Category: ECMOlogy

Would your ECMO Program consider VV ECMO for CDH Patients? There is much discussion surrounding the most appropriate type of ECMO for a patient with congenital diaphragmatic hernia (CDH). Take below as an example case study and see the reasons why one would argue VV may be a very appropriate form of ECMO for this diagnosis.

A neonate is being admitted to your facility with respiratory failure secondary to a diagnosis of Left congenital diaphragmatic hernia. The patient is on HFOV, INO, Dopamine at 20 mcg/kg/min, and Epi at 0.2 mcg/kg/min. Despite being on maximal vent settings your patient’s Oxygen Index remains >40 with pre-ductal sats in the 70’s. ECHO shows no heart defects, good squeeze, but severe PPHN. The new attending physician with very little ECMO experience is debating whether to place the patient on VV or VA ECMO. From your experience you explain to the physician the pros of VV ECMO.
1. You maintain the native heart function by maintaining natural blood flow through the lungs.
2. The patient does not truly need heart support in the form of VA ECMO as the patient’s heart is structurally intact and has good function.
3. Oxygen is a very powerful drug and once the heart and body is adequately oxygenated you will most likely be able to dramatically wean down, if not off of, the vasoactive dips.
4. By using VA ECMO you risk the heart going into stun.
5. Only one vessel will have to be to be manipulated with VV ECMO and carotid artery will not have to be ligated once the patient is weaned off ECMO.
6. VV ECMO can adequately supply the oxygen needed to fully support this patient as long as an adequate size cannula can be placed. Some ECMO Centers may also consider a cephalad cannula for added drainage.
7. Studies have shown VA ECMO for CDH’s had higher neurologic morbidity than VV ECMO.

The physician has listened to your advice and has decided to place the patient on VV ECMO with a double lumen cannula. Cannulation is uneventful and the patient is now on full flow of 150ml/kg/min with his sats in the 90’s. The patient has been transitioned from HFOV to conventional vent. Epi was turned off almost immediately and over the next several hours Dopamine was weaned down to 8mcg/kg/min.

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.

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.

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!