OCT 21-22, 2019 2019 ACUTE CIRCULATORY SUPPORT SYMPOSIUM Billings Hospital 5841 S. Maryland Ave. Chicago, IL THE UNIVERSITY OF CHICAGO MEDICINE COURSE DIRECTOR Tae Song, MD Director, Acute Circulatory Support University of Chicago Medicine Robert H. Bartlett, MD Professor of Surgery Emeritus The University of Michigan KEYNOTE SPEAKER Course Credit: https://cme.uchicago.edu/ACSS2019 Syllabus/Slides: https://cme.uchicago.edu/ACSS2019Syllabus
Transcript
OCT 21-22, 2019
2019 ACUTE CIRCULATORY SUPPORT SYMPOSIUM
Billings Hospital 5841 S. Maryland Ave. Chicago, IL
THE UNIVERSITY OF CHICAGO MEDICINECOURSE DIRECTORTae Song, MD Director, Acute Circulatory Support University of Chicago Medicine
Robert H. Bartlett, MDProfessor of Surgery Emeritus The University of Michigan
2019 ACUTE CIRCULATORY SUPPORT SYMPOSIUMUniversity of Chicago MedicineOctober 21-22, 2019
DESCRIPTION
The 2019 Acute Circulatory Support Training Symposium will offer lectures and hands-on didactic sessions covering the fundamentals of patient management, medical knowledge, safe equipment use, patient transport, and interprofessional collaboration.
This educational intervention will provide an overview of the fundamentals of acute circulatory support, including patient management, ethics, emergency scenarios, team management, and patient transport with a full day of lectures and a half day of didactic workshops. The goal of this activity is to enhance collaborative, technical, behavioral, and cognitive skills required for extracorporeal membrane oxygenation (ECMO) management by providing participants with defined evidence-based practices that will improve patient outcomes.
TARGET AUDIENCE
This activity is designed for surgeons, cardiologists, pulmonologists, intensivists, perfusionists, bedside nurses, administrators, helicopter pilots, and other healthcare professionals dedicated to acute circulatory support patient care.
LEARNING OBJECTIVES
At the conclusion of this education activity, participants will be able to:
• Select patients for which acute circulatory support would be appropriate using an evidence based approach;
• Identify how to apply the fundamentals of acute circulatory support management across all patient populations;
• Modify acute circulatory support treatment plans based on patients’ individual clinical parameters;
• Perform appropriately in medical and mechanical challenges and emergency situations pertaining to acute circulatory support patients;
• Identify the function of each component of equipment used during acute circulatory support;
• Describe common clinical and mechanical challenges and emergencies during acute circulatory support management;
• Assess the interprofessional needs of an institution that aspires to provide acute circulatory support.
ACCREDITATION AND CREDIT DESIGNATION
PHYSICIAN CREDITThe University of Chicago Pritzker School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The University of Chicago Pritzker School of Medicine designates this live activity for a maximum of 9.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
NURSING CREDITUniversity of Chicago Medicine is approved as a provider of nursing continuing professional development by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)
This live activity is designated for a maximum of 9.5 continuing nursing education units.
PHYSICAL THERAPIST & OCCUPATIONAL THERAPIST CREDITThe University of Chicago Medical Center is a licensed continuing education provider with the Illinois Department of Financial and Professional Regulation for Physical Therapy, license # 216-000030. All participants will be provided with a certificate of attendance. This course is approved for 9.5 continuing education hours for licensed therapists (PT, PTA, OT, or COTA) in Illinois. The University of Chicago Medical Center has not applied to any other state for therapist CE credit. Participants will need to do this individually through their jurisdiction outside of Illinois.
OTHER HEALTHCARE PROFESSIONS CREDITNurses and other healthcare professionals will receive a Certificate of Participation. For information on the applicability and acceptance of Certificates of Participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by the ACCME, please consult your professional licensing board.
2019 ACUTE CIRCULATORY SUPPORT SYMPOSIUMUniversity of Chicago MedicineOctober 21-22, 2019
EDUCATIONAL GRANTS/COMMERCIAL SUPPORTEducational grant funding has been generously provided by:
Abbott Laboratories
LivaNova
We would also like to thank our exhibitors:
Platinum LevelAbbott Laboratories
Liva Nova
Silver LevelLa Jolla Pharmaceutical
2019 ACUTE CIRCULATORY SUPPORT SYMPOSIUMUniversity of Chicago MedicineOctober 21-22, 2019
DISCLOSURE DECLARATIONS
As a provider accredited by the ACCME, The University of Chicago Pritzker School of Medicine asks everyone who is in a
position to control the content of an education activity to disclose all relevant financial relationships with any commercial
interest. This includes any entity producing, marketing, re-selling, or distributing health care goods or services consumed
by, or used on, patients. The ACCME defines “relevant financial relationships” as financial relationships in any amount,
occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict
of interest. Mechanisms are in place to identify and resolve any potential conflict of interest prior to the start of the activity.
Additionally, The University of Chicago Pritzker School of Medicine requires Authors to identify investigational products or off-
label uses of products regulated by the US Food and Drug Administration at first mention and where appropriate in the content.
COURSE FACULTY The following individuals have disclosed no relevant financial relationships:
Tina Boersma, MSN, RNC-NIC Annalyse Chinco, BSNNikunj K. Chokshi, MDChawki El-Zein, MDMichele Emory, PA-C, MMSCheryl L. Esbrook, OTR/L, BCPRNarutoshi Hibino, MD
Gene H. Kim, MDColleen LaBuhn, MSN, FNP-C, CCRNKristen Nelson McMillan, MDRyan Piech, MS, MBA, CCPCharles Rhee, MDRebecca Rose, BA, RRT-NPSAlan Schurle, MD
Robert Bartlett, MD has no relevant financial relationships to disclose. Dr. Bartlett will discuss standard ECMO procedures.
Victoriya Kagan, MSN, APN-BC has no relevant financial relationships to disclose. Victoriya will discuss cannulation techniques using cannulas that are off label use including protek duo, centrimag, and other acute MCS.
Tae Song, MD has no relevant financial relationships to disclose. Dr. Song will discuss the use of extracorporeal circulatory support devices in non-FDA approved indications.
Geoffrey Wool, MD, PhD has worked as a consultant for Diagnostica Stago.
The staff of the Center for Continuing Medical Education have no relevant financial relationships to disclose.
DISCLAIMERThe views expressed in this activity are those of the individual speaker. It should not be inferred or assumed that they are expressing the views of any pharmaceutical or product/device manufacturer, provider of commercial services, or The University of Chicago. The drug selection and dosage information presented in this activity are believed to be accurate. However, participants are urged to consult the full prescribing information on any agent(s) presented in this activity for recommended dosage, indications, contraindications, warnings, precautions, and adverse effects before prescribing any medication. This is particularly important when a drug is new or infrequently prescribed.
