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HOW TO START A SUCCESSFUL VV-
ECMO CENTER IN AN INSTITUTION
WITHOUT CARDIOSURGICAL WARD?
Mirosław Czuczwar
II Department of Anesthesiology and Intensive Therapy
DISCLOSURE
I have received honoraria for lectures and advisory groups
on extracorporeal life support from the following companies:
Fresenius Medical
Dutchmed
Xenios
Maquet
VV-ECMO IN POLAND
ECMO CENTERS IN POLAND
ECMO CENTERS IN POLAND
Too early!
Too late!
Too
busy!
Call later! Sepsis?
No!!!
Too sick
to
transport!
Too far!
No beds!
OUR INSTITUTION
• General surgery
• Oncological surgery
• Vascular surgery
• Hematooncology
• Infectious diseases
• ICU
CRITICAL CARE PERSPECTIVE
Position Paper for the Organization of Extracorporeal
Membrane Oxygenation Programs for Acute Respiratory
Failure in Adult Patients
Alain Combes1, Daniel Brodie2, Robert Bartlett3, Laurent Brochard4, Roy Brower5, Steve Conrad6, Daniel De Backer7,
Eddy Fan8, Niall Ferguson8, James Fortenberry9, John Fraser10, Luciano Gattinoni11, William Lynch3,
Graeme MacLaren12, Alain Mercat13, Thomas Mueller14, Mark Ogino15, Giles Peek16, Vince Pellegrino17,
Antonio Pesenti18, Marco Ranieri19, Arthur Slutsky4, and Alain Vuylsteke20; The International ECMO Network
(ECMONet)
1Institute of Cardiometabolism and Nutrition, Groupe Hospitalier Pitie–Salpetriere, Pierre Marie Curie University, Paris, France; 2ColumbiaUniversity, New York, New York; 3University of Michigan, Ann Arbor, Michigan; 4St. Michael’s Hospital, University of Toronto, Toronto,Ontario, Canada; 5Johns Hopkins University School of Medicine, Baltimore, Maryland; 6Louisiana State University Health SciencesCenter, Shreveport, Louisiana; 7Erasme Hospital, Universite libre de Bruxelles, Bruxelles, Belgium; 8Toronto General Hospital,University of Toronto, Toronto, Ontario, Canada; 9Emory University School of Medicine, Atlanta, Georgia; 10The Prince CharlesHospital and The University of Queensland, Brisbane, Queensland, Australia; 11Ospedale Maggiore Policlinico, Milan, Italy; 12NationalUniversity Hospital, Singapore, Singapore; 13University of Angers, Angers, France; 14University of Regensburg, Regensburg,Germany; 15Alfred I. duPont Hospital for Children, Wilmington, Delaware; 16East Midlands Congenital Heart Centre, Leicester, UnitedKingdom; 17The Alfred Hospital and Monash Medical Centre, Melbourne, Victoria, Australia; 18Universita di Milano-Bicocca, Monza,Italy; 19S. Giovanni Battista Molinette Hospital, Turin, Italy; and 20Papworth Hospital NHS Foundation Trust, Papworth, United Kingdom
Abstract
Theuseofextracorporeal membraneoxygenation(ECMO) for severeacuterespiratory failure(ARF) in adultsisgrowing rapidly givenrecent advancesin technology, even though thereiscontroversyregardingtheevidencejustifyingitsuse.BecauseECMOisacomplex,high-risk, and costly modality, at present it should beconducted incenterswith sufficient experience, volume, and expertiseto ensureit isusedsafely.Thispositionpaper representstheconsensusopinionof an international group of physiciansand associated health-careworkerswho haveexpertisein therapeutic modalitiesused in thetreatment of patientswith severeARF, with afocuson ECMO. Theaimof thispaper istoprovidephysicians,ECMOcenter directorsandcoordinators, hospital directors, health-careorganizations, and
regional, national, and international policy makersadescription oftheoptimal approach to organizing ECMO programsfor ARFinadult patients. Importantly, thiswill help ensurethat ECMO isdelivered safely and proficiently, such that futureobservational andrandomized clinical trialsassessingthistechniquemaybeperformedbyexperienced centersunder homogeneousand optimal conditions.Given theneed for further evidence, weencouragerestraint in thewidespread useof ECMO until wehaveabetter appreciation forboth thepotential clinical applicationsand theoptimal techniquesfor performing ECMO.
