1
|
Ludwig A, Slota J, Nunes DA, Vranas KC, Kruser JM, Scott KS, Huang R, Johnson JK, Lagu TC, Nadig NR. Interhospital Transfer of Patients With Acute Respiratory Failure in the United States: A Scoping Review. Crit Care Explor 2024; 6:e1120. [PMID: 38968159 PMCID: PMC11230760 DOI: 10.1097/cce.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024] Open
Abstract
OBJECTIVES Interhospital transfer of patients with acute respiratory failure (ARF) is relevant in the current landscape of critical care delivery. However, current transfer practices for patients with ARF are highly variable, poorly formalized, and lack evidence. We aim to synthesize the existing evidence, identify knowledge gaps, and highlight persisting questions related to interhospital transfer of patients with ARF. DATA SOURCES Ovid Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, CINAHL Plus, and American Psychological Association. STUDY SELECTION We included studies that evaluated or described hospital transfers of adult (age > 18) patients with ARF between January 2020 and 2024 conducted in the United States. Using predetermined search terms and strategies, a total of 3369 articles were found across all databases. After deduplication, 1748 abstracts were screened by authors with 45 articles that advanced to full-text review. This yielded 16 studies that fit our inclusion criteria. DATA EXTRACTION The studies were reviewed in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews by three authors. DATA SYNTHESIS Included studies were mostly retrospective analyses of heterogeneous patients with various etiologies and severity of ARF. Overall, transferred patients were younger, had high severity of illness, and were more likely to have commercial insurance compared with nontransferred cohorts. There is a paucity of data examining why patients get transferred. Studies that retrospectively evaluated outcomes between transferred and nontransferred cohorts found no differences in mortality, although transferred patients have a longer length of stay. There is limited evidence to suggest that patients transferred early in their course have improved outcomes. CONCLUSIONS Our scoping review highlights the sparse evidence and the urgent need for further research into understanding the complexity behind ARF transfers. Future studies should focus on defining best practices to inform clinical decision-making and improve downstream outcomes.
Collapse
Affiliation(s)
- Amy Ludwig
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, IL
| | - Jennifer Slota
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Denise A. Nunes
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kelly C. Vranas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Jacqueline M. Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - Kelli S. Scott
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Reiping Huang
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julie K. Johnson
- Northwestern Quality Improvement, Research, and Education in Surgery (NQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Tara C. Lagu
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Nandita R. Nadig
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
2
|
Condella A, Lindo EG, Badulak J, Johnson NJ, Maine R, Mandell S, Town JA, Luks AM, Elizaga S, Bulger EM, Stewart BT. Veno-venous Extracorporeal Membrane Oxygenation for COVID-19: A Call For System-Wide Checks to Ensure Equitable Delivery For All. ASAIO J 2023; 69:272-277. [PMID: 36847809 PMCID: PMC9949367 DOI: 10.1097/mat.0000000000001823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has emerged in the COVID-19 pandemic as a potentially beneficial yet scare resource for treating critically ill patients, with variable allocation across the United States. The existing literature has not addressed barriers patients may face in access to ECMO as a result of healthcare inequity. We present a novel patient-centered framework of ECMO access, providing evidence for potential bias and opportunities to mitigate this bias at every stage between a marginalized patient's initial presentation to treatment with ECMO. While equitable access to ECMO support is a global challenge, this piece focuses primarily on patients in the United States with severe COVID-19-associated ARDS to draw from current literature on VV-ECMO for ARDS and does not address issues that affect ECMO access on a more international scale.