2019 ACUTE CIRCULATORY SUPPORT SYMPOSIUMUniversity of Chicago MedicineOctober 21-22, 2019
CONFERENCE FACULTY
Course Director
Tae Song, MDDirector, Acute MCS ProgramSurgical Director, Lung Transplant ProgramAssistant Professor, Cardiac SurgeryUniversity of Chicago Medicine
Keynote Speaker
Robert H. Bartlett, MD Professor of Surgery EmeritusUniversity of Michigan
Course Faculty Lecturers
Tina Boersma, MSN, RNC-NICECMO Specialist, Pediatric NurseUniversity of Chicago Medicine
Nikunj K. Chokshi, MDAssistant Professor of Pediatric SurgeryUniversity of Chicago Medicine
Chawki El-Zein, MDPediatric Cardiac Surgeon, Advocate Children’s HospitalClinical Associate Professor of Surgery, University of Illinois at ChicagoUniversity of Chicago Medicine
Michele Emory, PA-C, MMSLung Transplant and Acute MCS Specialty PAUniversity of Chicago Medicine
Cheryl L. Esbrook, OTR/L, BCPRProgram Coordinator, Occupational Therapy Professional DevelopmentUniversity of Chicago Medicine
Narutoshi Hibino, MD, PhDAssociate Professor of Pediatric Cardiac SurgeryUniversity of Chicago MedicineAdvocate Children’s Hospital
Vika Kagan, MSN, APN-BCLead MCS APNSection of Cardiac SurgeryUniversity of Chicago Medicine
Gene H. Kim, MDAssistant Professor of MedicineInterim Medical Director, Advanced Heart Failure and Cardiac Transplant ProgramUniversity of Chicago Medicine
Colleen LaBuhn, MSN, APN-C, CCRNCardiac Surgery Program ManagerUniversity of Chicago Medicine
Kristen Nelson McMillan, MDAssociate Professor, Department of PediatricsUniversity of Chicago MedicineAdvocate Children’s HospitalAdvocate Children’s Heart Institute
Ryan Piech, MS, MBA, CCPChief of PerfusionUniversity of Chicago Medicine
Charles Rhee, MDAssistant Professor of MedicineDirector, Hospice and Palliative Medicine Fellowship ProgramUniversity of Chicago Medicine
Rebecca Rose, BA, RRT-NPSManager, Acute MCS ProgramUniversity of Chicago Medicine
Alan Schurle, MDAssistant Professor of Anesthesia and Critical CareUniversity of Chicago Medicine
Megan Stulberg, PT, DPT, CCSSenior Physical TherapistProgram Coordinator, Cardiac and Pulmonary RehabilitationUniversity of Chicago Medicine
• Medtronic Balance Biosurface: Hydrophilic polymer coating without heparin
• Medtronic Trillium: Hydrophlic polymer coating with covalent heparin bonding
• Medtronic Cortiva BioActive Surface: formerly called Carmeda, polymer deposit and covalent heparin bonding
PMP
• Current generation oxygenators are hollow fiber (membrane) oxygenators, and the ones used for ECMO are almost always made with Polymethylpentene (PMP) which drastically reduces plasma leakage.
• PMP is sometimes called TPX (trademark of Mitsui Chemicals). If a standard CPB membrane is used for ECMO, it would start frothing and fail within a day or so.
Patient selection
Cardiopulmonary Support Considerations
• Mode of failure and required support
• Level of urgency
• Inotropes and pressors
• Cannulation location
• Cannulation site
• Required flow
• Percutaneous vs open
• Peripheral vs central
• Central venous access, access for ultrafiltration
• Airway stability, anesthesia requirements
Forms of ECMO
• V-V
• V-A
• VV-A, V-AV / V-VA
• A-V
• VVV-A, V-AA, VV-AA
• A-A!
Cannulation sites
• Femoral artery & vein
• Internal jugular vein
• Axillary/Subclavian artery & vein
• Carotid artery
• Central: aorta, right atrium, pulmonary artery, LV apex, left atrium
Peripheral VA ECMO
• 17-21F arterial cannula
• 8F distal perfusor
• 23-27F venous cannula
Percutaneous RIJ cannulation
• Ultrasound guidance sufficient for short outflow cannula
• Fluoroscopy: necessary for placement of multi-stage drainage cannula into IVC, placement of percutaneous PA cannula
• Placed percutaneously with fluoroscopy and TEE guidance.
Bicaval dual lumen cannula (Avalon)
OxyRVAD / RA-PA ECMO Axillary artery cannulation
• Open, with 8-10 mm graft to axillary artery
• Long-term ambulatory VA ECMO
Percutaneous subclavian artery cannulation BiVADs without sternotomy
LVAD: LV apex cannulation with mini-thoracotomy, axillary cut-down with graft and arterial cannula placement.
RVAD: Percutaneous RA-PA via RIJ.
BiVADs without sternotomy BiVADs with Protek Duo cannulas
Bleeding at cannulation sites
• All sites can bleed!
• Cannulation site bleeding sometimes requires surgical management.
Bleeding on ECMO
• Due to:
– Coagulopathy related to extracorporeal circulation: consumption, platelet dysfunction (acquired Von Willebrand disease).
– Access to major vessels.
– Often post-op, or invasive procedures required.
• Key points to reduce bleeding after ECMO cannulation:
– Technically sound cannulation.
– Close monitoring, with consideration of clinical status.
– Prompt attention to bleeding, or evidence of blood loss.
– Bleeding is much more common than clotting. Coagulopathy should be reversed, and bleeding should be stopped early.
• Monitor using PTT, anti Xa, and ACT as needed, with clinical correlation.
• Thromboelastography (TEG) also used.
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Considerations after cannulation
• Adequate level of support
• Speed / hemolysis
• Maintenance of pulsatility / LV ejection / LV unloading
• Weaning of inotropes and pressors
• Early conversion to ambulatory ECMO, extubation, mobilization
Summary
• Dr. Bartlett’s career IS the history of ECMO!
• Current generation pumps and circuits have greatly facilitated ECLS, and have decreased complications.
• The type of support needed, and urgency, will determine cannulation strategy.
• Sound cannulation technique and attention to detail is important to provide adequate circulatory support, and minimize complications.
• Plans for transition to other forms of support should be taken into account time of initial cannulation.
Thank you!
Questions?
