A 22-year experience in global transport extracorporeal membrane oxygenation

Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel.

OBJECTIVES

To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams.

METHODS

Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired.

RESULTS

Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%).

CONCLUSIONS

An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.

Perspectives from military neonatal transport: past, present, and future

This article traces the historical development of neonatal transport, from ancient Greek mythology to the modern era, with a particular focus on the contributions of U.S. military aviation. The narrative begins with early efforts in thermoregulation through stationary incubators and progresses to the pivotal role of aerial hospitals during World War II. Post-WWII, the establishment of neonatal transport services in New York and advancements in incubator technology set the stage for further innovation. The U.S. military's involvement in neonatal transport, initiated in the 1970s, witnessed significant milestones, including the adaptation of ECMO technology for air transport. The narrative unfolds through the lens of U.S. military neonatology in the Western Pacific, particularly at Clark Air Base. The article concludes with insights into the U.S. Indo-Pacific Command's neonatal transport mission, highlighting challenges faced during the SARS-CoV-2/COVID-19 pandemic and the development of specialized infection containment transport systems.

A model for delivery of extracorporeal life support in a stand-alone veterans affairs medical center

INTRODUCTION

For the Veterans Health Administration (VHA) to continue to perform complex cardiothoracic surgery, there must be an established pathway for providing urgent/emergent extracorporeal life support (ECLS). Partnership with a nearby tertiary care center with such expertise may be the most resource-efficient way to provide ECLS services to patients in post-cardiotomy cardiogenic shock or respiratory failure. The goal of this project was to assess the efficiency, safety, and outcomes of surgical patients who required transfer for perioperative ECLS from a single stand-alone Veterans Affairs Medical Center (VAMC) to a separate ECLS center.

METHODS

Cohort consisted of all cardiothoracic surgery patients who experienced cardiogenic shock or refractory respiratory failure at the local VAMC requiring urgent or emergent institution of ECLS between 2019 and 2022. The primary outcomes are the safety and timeliness of transport.

RESULTS

Mean time from the initial shock call to arrival at the ECLS center was 2.8 h. There were no complications during transfer. Six patients (86%) survived to decannulation.

CONCLUSION

These results suggest that complex cardiothoracic surgery can be performed within the VHA system and when there is an indication for ECLS, those services can be safely and effectively provided at an affiliated, properly equipped center.

Primary neonatal and pediatric ECMO transport: First experience in Spain

INTRODUCTION

The organization of primary Extracorporeal membrane oxygenation (ECMO) transport is highly variable.

METHODS

To present the experience of the first mobile pediatric ECMO program in Spain, we designed a prospective descriptive study of all primary neonatal and pediatric (0-16 years) ECMO transports carried out over 10 years. The main variables recorded include demographic information, patient background, clinical data, ECMO indications, adverse events, and main outcomes.

RESULTS

39 primary ECMO transports were carried out with a 66.7% survival to hospital discharge. The median age was 1.24 months[IQR: 0.09-96]. Cannulation was mostly peripheral venoarterial (33/39). The mean response time from the call from the sending center to the departure of the ECMO team was 4 h[2.2-8]. The median inotropic score at the time of cannulation was 70[17.2-206.5], with a median oxygenation index of 40.5[29-65]. In 10% of the cases, ECMO-CPR was performed. Adverse events occurred in 56.4%, mostly related to the means of transport (40% overall). On arrival at the ECMO center, 44% of the patients underwent interventions. The median PICU stay was 20.5 days[11-32]. 5 patients developed neurological sequels. Statistically significant differences between survivors and deceased patients were not found.

CONCLUSIONS

A good survival rate, with a low prevalence of serious adverse events, suggests a clear benefit of primary ECMO transport when conventional therapeutic measures are exhausted and the patient is too unstable to undergo conventional transport. A nationwide primary ECMO-transport program must therefore be offered to all patients regardless of their location.

Transportation of patients under extracorporeal membrane oxygenation support on an airliner: Flying bridge to transplantation

BACKGROUND

A retrieval programme was developed in Martinique (French West Indies) to provide extracorporeal membrane oxygenation for patients in the Caribbean, where heart transplantation and ventricular assist devices are not available. In 2011, the Department of Cardiac Surgery at the University Hospital of Fort-de-France (Martinique) developed a transfer programme to Paris (France) on an airliner, to refer patients for whom extracorporeal membrane oxygenation was not weanable to heart transplantation or a ventricular assist device.

AIM

To report this unique experience of transportation of patients under extracorporeal membrane oxygenation support on an airliner from the French West Indies to Paris.

METHODS

This was an observational and retrospective study of all patients under extracorporeal membrane oxygenation support who were transferred from Martinique to the Pitié-Salpêtrière Hospital/Sorbonne University in Paris between September 2011 and September 2019. Transport characteristics, complications during repatriation, cost and clinical outcomes at 30days and 1year were reported.

RESULTS

Twenty-six patients were transferred on an airliner; the retrieval distance was 7260km, and the mean duration was 14hours. Only two patients developed complications (pulmonary oedema and leg ischaemia), and no patient died during the flight. Nine patients had a ventricular assist device implanted, and six patients were transplanted. Thirty-day survival was 65.4%, and 1-year survival was 38.5%.

CONCLUSIONS

Transport under extracorporeal membrane oxygenation support on an airliner is safe and efficient, with an acceptable cost. This programme allowed patients under extracorporeal membrane oxygenation support in a remote centre, without access to transplantation or a ventricular assist device, to be referred for these techniques in specialized centres. This experience strengthens the strategy of developing regional networks around specialized extracorporeal membrane oxygenation centres.

Intensivist-Led Transportation of Patients on Extracorporeal Membrane Oxygenation: A Single Center Experience

This study evaluated the suitability, feasibility, safety, and outcomes of transport of the ECMO-dependent patient (EDP) by EDP transport team (EDPTT) in China. Eighty-two EDPs (forty-one cases on VV ECMO and forty-one cases on VA ECMO) received transport between June 2018 and June 2021 and were retrospectively analyzed. ECMO circulation was performed by the outlying hospital, mainly using percutaneous ECMO cannulation. The EDPTT consists of three intensive therapists, one of whom serves as a team leader, and one intensive care unit nurse. Of these, 81 (98.8%) patients were transferred by ambulance, no deaths occurred during transport, the EDP-related complications were 19% (n = 16); bleeding at the cannula site (n = 7, 8.5%) was the most prominent; equipment-related problems accounted for 14.6% of the problems requiring urgent intervention, with hand cranking being the most common (9.7%). The survival rate during transport was 100%, with 36 (43.9%) patients surviving to discharge. The ECMO weaning rate was 61% for VV ECMO and 63.7% for VA ECMO. The results demonstrated the suitability, feasibility, and safety of transporting EDP in a team led by an intensivist, with few complications and no deaths during transport. This may be the recommended staffing model for EDP transport in developing countries.

Adult ECMO in the En Route Care Environment: Overview and Practical Considerations of Managing ECMO Patients During Transport

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.