Collapse
Affiliation(s)
- Anna Condella
- From the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Washington
| | - Edwin G. Lindo
- School of Medicine, University of Washington, Washington
| | - Jenelle Badulak
- Department of Emergency Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Washington
| | - Nicholas J. Johnson
- Department of Emergency Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Washington
| | - Rebecca Maine
- Department of Surgery, University of Washington, Washington
| | - Samuel Mandell
- Parkland Hospital, University of Texas Southwestern, Dallas, Texas
| | - James A. Town
- From the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Washington
| | - Andrew M. Luks
- From the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Washington
| | - Shelby Elizaga
- Cardiothoracic Surgery, University of Washington, Washington
| | | | - Barclay T. Stewart
- Department of Surgery, University of Washington, Harborview Injury Prevention and Research Center, Washington
| |
Collapse
|
3
|
Sams VG, Anderson J, Hunninghake J, Gonzales M. Adult ECMO in the En Route Care Environment: Overview and Practical Considerations of Managing ECMO Patients During Transport. CURRENT TRAUMA REPORTS 2022; 8:246-258. [PMID: 36284567 PMCID: PMC9584252 DOI: 10.1007/s40719-022-00245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 11/05/2022]
Abstract
Purpose of Review The authors’ experience as a part of the U.S. Military ECMO program to include the challenges and successes learned from over 200 transports via ground and air is key to the expertise provided to this article. We review the topic of ECMO transport from a historical context in addition to current capabilities and significant developments in transport logistics, special patient populations, complications, and our own observations and approaches to include team complement and feasibility. Recent Findings ECMO has become an increasingly used resource during the last couple of decades with considerable increase during the Influenza pandemic of 2009 and the current COVID-19 pandemic. This has led to a corresponding increase in the air and ground transport of ECMO patients. Summary As centralized ECMO resources become available at health care centers, the need for safe and effective transport of patients on ECMO presents an opportunity for ongoing evaluation and development of safe practices.
Collapse
Affiliation(s)
- Valerie G. Sams
- grid.416653.30000 0004 0450 5663Department of Surgery, Trauma Critical Care, Brooke Army Medical Center, Ft Sam, Houston, TX USA
| | - Jess Anderson
- grid.416653.30000 0004 0450 5663Department of Medicine, Pulmonary Critical Care, Brooke Army Medical Center, Ft Sam, Houston, TX USA
| | - John Hunninghake
- grid.416653.30000 0004 0450 5663Department of Medicine, Pulmonary Critical Care, Brooke Army Medical Center, Ft Sam, Houston, TX USA
| | - Michael Gonzales
- grid.416653.30000 0004 0450 5663Department of Medicine, Pulmonary Critical Care, Brooke Army Medical Center, Ft Sam, Houston, TX USA
| |
Collapse
|
4
|
Abstract
OBJECTIVES To assess recent advances in interfacility critical care transport. DATA SOURCES PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
Collapse
|
5
|
Creel-Bulos C, Miller C, Hassani B, Farthing H, Caridi-Schieble M, Connor MJ, Javidfar J, Daneshmand M. "Pushing Geographic Boundaries: Interfacility transport and remote extracorporeal membrane oxygenation cannulation of patients during COVID-19 pandemic". Perfusion 2022; 38:725-733. [PMID: 35317693 PMCID: PMC8943490 DOI: 10.1177/02676591221078694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Amidst the pandemic, geographical boundaries presented challenges to those in
need of higher levels of care from referral centers. Authors sought to evaluate
potential predictors of treatment success; assess our transport and remote
cannulation process; and identify transport associated complications. Retrospective series of critically ill adults with COVID-19 transferred by our
Extracorporeal Membrane Oxygenation (ECMO) team 24 March 2020 through 8 June
2021. Descriptive statistics and associated interquartile ranges (IQR) were used
to summarize the data. Sixty-three patients with COVID associated acute respiratory distress syndrome
(ARDS) requiring ECMO support were admitted to our ECMO center. Mean age was
44 years old (SD 12; IQR 36–56). 59% (n = 37) of patients were
male. Average body mass index was 39.7 (SD 11.3; IQR 31–48.5). Majority of
patients (77.8%; n = 35) had severe ARDS. Predictors of
treatment success were not observed. Transport distances ranged from 2.2 to 236 miles (median 22.5 miles; IQR 8.3–79);
round trip times from 18 to 476 min (median 83 min; IQR
44–194). No transport associated complications occurred.
Median duration of ECMO support was 17 days (IQR 9.5–34.5). Length of stay in
the Intensive Care Unit (median 36 days; IQR 17–49) and hospital (median
39 days; IQR 25–57) varied. Amongst those discharged, 60% survived.