Daily Management of Patients on Acute Circulatory SupportVika Kagan, MSN, APN-BC
• Availability of durable membranes and portable circuits
• Ability of VA‐ECMO to provide left, right, and biventricular support
• Ease of implantation in the catheterization laboratory or at the bedside
• Increased familiarity with the technology by cardiologists and surgeons
• The need for a short‐term bridge to transplantation or mechanical support
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Common Objectives for VA ECMO
• Bridge to recovery:– Temporize circulatory support while definitive and supportive treatment strategies are
deployed to restore myocardial recovery
• Bridge to decision – To determine the reversibility of end‐organ damage commonly seen after a catastrophic or
critical myocardial event or to decide the next level of action
• Bridge to bridge – To achieve a brief stability for end‐organ perfusion until more definitive pump support (durable
mechanical circulatory support)
• Bridge to transplant– To achieve a brief stability for end‐organ perfusion until cardiac transplantation is performed
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Indications for VA ECMO• Cardiac arrest (extracorporeal CPR) • Cardiogenic shock due to acute MI
• Progression of cardiomyopathy, ischemic or nonischemic
• Acute RV failure due to pulmonary embolism • Progression of RV failure due to pulmonary disease • Progression of congenital heart disease • Primary graft failure and acute allograft rejection after OHT• Overdose of cardiotoxic drugs • Septic cardiomyopathy • Refractory ventricular tachycardia • RV failure during LVAD support • Failure to wean off cardiopulmonary bypass
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19Kar et al, Circulation 2013
Mechanical Assist Device Available for the Treatment of CS
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IABP Impella 2.5 Impella 5 Tandem Heart ECMO Centrimag
Previous parental refusal for the use of mechanical support
Ineffective medical CPR performed out of ICU or out of hospital
Inititation Can be done in ICU, cardiac cath lab, ER, step down unit
ECMO team: ECPR initiated within 5 minutes of cardiac arrest if no return of spontaneous cardiac activity
Medical CPR continued through cannulation
Pre-primed ECMO circuit
ECMO and cannulation equipments
Patient’s preparation
CannulationCannulation site depends on underlying circumstances and patient’s cardiac anatomy:
Central Cannulation: aortic and right atrial done through median sternotomy incision
Peripheral cannulation: femoral, common carotid artery or axillary artery. Femoral or internal jugular vein
Neck Cannulation
Central Cannulation Central Cannulation
Central vs PeripheralAdvantages
Large size cannulas Ease of cannulation
High flow rates Less risk of bleeding in postoppatients
Fast access for emergency Can be done while doing in postcardiotomy patients chest compression Perfuse all parts of the Less risk of wound infection
body Access to decompress left Patient can be extubated andventricle if need be mobilized
Central vs PeripheralDisadvantages
Requires sternotomy for Limited cannulas size and cannulation and decannulation flow rates
Higher risk of infection and Needs special procedures bleeding to decompress LV
Higher chance of ischemic Differential body perfusion emboli (North-South syndrome)
Risk of thrombosis above Lower body ischemia inaortic valve femoral artery cannulation
Generally precludes patient’s extubation and mobilization
Requires interruption of cardiaccompression during cannulation
Cannulation
ECMO cannulation:Specific considerations based on underlying pathology:•Heterotaxy, abnormal venous anatomy•Bidirectional Glenn, Fontan•Vessel occlusion from previous cath or surgery
CannulationECMO cannulation, assessment of adequacy of flow:Specific considerations based on underlying pathology:
S-P shunts: increase flow rates to 200ml/kg/min
Partial shunt clamping vs use the shunt in patients with no lung pathology
ECPR ECMO Hypothermia: Temp 35°C, warm up by 0.5°C every 6
hours after 24 hours
Reoxygenation injury: start with FiO2 21%, go up slowly, maintain PaO2 35-45 in patients with mixed circulation.
Left ventricular unloading during Veno-arterial ECMO
Percutaneous trans-septal left atrial and LV venting
Direct surgical LV and LA venting
Left ventricular unloading during Veno-arterial ECMO
ECPR Outcomes
Temporary Mechanical Circulatory Support: Ethical & Social Aspects of CareKristen Nelson McMillan, MD
Temporary MechanicalCirculatory Support:
Ethical and Social Aspects ofCare
Kristen Nelson McMillan, MD Pediatric Cardiac Critical Care
University of ChicagoAdvocate Children’s Hospital/Pediatric Heart Institute
October 28, 2019 2
Disclosure
• I have no disclosures related to this presentation.
• I will discuss off‐label therapies for lung injury.
• All patient pictures have been approved for this presentation by herparents (and her).
October 28, 2019 3
Let’s take a trip down memory lane….• 1952‐Cardiopulmonary bypass• 1963‐Initial attempt at VAD implantation by Dr. Hall• 1966‐Dr. DeBakey’s first successful VAD placement• 1970‐ECMO‐infants with CHD• 1975‐ECMO‐neonates with resp failure• 1991‐adult‐sized Berlin Heart was used for the first time in a pediatric patient
Critical Heart Disease in Infants and Children, 3rd Ed; Ungerleider, Meliones, Nelson McMillan, Cooper, Jacobs
October 28, 2019 4
How Far Have We Come?
October 28, 2019 5
VADs today….
brate the 10 year old who gets a VAstarts walking, eating a regular diet
y goes homeone, we start thinking about how totransplant or recovery/remissioned….now what to do if these patients ne
• We all celedays later,eventuall
D, gets extubated 2without vomiting and
optimize this patient
ed ECMO first…
• From dayfor either
• It’s expect• We even k
October 28, 2019 7
Let’s Consider….
• Over the last 10 years, ECMO has been used forpulmonary indications in over 4,000 pediatric patients, for an average duration of 11 days, with 59% survival tohospital discharge
• In the past, if RV heart failure or no lung recovery occurred after 20‐30 days of ECLS, ALI was consideredirreversible, ECMO was discontinued, and the patientdied
What can we learn about what to do with’limits’ from pediatric cardiac ECMO?
• ELSO registry data: If a patient requires ECMO for cardiac support, minimal survival beyond 9 days if there no evidence of cardiacrecovery
• Use of more durable cardiac devices….early• Get up and move!• Improve nutrition!
Is there a ‘limit’ for pulmonary ECMO?
• Several reports of patients being maintained on ECMO for months, year(s)
• Creativity‐alteration of configurations, cannulations, management strategies
• Mobility and nutrition• Lessons learned from patients waiting for heart transplant
• What if we ‘expected’ these patients would need Lung Assist Devices (LAD) if they don’t show recovery in a certain amount of time?
• Would we not only wake them up during the day, but let them sleep at night, walkthem, improve their nutrition….send them home???
The question then becomes…
• Since we can support patients for long periods of time….• Should we? Whom should we support?• For how long?
• If we do…• We need to ‘do’ all aspects exceedingly well
Ethical Aspects of MCS
• Lack of scoring systems for early identification of those most likely torecover
• Disagreements or misunderstandings between health care providersand families/patients and/or each other
• Typically dealing with events that are unexpected, unanticipated• Communication of goals is very difficult, especially when multipleteams are involved
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Let’s Use a Case as an Example….
• 7 yr old previously healthy female child admitted to the PICU in lateMay 2014
• Sustained 35% TBSA flame burns to R face, R neck, R lower arm, Rhand, R leg and L leg from house fire as well as inhalational injury
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Progressive ARDS• Over 1st week post‐burn, increasing ventilatoryand oxygen requirements
• Significant inhalational injury component with highrisk for secondary bacterial pneumonia
• 5 days after admission, ECHO with elevated RVpressure and iNO started
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VA ECMO Cannulation
• On post‐burn day 7, during a bedside burndebridement, she went into PEA arrest and was placed on ECMO via the groin (ROSC prior to cannulation)
• left A 13 Fr with 8 Fr reperfusion cannula, right V 17 Fr• 1st cardiac arrest• Phase 1
• She was subsequently febrile and found to be septic with evolvingpneumonia (Pseudomonas)
• Developed limb ischemia despite reperfusion cannula, ultimatelyrequiring left BKA (on ECMO)
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Transition to VV ECMO
• After 6 days of VA ECMO, cardiac recovery achieved and transitioned to VV cannulation
• maintained R groin and cannulated right IJ• Severe lung disease with necrotizing pneumonia, hemopneumothorax
• Ultimately required 5 thoracotomies on ECMO for left chest clean out
• VV ECMO‐phase 2
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VV ECMO….but we need more help• Lung rest settings, but with 100% FiO2 on blender andvent and 12 L/min of sweep gas
• SpO2 was 73‐85% and pCO2 50‐60’s• Significant hemolysis, renal insufficiency
• CXR with complete white out and recurrent bronchoscopies revealed significant airway clots, debris and bleeding
• Ultimately 4 cardiac arrests on VV ECMO
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28, 2019
Problem List: ECMOIntubated SedatedBurn management ongoing (and other wounds)Severe lung injurySepsisNecrotizing pneumonia Persistent vasoactive needRenal failure
Is there a chance this can getbetter?How can we better evaluate if wecan?What else can we do? Whatshould we do?