Outcomes of Patients Undergoing Interfacility Extracorporeal Membrane Oxygenation Transfer Based on Cannulation Location and Mode of Transport

As the use of extracorporeal membrane oxygenation (ECMO) expands, so has the need for interfacility transfer to ECMO centers. However, the impact of these transfers has not been fully studied. This study evaluates complications and inhospital mortality in adult patients treated with venovenous (V-V) ECMO based on institutional location of cannulation and mode of transport.

Pediatric Extracorporeal Life Support Transport in Western Canada: Experience over 14 years

This retrospective cohort study describes all children transported on extracorporeal life support (ECLS) by the Stollery Children's Hospital Pediatric Transport team (SCH-PTT) between 2004 and 2018. We compared outcomes and complications between primary (SCH-PTT performed ECLS cannulation) vs. secondary (cannulation performed by referring facility) transports, as well as secondary transports from referring centers with and without an established ECLS cannulation program. SCH-PTT performed 68 ECLS transports during the study period. Median (IQR) transport distance was 298 (298-1,068) kilometers. Mean (SD) times from referral call to ECLS-initiation were: primary transports 7.8 (2.9) vs. 2.5(3.5) hours for secondary transports, p value < 0.001. Complications were common (n = 65, 95%) but solved without leading to adverse outcomes. There were no significant differences in the number of complications between primary and secondary transports. There was no significant difference in survival to ECLS decannulation between primary 9 (90%) and secondary transports 43 (74%), p value = 0.275. ECLS survival was higher for children cannulated by the SCH-PTT or a center with an ECLS cannulation program: 42 (82%) vs. 10 (59%), p value = 0.048. Critically ill children on ECLS can be safely transported by a specialized pediatric ECLS transport team. Secondary transports from a center with an ECLS cannulation program are also safe and have similar results as primary transports.

Unité mobile d’assistance circulatoire et respiratoire de l’enfant et du nouveau-né : une revue narrative

Les unités mobiles d’assistance circulatoire et respiratoire de l’enfant et du nouveau-né se sont développées au cours des dix dernières années. En effet, la mise en place d’une suppléance extracorporelle respiratoire ou circulatoire nécessite une équipe expérimentée et n’est pas disponible dans tous les centres hospitaliers pédiatriques. Or, les enfants atteints d’une défaillance circulatoire ou respiratoire réfractaire ne sont, pour la plupart, pas déplaçables vers une unité délivrant ce type de traitement de sauvetage. Les unités mobiles ont donc pour objectif de mettre à disposition ces technologies d’exception sur l’ensemble du territoire afin de garantir une égalité d’accès aux soins. Cependant, la haute technicité de ces thérapeutiques nécessite une équipe entraînée sachant poser et régler une assistance extracorporelle, prendre en charge un patient en défaillance respiratoire et/ou hémodynamique réfractaire et aguerrie à ces transports à haut risque. Le territoire français était jusqu’en 2014 très mal couvert par les unités mobiles pédiatriques et néonatales. Depuis, la création de plusieurs unités a permis une couverture totale du territoire. L’objectif de cette revue narrative sur les unités mobiles pédiatriques et néonatales est de résumer les différentes modalités de suppléance respiratoire et hémodynamique extracorporelle, d’en illustrer leurs différentes missions et leurs modalités de fonctionnement. Nous finirons par une description de leur efficacité en termes de survie et de survenue d’incidents en cours de transport.

Implementation and Outcomes of a Mobile Extracorporeal Membrane Oxygenation Program in the United States During the Coronavirus Disease 2019 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic began in the United States around March 2020. Because of limited access to extracorporeal membrane oxygenation (ECMO) in the authors' region, a mobile ECMO team was implemented by April 2020 to serve patients with COVID-19. Several logistical and operational needs were assessed and addressed to ensure a successful program, including credentialing, equipment management, and transportation. A multidisciplinary team was included in the planning, decision-making, and implementation of the mobile ECMO. From April 2020 to January 2021, mobile ECMO was provided to 22 patients in 13 facilities across four southern California counties. The survival to hospital discharge of patients with COVID-19 who received mobile ECMO was 52.4% (11 of 21) compared with 45.2% (14 of 31) for similar patients cannulated in-house. No significant patient or transportation complications occurred during mobile ECMO. Neither the ECMO nor transport teams experianced unprotected exposures to or infections with severe acute respiratory syndrome coronavirus 2. Herein, the implementation of the mobile ECMO team is reviewed, and patient characteristics and outcomes are described.

[Patient transport and networks for use of extracorporeal life support]

Neue Technologien und die kontinuierliche Weiterentwicklung extrakorporaler Unterstützungssysteme haben das Anwendungsspektrum des Extracorporeal Life Support (ECLS) in den letzten Jahren erweitert. Neben dem Einsatz im kardiogenen Schock oder unter Reanimation nehmen die Anfragen zur Übernahme instabiler Patienten aus peripheren Krankenhäusern zu. Durch organisatorische Herausforderungen wie die Etablierung von Netzwerken und ein strukturiertes Teamtraining aller Beteiligten ergibt sich eine rasche Verfügbarkeit des ECLS-Teams, um schnell beim zu versorgenden Patienten einzutreffen.

Rates of nosocomial infection associated with interhospital transfer of patients receiving extracorporeal membrane oxygenation

OBJECTIVES

Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) frequently require interhospital transfer to a center that has ECMO capabilities. Patients receiving ECMO were evaluated to determine whether interhospital transfer was a risk factor for subsequent development of a nosocomial infection.

DESIGN

Retrospective cohort study.

SETTING

A 425-bed academic tertiary-care hospital.

PATIENTS

All adult patients who received ECMO for >48 hours between May 2012 and May 2020.

METHODS

The rate of nosocomial infections for patients receiving ECMO was compared between patients who were cannulated at the ECMO center and patients who were cannulated at a hospital without ECMO capabilities and transported to the ECMO center for further care. Additionally, time to infection, organisms responsible for infection, and site of infection were compared.

RESULTS

In total, 123 patients were included in analysis. For the primary outcome of nosocomial infection, there was no difference in number of infections per 1,000 ECMO days (25.4 vs 29.4; P = .03) by univariate analysis. By Cox proportional hazard analysis, transport was not significantly associated with increased infections (hazard ratio, 1.7; 95% confidence interval, 0.8-4.2; P = .20).

CONCLUSION

In this study, we did not identify an increased risk of nosocomial infection during subsequent hospitalization. Further studies are needed to identify sources of nosocomial infection in this high-risk population.

Safety of Interhospital ECMO Transport by Low-Volume ECMO Transport Centers

We present our 20 years of experience as a low-volume extracorporeal membrane oxygenation (ECMO) transport center from the Southeast United States. This is a retrospective chart review of all ECMO transported patients between 1998 and 2017. Of 26 patients who were ECMO transported, median age was 15.5 days, 14 patients (54%) were neonates, 18 (69%) patients had primary cardiac pathologies, and 16 (61.5%) patients had primary ECMO transport. Median distance traveled was 81 miles. All patients were on venoarterial ECMO. Complications occurred in three patients (11.5%). Survival to discharge was 69%. Neonatal and pediatric ECMO transport by a low-volume ECMO transport center is safe.

Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team

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.

Pediatric Extracorporeal Membrane Oxygenation Reach-Out Program: Successes and Insights

The shortage of dedicated pediatric extracorporeal membrane oxygenation (ECMO) centers and the expanding indications for pediatric ECMO necessitate a regional program for transport of ECMO-supported patients. Data about feasibly and safety of pediatric ECMO transport are scarce. Our aim is to describe our experience with a pediatric ECMO reach-out program and review pertinent literature. Demographic, clinical, and outcome data were collected retrospectively from the charts of all patients cannulated onto ECMO at referring centers and transported to our center from 2003 to 2018. Similar data were recorded for patients who were referred for ECMO support from within the hospital. The cohort included 80 patients cannulated at 17 referring centers. The transport team included a senior pediatric cardiac surgeon and an ECMO specialist. All transfers but one were done by special emergency medical service ambulance. No major complications or deaths occurred during transport, and all patients were stable upon arrival to our unit. Mortality was lower in the ECMO reach-out cohort than in-house patients referred for ECMO support. This is the first study from Israel and one of the largest to date describing a dedicated pediatric ECMO transport program. Extracorporeal membrane oxygenation transport appears to be feasible and safe when conducted by a small, highly skilled mobile team. Successful reach-out program requires open communication between the referring physician and the accepting center. As survival correlates with ECMO volume, maintaining a large ECMO center with 24/7 retrieval capabilities may be the best strategy for pediatric mechanical circulatory support program.

Patient Safety during ECMO Transportation: Single Center Experience and Literature Review

Background

Extracorporeal membrane oxygenation (ECMO) has been proven to support in lifesaving rescue therapy. The best outcomes can be achieved in high-volume ECMO centers with dedicated emergency transport teams.

Aim

The aim of this study was to analyze the safety of ECMO support during medical transfer on the basis of our experience developed on innovation cooperation and review of literature.

Methods

A retrospective analysis of our experience of all ECMO-supported patients transferred from regional hospital of the referential ECMO center between 2015 and 2020 was carried out. Special attention was paid to transportation-related mortality and morbidity. Moreover, a systematic review of the Medline, Embase, Cochrane, and Google Scholar databases was performed. It included the original papers published before the end of 2019.

Results

Twelve (5 women and 7 men) critically ill ECMO-supported patients with the median age of 33 years (2-63 years) were transferred to our ECMO center. In 92% (n = 11) of the cases venovenous and in 1 case, venoarterial supports were applied. The median transfer length was 45 km (5-200). There was no mortality during transfer and no serious adverse events occurred. Of note, the first ECMO-supported transfer had been proceeded by high-fidelity simulations. For our systematic review, 68 articles were found and 22 of them satisfied the search criteria. A total number of 2647 transfers were reported, mainly primary (90%) and as ground transportations (91.6%). A rate of adverse events ranged from 1% through 20% but notably only major complications were mentioned. The 4 deaths occurred during transport (mortality 0.15%).

Conclusions

Our experiences and literature review showed that transportation for ECMO patients done by experienced staff was associated with low mortality rate but life-threatening adverse events might occur. Translational simulation is an excellent probing technique to improve transportation safety.

The "Hub and Spoke" (HandS) ECMO for "Resuscitating" Neonates with Respiratory Life-Threatening Conditions

Background: Extracorporeal membrane oxygenation (ECMO) implantation for neonates with severe cardiorespiratory life-threatening conditions is highly effective. However, since ECMO is a high-risk and complex therapy, this treatment is usually performed in centers with proven expertise. Methods: A retrospective review of neonates, from January 2014 to January 2020, presenting with life-threatening conditions and treated by means of Hub and Spoke (HandS) ECMO in peripheral (spoke) hospitals. Data were retrieved from our internal ECMO registry. Protocols and checklists were revised and shared with all spoke hospitals located in North-Eastern Italy. Results: Eleven neonates receiving maximal respiratory and cardiovascular support at a spoke hospital underwent HandS ECMO management. All but three patients were affected by life-threatening meconium aspiration syndrome (MAS). The median ECMO support duration and hospitalization were four (range 2–32) and 30 days (range 8–50), respectively. All but two patients (with congenital diaphragmatic hernia), were weaned off ECMO and discharged home. At a mean follow up of 33.7 ± 29.2 months, all survivors were alive and well, without medications, and normal somatic growth. All but one had normal neuropsychological development. Conclusion: HandS ECMO model for neonates with life-threatening conditions is effective and successful. A specialized multidisciplinary team and close cooperation between Hub and Spoke centers are essential for success.

Simulation study on flow rate accuracy of infusion pumps in vibration conditions during emergency patient transport

Infusion pumps are frequently used when transferring critically ill patients via patient transport cart, ambulance, or helicopter. However, the performance of various infusion pumps under these circumstances has not been explored. The aim of this study was to evaluate the flow rate accuracy of infusion pumps under various clinical vibration conditions. Experiments were conducted with four different types of pumps, including two conventional syringe pumps (Injectomat MC Agilia, Fresenius Kabi and TE-331, Terumo), one conventional peristaltic pump (Volumed μVP7000; Arcomed), and one new cylinder pump (H-100, Meinntech). The flow rate was measured using an infusion pump analyzer on a stable table (0 m/s²) for 1 h with 1 ml/h and 5 ml/h. Experiments were repeated in mild vibration (2 m/s²) (representing vibration of patients in a moving stretcher or ambulance), and in moderate vibration (6 m/s²) (representing vibration in helicopter transport). Any accidental bolus occurrence in extreme vibration situations (20 m/s²) was also analyzed. Simulated vibrations were reproduced by a custom-made vibration table. In the resting state without vibration and in mild vibration conditions, all pumps maintained good performance. However, in moderate vibration, flow rates in syringe pumps increased beyond their known error ranges, while flow rates in peristaltic pumps remained stable. In extreme vibration, accidental fluid bolus occurred in syringe pumps but not in peristaltic pumps. The newly developed cylinder pump maintained stable performance and was unaffected by external vibration environments.

International Survey on Extracorporeal Membrane Oxygenation Transport

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for severe respiratory and circulatory failure. It is best performed in high-volume centers to optimize resource utilization and outcomes. Regionalization of ECMO might require the implementation of therapy before and during transfer to the high-volume center. The aim of this international survey was to describe the manner in which interhospital ECMO transport care is organized at experienced centers. Fifteen mobile ECMO centers from nine countries participated in this survey. Seven (47%) of them operated under the "Hub-and-Spoke" model. Transport team composition varies from three to nine members, with at least one ECMO specialist (i.e., nurse or perfusionist) participating in all centers, although intensivists and surgeons were present in 69% and 50% of the teams, respectively. All centers responded that the final decision to initiate ECMO is multidisciplinary and made bedside at the referring hospital. Most centers (75%) have a quality control system; all teams practice simulation and water drills. Considering the variability in ECMO transport teams among experienced centers, continuous education, training and quality control within each organization itself are necessary to avoid adverse events and maintain a low mortality rate. A specific international ECMO Transport platform to share data, benchmark outcomes, promote standardization, and provide quality control is required.