Collapse
Affiliation(s)
- Christina Creel-Bulos
- Division of Critical Care Medicine, Department of Anesthesiology, Emory Critical Care Center, 12239Emory University School of Medicine, Atlanta, GA, USA.,Department of Emergency Medicine, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Casey Miller
- Division of Cardiothoracic Surgery, Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Brian Hassani
- Division of Critical Care Medicine, Department of Anesthesiology, Emory Critical Care Center, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Heather Farthing
- Department of Emergency Medicine, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Mark Caridi-Schieble
- Division of Critical Care Medicine, Department of Anesthesiology, Emory Critical Care Center, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Michael J Connor
- Divisions of Pulmonary, Allergy, Critical Care, & Sleep Medicine, Division of Renal Medicine, Department of Medicine, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey Javidfar
- Division of Cardiothoracic Surgery, Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Mani Daneshmand
- Division of Cardiothoracic Surgery, Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
6
|
Hadaya J, Sanaiha Y, Gudzenko V, Qadir N, Singh S, Nsair A, Cho NY, Shemin RJ, Benharash P. Implementation and Outcomes of an Urban Mobile Adult Extracorporeal Life Support Program. JTCVS Tech 2022; 12:78-92. [PMID: 35403027 PMCID: PMC8987336 DOI: 10.1016/j.xjtc.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 12/04/2021] [Indexed: 11/26/2022] Open
Abstract
Objective Methods Results Conclusions
Collapse
|
7
|
Extracorporeal Membrane Oxygenation Rescue for Severe Aspiration Pneumonitis in Two Patients after Roux-en-y Gastric Bypass Procedure. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:199-203. [PMID: 34658412 DOI: 10.1182/ject-2100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/31/2021] [Indexed: 11/20/2022]
Abstract
Roux-en-y gastric bypass (RYGB) is one of the most common weight loss surgical procedures performed in the United States. Early post-operative small bowel obstruction is a rare but potentially morbid, complication of RYGB. We report two patients who underwent RYGB and required subsequent treatment for a post-operative small bowel obstruction. Their post-operative course was complicated by severe aspiration pneumonitis leading to hypoxemic respiratory failure requiring rescue with femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO). Both patients were successfully extubated, weaned off V-V ECMO support, and discharged to home. These cases highlight the potential role of V-V ECMO for patients who have undergone RYGB and develop severe aspiration pneumonitis. They also highlight the need for cautionary use of gastrografin in RYGB patients. Early engagement of a multidisciplinary team experienced with adult ECMO is vital for favorable patient outcomes.
Collapse
|
8
|
Welker C, Huang J, Ramakrishna H. Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support. J Cardiothorac Vasc Anesth 2021; 36:2207-2219. [PMID: 34332842 DOI: 10.1053/j.jvca.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.
Collapse
Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
9
|
Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
Collapse
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
10
|
Read MD, Nam JJ, Biscotti M, Piper LC, Thomas SB, Sams VG, Elliott BS, Negaard KA, Lantry JH, DellaVolpe JD, Batchinsky A, Cannon JW, Mason PE. Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team. Mil Med 2021; 185:e2055-e2060. [PMID: 32885813 DOI: 10.1093/milmed/usaa215] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/01/2020] [Accepted: 07/15/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients. MATERIALS AND METHODS We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth. RESULTS The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%. CONCLUSIONS Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.