October 19
Use of Cryotherapy
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Use of Perfluorocarbon and Inhaled Factor 7
• 9 treatments of PFC• 1st 4 treatments with inhaledfactor 7
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• Sweep requirements decreasedand SpO2 improved
200
October 2 22
180
160
140
120
100
80
60
40
20
0
TV, Compliance, and ETC02Blue vertical lines are PFCdoses
• Recurrent Pseudomonas and fungal sepsis• Renal failure• Persistent need for vasoactive agents• Severe RV dysfunction
• Impacting LV• Lungs improving slowly but will need several months and RV needs to be unloaded
• Mobility with a new amputation is a real challenge• Significant sedation for almost 2 months
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On to Phase 3…
• After 54 days of VV ECMO(total 60 days of ECMO)
• RVAD inserted‐phase 3• RA, PA configuration; tunneled
cannulas to allow chest closure (DSC after 4 days)
• CentriMag pump with adultoxygenator
• Further vent weaning• Trach 1 week later• Weaning of sedation• Negative blood cultures• Discontinuation of vasoactives
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Anticoagulation• Maintained without anticoagulation for 2 weeks post‐op
• Significant difficulty with heparin• Persistent thrombocytopenia despite negative HIT
• Conjunctival and oropharyngeal bleeding• Concern for PE despite therapeutic heparin
• Transitioned to bivalirudin• Resolution of thrombocytopenia and bleeding• Maintained throughout remainder of course
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Renal Failure
• Dialysis initially maintained through connection via the oxygenator
• Ultimately a tunneled dialysis catheter was placed
• PD catheter placed several months later
Longroadahead....
October 32
October 28, 2019 33
Mobility andPsychological/Social
Aspects‐Important Keys to Recovery
October 28, 2019 34
Where Do We Start?
October 8, 2019
Mobility‐Important Key to Recovery
October 2 36
8, 2019
It’s not simple to just get up and move with all ofthe technology….but it was done over and overagain
October 2 37 October 2 38
October 28, 2019 3
Mobility‐Important Key to Recovery
Minimal vent settings, 40% FiO2Sweep 2 L/min and blender 0.21‐.40%ECHO with near normal Rventricular function, LV nml functionBut 3 L/min is a lot of support
October 28, 2019 4
CentriMag to PediMag‐Phase 4
019October 28, 2 41
PediMag to Tunneled Avalon (Phase 5) to Decannulation
491 days of RVAD/oxygenator and 54 days of ECCO2With 60 days of ECMO=605 days
October 28, 2019 42
Still Moving…Eventually…all Hands Free
October 28, 2019 43 October 44
October 28, 2019 45 October 28, 2019
But What Did She Want Most?
October 28, 2019 47
Making Life as Normal as Possible
8, 2019October 2 48
School‐Virtual and One‐on‐one
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Psychological Aspects
• Counseling sessions
• Memory of events
• Sleep restoration• Lack of sleep‐negative impact on many aspects of health
Time to go home…after 662 days
• Mechanical ventilation• Around the clock• 4‐5 L O2 bled in• Lots of meds‐oral and inhalational
• Peritoneal dialysis• Nighttime
• Home adaptation
• School• Initially home schooling(expected grade!)
• Then half days• Then full days• Then no wheelchair
So what did we/can we learn?• Medical aspects….
• PFC for severe ARDS and use of inhaled factor 7 for DAH, airway obstruction• Alternative pulmonary clearance adjuvants‐cryotherapy
• Regenerative capacity of lungs‐more thanwe have previously believed
• Bivalirudin anticoagulation worked very well and better than heparin
• Earlier use of RVAD configurationwith oxygenator• Reverse remodeling of RV• Early trach and aggressive vent weaning• Enhanced mobility• Impact of renal disease• Quality of life• Continuity providers‐importance for long‐term patients• Resource utilization
• Development of Lung Assist Devices‐we figured it out for hearts….
What about social and ethical lessons?
• All MCS patients should be provided with:
• grief counseling for patients and families• discussions regarding possible end of life‐cardiac arrest, DNR/AND, brain death
• Organ donation on MCS (OP‐ECMO)• ongoing and direct communication about the prolonged physical, cognitive, and emotional effects of ECMO (and whatever resulted in the need for ECMO) on thepatient (and family/surrogate), financial costs, geographic inequalities and thescarcity of ECMO technologies
• palliative and spiritual care, to ease social, physical, and emotional pain and suffering and to accommodate the cultural, religious, and spiritual needs of thepatient
Consider what we are asking….• every healthcare provider who needs to be involved with such critical family (and patient) conversations must acknowledge, and prepare, forthe reality that thoughts about continuing life‐sustaining therapies isvery different when one is dealing with the abstract versus theimpending and immediate reality
• Instead of thinking families and surrogates “change their minds,”understand they are being confronted with new information andneed further guidance and support in decision‐making (e.g., discussions about quality life now versus then)
If you do start down an extended road of MCS….
• Inform the team of ‘why’ and ‘how’• What is the limit? What would make us stop?• Includes multiple disciplines
• Care Conferences can be very helpful• Open it to everyone
• Involve the families whenever possible‐allow them to voice their opinions, concerns, etc…to the group if they want
• Reach out‐we only get better when we learn from each other
Where is she now?• She has been home for over 3 years now• She is now on RA during the day, nasal BIPAP at night, with her trach capped
• ECHO nml with no evidence of pulm HTN, off all medications
• No episodes of bacterial respiratory infectionrequiring readmission
• Physical therapy and dance class• All A’s and B’s!
October 28, 2019 56
This level of support is not sustainable for multitudes of patients….• Financial implications• Resource utilization
• Development of LADs (lung assist devices) that would allow dischargeto home, much like long term VADs
Can we build a bridge?
• Clinical/medical, social, legal, economical and ethical elements ofECMO are all important elements
• We must share our experiences, patient and caregiver stories, both‘good’ and ‘not so good’ to help all of us create shared decision‐making and find a bridge to an agreed upon destination
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October 28, 2019
And mostimportantly…. showingher calf
And even winning!