Mobile Extracorporeal Membrane Oxygenation: 5-Year Experience of a French Pediatric and Neonatal Center

OBJECTIVES

Extracorporeal membrane oxygenation is an established therapy for refractory cardiac and/or pulmonary failure that is not available in all centers. When infants and children require extracorporeal membrane oxygenation, they are sometimes placed on extracorporeal membrane oxygenation support in peripheral centers where extracorporeal membrane oxygenation is not available and then transferred on extracorporeal membrane oxygenation to specialized centers. The objective of this study is to first describe one of the largest cohorts of infants and children transported by a mobile unit while on extracorporeal membrane oxygenation.

DESIGN

We undertook a single-center retrospective study that included patients transported while on extracorporeal membrane oxygenation between November 1, 2014, and May 31, 2019.

PATIENTS

All patients transported by our mobile extracorporeal membrane oxygenation unit during the study period were included. Computerized data collection was approved by the French Data Protection Authority (Commission nationale de l'informatique et des libertés n° 2121127V0).

MAIN RESULTS

Over the study period, our extracorporeal membrane oxygenation mobile team transported 80 patients on extracorporeal membrane oxygenation among which 20 were newborns (25%) and 60 were children of 1 month to 17 years old (75%); 57 patients were on venoarterial-extracorporeal membrane oxygenation (71%) and 23 on venovenous-extracorporeal membrane oxygenation (29%). The average duration of transport was 8.4 hours with a median of 8 hours; the average distance travelled was 189 ± 140 km. Transport was by air and then ground for 50% of the patients and by ground for 42%. We observed a significant decrease in the Vasoactive-Inotropic Score (125 vs 99; p = 0.005) and PaCO2 levels (67 vs 49 mm Hg; p = 0.0005) after arrival in our unit. Survival rate 6 months after PICU discharge was 46% (37). There was a statistically significant relationship between initial lactate level and mortality (p = 0.02). We observed minor adverse events in 39% of the transports and had no mortality during transport.

CONCLUSIONS

We describe one of the largest cohorts of infants and children transported by a mobile unit while on extracorporeal membrane oxygenation. Our findings confirm that it is safe to start extracorporeal membrane oxygenation in a referring center and to transport patients using an extracorporeal membrane oxygenation mobile team. The only risk factor associated with higher mortality was an initially elevated lactate level.

Thromboelastography on-the-go: Evaluation of the TEG 6s device during ground and high-altitude Aeromedical Evacuation with extracorporeal life support

BACKGROUND

Coagulation monitoring capabilities during transport are limited. Thromboelastography (TEG) is a whole-blood clotting test measuring clot formation, stabilization, and fibrinolysis and is traditionally performed in a laboratory. We evaluated a new point-of-care TEG analyzer, TEG 6s (Haemonetics, Braintree, MA), in a large animal model of combat-relevant trauma managed with extracorporeal life support during ground and high-altitude aeromedical evacuation. The objective was to compare TEG 6s used during transport versus the predicate device, TEG 5000, used in the laboratory. We hypothesized that TEG 6s would be comparable with TEG 5000 during dynamically changing transport conditions.

METHODS

Thromboelastography parameters (R, K, angle, MA, LY30) derived by TEG 6s and TEG 5000 were compared during transport of 8 swine. TEG 6s was transported with animals during ground transport and flight. TEG 5000 was stationary in an adjacent building. TEG 6s activated clotting time (ACT) was compared with a Hemochron Junior ACT analyzer (Accriva Diagnostics, San Diego, CA). Statistics were performed using SAS 9.4 with Deming regressions, Spearman correlations, and average differences compared.

RESULTS

Correlation between devices was stronger at sea-level (R, r = 0.7413; K, r = 0.7115; angle, r = 0.7192; MA, r = 0.8386; LY30, r = 0.9099) than during high-altitude transport (R, r = 0.4787; K, r = 0.4007; angle, r = 0.3706; MA, r = 0.6573; LY30, r = 0.8481). Method agreement was comparable during stationary operation (R, r = 0.7978; K, r = 0.7974; angle, r = 0.7574; MA, r = 0.7841; LY30, r = 0.9140) versus ground transport (R, r = 0.7927; K, r = 0.6246; angle, r = 0.6967; MA, r = 0.9163; LY30, r = 0.8603). TEG 6s ACT trended higher than Hemochron ACT when subjects were heparinized (average difference, 1,442 ± 1,703 seconds) without a methodological difference by Deming regression.

CONCLUSION

Mobile TEG 6s during ground and altitude transport is feasible and provides unprecedented information to guide coagulation management. Future studies should assess the precision and accuracy of TEG 6s during transport of critically ill.

Past and present role of extracorporeal membrane oxygenation in combat casualty care: How far will we go?

Advanced extracorporeal therapies have been successfully applied in the austere environment of combat casualty care over the previous decade. In this review, we describe the historic underpinnings of extracorporeal membrane oxygenation, review the recent experience with both partial and full lung support during combat operations, and critically assess both the current status of the Department of Defense extracorporeal membrane oxygenation program and the way forward to establish long-range lung rescue therapy as a routine capability for combat casualty care.

Safety and Flight Considerations for Mechanical Circulatory Support Devices During Air Medical Transport and Evacuation: A Systematic Narrative Review of the Literature

OBJECTIVE

The air medical transportation industry has seen a steady rise in the use of mechanical circulatory support devices (eg, intra-aortic balloon pumps, ventricular assist devices, and extracorporeal membrane oxygenation) during transport missions, either for definitive management or repatriation. As these complex devices become more common, the industry will have to adapt to support their use in their clientele. The goal of this narrative review was to assess our current experiences regarding mechanical circulatory support devices in air medical transportation and to identify important factors to ensure successful transport.

METHODS

We conducted a systematic search on MEDLINE and Embase using the following search terms: aeromedical transportation, air transportation, intra-aortic balloon pump, ventricular assist device, and extracorporeal membrane oxygenation. Results were cross-referenced to identify articles addressing both air medical transport and mechanical circulatory support devices.

RESULTS

After a systematic review of the available literature, 49 articles addressing mechanical support devices transported by rotary wing and fixed wing aircraft were reviewed. In summary, our review encompassed 811 total aerial transports (152 by balloon pumps, 12 by ventricular assist devices, and 647 by extracorporeal membrane oxygenation). We found air medical transportation with these devices carried out in the public, private, or military sectors, to be safe, with low rates of serious adverse events. Dedicated training sessions focused on device troubleshooting and problem-solving during transport, optimal medical crew composition, predeparture logistical preparations, and on-demand specialist consultation can improve mission success.

CONCLUSION

We report that air medical transportation of patients supported by mechanical circulatory support devices is safe. Complications can be mitigated by training and addressed either during the predeparture or in-transportation phase.

