Category: Randy’s Ruminations

Staying Current in the World of ExtraCorporeal Support

Part of my job as owner of ECMO Advantage, and part of my passion as an ECMOlogist, is staying current with the ever changing and expanding world of extracorporeal support.  In that attempt, I spend a lot of time scouring the internet for the latest information regarding ECMO, ECLS, training, modalities, research, products, practices, services…you name it.  I have found there is definitely a growing interest and awareness of ECMO…especially Adult ECLS.

One of the most rapid and aggressive swings we have seen in the ECMO community is the growth of Adult extracorporeal life support.  The ELSO database makes that quite clear.  The ELSO data depicts a sharp increase in Adult patients supported with ECMO starting in 2009.  In 2010, for the first time in ELSO recorded history, Adult ECLS patients surpassed Neonatal ECMO patients in number (Adult-887 / Neo-678).  Since that time Adult patients supported on ECMO has almost tripled to 2574 Adult ECMO patients recorded by ELSO in 2014.  Part of that increase is certainly due to more ECMO Centers reporting to ELSO.  But part of that increase is also due to a wider acceptance of ECLS as valuable for all patient populations including Adult ECMO patients.

But one of the more concerning aspects of scouring the web in an attempt at staying current in the world of extracorporeal support is the fact that there are a lot of inaccuracies out there.  I just read a pretty good article yesterday that discussed ECPR (using ECMO in the process of CPR).  90% of the information was informative and pretty accurate.  But the very first paragraph included gross inaccuracies in a significantly overstated benefit of ECPR.  The quote was, “More than 50,000 patients have survived because of ECPR, and this revolutionary treatment offers hope where there was none before,…”  So while it’s true that ECPR may offer hope to those for whom all hope may have seemed to evaporate, there is no documentation or report (that I could find) to substantiate that 50,000 patients have survived because of ECPR.  I would guess that they were improperly evaluating ELSO data that shows there have been over 50,000 patients reported to the ELSO registry as number of patients supported on ECMO since 1989. COMPLETELY different than 50,000 surviving because of ECPR.

And just today I found a web site authored by a physician in fellowship that presented information regarding ECMO.  Although much of what was portrayed on that site was good information, there were key pieces that were not accurate and if simply accepted at face value could lead one to make improper judgements in caring for a patient on ECLS.  There obviously are many more examples of this on the web across all specialties.

My point I guess is that if you are looking for information about ECMO, ECLS, ECMO specialist training, ECMO training programs, etc…make sure you are connecting with the experts in the field in order to get the best, most comprehensive, and accurate information possible.

Randy Bartilson, President of ECMO Advantage – Serving the ExtraCorporeal Community.

 

Anticoagulation Tests…is the ACT Still the Gold Standard?

For many of the last 25 years of ECMO support in the United States, activated clotting time (ACT) point of care testing has been the primary standard for assisting the ECMO Specialist adjust heparin.  The delicate balance of keeping the system from clotting and keeping the patient from bleeding rested on a very primitive test done at the patient bedside.  I have heard it said that using the ACT to adjust heparin is a little like using a sledge hammer to play a concert piano. Yet the ACT remains one of the most frequently used tests for ECMO patients.

With that said, over the last few years there has been a definite move towards adding additional tests to the equation and in some places the ACT has been completely eliminated from the equation.  There have been numerous reports, papers, abstracts, and research articles discussing how tests such as aPTT, antix-a, ATII, PT/PTT, TEG, and others are used in conjunction with or instead of ACT to help balance appropriate anticoagulation for the ECMO patient.

So, here is my chance to share some of the results of my ruminations.

I would suggest consideration of utilizing the COMBINATION of

  1. ACT (Activated Clotting Time)
  2. Anti Xa (Heparin Assay)
  3. ATIII
  4. Fibrinogen Level
  5. Platelet Count

Some might notice the absence of APTT (Activated Partial Thromboplastin Time).  I am not completely opposed to it.  Some use it exclusively.  It’s not in my top 5…yet.  There are conflicting reports regarding how APTT correlates with the old and crude ACT standard for ECMO patients.  But there are conflicting reports about anticoagulation strategies as a whole. I wanted to at least acknowledge that APTT should be part of a discussion and discovery process as you explore what works best for your center.

So why the 5 tests that I listed?  Check back for more explanation of Randy’s Ruminations related to anticoagulation management for ECMO patients.

ECMO tech vs ECMO Specialist…Does it really matter?

ECMO tech vs ECMO SPECIALIST…Does it really matter?
Let me answer that before you read on.  YES!!  It matters greatly!

ECMO Advantage has the opportunity to work with many institutions across the United States. We are also able to communicate and associate with other providers of extracorporeal support. One striking thing that I have noticed over the years is the wide range of expectations of the professional sitting behind the ECMO pump. These expectations range from simply having a bedside RN write down numbers and call someone if there is a problem…to a well trained, highly experienced ECMO Specialist (RN, RRT, or CCP) that has full command and understanding of not only the ECMO equipment, but also the disease process, ICU care of that disease process, and how the ECMO support process can best be utilized to provide the most benefit to the patient.

There are several ways to provide ECMO support and there are several devices and configurations of an ECMO system that can be used to support ECMO patients. There are many ways to manage the patient on ECMO. But I believe one aspect of quality care that is often overlooked is the ability of the ECMO Specialist to make all those things work together for the benefit of the patient. That is what we strive for at ECMO Advantage. All of our ECMO Specialists are RN’s, RRT’s, or CCP’s who have ICU backgrounds in addition to their many years as an ECMO Specialist. They all know what it’s like to provide long term care for a critically ill patient in the ICU. They understand the ICU environment and what is involved in the care of a patient on ECMO from the perspective of the ICU healthcare provider. In addition, they have full command and understanding of the ECMO process (that is not to say we are not all still learning!). The combined knowledge, skills, and experiences definitely provide an ECMO Advantage to the clients and patients we serve whether that be in the role of consultant, educator, preceptor, primer, coordinator, or the ECMO Specialist sitting behind the pump.