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Thank You• Our patient and her entirefamily
• The entire PICU staff and all consultants
• with extra thanks to ECMO/VADcoordinators and all of theECMO/VAD specialists who sat her pump daily and ensured hersafety
• Dr. Luca Vricella• Dr. Naru Hibino• Dr. Dylan Stewart• Dr. John Coulson
• Dr. Bob Bartlett, who supported me/us throughout this long run and was a constant resource
• Kevin McDonald, CentriMag
Heroes Don’t Always Wear Capes
Physiology of Pediatric Disease States Supported with Extracorporeal CirculationNikunj Chokshi, MD
Physiology of Pediatric Patients Supported with ECLS
Nikunj K. Chokshi, MDAssistant Professor of SurgerySection of Pediatric Surgery
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Disclosure InformationAcute Circulatory Support SymposiumNikunj K. Chokshi, MD
October 21, 2019
• I have no financial relationships to disclose
– Everything I make goes to my wife and son
• I will not discuss off label use or investigational use in my presentation
ECLS in Modern Pediatric Care• ECMO used in patients of all ages with acute
severe respiratory failure
• Consistent trends in utilization– Neonatal use down– Pediatric use increased – Adult use increasing
• ECMO support potentially effective when implemented before irreversible organ damage develops
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October 21, 2019
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ECMO Goal October 21, 2019
• Maintain systemic oxygen delivery and CO2 removal in proportion to the patient’s systemic metabolism – Eliminate ventilator induced lung injury– Improve systemic perfusion
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October 21, 2019 Increasing Utilization October 21, 2019
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Increasing Utilization October 21, 2019
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Increasing Utilization October 21, 2019
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Pediatric Respiratory ECLS October 21, 2019
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Pediatric Respiratory Failure October 21, 2019
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Indications by age
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Epidemiology of Pediatric Respiratory Failure and ECMO• 400 – 500 cases per year (ELSO)
• No clinical trials have established efficacy
• Centers with ECMO available may have lower mortality than centers without
– Allogenic bone marrow transplant recipients with pulmonary infiltrates
– Incurable malignancy
– Uncontrollable hemorrhage despite maximal medical and surgical therapy
October 21, 2019
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Contraindication to ECLS
• Relative– Duration of pre-ECLS mechanical ventilation
>14days
– Recent neurosurgical procedure or severe intracranial hemorrhage
– Pre-existing chronic illness with poor long-term prognosis
October 21, 2019
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Contraindication to ECLS
• High Risk Patients– Infants with pertussis pneumonia or
disseminated herpes simplex virus
– Cytomegalovirus infection
– Severe multiorgan failure
– Severe coagulopathy or thrombocytopenia
– Repeat ECLS
October 21, 2019
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How Do We Decide?
1. Look at estimated mortality and morbidity from the underlying acute clinical disease process + preexisting comorbidities, with and without ECLS
2. Assessment of rate and direction of clinical compensation over a reasonable time frame
3. Reversibility of acute disease process
4. Likelihood of post-survival quality of life, framed by patient and family’s goals of care
October 21, 2019
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Pediatric ARDS
• Defined as a condition characterized by non-cardiogenic, new-onset pulmonary infiltrates in the setting of oxygen deficit in patients ranging from infants through young adults
• OI used to define severity– Mild (4 ≤ OI < 8)
– Moderate (8 ≤ OI < 16)
– Severe (OI ≥ 16)
October 21, 2019
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Pediatric ARDS
• Pediatric ARDS is ~4% of all PICU admissions
• Overall mortality of 18-35%
October 21, 2019
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Pediatric ARDS
• OI has best discrimination of mortality risk– Moderate ARDS <23%
– Severe ARDS >30%
• OI > 20 with mortality >40%
• Each additional increase in OI by one point led to odds ratio increase in mortality of 1.04
October 21, 2019
24
Khemani RG, et al. Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr CritCare Med. 2015 Jun;16(5 Suppl 1):S23‐40
Other Indications For ECLS
• Airway recovery
• Mediastinal masses
• Pulmonary Embolism
• Fluid overload
• Drug overdose
• Burn patients
October 21, 2019
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Airway Recovery
• Support of tracheobronchial tree– Following tracheobronchial surgery
– Following tracheobronchial trauma
• VV ECLS with low ventilator settings- Minimize positive pressure applied to surgical site
• Extubation in appropriate setting
• Minimal sedation / no paralysis
October 21, 2019
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Mediastinal Masses
• Anterior Mediastinal Masses– Proximal airway compression with
deformation of trachea
– Loss of negative pressure ventilation leads to collapse of trachea
– Inability to intubate due to compression
• ECLS Circuit always on standby for these procedures
October 21, 2019
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Long-term Morbidity
1. 16% prevalence of developmental delay and/or seizures. 62% hospital readmission within 1.2 years (median)
2. 38% mild or moderate disability at a median of >5 years after ECMO (parental telephone interview)
3. 70% incidence of abnormal quality of life (based on medical record review and parental telephone survey)
October 21, 2019
28
Long-term Morbidity
1. 16% prevalence of developmental delay and/or seizures. 62% hospital readmission within 1.2 years (median
2. 38% mild or moderate disability at a median of >5 years after ECMO (parental telephone interview)
3. 70% incidence of abnormal quality of life (based on medical record review and parental telephone survey)
October 21, 2019
29
Long-term Morbidity
1. 16% prevalence of developmental delay and/or seizures. 62% hospital readmission within 1.2 years (median
2. 38% mild or moderate disability at a median of >5 years after ECMO (parental telephone interview)
3. 70% incidence of abnormal quality of life (based on medical record review and parental telephone survey)
October 21, 2019
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Summary
• ECLS for children with hypoxemia and/or hypercapnic respiratory failure unresponsive to other therapies
• Serial measurement of OI / VI to determine clinical trajectory
• Institute ECLS in timely manner, prior to end organ damage or severe hemodynamic instability
October 21, 2019
3132VV vs VA ECMO
Conclusion
• All who drink of this remedy recover in a short time, except those whom it does not help, who all die. Therefore, it is obvious that it fails only in incurable cases.
– Galen, Greek physician in the Roman Empire
Keynote Address: Extracorporeal Support for Shock Robert H. Bartlett, MD
Mechanical Support for acute cardiogenic shock
Disclosure
•Dr Bartlett is consultant to MC3 and Cytosorbents
Venoarterial ECMO in a neonate RHB VA: Venoarterial access via the femoral vessels RHB
Indications for VA ECMO in cardiogenic shock
Other treatment is failing for __ hours ( 80+ mortality risk)Hypotension (<90 syst) despite vasopressors and inotropesDO2:VO2 < 2, SVO2 <50lactate > 2intractable arrythmia
Other treatment= Medications,cardioversion, IABP, Impella, Tandemheart,
Cardiac Arrest, CPR, ( in hosp, OHCA)
Contraindications Time ?, lactate > ?, Age?, co morbidity
Cardiac ECLS: Management• O2 Delivery ( based on SVO2)• Normal hematocrit• Gas Exchange ( native lung function?)• Anticoagulation and bleeding• Extubated, awake• Dry weight, hemofiltration• Cardiac management:
Maintain some cardiac flow (inotropes)Frequent ECHO off ECMO
• What’s the goal? Recovery vs VAD
VA support, no cardiac functionBridge to LVAD, then cardiac recovery
2121
Cardiac ECLS algorithm
Day2-3: CNS OK? Cardiac Function returning?
NO: Transplant candidate? YES: Bridge to recovery
NO: Bridge to recovery,set goal
Futility: Stop, Organ donation?
Yes: Donor list ,bridge to VAD
Cardiac VA supportSpecial considerations
• Some cardiac function ( pulsatility)Lung function/ harlequin syndrome
• No cardiac functionVent left side, septostomy, Impella
• Leg perfusionbefore leaving the bedside
• Femoral vs proximal perfusionsubclavian, carotid
• Central accesspost cardiotomy, high flow sepsis
harlequin
Differential circulation in VA ECMO
The harlequin or north‐south syndrome
Occurs when the heart is recovering but lung function is poor. Hypoxic blood from the LV mixes in the aortic arch with oxygenated ECMO perfusion blood.
V‐AV: Femoral VA with venous infusion added
No cardiac functionLeft side vent ( atrial septostomy, LV vent, PA drainage,LVpump)
Intravascular clottingFull anticoagulation, prevent LV function ( lidocaine)
Acute Circulatory Support SymposiumOctober 21, 2019
Ryan Piech, MS, MBA, CCPChief of Perfusion
PPrreesseennttaattiioonn OObbjjeeccttiivveess• 1. To Categorize Complications of AMCS • 2. To Define Each Complication • 3. Focus of Mechanical Complications• 4. Define Strategy of ”How to Deal”• 5. 10,000 Foot View of Major Circuit Complications
• Any difficulty or problem directly related to the physical ECMO circuit and its components that causes or has the potential to cause interrupted ECMO support, patient harm, or death.
