trust by lack of communication is heart breaking.

The healthcare community should read this story, perhaps this entire book. We are given a great charge to take care of our patients, and by extension, their families. We have a responsibility to provide accurate, on-time information and to assure that the information is understood clearly.

This effort begins with informed consent. Patients and families should be told the unvarnished truth about their condition. They should also be told the specifics about the procedures or treatments that may or may not fix it. The chance that something could go wrong should also be discussed in clear terms.

Informed consent in ECLS is difficult. Do you obtain consent for every cardiac procedure just in case the patient arrests? Do you obtain consent for every intensive care patient for the potential that there may be a life-threatening event that requires extracorporeal life support?

Even more difficult is the obtaining of consent during duress. Asking for permission to use ECMO as a life saving technology because a parent’s child is at risk of dying (sometimes eminently) almost precludes the answer from being no. Does that parent hear the risk of bleeding or mechanical failure? Do the parents understand that the chance that the lung or cardiac failure may not be reversible and that the clinicians may have to stop ECMO at some point? Probably not. Consent in ECLS is a continuous conversation. Obtaining a signature on a form does not end the conversation. Discussion must be held at least every day so that the family understands the condition of the patient and how things are going. Any untoward complication must be explained in layman’s terms. Employing ancillary personnel, such as chaplaincy, social services or palliative care, to assist in clarifying terms is very important. Hearing things in many ways helps to build understanding and trust.

There are no easy answers regarding conversations and obtaining consent. Perhaps this topic should be discussed in ethics committee or the ECMO supervisory group in your institution. Do you have a separate ECMO consent or do you just fill in the blanks on a generic procedure consent? Have you reviewed your ECMO consent lately? Is it truthful? It is all-encompassing? Does it mention the fact that the patient may die from a complication of ECMO? Does it mention that ECMO may be stopped if it is futile? If not, a thorough review of the language with your ethicists and legal team may be in order.

ECMO does not guarantee survival. It is but one tool in the arsenal of physicians and the healthcare team that can be used to potentially save the life of a patient. To give any other impression is wrong and untruthful. ECMOlogists are in the business of hope – but we must be careful not to overstep the boundaries by saying we WILL save a life.

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”

Annual Competency Checks for ECMO/ECLS Teams

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Spring time – such a lovely time of the year! The cherry trees are blooming, the daffodils are so pretty. It’s time to dust off the winter blahs, think about renewal and growth… Oh – and it’s time to think about the calendar! When are we going to do our annual competencies? Yikes!Annual competencies are a very necessary part of an ECLS Program. Initial training courses are fine for introducing new skills and baseline knowledge. Follow – thru with check-offs for a skill ‘certifies’ your ECMO Specialists in your institution. How do you assure that they stay competent? How does staff demonstrate these skills in a safe but meaningful environment?Annual comps are not just an institutional requirement; there are more and more requirements for documentation of competency on the part of medical staff. The Joint Commission will come through your center and trace back every one who cares for a particular patient. That includes the ECMO Specialist, the ECMO primer and the bedside caregiver.

How do you assure that all these groups of people are up to date with their ECLS knowledge? Do you have education that is just-in-time or planned and prepared materials?

Each of these groups is diverse and requires continuing education in different ways. Bedside nurses may benefit from an on-line learning module. ECMO primers may need an observation of technique with demonstration that all protocols are being followed. The ECMO Specialist requires in depth review of patient populations, high-risk skills and demonstration of competency.

Simulation education is one of the best ways to capture that knowledge. Use of this education tool is becoming more prevalent in health care. Many studies have shown that it is a useful training technique, allowing practice in a safe and controlled environment. Staff feel better prepared for real-life situations after completing simulations.

Do you conduct simulation training in your facility? If not, why not consider hiring ECMO Advantage to come in and provide a tailored educational experience for your team? Not every institution has the facilities or personnel to develop or conduct simulations. We bring the materials, the equipment and experienced trainers to your facility and will provide competencies checks based on your policy and procedures for your entire team.

Preparing for comps is a time consuming part of the ECMO Coordinators job. Finding time in a variety of shifts for all the specialists to be able to attend, scheduling trainers and developing materials is a huge task. Providing simulations for the very first time may be daunting. Call us today. We can help!

Authored by: Micheal Heard

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
 

ECLS Team Selection

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It’s the season for college in my house – admission packets, orientation, decisions about what to study…it’s all vaguely familiar. I think every ECLS program goes through a similar process when deciding about their education process. Who will take care of the ECMO patient? Who will take care of the ECMO pump and circuit? How do you find them and choose them? An application process may not be a bad idea. What qualifications do you think your team should have at a minimum? ELSO has guidelines that will help you determine what those minimum qualities are. Should you have them obtain references? References offer valuable information and lets a leader see what a prospective specialist is thought of by their co-workers. It may be worthwhile to have a screening test and determine what their baseline knowledge is. Should you have an interview process? Leaders learn so much about individuals in an interview. How does this person communicate? How do they present themselves? Interview techniques tease out many variables and may help identify the best possible ECLS team members for your program.