Collapse
Affiliation(s)
- Matthew D Read
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Jason J Nam
- US Army Special Operations Command, Bldg X4047 New Dawn Drive, Fort Bragg, NC 78234
| | - Mauer Biscotti
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Lydia C Piper
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Sarah B Thomas
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Valerie G Sams
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | | | - Kathryn A Negaard
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - James H Lantry
- University of Maryland School of Medicine, 655 W Baltimore St S, Baltimore, MD 21201
| | - Jeffry D DellaVolpe
- Methodist Healthcare System, 8109 Fredericksburg Rd, San Antonio, TX 78229.,Geneva Foundation, 917 Pacific Ave, Tacoma, WA 98402
| | - Andriy Batchinsky
- Autonomous Reanimation and Evacuation Program, The Geneva Foundation, 917 Pacific Ave, Tacoma, WA 98402
| | - Jeremy W Cannon
- University of Pennsylvania and the Presbyterian Medical Center, 3801 Filbert St #212, Philadelphia, PA 19104
| | - Phillip E Mason
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| |
Collapse
|
11
|
Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
Collapse
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
| |
Collapse
|
12
|
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a "hub and spoke" model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate. OBJECTIVES The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA). METHODS This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events. RESULTS Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events. CONCLUSIONS In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.
Collapse
|
13
|
Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
Collapse
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
14
|
Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
Collapse
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
15
|
Akiyama D, Katagiri N, Mizuno T, Tsukiya T, Takewa Y, Tatsumi E. Preclinical biocompatibility study of ultra-compact durable ECMO system in chronic animal experiments for 2 weeks. J Artif Organs 2020; 23:335-341. [PMID: 32514701 DOI: 10.1007/s10047-020-01180-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/23/2020] [Indexed: 11/28/2022]
Abstract
Although the innovation has come in ECMO field, many problems remain unresolved. One of the main problems is about long-term durability and biocompatibility. Another is the system's size, weight, and its complicated equipment. For the former problem, we have previously developed ECMO system which consists of a tiny, hydrodynamically levitated centrifugal pump (BIOFLOAT-NCVC), a membrane oxygenator with hollow polyolefin fibers (BIOCUBE-NCVC), and the circuit treated with a heparin-bonding material (T-NCVC coating), and reported three cases of animal experiments for 30-day heparin-free drive. For the latter problem, we have integrated these elements to the compact system with sensors of temperature, pressure, and SvO2, and blood flow. Its installation area is 595 cm2, weighs 8.9 kg with attachable oxygen cassette, and battery which could last an hour at least. To evaluate the biocompatibility of this system, this ECMO was installed in four goats. Scheduled duration was 14 days. Heparin was continuously infused to control their ACT between 150 and 200 s except one 2-week experiment without systemic heparinization. All of the four goats survived till the scheduled termination. Function of the pump and the oxygenator during ECMO was stable. No obvious adverse events were observed. All lab data were of normal range after 1 week. Small infarctions were found at kidneys, but they were not clinically significant. No thrombus was found in the pump system. The oxygenators were extremely clean except a little thrombus formation; while, the heparin-free examination revealed acceptable cleanliness. The present study revealed good anti-thrombogenicity of this ultra-compact durable ECMO system with heparinization. Our system encourages awake and extubated management, rehabilitation, inter-hospital transfer, and prehospital initiation of ECMO.
Collapse
Affiliation(s)
- Daichi Akiyama
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan. .,Department of Cardiac Surgery, University of Tokyo Hospital, Tokyo, Japan.
| | - Nobumasa Katagiri
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Toshihide Mizuno
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Tomonori Tsukiya
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Yoshiaki Takewa
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Eisuke Tatsumi
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| |
Collapse
|
16
|
Vieira J, Frakes M, Cohen J, Wilcox S. Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting. Air Med J 2020; 39:124-132. [PMID: 32197690 DOI: 10.1016/j.amj.2019.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment. Coagulopathy and bleeding are the most common complications occurring in up to 50% of ECMO patients. Loss of flow and hypotension from loss of volume or profound vasodilation after ECMO initiation need to be managed accordingly. Oxygenator malfunction can occur, and clinicians must be able to recognize the indicators of this complication promptly. Loss of pulsatility, low end-tidal carbon dioxide (ETCO2), and differential hypoxia are common complications in venoarterial ECMO. In addition, an air embolism is life-threatening on venoarterial ECMO but may be better tolerated in the setting of venovenous ECMO. Recirculation in venovenous ECMO leads to circulation of poorly oxygenated blood and must be recognized and addressed. Lastly, pump failure, circuit rupture, and decannulation are devastating complications. Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has accelerated rapidly,1-3 providing support for patients in severe respiratory or cardiac failure. With ongoing clinical experience and improvements in technology, the indications for ECMO are increasing.4 Many areas are developing centralized ECMO centers to serve their surrounding communities.5-7 To use a centralized ECMO referral model, patients need access to effective, safe critical care transport, but transporting a patient on ECMO carries a significant risk of adverse events.8-13 The purpose of this review is to highlight some of the most common adverse events in ECMO transports and provide management suggestions. Note that these recommendations are not a substitution for close collaboration with medical control, and all adverse events should be promptly reported per organizational protocols.