The first five years of neonatal and pediatric transports on extracorporeal membrane oxygenation in the center and south of Italy: The pediatric branch of the Italian "Rete Respira" network

INTRODUCTION

Neonatal and pediatric ECMO is a high-risk procedure that should be performed only in expert centers. Children who are eligible for ECMO and are managed in hospitals without ECMO capabilities should be referred to the closest ECMO center before the severity of illness precludes safe conventional transport. When the clinical situation precludes safe conventional transport, ECMO should be provided on site with the patient transported on ECMO.

METHODS

We retrospectively reviewed our institutional database of all ECMO transports for neonatal and pediatric respiratory failure from February 2013 to February 2018.

RESULTS

Over the last 5 years, we provided 24 transports covering all requests from the center and south of Italy except for the islands. Of these transports, 20 were performed on ECMO and 4 without ECMO. No patient died during transportation. Five complications were reported only during the ECMO transports, and all of these were managed without compromising the patient's safety. The preferred modes of transport were by ambulance (70%) and ambulance transported into the fixed wing aircraft (30%) for longer national distances. The survival to hospital discharge of the patients transported with ECMO was 75% among the neonatal transports and 83.3% among the pediatric transports. The survival to hospital discharge of the four patients transported without ECMO was 100% for both neonates and children.

CONCLUSIONS

Neonatal and pediatric ECMO transports can be safely performed with a dedicated team that maintains stringent adherence to well-designed management protocols.

BEST Life-"Bringing ECMO Simulation To Life"-How Medical Simulation Improved a Regional ECMO Program

The implemented "ECMO for Greater Poland" program takes full advantage of the ECMO (extracorporeal membrane oxygenation) perfusion therapy to promote health for 3.5 million inhabitants in the region. The predominant subjects of implementation are patients with hypothermia, with severe reversible respiratory failure (RRF), and treatment of other critical states leading to heart failure such as sudden cardiac arrest, cardiogenic shock or acute intoxication. Finally, it promotes donation after circulatory death (DCD) strategy in selected organ donor cases. ECMO enables recovery of organs' function after unsuccessful lifesaving treatment. Because this organizational model is complex and expensive, we use advanced high-fidelity medical simulation to prepare for real-life implementation. During the first four months, we performed scenarios mimicking "ECMO for DCD," "ECMO for ECPR (extended cardiopulmonary resuscitation)," "ECMO for RRF" and "ECMO in hypothermia." It helped to create algorithms for aforementioned program arms. In the following months, three ECMO courses for five departments in Poznan (capitol city of Greater Poland) were organized and standardized operating procedures for road ECMO transportation within Medical Emergency System were created. Soon after simulation program, 38 procedures with ECMO perfusion therapy including five road transportations on ECMO were performed. The Maastricht category II DCD procedures were done four times on real patients and in two cases double successful kidney transplantations were carried out for the first time in Poland. ECMO was applied in two patients with hypothermia, nine adult patients with heart failure, and five with RRF, for the first time in the region. In the pediatric group, ECMO was applied in four patients with RRF and 14 with heart failure after cardiac surgery procedures. Additionally, one child was treated successfully following 200 km-long road transport on ECMO. We achieved good and promising results especially in VV ECMO therapy. Simulation-based training enabled us to build a successful procedural chain, and to eliminate errors at the stage of identification, notification, transportation, and providing ECMO perfusion therapy. We discovered the important role of medical simulation, not only to test the medical professional's skills, but also to promote ECMO therapy in patients with critical/life-threatening states. Moreover, it also resulted in increase of the potential organ pool from DCD in the Greater Poland region.

HandS ECMO: Preliminary Experience With "Hub and Spoke" Model in Neonates With Meconium Aspiration Syndrome

We aim to evaluate clinical outcomes of emergent extracorporeal membrane oxygenation (ECMO) implantation in newborns with life-threatening meconium aspiration syndrome (MAS) in peripheral hospitals with Hub and Spoke (HandS) setting. We retrospectively reviewed all neonates presenting with MAS, with no other comorbidities, treated with HandS ECMO, in peripheral hospitals. Team activation time (TAT) was described as the time from first alerting call to ECMO support initiation. From May 2014 to December 2016, 4 patients met our inclusion criteria. In addition, 2 cases occurred on the same day, requiring a second simultaneous HandS ECMO team activation. All patients were younger than 8 days of life (1, 1, 4, and 7), with a mean BSA 0.21 ± 0.03m² , and TAT of 203, 265, 320, and 340 min. One patient presented ventricular fibrillation after priming administration. Veno-arterial ECMO was established in all patients after uneventful surgical neck vessels cannulation (right carotid artery and jugular vein). Mean time from skin incision to ECMO initiation was 19 ± 1.4 min. Mean length of ECMO support was 2.75 ± 1.3 days. All patients were weaned off support without complications. At a mean follow up of 20.5 ± 7.8 months, all patients are alive, with no medications, normal somatic growth, and neuropsychological development. MAS is a life-threatening condition that can be successfully managed with ECMO support. A highly trained multidisciplinary HandS ECMO team is crucial for the successful management of these severely ill newborns in peripheral hospitals.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Safety and Outcomes of Mobile ECMO Using a Bicaval Dual-Stage Venous Catheter

There is little published data on the safety and effectiveness of mobile (inter-hospital) extracorporeal membrane oxygenation (ECMO) in adults, particularly focusing on the cannulation strategy. We sought to study the outcomes of patients cannulated with a bicaval dual lumen catheter needing mobile compared with conventional ECMO. Specifically, we evaluated the safety of using this cannulation strategy during initiation, in transport and overall performance. Multivariate adjustment was performed to report on adjusted 6 month survival as well as complications and performance from cannulation and the ECMO run. A total of 170 consecutive patients (44 mobile ECMO, 126 conventional ECMO) with severe hypoxemic respiratory failure were included in our cohort from 2010 to 2014. Improved in-hospital survival and adjusted lower 6 month mortality favored the mobile ECMO group (86% vs. 79%; odds ratio [OR] 0.24 [0.07-0.69]). Performance of ECMO and complications were similar between the two groups. There were no serious ECMO cannulation-related complications reported during cannulation and on transport. We conclude that the use of bicaval dual lumen catheters instituted with fluoroscopy guidance at referral sites is safe and should be considered in mobile ECMO patients. Furthermore, mobile ECMO is associated with an unexpected mortality benefit in severely hypoxemic patients. Further prospective study is needed to elucidate this finding.