2 Types:1. IMMEDIATELY LIFE THREATENING COMPLICATIONS2. POTENTIALLY HARMFUL COMPLICATIONS
ELSO Reported Mechanical ComplicationsSource: www.ELSO.org, through July 31, 2019
ECMO Complications – Interesting Facts• National trend of complications decreasing while case volume increasing
• Why ?• Circuit clotting is increasing• Raceway rupture is decreasing• Oxygenator failure has significantly decreased • Heat exchanger malfunction hasn’t been reported in 3 years
• What was least reported but growing the fastest ????
• Although more complications are reported at higher volume centers, compounding problems are more prevalent at lower volume centers.
Role of ECMO Specialist in Emergency Management
• First Responder: Perfusionists and ECMO Specialiststhe pump experts. ‐ CALL THEM
• Identify Problems
• Get Help• Fix Problem – Use the 4 Step Sequence
Dealing With Complications
• They’re going to happen – how to respond• 4 Step sequence or cadence for the ECMO specialist and team• Practice, practice, practice the response: CE, SIM LAB! • Debrief each complication and near‐miss
• Plan/revise for future ECMO runs
Emergency Management Begins With Being Prepared
• Practice Emergency Response
• ECMO Circuit Checks: Hourly, Continuous
• ECMO Cart in room
• ECMO Emergency Kit
ECMO Circuit Checks: Every Hour• Inspect circuit for clots, fibrin, air, leaks• Verify function of each equipment piece: arterial head, oxygenator, transducers, heater, blender, CDI
• Meds and blood products running appropriately• Oxygen tank, ECMO cart, Emergency Kit available • Power cords secure• Bridge flashed• Back‐up equipment available
ECMO Circuit Checks: Continuous Scanning
• Practice: continuous visual scanning
• Visually trace the circuit backwards beginning with the arterial cannulae
• Scan the FLOW and RPM first, then main circuit: Arterial and Venous limbs • Check for stable vitals: BP, HR, Rhythm, PAP, CVP, Pt. Temp
1. Identify the Problem and ASK: Is this an immediate life threatening emergency ? IF YES, then continue…
2. Clamp and Call: Clamp ECMO AV Lines, turn off pump, Call for Help• Remember ‘VBA’: Venous Line, Bridge, Arterial Line• Call: ICU and Surgery attending physician – assign this task to an individual
3. Ventilate or Handbag the patient 4. Fix the problem or get a new circuit
Identify: Clots in Circuit, Thrombosis Clots In Circuit• Visual inspection of all circuit components and tubing• Non‐visual indicators: system pressures, flow issues
• 4 step sequence: Is this an immediate life threatening emergency?• If Yes, follow 4 step sequence and replace clotted component • If No, continue to evacuate clot without coming off ECMO
• It may be OK to continue ECMO flow with minor clots in the circuit, IF:• The clots are on the venous side of oxygenator • No change to flow • Acceptable and minimal changes to pre/post pressures• No changes to anticoagulation strategy and results : clot begets clot
Identify: Cannulae Problem • ECMO Flow is limited by improper placement and/or improper size
• Arterial cannulae issue: High post‐membrane pressure, normal venous pressure, lower cerebral sats,
• Verify proper size of cannulae according to IFU
• Verify placement by X‐ray, TTE, TEE, imaging
Identify: Accidental Decannulation• Usually preventable: cannulae properly sutured, tied down, secured• Observe and record depth of cannulae at insertion site• Pump near patient bed and brake engaged• ECMO VA lines and pump are protected from other equipment
• Use line holders, towel clamps, tubing trays, when appropriate• Restrain patient as necessary
• Less common causes: tissue fatigue, extended high line pressure, suture rupture
Manage Accidental Decannulation
• 4 Step Sequence• RN Place direct pressure on site• One cannulae usually OK – USE FOR VOLUME INFUSION• Recirculate ECMO circuit to maintain integrity
Identify: Total Power Loss
• Centrimag circuit will continue to run 1‐6 hours on internal battery• Battery dependent on RPM • Battery indicator with time remaining on console
• Unplug extra monitor from back of console
• Retrieve back‐up console for extended on‐battery time
Identify: Air in ECMO Circuit Identify: Air in ECMO Circuit Ancillary Circuit Air
Ancillary Circuit air is not located in the main arterial or venous limbs of the ECMO circuit
• Isolate the air with clamps • Do not move air to main A or V limb of circuit!
• Aspirate air via stopcock• Clamp, cut, and replace if aspiration is not possible
Identify: Air in ECMO Circuit Venous Air
• Venous Air: air in the main venous limb of the circuit from the venous drainage cannulae to the inlet of the oxygenator
• Small bubbles or airlock?• If small bubbles, aspirate via stopcock • If airlock impeding flow: walk air to venous luer connector • If air constantly entrained from venous cannulae, call attending surgeon and continually evacuate air while maintain flow if possible
Identify: Air in ECMO Circuit Arterial Air
• Arterial Air: air in the main arterial limb of the circuit from the outlet of the oxygenator to the arterial cannulae
• If air has reached the patient: initiate 4‐step emergency sequence and ICU’s massive air embolus protocol
• Head down, cool patient, barbiturate coma, surgeon decides to reverse A&V cannulaes to remove air
• Remove air from circuit utilized recirculation line and/or cartiotomy
• If completely deprimed, retrieve back‐up circuit and exchange
Identify: Oxygenator Failure • Signs: ↑Pre‐membrane pressure, decreased gas exchange, blood leaking from “gas out” port
• Acute vs. Chronic• Acute: Immediate loss of function within minutes • Chronic: Slow loss of function over hours
• Causing air entrainment or blood loss?• Can we fix the problem without coming off? (Usually stopcocks)• If air, did it reach the patient? Activate 4 step sequence and Air Embolism protocol
• If blood loss, activate 4 step sequence and replace connector or stopcock
Identify: Pump Malfunction
• Pump is unable to flow due to electrical, software, or other reasons• Verify that pump head is seated properly, check for kinks and obstructions, increase RPMs, verify cannulae placement, clot free
• Can pump recirculate through bridge?
• Activate 4 step sequence, leave circuit intact, move arterial head to new motor drive, reestablish blood flow
Just Remember
• Stay Calm !! STAY CALM !!!!
• Follow the 4‐step sequence • I, C&C, V, F
• You’ll be fine!
Technical Considerations of Acute Circulatory Support Michele Emory, PA-C
Michele R. Emory, PA-C, MMSUniversity of Chicago HospitalsLung Transplant and Acute MCS
October 21, 2019
Technical Considerations of Acute Circulatory Support
Disclosure Information2019 Acute Circulatory Support Symposium
• I have no financial relationships to disclose.