Collapse
Affiliation(s)
| | | | - Jason Cohen
- Boston MedFlight, Bedford, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Susan Wilcox
- Boston MedFlight, Bedford, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
17
|
Ali JM, Vuylsteke A, Fowles JA, Pettit S, Salaunkey K, Bhagra S, Lewis C, Parameshwar J, Kydd A, Patvardhan C, Jones N, Rubino A, Abu-Omar Y, Sudarshan C, Tsui S, Catarino P, Jenkins DP, Berman M. Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:374-382. [DOI: 10.1053/j.jvca.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/10/2019] [Accepted: 05/11/2019] [Indexed: 01/06/2023]
|
18
|
Mihama T, Liem S, Cavarocchi N, Hirose H. Outcomes of out-of-hospital extracorporeal membrane oxygenation transfers: significance of initiation site and personnel. Perfusion 2020; 35:633-640. [PMID: 31948383 DOI: 10.1177/0267659119897784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation is an accepted therapy option for refractory cardiac or respiratory failure. The outcomes of cases initiated at non-extracorporeal membrane oxygenation centers and subsequently transported for management to an extracorporeal membrane oxygenation center require further investigation. METHODS Retrospective institutional review board-approved database research and chart reviews were performed on referrals for extracorporeal membrane oxygenation initially admitted to an outside non-extracorporeal membrane oxygenation center hospital (OSH) then transferred to our extracorporeal membrane oxygenation center (Thomas Jefferson University Hospital (TJUH)). Unstable patients were placed on extracorporeal membrane oxygenation at OSH (Group A) before transport, while others were initiated at our certified extracorporeal membrane oxygenation center (Group B) upon arrival. Group A was further subdivided into patients cannulated by OSH personnel (Group AOSH) or TJUH transport team (Group ATJUH). Outcomes and complications were compared between the different initiation sites and personnel. RESULTS A total of 108 patients were transferred from August 2010 to June 2018. The technical complication rate for all Group A patients was 33/49 (67%), while that of Group B was 24/59 (41%); p = 0.006. Within Group A, Group AOSH had a greater technical complication rate with 29/33 (88%) than Group ATJUH with 4/16 (25%); p < 0.001. extracorporeal membrane oxygenation survival rate was 34/49 (69%) in Group A and 43/59 (73%) in Group B; p = 0.690. The extracorporeal membrane oxygenation survival rate for Group AOSH and Group ATJUH was 21/33 (64%) and 13/16 (81%), respectively; p = 0.210. CONCLUSION Promising extracorporeal membrane oxygenation survival rates were observed in transferred patients. The complication rates related to cannulation technique were significantly higher when patients were initiated at non-extracorporeal membrane oxygenation centers, especially when placed by personnel from non-extracorporeal membrane oxygenation centers.
Collapse
Affiliation(s)
- Toru Mihama
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Spencer Liem
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
19
|
Eckman PM, Katz JN, El Banayosy A, Bohula EA, Sun B, van Diepen S. Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Circulation 2019; 140:2019-2037. [DOI: 10.1161/circulationaha.119.034512] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation has evolved, from a therapy that was selectively applied in the pediatric population in tertiary centers, to more widespread use in diverse forms of cardiopulmonary failure in all ages. We provide a practical review for cardiovascular clinicians on the application of veno-arterial extracorporeal membrane oxygenation in adult patients with cardiogenic shock, including epidemiology of cardiogenic shock, indications, contraindications, and the extracorporeal membrane oxygenation circuit. We also summarize cannulation techniques, practical management and troubleshooting, prognosis, and weaning and exit strategies, with attention to end of life and ethical considerations.