Retrieval of Adult Patients on Extracorporeal Membrane Oxygenation by an Intensive Care Physician Model

The optimal staffing model during the inter-hospital transfer of patients on extracorporeal membrane oxygenation (ECMO) is not known. We report the complications and outcomes of patients who were commenced on ECMO at a referring hospital by intensive care physicians and compare these findings with patients who had ECMO established at an ECMO center in Australia. This was a single center, retrospective observational study based on a prospectively collected ECMO database from Melbourne, Australia. Patients with severe cardiac and/or respiratory failure failing conventional supportive treatment between 2007-2013 were placed on ECMO via a physician-led model of ECMO retrieval, including two intensivists in a four person team, using percutaneous ECMO cannulation. Patients (198) underwent ECMO over the study period, of which 31% were retrieved. Veno-venous (VV)-ECMO and veno-arterial (VA)-ECMO accounted for 27 and 73% respectively. The VA-ECMO patients had more intra-transport interventions compared with VV-ECMO transported patients, but none resulting in serious morbidity or death. There was no overall difference in survival at 6 months between retrieved and ECMO center patients: VV-ECMO (75 vs. 70%, P = 0.690) versus VA-ECMO (70 vs. 68%, P = 1.000). An intensive care physician-led team was able to safely place all critically ill patients on ECMO and retrieve them to an ECMO center. This may be an appropriate staffing model for ECMO retrieval.

Interhospital Transport of Children Undergoing Cardiopulmonary Resuscitation: A Practical and Ethical Dilemma

OBJECTIVES

To discuss risks and benefits of interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation.

DESIGN

Narrative review.

RESULTS

Not applicable.

CONCLUSIONS

Transporting children in cardiac arrest with ongoing cardiopulmonary resuscitation between hospitals is potentially lifesaving if it enables access to resources such as extracorporeal support, but may risk transport personnel safety. Research is needed to optimize outcomes of patients transported with ongoing cardiopulmonary resuscitation and reduce risks to the staff caring for them.

Inter-hospital transports on extracorporeal membrane oxygenation in different health-care systems

The feasibility and the recognition of the possibility to transport patients on extracorporeal membrane oxygenation (ECMO) aroused in the 1970s. The number of transporting facilities worldwide was less than 20 in the beginning of the second Millennium. In 2009 the H1N1 pandemic and a publication showing survival benefit for adult patients transported to a hospital with ECMO resource increased both awareness and interest for ECMO treatment. The number of transport organizations increased rapidly. As of today, the number of transport organizations increases world-wide, though some centers where ECMO is an established treatment report decreasing numbers of transports. Since the introduction of the more user-friendly equipment (ECMO-2 era) increasing numbers of low-volume ECMO centers perform these complex treatments. This overview is based on the current literature, personal experience in the field, and information from the authors' network on the organization of ECMO transport systems in different settings of health care around the globe. Registry data since the entry into ECMO-2 shows that the number of ECMO treatments matter. The more treatments performed at a given center the better the patient outcome, and the better these resources are spent for the population served. A Hub-and-Spoke model for national or regional organization for respiratory ECMO (rECMO) should be advocated where central high-volume ECMO center (Hub) serves a population of 10 to 15 million. Peripheral units (Spokes) play an important part in emergency cannulations keeping the patient on ECMO support till a mobile ECMO team retrieves the patient. This ECMO team is preferably organized from the Hub and brings competencies for assessment and decision to initiate ECMO treatment bedside at any hospital, for cannulation, and a safe transport to any destination. To conclude, most ECMO transport organizations are reflections of the health care paradigm within which they act. Most transport organizations are established by the staff within who recognize the need. The legal space seems open in most countries; anyone may set up a transport organization anywhere. Quality follow-up varies. Some keep track of adverse events and report whereas most transport entities do not seem to prioritize this. There is no international body for ECMO transports. Such would be the key for definitions, support, networking, and a registry that successively would increase knowledge concerning adverse events, morbidity and mortality.

Remote ECLS-Implantation and Transport for Retrieval of Cardiogenic Shock Patients

OBJECTIVE

Extracorporeal life support (ECLS) emerges as a salvage option in therapy refractory cardiogenic shock but is limited to highly specialized tertiary care centers. Critically ill patients are often too unstable for conventional transport. Mobile ECLS programs for remote implantation and subsequent air or ground-based transport for patient retrieval could solve this dilemma and make full-spectrum advanced cardiac care available to patients in remote hospitals in whom shock otherwise might be fatal.

METHODS

From December 2012 to March 2016, 40 patients underwent venoarterial ECLS implantation in remote hospitals with subsequent transport to our center and were retrospectively analyzed. The mobile ECLS team was available 24/7, implantation was performed percutaneously bedside, and compact support systems designed for transport were used.

RESULTS

Twenty percent of the patients were female; the mean age was 55 ± 10 years, and the mean Interagency Registry for Mechanically Assisted Circulatory Support score was 1.3 ± 0.5. Patient retrieval was accomplished via ground-based (n = 29, 72.5%, mean distance = 27.9 ± 29.7 km [range, 5.6-107.1 km]) or air (n = 11, mean distance = 62.4 ± 27.2 km [range, 38.9-116.4 km]) transport. No ECLS-related complications occurred during transport. The ECLS system could be explanted in 65.0% (n = 26) of patients, and the 30-day survival rate was 52.5% (n = 21).

CONCLUSION

Remote ECLS implantation and interfacility transport on ECLS are feasible and effective. Interdisciplinary teams and full-spectrum cardiac care are essential to achieve optimal outcomes. Rapid-response ECLS networks have the potential to substantially increase the survival of cardiogenic shock patients.

Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature

Background

Utilization of extracorporeal membrane oxygenation (ECMO) has increased worldwide, but its use remains restricted to severely ill patients, and few referral centers are properly structured to offer this support. Inter-hospital transfer of patients on ECMO support can be life-threatening. In this study, we report a single-center experience and a systematic review of the available published data on complications and mortality associated with ECMO transportation.

Methods

We reported single-center data regarding complications and mortality associated with the transportation of patients on ECMO support. Additionally, we searched multiple databases for case series, observational studies, and randomized controlled trials regarding mortality of patients transferred on ECMO support. Results were analyzed independently for pediatric (under 12 years old) and adult populations. We pooled mortality rates using a random-effects model. Complications and transportation data were also described.

Results

A total of 38 manuscripts, including our series, were included in the final analysis, totaling 1481 patients transported on ECMO support. A total of 951 patients survived to hospital discharge. The pooled survival rates for adult and pediatric patients were 62% (95% CI 57–68) and 68% (95% CI 60–75), respectively. Two deaths occurred during patient transportation. No other complication resulting in adverse outcome was reported.

Conclusion

Using the available pooled data, we found that patient transfer to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0232-7) contains supplementary material, which is available to authorized users.

Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) may be a lifesaving rescue therapy in refractory, severe respiratory, and/or circulatory failure. To provide the best cost efficiency to the population served and patient outcome, ECMO therapy should be provided by specialized high volume ECMO centers. This requires dedicated transport teams to organize and perform these complex transports. Concerning adverse events and complications during these transfers, only a minimal amount of data has been published.

METHODS

To shed light on this matter, all medical transport records from transports on ECMO between January 2010 and June 2016 were analyzed. The data was classified in constituent groups and categorized to risk groups.

RESULTS

During the study period, 536 transports on ECMO were performed. The transport records could be identified in 514 of these cases (95.9%). In 163 (31.7%) transports 206 adverse events occurred. In 34 transports two or more adverse events passed on the same trip. No deaths occurred during transport. Sixty-five percent (134) of the complications were Patient related; the most prominent was loss of tidal volume with or without fluid flooding of the lung (n = 57, 43%). Lack of control of equipment was the most common Staff related flaw. Causes due to Equipment/technical (n = 30) could be traced to 14.6% of the events. Vehicle/transportation related complications were reported from 26 transfers, a sub-group in which 50% of the reports concerned malfunction of Ambulance utility/electrical, or Wrong ambulance size at hospital or airport.