It is true that many ECLS programs have a problem with attrition. It’s not uncommon to lose 50% by end of the first year. Staff resignations may start with the very first day of class: they sit down, ready to learn and then “POW” – it’s overwhelming to them. Extracorporeal Life Support is not an easy concept. It’s not just a matter of a pump and some tubing – hook it up to a patient and go. The typical ECLS class is long and involved. Staff members are required to learn and be tested on physiology related to VV or VA ECMO, systems management, equipment and circuitry troubleshooting and anticoagulation management. Or they finish class, make it through orientation and then sit by themselves at an ECLS patient’s bedside. The reality of how critically ill that patient is, and more importantly, how dependent that patient is on their skills and knowledge is too much to bear, and they quit the team.

Finding out if the team member is going to be able to handle the critical stress that will be a part of every day care is an important part of the selection process. Some ECMO programs have a detailed process for picking team members that isn’t fully complete until they finish orientation. A developed mentorship program can be incredibly beneficial. Most institutions have a mentoring program for new staff – can you modify your existing process for your ECLS team? If a leader maintains the thought that new ECLS staff must be nurtured and encouraged along the way – especially the first year – they will have an increased likelihood of keeping that staff member engaged and happy in their work.

If this is all new to you and your institution, or if you have a unique aspect to your ECLS team selection process – lets chat about it. Leave me a comment!

I am hopeful that we have made the right decisions with our child about college. I am certain he has met their application requirements. Now all that remains is for the college to mentor him through his first year, and for him to complete the process and graduate!

There is no ‘I’ in Team!

Team
Noun – A group of individuals that come together for a cooperative effort, to achieve common goals. A functional family.

Team Of 8 Blue People Holding Up Connected Pieces To A Colorful Puzzle That Spells Out "Team," Symbolizing Excellent Teamwork, Success And Link Exchanging Clipart Illustration GraphicThe ECMO Team is definitely a functional family. It exists for a common purpose: to provide the best possible care for an extremely critically ill patient. The team is usually formed out of a larger group of people. Teams have complimentary skills and work through a coordinated effort to achieve the goal. Naresh Jain states “Team members need to learn how to help one another, help other team members realize their true potential and create an environment that allows everyone to go beyond his or her limitations.”

How does that relate to extracorporeal life support? Don’t you just need a physician and a perfusionist? The nurses are already taking care of the patient; and other health care providers are involved. Why do you have to have a defined team – what’s the point?

The difference with ECMO or ECLS is the intensity of care. The level of involvement is different for these patients. The increased risk of dying and the possibility of complications are beyond anything that could happen to an ‘ordinary’ ICU patient. The stress of that can not be highlighted enough. Everyone who has an encounter with that patient will be touched. And everyone who touches the patient should have an advanced knowledge of what is happening.

How do you develop an ECMO Team? Who do you have to have? Who do you want to have?

Well first you have to have a leader. I believe the leader should be a champion for extracorporeal life support. They should be knowledgeable of the inner workings of the institution, the philosophy of medicine that is expounded and how the ICUs work as teams. The leader is going to bring about the beginning of the ECLS program and assure its performance over time, with reproducible results.

The leader will assemble the team – bringing to the table all the disciplines that are required to take care of the patient. The team will include nursing, perfusion, nursing, or respiratory care ECMO Specialists, respiratory, as well as medicine. It will include ancillary personnel such as blood bank, laboratory, radiology, and pharmacy. The leader should also consider how the ECMO patient affects those outside of direct patient care. That may include the administration side with the involvement of the marketing group, the business center and finance. There are so many different aspects of the team and all need to be considered.

How do you bring about the team? That particular feeling of camaraderie? A unique and smooth ability to function under pressure and deal with the issue at hand? I think it begins with education. Providing education to all members of the team assures that everyone is starting from the same point of reference. Leaving out key members of the healthcare team can be disastrous. The ECMO training course is a special event, allowing nurses to work with physicians, perfusionists to work with the new ECMO specialists in a non-stressful environment where all can interact without fear of reprisal. The course is often the first step in building those relationships that become so important at the bedside.

After education, the next step is involvement; in daily patient care, case reviews, team meetings and inservices. Every member has something to contribute or, even better, to learn from the experiences of others.

Finally, you have to continue to build the relationships. ‘Doing’ ECMO is hard. It can take a great big chunk of your professional life and spirit. Building up the people that take care of those sick patients will only make them better caregivers. Remember to involve them in the celebrations. Celebrate the milestones: the number of patients completed, the anniversary of the program; and of course, the amazing success stories. The patient survival stories are what sustain caregivers. The stories help to reignite the passion of the team’s goals. I would encourage teams to stay in touch with their patients. Have a reunion. Seeing the smiles on their faces and hearing their stories is a great moral boost to an ECMO Team.

So go forth and build a great team! Take care of your ECMO patients as a team – and you will have great success!

written by: Micheal Heard, Director of Training and Development…ECMOlogist

Welcome

Welcome to the ECMO Advantage blog “ECMOlogy…a discussion of all things related to ECMO”   You may see posts by members of the ECMO Advantage team as well as invited guest ECMOlogists from the ExtraCorporeal Community.

We will be providing regular posts providing insight into common, and not so common, issues related to ECMO or ECLS.  The ECMOlogy blog will also feature review of research articles of interest and/or recent news related to ECMO or ECLS.

Check back frequently for updates and new blog posts!

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