Collapse
Affiliation(s)
| | - Jason N. Katz
- Department of Medicine, Duke University Medical Center, Durham, NC (J.N.K.)
| | - Aly El Banayosy
- Department of Advanced Cardiac Care, INTEGRIS Baptist Medical Center, Oklahoma City, OK (A.E.B.)
| | - Erin A. Bohula
- Thrombosis in Myocardial Infarction Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (E.A.B.)
| | | | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.V.D.)
| |
Collapse
|
20
|
Vieira J, Frakes M, Cohen J, Wilcox S. Extracorporeal Membrane Oxygenation in Transport Part 1: Extracorporeal Membrane Oxygenation Configurations and Physiology. Air Med J 2019; 39:56-63. [PMID: 32044071 DOI: 10.1016/j.amj.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 12/30/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO), a term used to describe oxygenation that occurs outside of the body, is an increasingly common means of supporting the most critically ill patients. Because of the invasiveness and high probability of serious complications during ECMO, ECMO is typically indicated only when there is a high likelihood of death with conventional treatment. With continued improvements in technology and increasing clinical experience, transport clinicians are increasingly likely to be called on to transport patients on ECMO. ECMO can be initiated in 2 distinct forms, venovenous or venoarterial, and can primarily support the respiratory system or the cardiac and respiratory systems concurrently. This review will cover the basic physiology and components of ECMO as well as the preparation for ECMO transport for adults.
Collapse
Affiliation(s)
| | | | - Jason Cohen
- Boston MedFlight, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Susan Wilcox
- Boston MedFlight, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
21
|
Mazzeffi M, Del Rio JM, Gutsche J. Give Me Your Tired, Your Poor, Your Extracorporeal Membrane Oxygenation Patients. J Cardiothorac Vasc Anesth 2019; 33:3054-3055. [PMID: 31351876 DOI: 10.1053/j.jvca.2019.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - J Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jacob Gutsche
- Department of Anesthesiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| |
Collapse
|
22
|
Bonadonna D, Barac YD, Ranney DN, Rackley CR, Mumma K, Schroder JN, Milano CA, Daneshmand MA. Interhospital ECMO Transport: Regional Focus. Semin Thorac Cardiovasc Surg 2019; 31:327-334. [PMID: 30616006 DOI: 10.1053/j.semtcvs.2019.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/02/2019] [Indexed: 11/11/2022]
Abstract
Utilization of extracorporeal membrane oxygenation (ECMO) has increased dramatically over the last decade. Despite this trend, many medical centers have limited, if any, access to this technology or the resources necessary to manage these complex patients. In an effort to improve the current infrastructure of regional ECMO care, ECMO centers of excellence have an obligation to partner with facilities within their communities and regions to increase access to this potentially life-saving technology. While the need for this infrastructure is widely acknowledged in the ECMO community, few reports describe the actual mechanisms by which a successful interfacility transport program can operate. As such, the purpose of this document is to describe the elements of and methods for providing safe and efficient mobile ECMO services from the perspective of an experienced, high-volume tertiary ECMO center of excellence in the Southeastern United States.
Collapse
Affiliation(s)
- Desiree Bonadonna
- Duke University Medical Center, Perfusion Services, Durham, North Carolina
| | - Yaron D Barac
- Duke University Medical Center, Department of Surgery, Durham, North Carolina
| | - David N Ranney
- Duke University Medical Center, Department of Surgery, Durham, North Carolina
| | - Craig R Rackley
- Duke University Medical Center, Department of Medicine, Durham, North Carolina
| | - Kevin Mumma
- Duke University Medical Center, Duke Life Flight, Department of Emergency Medicine, Durham, North Carolina
| | - Jacob N Schroder
- Duke University Medical Center, Department of Surgery, Durham, North Carolina
| | - Carmelo A Milano
- Duke University Medical Center, Department of Surgery, Durham, North Carolina
| | - Mani A Daneshmand
- Duke University Medical Center, Department of Surgery, Durham, North Carolina.