CONCLUSIONS

If transporting on ECMO high-risk or sudden threat-of-life situations are inevitable and have to be dealt with immediately, sometimes within seconds. A well-trained staff and an experienced high-volume organization are recommended. Key words: extra corporeal membrane oxygenation; ECMO, transport; adverse event; complication.

Development of a new interfacility extracorporeal membrane oxygenation transport program for pediatric lung transplantation evaluation

Pediatric lung transplantation is a life-saving intervention for children with irreversible end-stage lung disease. Access to transplant can be limited by geographic isolation from a center or the presence of comorbidities affecting transplant eligibility. Extracorporeal membrane oxygenation (ECMO)-supported patients are an uncommon but historically high-risk cohort of patients considered for lung transplant. We report the development of a service at our center to provide transport services to our hospital for patients unable to wean from ECMO support at their local institution for the purpose of evaluation for lung transplantation by our program. We developed a process for pre-transport consultation by the lung transplant physician team, standardized hand-off tools and equipment lists, and procedures for transitioning patients to transport ECMO machinery. Four patients have been transported to date including fixed wing (FW) and helicopter transports. All patients were successfully transported with either none or minor complications. Transport of ECMO-supported patients is a feasible method to increase access of patients with irreversible lung injured patients to evaluation for lung transplant.

Outcome Comparison in Children Undergoing Extracorporeal Life Support Initiated at a Local Hospital by a Mobile Cardiorespiratory Assistance Unit or at a Referral Center

PURPOSE

To compare characteristics and outcome in children undergoing extracorporeal life support initiated in an extracorporeal life support center or at the patient's bedside in a local hospital, by means of a mobile cardiorespiratory assistance unit.

METHODS

A retrospective study in a single PICU during 6 years. Extracorporeal life support was started either in our center (control group) or in the local hospital (mobile cardiorespiratory assistance unit group). The data collected were demographics, markers of patient's preextracorporeal life support condition, and outcome.

RESULTS

One hundred twenty-six children underwent extracorporeal life support, 105 in the control group and 21 in the mobile cardiorespiratory assistance unit group. There was no difference between groups in terms of age, weight, or Pediatric Risk of Mortality II score. There was a significant difference in organ failure etiology between groups, with more respiratory cases in the mobile cardiorespiratory assistance unit group (76.2%) and more cardiac surgery cases in the control group (60%; p < 0.001). The duration of extracorporeal life support was longer in the mobile cardiorespiratory assistance unit group than in the control group (10 [1-36] vs 5 [0-33] d; p = 0.003). PICU length of stay and mortality (60% vs 47.6%; p = 0.294) were not significantly different between the two groups. To allow comparison of a more homogenous population, a subgroup analysis was performed including only respiratory failure patients from the two groups (R-control group [n = 22] and R-mobile cardiorespiratory assistance unit group [n = 16]). PICU length of stay was 17 (3-64) days in the R-control group and 23 (1-45) days in the R-mobile cardiorespiratory assistance unit group (p = 0.564), and PICU mortality rate was 54.5% in the R-control group and 43.8% in the R-mobile cardiorespiratory assistance unit group (p = 0.511). There was no difference between the R-groups for age, weight, Pediatric Risk of Mortality II score, and markers of kidney or liver dysfunction, and lactate blood levels.

CONCLUSION

Extracorporeal life support can be safely initiated at children's bedside in the local hospital and then transported to the specialized referral center. Our results support the validity of an interregional organization of mobile cardiorespiratory assistance unit teams.

Successful 2,000-Kilometer International Transfer of an Infant Receiving Extracorporeal Membrane Oxygenation for Severe Respiratory Failure

There is minimal reported experience with long-range retrieval of pediatric patients receiving extracorporeal membrane oxygenation (ECMO) support. We report the case of a 10-month old boy with necrotizing staphylococcal pneumonia complicated by a bronchopleural fistula, who was successfully retrieved and transported while receiving ECMO to our unit in Sydney, Australia, from a referring hospital 2,000 kilometers away in the Pacific Islands. He was successfully weaned from ECMO to receive single-lung ventilation after 13 days, and he underwent surgical repair of his bronchopleural fistula through a thoracotomy 3 days after decannulation. He has made a full recovery.

Transportation of Critically Ill Patients on Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) may be a life-saving procedure for patients with severe reversible pulmonary or cardiac failure or for patients in need for a bridge to transplantation. ECMO is provided by specialized centers, but patients in need of ECMO are frequently taken care of at other centers. Conventional transports to an ECMO center can be hazardous and deaths have been described. For this reason, many ECMO centers have developed transport programs with mobile ECMO. After request, the mobile team including all necessary equipment to initiate ECMO is sent to the referring hospital, where the patient is cannulated and ECMO commenced. The patient is then transported on ECMO to the ECMO facility by road, helicopter, or fixed-wing aircraft depending on distance, weather conditions, etc. Eight publications have reported series of more than 50 transports on ECMO of which the largest included over 700. Together, these papers report on more than 1400 patient transports on ECMO. Two deaths during transport have occurred. A number of other adverse events are described, but without effect on patient outcome. Survival of patients transported on ECMO is equivalent to that of non-transported ECMO patients. It is concluded that long-, short-distance interhospital transports on ECMO can be performed safely. The staff should be experienced and highly competent in intensive care, ECMO cannulation, ECMO treatment, intensive care transport, and air transport medicine.

Mobile Extracorporeal Membrane Oxygenation Teams: The North American Versus the European Experience

OBJECTIVE

To evaluate differences in the inclusion of anesthesiologists in mobile extracorporeal membrane oxygenation (ECMO) teams between North American and European centers.

DESIGN

A retrospective review of North American versus European mobile ECMO teams. The search terms used to identify relevant articles were the following: "extracorporeal membrane transport," "mobile ECMO," and "interhospital transport."

SETTING

MEDLINE review of articles.

PARTICIPANTS

None.

INTERVENTIONS

None.

RESULTS

Between 1986 and 2015, 25 articles were published that reported the personnel makeup of mobile ECMO teams in North America and Europe: 6 from North American centers and 19 from European centers. The included articles reported a total of 1,329 cases: 389 (29%) adult-only cohorts and 940 (71%) mixed-age cohorts. Among North American studies, 0 of 6 (0%) reported the presence of an anesthesiologist on the mobile ECMO team in contrast to European studies, in which 10 of 19 (53%) reported the inclusion of an anesthesiologist (Fisher exact p for difference = 0.05). In terms of number of cases, this discrepancy translated to 543 total cases in North America (all without an anesthesiologist) and 499 cases in Europe (37%) including an anesthesiologist on the team (Fisher exact p for difference<0.001).

