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