Keywords: extracorporeal membrane oxygenation; acuterespiratory distress syndrome; hospital organization; critical carenetworks; position article
The use of extracorporeal membraneoxygenation (ECMO) for severe acuterespiratory failure (ARF) in adults isgrowing rapidly given recent advances in
technology, although there is controversyregarding the evidence justifying its use(1–9). The recent experience in 2009using ECMO for pandemic influenza A
(H1N1)–associated acute respiratorydistress syndrome (ARDS) revealed thatmany centers initiated ECMO programswithout significant experience and with
(Received in original form April 4, 2014; accepted in final form July 6, 2014)
This position article has been endorsed by The Extracorporeal Life Support Organization. See Appendix for the list of physicians who approved the content of
this position paper.
Author Contributions: Drafting of the article: A.C. and D.B. Critical revision of the article for important intellectual content: A.C., D.B., R. Bartlett, L.B.,
R. Brower, S.C., D.D.B., E.F., N.F., J. Fortenberry, J. Fraser, L.G., G.M., W.L., A.M., T.M., M.O., G.P., V.P., A.P., M.R., A.S., and A.V. Final approval of thearticle: All signatories.
Correspondence and requests for reprints should be addressed to Alain Combes, M.D., Ph.D., Service de Reanimation Medicale, iCAN, Institute of
Cardiometabolism and Nutrition, Groupe Hospitalier Pitie–Salpetriere, 47, boulevard de l’Hopital, 75651 Paris, France. E-mail: alain.combes@psl.aphp.fr
Am J Respir Crit Care Med Vol 190, Iss 5, pp 488–496, Sep 1, 2014
Copyright © 2014 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201404-0630CP on July 25, 2014
Internet address: www.atsjournals.org
488 American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 |September 1 2014
ELSO Guidelines for ECMO Centers
March 2014 Version 1.8 Page 1
ELSO GUIDELINES FOR ECMO CENTERS
PURPOSE
These guidelines developed by the Extracorporeal Life Support Organization, outline the
ideal institutional requirements needed for effective use of extracorporeal membrane
oxygenation (ECMO). The Extracorporeal Life Support Organization recognizes that
differences in regional and institutional regulations especially concerning hospital
policies may result in variations from these guidelines.
INFORMATION AND BACKGROUND
Extracorporeal Membrane Oxygenation (ECMO) was first used successfully for neonates
with respiratory failure in 1975. Today it is an accepted treatment modality for neonatal,
pediatric and adult patients with respiratory and/or cardiac failure failing to respond to
conventional medical therapy.
ECMO is defined as the use of a modified cardiopulmonary bypass circuit for temporary
life support for patients with potentially reversible cardiac and/or respiratory failure.
ECMO provides a mechanism for gas exchange as well as cardiac support thereby
allowing for recovery from existing lung and/or cardiac disease.
It has been estimated that approximately 2800 newborns could benefit could benefit from
ECMO annually in the US (one of every 1309 live births). Pediatric and adult patients
are being successfully treated in increasing numbers.
HEAD OF THE VV-ECMO CENTER
• Critical care specialist
• Cardiovascular specialist
• Thoracic, vascular or
trauma surgeon
• OTHER SPECIALIST?
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
PHYSICIANS
• Training in the ECMO machine
and circuit maintenance and
troubleshooting
• Proficiency in the US
examination
• vascular Doppler
echocardiography
• cardiac Doppler
echocardiography
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
NURSES
• Training in the ECMO
machine and circuit
maintenance and
troubleshooting
• The ratio of nurses to
patients receiving ECMO
should be at least 1:1 to 1:2
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
EQUIPMENT
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
VASCULAR ACCESS
VASCULAR ACESS
USG
USG
• centers caring for more than 20 to
25 cases per year have significantly
better outcomes (at least 12 VV
ECMO)
• 5 - 10 people per milion require
ECMO
• a single center should cover an area
inhabited by 2 - 3 millions of people
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
PATIENTS
PATIENT REFERRAL
Too early!
Too late!
Too
busy!
Call later! Sepsis?
No!!!
Too sick
to
transport!
Too far!
No beds! INDICATIONS
INCLUSION
CRITERIA
TIMING
TRANSPORT
INCLUSION CRITERIA
Anestezjologia Intensywna Terapia 2017, tom 49, numer 2, 92–104
• ARDS according to Berlin definition
• PaO2/FIO2 < 80 for over 3 h
• pH < 7,25
• despite VT 6 ml kg-1 and PEEP over 5 cmH2O
INCLUSION CRITERIA
MOBILE ECMO TEAM
Updated: May 2015
This document is scheduled to expire by May 2018. After this date, users are encouraged to contact the ELSO Guidelines Editorial Board to confirm that this document remains in effect.