CONCLUSIONS

This study demonstrated significant geographic discrepancies in the inclusion of anesthesiologists on mobile ECMO teams, with European centers more likely to incorporate an anesthesiologist into the mobile ECMO process compared with North American centers.

Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

Extracorporeal membrane oxygenation: a breakthrough for respiratory failure

Extracorporeal membrane oxygenation (ECMO) is a method for providing long-term treatment of a patient in a modified heart-lung machine. Desaturated blood is drained from the patient, oxygenated and pumped back to a major vein or artery. ECMO supports heart and lung function and may be used in severe heart and/or lung failure when conventional intensive care fails. The Stockholm programme started in 1987 with treatment of neonates. In 1995, the first adult patient was accepted onto the programme. Interhospital transportation during ECMO was started in 1996, which enabled retrieval of extremely unstable patients during ECMO. Today, the programme has an annual volume of about 80 patients. It has been characterized by, amongst other things, minimal patient sedation. By 31 December 2014, over 900 patients had been treated, the vast majority for respiratory failure, and over 650 patients had been transported during ECMO. The median ECMO duration was 5.3, 5.7 and 7.1 days for neonatal, paediatric and adult patients, respectively. The survival to hospital discharge rate for respiratory ECMO was 81%, 70% and 63% in the different age groups, respectively, which is significantly higher than the overall international experience as reported to the Extracorporeal Life Support Organization (ELSO) Registry (74%, 57% and 57%, respectively). The survival rate was significantly higher in the Stockholm programme compared to ELSO for meconium aspiration syndrome, congenital diaphragmatic hernia in neonates and pneumocystis pneumonia in paediatric patients.

Five-year experience with mobile adult extracorporeal membrane oxygenation in a tertiary referral center

INTRODUCTION

Mobile extracorporeal membrane oxygenation (ECMO) is reserved for critically unstable patients who may not otherwise survive transfer to the ECMO center. We describe our experience with mobile ECMO.

METHODS

We retrospectively reviewed adult patients between 2010 and 2014 who were referred for ECMO support and were too unwell for conventional transfer. They were cannulated at their referring center by our team and subsequently transported back to our hospital on ECMO.

RESULTS

A total of 102 patients were put on ECMO by our team. Of 102 patients, 95 (93%) were managed by venovenous ECMO, and 7 (7%), by venoarterial ECMO. The average distance traveled was 195 miles (SD, ±256.8; range, 3.6-980). Transportation was via road in 77 cases (77%), by air in 22 cases (22%), and in 3 cases (3%) a combination of road and air was used. A double-lumen Avalon cannula was used in 72 patients (70%). One patient had a ventricular tachycardia arrest during cannulation but was successfully resuscitated. There was no mortality or major complications during transfer.

CONCLUSION

The use of mobile ECMO in adult patients is a safe modality for transfer of critically unwell patients. We have safely used double-lumen cannulas in most of these patients.

The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation

Introduction

In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenation (ECMO) may be a lifesaving procedure. Specialized departments provide ECMO, and these patients often have to be transferred for treatment. Conventional transportation is hazardous, and deaths have been described. Only a few centers have performed more than 100 ECMO transports. To date, our mobile ECMO teams have performed more than 700 transports with patients on ECMO since 1996. We describe 4 consecutive years (2010–2013) of 322 national and international ECMO transports and report adverse events.

Methods

Data were retrieved from our local databases. Neonatal, pediatric and adult patients were transported, predominantly with refractory severe respiratory failure.

Results

The patients were cannulated in 282 of the transports, and ECMO was started in these patients at the referring hospital and then they were transported to our ECMO intensive care unit. In 40 cases, the patient was already on ECMO. Of the transports, 60 % were by aircraft, and the distances varied from 6.9 to 13,447 km. In about 27.3 % of the transports, adverse events occurred. Of these, the most common were either patient-related (22 %) or equipment-related (5.3 %). No deaths occurred during transport, and transferred patients exhibited the same mortality rate as in-hospital patients.

Conclusions

Long- and short-distance interhospital transports on ECMO can be safely performed. A myriad of complications can occur, but the mortality risk is very low. The staff involved should be highly competent in intensive care, ECMO physiology and physics, cannulation, intensive care transport and air transport medicine. They should also be skilled in recognition of risk factors involved in these patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0994-6) contains supplementary material, which is available to authorized users.

One Hundred Transports on Extracorporeal Support to an Extracorporeal Membrane Oxygenation Center

BACKGROUND

Extracorporeal life support technology has gained acceptance as a salvage mode for patients in respiratory or cardiac failure. Patients who are sick enough to require extracorporeal membrane oxygenation (ECMO) support are often too unstable for transfer to a hospital with ECMO capabilities. We highlight the progressive development of an ECMO transport team and the manner in which it provides reliable transport with excellent outcomes.

METHODS

All data were collected retrospectively from our hospital's electronic medical record. Patient outcomes are reported through April 2, 2014.

RESULTS

Our institution began an ECMO transport program in 2008, with the initial phase involving transport of highly selected patients for short distances. With experience we refined our intake and evaluation process. We also consolidated care for ECMO patients into two intensive care units and developed a dedicated ECMO intensivist position. As the program has matured, patient selection has become more inclusive and we have extended our capabilities to include interstate and international transport. All 100 patients were successfully placed on ECMO and transported to our center. Seventy-nine patients were placed on venovenous ECMO, 19 on venoarterial ECMO, and 2 on venovenous arterial ECMO. The median transport distance was 16 miles and ranged from 2.5 to 7,084 miles.

CONCLUSIONS

Extracorporeal membrane oxygenation transport can be performed safely and reliably with excellent outcomes with a dedicated team that maintains stringent adherence to well-designed management protocols.

Paediatric ECMO at low-volume paediatric cardiac centres in the Nordic countries

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a life-saving resource-intensive technology for patients with respiratory and/or circulatory failure. We aimed to evaluate outcome data from three Nordic paediatric centres comparing with data from the International Registry of the Extracorporeal Life Support Organization (ELSO) and selected high-volume single-centre studies.

METHODS

One-hundred nineteen patients < 19 years from 2002 to 2012 were enrolled. Data on demographics and outcome were collected using a standardised registration form. Outcome data were compared with the ELSO registry and high-volume single-centre studies.

RESULTS

Demographics, indications and diagnosis were similar to the ELSO register. Survival after ECMO was similar to outcome data from the ELSO register, apart from paediatric cardiac ECMO, where a significantly better survival to discharge was seen in the Nordic centres (68% vs. 49%; P = 0.03). Comparison with high-volume centres in the period after 2005 demonstrated a significantly better survival after cardiac ECMO in a single high-volume centre study, whereas four studies had significantly lower survival after cardiac ECMO. No significant difference was seen in children receiving respiratory ECMO in the Nordic centres and high-volume centres.

CONCLUSIONS

Survival after ECMO in three low-volume Nordic centres demonstrated comparable outcome data with ELSO data and data from high-volume centres. We believe regular quality assurance surveys, as the present study, should be performed in order to maintain excellent therapy within the individual ECMO centres.