| |
Collapse
|
23
|
Tipograf Y, Liou P, Oommen R, Agerstrand C, Abrams D, Brodie D, Bacchetta M. A decade of interfacility extracorporeal membrane oxygenation transport. J Thorac Cardiovasc Surg 2018; 157:1696-1706. [PMID: 30655061 DOI: 10.1016/j.jtcvs.2018.09.139] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/17/2018] [Accepted: 09/22/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) is used to provide support for patients with cardiopulmonary failure. Best available medical management often fails in these patients and referring hospitals have no further recourse for escalating care apart from transfer to a tertiary facility. In severely unstable patients, the only option might be to use ECMO to facilitate safe transport. This study aimed to examine the characteristics and outcomes of patients transported while receiving ECMO. METHODS Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients transported while receiving ECMO to Columbia University Medical Center between January 1, 2008, and December 31, 2017. RESULTS Two hundred sixty five adult patients were safely transported while receiving ECMO with no transport-related complications that adversely affected outcomes. Transport distance ranged from 0.2 to 7084 miles with a median distance of 16.9 miles. One hundred eighty-three (69%) received on veno-venous, 72 (27%) veno-arterial, and 10 (3.8%) veno-venous arterial or veno-arterial venous configurations. Two hundred ten (79%) cannulations were performed at our institution at the referring hospital. Sixty-four percent of patients transported while receiving ECMO survived to hospital discharge. CONCLUSIONS Interfacility transport during ECMO was shown to be safe and effective with minimal complications and favorable outcomes when performed at an experienced referral center using stringently applied protocols.
Collapse
Affiliation(s)
- Yuliya Tipograf
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Peter Liou
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Roy Oommen
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
| |
Collapse
|
24
|
McDonald MD, Laudanski K, Vernick WJ, Bhardawaj A, Mackay E, Gutsche JT. Acute Respiratory Failure Managed via Inter-Facility Transport for Extracorporeal Life Support: A 3-Year Experience. J Cardiothorac Vasc Anesth 2018; 33:1865-1870. [PMID: 30559066 DOI: 10.1053/j.jvca.2018.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of this study were as follows: (1) to describe a successful design for a mobile lung rescue program, focusing on challenges and resources required to support such a program, and (2) report short-term outcomes for patients placed on venovenous extracorporeal life support (VV-ECLS) by a transferring team before inter-facility transport to a specialized extracorporeal life support (ECLS) center. DESIGN This retrospective review and analysis used patient chart review to collect outcomes data and resource demand. SETTING A single institutional experience in an academic center in the United States. PARTICIPANTS Patient selection targeted the 75 patients who were placed on VV-ECLS for acute respiratory failure at an outside institution by the authors' team before transport from January 1, 2015, through December 31, 2017. INTERVENTIONS No intervention was made. MEASUREMENTS AND MAIN RESULTS Average time for dispatch and transfer was 4 hours and 10 minutes for ground and 3 hours and 30 minutes for air transport (p = 0.029). Demand was highest in winter, with 61% (46/75) of patients presenting from November through April, and daytime, with 73% (55/75) occurring from 8 am to 8 pm. Demand increased during the study period, with 21 patients in 2015, 24 in 2016, and 30 in 2017. Mortality was low, with 72% of patients surviving to discharge. CONCLUSIONS Herein a successful mobile lung rescue program for transfer to a regional ECLS center is described. These findings demonstrate bed availability during high census and presence of a physician for duration of transport. These challenges can be overcome and successful implementation can be made with low mortality, supporting the development of regional ECLS centers.
Collapse
Affiliation(s)
- Michael D McDonald
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - William J Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Abhishek Bhardawaj
- Medical Intensive Care Unit, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Emily Mackay
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA.
| |
Collapse
|
25
|
Vascular Complications and Use of a Distal Perfusion Cannula in Femorally Cannulated Patients on Extracorporeal Membrane Oxygenation. ASAIO J 2018; 64:328-333. [DOI: 10.1097/mat.0000000000000656] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|