• Review of cannula types and sizes• Adults with Respiratory Failure
• Decision Making• Two Site• Single Site
• Adults with Cardiac Failure• Central cannulation • Peripheral cannulation
• Extracorporeal Cardiopulmonary Resuscitation in Adults• Patient selection
3
Outline Cannulas
4
“Arterial” sizes (F): 15, 17, 19, 20, 21, 23“Venous” sizes (F): 21, 23, 25, 27, 34, 36Long / ShortSingle‐stage / Multi‐stageStraight tip / Dispersion tip / Diffusion tip
Adults with Respiratory Failure
Decision Making
• Hypercarbia, hypoxia, or both
• Hemodynamically Supportable Respiratory failure
• Respiratory Failure with Unstable Hemodynamics
• Respiratory Failure and Sepsis
ECLS Cart
6
7
Adults with Respiratory Failure
VV ECLS Cannulation• Two site or Multiple
- Ultrasound
- Access sites: internal jugular and femoral vein
• Percutaneous Seldinger technique
• Initiation of support
RecirculationDecreasing arterial saturations with increasing pump flows
9
Adults with Respiratory Failure
VV ECLS Cannulation – Single site• Percutaneous Seldinger approach
• Serial Dilations
• Anticoagulation
• Final positioning
• Initiating support
- 0.5-1.0 liter/minmaximum flow
Adults with Respiratory Failure
VV ECLS Cannulation • Single site, Dual Lumen
• Preferred site RIJ
- Ultrasound
- Flouroscopy
- Echocardiography
• Flow limited by lumen diameter
12
Adults with Cardiac Failure
Cannulation Technique• Type of support
• Patient’s age and size
• Specific clinical situation
Central Cannulation
Peripheral Cannulation
Percutaneous Femoral Cannulation
-Knowledge of anatomy is key!
-Ultrasound guidance
-Initial access with micropuncture kit: 21G needle, 0.018” guidewire,
Multiple punctures‐ High pressure‐ Use micropuncture needle
Adults with Cardiac Failure
Initiation of flow• Maintain adequate hemodynamics and organ perfusion
• Target MAP 65-70 mmHg
• Goal Flow: 2.4 x Body Surface Area (BSA)
Anticoagulation vs. Bleeding
Additional Devices used simultaneously• LV Vent
• IABP
• Impella
Extracorporeal Cardiopulmonary Resuscitation in Adults
ECPRApplication of ECLS in patient who remain in cardiac arrest despite conventional CPR, or when intermittent ROSC occurs, but repetitive cardiac arrest reoccurs.
Optimal duration of refractory cardiac arrest prior to ECPR unknown
23
ECPR Cannulation
Patient Criteria
1.Witnessed sudden arrest
2.Assuption of cardiac etiology and reversible cause
3. High-quality CPR
4. Intermittent ROSC
5. No major comorbidities
6. Age on individual basis
QUESTIONS?
25
Resources
Brogan TV, Lequier L, Loruss R, MacLaren G, and Peek G. Extracoporeal Life Support: The ELSO Red Book, 5th Edition. 2017.
Camboni D, Philipp A, Lubnow M, et al. Extracorporeal membrane oxygenation by single-vessel access in adults: advantages and limitations. ASAIO J. 2012c; 58(6):616-621
Gothner M, Buchwald D, Strauch JT, Schildhauer TA, Swol J. The use of double lumen cannula for venovenous ECMO in trauma patients with ARDS. Scand J Trauma Resusc Emerg Med. 2015; 23: 30.
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Integration of Palliative Care into the Mechanical Circulatory Support Team Charles Rhee, MD
Integration of Palliative Care into theMechanical Circulatory Support Team
Charles Rhee, M.D.Assistant Professor of MedicineDirector, Cardiac Palliative Care ProgramSection of Geriatrics & Palliative MedicineDepartment of Medicine
Disclosures
• I have no financial or commercial relationships to disclose
2|
Misconceptions
“Palliative Care is the same thing as hospice”
OR
“Palliative care is only for dying people.”
3|
A brief look at where we came from…
4|
• The field of palliative care did arise from the hospice movement.
5|
NEJM, August 2010
6|
A paradigm shift
• The Temel study split patients with newly diagnosed metastatic non-small cell lung cancer into two groups : one receiving standard oncological care, the other receiving standard oncological care with palliative care support
• The study hoped to find an increase in quality of life measurements in the palliative care arm, which it found
• The surprise finding was that the palliative care arm showed a statistically significant increase in median survival (11.6 months vs. 8.9 months), despite having less aggressive care in the final days of life
7| 8|
9|
WHO Definition of Palliative Care
• Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:
• provides relief from pain and other distressing symptoms
• affirms life and regards dying as a normal process;
• intends neither to hasten or postpone death;
• integrates the psychological and spiritual aspects of patient care;
• offers a support system to help patients live as actively as possible until death;
• offers a support system to help the family cope during the patients illness and in their own bereavement;
• uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;
• will enhance quality of life, and may also positively influence the course of illness;
• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
10|
National Guidelines Regarding Palliative Care
• Growing number of guidelines from major cardiology societies, including the ACC Foundation, ISHLT, Heart Rhythm Society, and HF Society of America encouraging the use of palliative care into the care of patient with HF. Historically, these have focused on end-of-life decision making, especially with regard to device management
• More recently there has been an acknowledgement of the benefits of PC earlier in the disease trajectory, as well as involvement of PC in the decision making process.
• In 2012, the AHA issued a recommendation to refer to specialty palliative care for assistance with difficult decision making, symptom management in advanced disease, and caregiver support, emphasizing that “the use of palliative care services should not be considered equivalent to the withdrawal of disease modifying therapies.”
• In 2013, the ISHLT issued a recommendation that specialty palliative care consultation should be included in the treatment of end-stage HF during the evaluation phase for MCS
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LVADs and Palliative Care
• As of October, 2014, the Joint Commission (JCAHO) has mandated that institutions which perform destination VAD implantations must have a “palliative care representative on the core interdisciplinary team”
• Shortly after, the Center for Medicare and Medicaid Services (CMMS) mandated inclusion of palliative care specialists in the multi-disciplinary team caring for VAD recipients
12|
ELSO GUIDELINES FOR ECMO CENTERS
9. The following consultants should be available as needed. • Pediatric/adult neurology • Pediatric/adult nephrology • Pediatric/adult pulmonology • Pediatric/adult infectious disease • Occupational/physical therapist • Developmental/rehabilitation specialist • Speech therapy/feeding therapy specialist • Social Services/Palliative Care • Spiritual Support
13|
Current literature on palliative care in ECMO
• Scant research regarding palliative care in (adult) ECMO patients.
• One article from Columbia looked retrospectively at the number of ECMO patients who received palliative care consultations (48.2%) with an equal number consulted early (< 7 days of ECMO initiation) and late ( > 7 days).
• The remainder of the literature focuses primarily on the ethical issues surrounding ECMO, particularly discussing the concept of “futile care"
14|
• Case #1
• 64 year old male suffering massive MI, transferred from OSH, placed on ECMO emergently.
• During prolonged hospital admission, has a tumultuous course including PEA arrest, renal failure (placed on CVVH), GI bleed
• On day 34, patient develops AMS and is found to have a large hemorrhagic stroke
• Palliative care is consulted at this time to assist with goals of care
• Case #1B
• 64 year old male suffering massive MI, transferred from OSH, placed on ECMO emergently.