1
Extracorporeal Life Support Organization (ELSO)
Guidelines for ECMO Transport
Authors:
Dan Dirnberger, MD (United States)
Richard (Tad) Fiser, MD (United States)
Chris Harvey, MD (United States)
Dirk Lunz, MD (Germany)
Matthew Bacchetta, MA, MBA (United States)
Bjorn Frenckner, MD (Sweden)
Steve Conrad, MD (United States)
Thomas Müller, MD (Germany)
Mauer Biscotti, MD (United States)
Editors:
Nicolas Brechot, MD, PhD (France)
Eddy Fan, MD, PhD (Canada)
Mark Ogino, MD (United States)
Graeme MacLaren, MBBS, FJFICM, FRACP (Singapore, Australia) Dan Dirnberger, MD (United States)
Mike McMullan, MD (United States)
Giles Peek, MBBS, FRCS, MD, FRCS CHt, FFICM (United States)
Vin Pellegrino, MBBS, FRACP, FCICM (Australia)
Dan Brodie, MD (United States)
Updated: May 2015
This document is scheduled to expire by May 2018. After this date, users are encouraged to contact the ELSO Guidelines Editorial Board to confirm that this document remains in effect.
7
i. Cannulating Physician
1. Primary responsibility is safe and proper placement of ECMO cannula(s)
2. For neonatal/pediatric ECMO, this is typically a pediatric surgeon or pediatric
cardiovascular surgeon
3. For adult ECMO, this may be general surgeon, vascular surgeon, cardiovascular
surgeon, or intensivist
4. In some circumstances, ECMO team may choose to work with a surgeon and
surgical team from the referring hospital if such collaboration facilitates timely
patient transfer
ii. ECMO Physician
a. Must have substantial experience in management of ECMO patients
Patient Requires Cannulation at
Referring Facility
Cannulating physician
Surgical Assistant (?)
ECMO Physician (if role not performed
by cannulating physician)
ECMO Specialist
Transport R.N./R.R.T.
ECMO Physician
ECMO Specialist
Transport R.N./R.R.T.
YES NO
GROUND AMBULANCE HELICOPTER FIXED WING AIRCRAFT
Space for team and
equipment
Sufficient
(4-5 team members)
More limited
(3-5 team members)
Variable
(≥ 4 team members)
Noise Relatively little Very loud Loud
Distance range Up to 400 km Up to 650 km Any distance
Weight limitations Unlimited Limited Variable
Loading and securing
equipment and patient
Relatively easy Relatively easy Variable
Costs ++ +++ ++++
Updated: May 2015
This document is scheduled to expire by May 2018. After this date, users are encouraged to contact the ELSO Guidelines Editorial Board to confirm that this document remains in effect.
1
Extracorporeal Life Support Organization (ELSO)
Guidelines for ECMO Transport
Authors:
Dan Dirnberger, MD (United States)
Richard (Tad) Fiser, MD (United States)
Chris Harvey, MD (United States)
Dirk Lunz, MD (Germany)
Matthew Bacchetta, MA, MBA (United States)
Bjorn Frenckner, MD (Sweden)
Steve Conrad, MD (United States)
Thomas Müller, MD (Germany)
Mauer Biscotti, MD (United States)
Editors:
Nicolas Brechot, MD, PhD (France)
Eddy Fan, MD, PhD (Canada)
Mark Ogino, MD (United States)
Graeme MacLaren, MBBS, FJFICM, FRACP (Singapore, Australia) Dan Dirnberger, MD (United States)
Mike McMullan, MD (United States)
Giles Peek, MBBS, FRCS, MD, FRCS CHt, FFICM (United States)
Vin Pellegrino, MBBS, FRACP, FCICM (Australia)
Dan Brodie, MD (United States)
FINAL DECISION
VV-ECMO THERAPY INITIATION
ECMO TRANSPORT
ECMO TRANSPORT
ECMO TRANSPORT
TRANSFER COMPLETE
TRANSPORT STATISTICS
• 30 patients on VV-ECMO since
2016
• 20 transports on ECMO
• ARF etiology
• Bacterial and viral pneumonia
• Aspiration
• Lung contusion
• Acute pancreatitis
• Autoimmunological
Mean distance
120 km
ANTICOAGULATION
INTRAOPERATIVE VV-ECMO
Number of patients 30
Number of transports 20 (67%)
Patients with primary pulmonary diagnosis 21
Mean therapy duration 6 days
Survival until end of ECMO 76%
Death during ECMO 3
Cumulative survival until ICU discharge 60%
Cumulative survival of medical patients 75%
Cumulative survival of surgical patients 50%
SUMMARY
Thank You for your attention