• During the first 72 hours, palliative care is consulted to support patient and family. After initial assessment, PC continues weekly visits and coordination with ECMO team
• During prolonged hospital admission, has a tumultuous course including PEA arrest, renal failure (placed on CVVH), GI bleed. On day 34, patient develops AMS and is found to have a large hemorrhagic stroke
15|
• Case #1 - Late involvement of palliative care
• “New face” or “another doctor”
• Difficult to achieve rapport/therapeutic alliance with family in short time frame, especially under stressful situations
• Palliative care team is not as familiar with the patient / family
• Case #1B – Early involvement of PC
• Allows for early introduction of the palliative care team in a less dire setting and “normalizes” the use of PC
• Allows for gradual rapport building with patient / family and more in depth conversations regarding their values
• Palliative care can assist with symptom management, including pain, anxiety, etc.
• Palliative care can provide family support through the entire illness and not simply at ”the end”
16|
Role of palliative care in supporting the ECMO team
• Numerous studies have shown the emotional toll caring for ECMO patients can have on the providers, particularly with the evolving concept of “moral distress” among staff
• Palliative care can assist with supporting staff, both by facilitating regular communications with the patient/family as well as leading communication training for the staff
• Palliative care can also assist with “debriefing sessions,” particularly after challenging cases
17|
In summary…
• Although there are no current firm guidelines, palliative care should be involved at the initiation of ECMO to maximize their supportive care for the patient and family during the entire hospital course and not simply at end-of-life situations
• Palliative care can also provide support to the members of the ECMO team, particularly in difficult cases / issues of “moral distress”
18|
Acknowledgements
• Cardiothoracic Surgery
– Tae Song
– Val Jeevanandam
– Vika Kagan
– Colleen LaBuhn
– Rebecca Rose
Cardiology
- Gene Kim
- Nir Uriel
- James Liao
• Palliative Medicine
– Stacie Levine
– Keith Swetz (UAB)
19|
Adding life to one’s years,
not simply years to one’s life.
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Building an Effective Team for Acute Circulatory Support: The Role of the Program Manager Colleen LaBuhn, APN
Colleen LaBuhn MSN, FNP-C, CCRN
Building a Successful MCS Program: The Role of The Program Manager
What is a program manger?
Acts as a coordinator with the best interests of the organization in mind. The program manager will supervise and organize the goals to align with the objectives of the team.
2
What is the main role of a program manager?
3
BEG FOR RESOURCES!!!
But really…..Do we beg??
We do…..we just do it in a formalized manner.
How do we get the resources we need and how do we determine what those resources are?
people, money, equipment, commitment
4
Start small and grow big
Identify what the goals are
Identify the resources
Become creative with the asks
5
Start with the structure that exists
Should we recreate the wheel??
How can you creatively utilize the resources you already have?
How can you get additional resources once identified?
6
Proving that the program is worth it
There must be a financial analysis
There must be buy in from administration.
Outcomes
Developing relationships with other hospitals
7
Build your team: What do you need?
Dedicated surgeon(s)
Cardiology partners
Nurse Practitioner support
Administrative support
Perfusion
ECMO specialist
8
The most important component of a successful program
Teamwork and Communication!!
9
How do we deal with multiple services that get involved?
Every team needs a quarterback
A central hub for information
The owner of the plan
10
Making sure the plan gets distributed
Meeting after meeting after meeting
Rounding after rounding after rounding
Communication, communication, communication
11
Debrief is crucial…..
Identify what worked
Identify what did not work
Identify areas of success
Identify areas of improvement
12
How do you build a referral base for ECMO??
Educate when to refer
Communicate with referring physician
Just say yes program
13
Follow up with the physicians
Regular follow up
Communication post discharge
May want to get creative with thank you options for referring physicians
14
Consistency is key…..
15 16
Thank you!!
Questions?
Acute Circulatory Support, Transport and FlightJannie White, RN
UUCCAANN aanndd EECCMMOO TTrraannssppoorrtt
Jannie White BSN, RN, CFRNUCAN Flight Nurse
I have no financial relationshipsto disclose
I will not discuss off label or investigational use in my presentation
Vehicle configurations
Preparation and Training Referral CriteriaIndications for V‐A ECMO
End organ hypoperfusion due to low cardiac output Cardiac index <2.2 L/min/m2 or SvO2 <60%
on two inotrpoes Rising lactate, worsening metabolic acidosis Hypotension requiring two or more of the
Contraindications for ECMO Referral Acute intracranial hemorrhage CPR >60 minutes Contraindications to anticoagulation Advanced cancer End stage liver disease End stage kidney disease
Referring Facilities are directed to contact: 773‐702‐1000: ECMO/Shock Pager 7722
Transport Specifics and Case Review Transport volumes
0
2
4
6
8
10
12
2019 2018 2017 2016
ECMO CannulationTotal transports
Transport RequestReferring Hospital request comes through ECMO pager or transfer center to ECMO teamUCAN team is notified of pending transport Pending bed status, UCAN team updates ECMO transport team on mode of transportation and timing
Team Mobilization
• Team configuration• 2 UCAN crew members are always required on transport
• CV Surgeon• ECMO Specialist• Perfusionist
• PA
• Cannulation vs Pt already on ECMO
• **Plan B**
• UCAN team mobilizes to transport:
• Ground vs Air• Multiple ambulance
Pre Transport Planning (Report)• UCAN flight nurse report
• Updated report from referring RN (standardized report sheet)
• Request (Cannulation)• T&S, ABG• 3 units PRBCs• 5% albumin• 5,000 units heparin• +/‐ extra vasoactive drips to bedside
• Request (ECMO)• T&S, ABG• 2‐3 units PRBCs• 5% albumin• +/‐ extra vasoactive drips to bedside
Report: Request for ECMO Cannulation for respiratory failure/ARDS. ‐ Rapidly deteriorating patient with flu like symptoms
‐ On NC yesterday‐ Now Peep +18 with SpO2 80’s
Pre‐transport planning (Equipment)
• UCAN team• Transport equipment for monitoring, medication administration (IV pumps), ventilation
• ECMO team• Transport Cardiohelp• ECMO bag
Pre Transport (Communication)
• Team briefing/patient report• Plan of care• Aircraft/Ambulance briefing
Transport (En Route to Patient)
• Safety First• Critical phases of flight• Controlled airspace• Clock Reporting• 4 to go, 1 to say no• Cell phones
At bedside• Abbreviated team assessment
• Patient on UCAN monitor
• Prep for cannulation• Coordinated on pump/transfer and titration of drips
• Coordinated patient movement
Transport (En route with patient)
• Communication
• Safety First• Critical phases of flight• Controlled airspace• Clock Reporting• 4 to go, 1 to say no
Transfer of care
• Stable patient• Standardized Report
“I’M UCAN”• Team coordinated movement
Post Transport
• Team debrief• Charting
• ECMO Physician Note• ECMO Specialist Note
• Fax to 2‐1993
• Charting details• ECMO settings on arrival• Cardiohelp settings on initiation or change of pumps
• Q15 min if stable• Q5 min if unstable or with changes
Lessons learned: Each case is different
I can hear you….• First case• 19 year old (73kg)• Hx asthma
• Intubated • Vent: AC 16‐450‐18‐100%• Propofol 65 mcg/kg/min
• PRBCs x2, 500ml heparin• Decreased propofol to 50mcg/kg/m
• Levophed added
• After recovery • Pt remembers events!
Hi Friend!• Called to cannulate for VV‐ECMO
• Hypoxic events with SpO2 60’s• AC 28‐400‐12‐85%• EF 55‐60%• Lung transplant work up
• Arrive bedside• Patient has a room mate…
• Uneventful cannulation and transport
We don’t always have to cannulate• Called to referring hospital 60min away to cannulate
