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Fadel RA, Almajed MR, Parsons A, Kalsi J, Shadid M, Maki M, Alqarqaz M, Aronow H, Cowger J, Fuller B, Frisoli T, Grafton G, Kim H, Jones C, Koenig G, Khandelwal A, Nemeh H, O’Neill B, Tanaka D, Williams C, Villablanca P, O’Neill W, Alaswad K, Basir MB. Feasibility and Outcomes of a Cardiovascular Medicine Inclusive Extracorporeal Membrane Oxygenation (ECMO) Service. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101359. [PMID: 39132589 PMCID: PMC11308757 DOI: 10.1016/j.jscai.2024.101359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 08/13/2024]
Abstract
Background There has been a significant increase in the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in recent years. Cardiothoracic surgery teams have historically led VA-ECMO care teams, with little data available on alternative care models. Methods We performed a retrospective review of a cardiovascular medicine inclusive VA-ECMO service, analyzing patients treated with peripheral VA-ECMO at a large quaternary care center from 2018 to 2022. The primary outcome was death while on VA-ECMO or within 24 hours of decannulation. Univariate and multivariate analyses were used to identify predictors of the primary outcome. Results Two hundred forty-four patients were included in the analysis (median age 61 years; 28.7% female), of whom 91.8% were cannulated by interventional cardiologists, and 84.4% were managed by a cardiology service comprised of interventional cardiologists, cardiac intensivists or advanced heart failure cardiologists. Indications for VA-ECMO included acute myocardial infarction (34.8%), decompensated heart failure (30.3%), and refractory cardiac arrest (10.2%). VA-ECMO was utilized during cardiopulmonary resuscitation in 26.6% of cases, 48% of which were peri-procedural arrest. Of the patients, 46% survived to decannulation, the majority of whom were decannulated percutaneously in the cardiac catheterization laboratory. There was no difference in survival following cannulation by a cardiac surgeon vs interventional cardiologist (50% vs 45%; P = .90). Complications included arterial injury (3.7%), compartment syndrome (4.1%), cannulation site infection (1.2%), stroke (14.8%), acute kidney injury (52.5%), access site bleeding (16%) and need for blood transfusion (83.2%). Elevated baseline lactate (odds ratio [OR], 1.13 per unit increase) and sequential organ failure assessment score (OR, 1.27 per unit increase) were independently associated with the primary outcome. Conversely, an elevated baseline survival after VA ECMO score (OR, 0.92 per unit increase) and 8-hour serum lactate clearance (OR, 0.98 per % increase) were independently associated with survival. Conclusions The use of a cardiovascular medicine inclusive ECMO service is feasible and may be practical in select centers as indications for VA-ECMO expand.
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Affiliation(s)
- Raef A. Fadel
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | | | - Austin Parsons
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jasmeet Kalsi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Muthanna Shadid
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Mohamed Maki
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Mohammad Alqarqaz
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Herb Aronow
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Jennifer Cowger
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Brittany Fuller
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Tiberio Frisoli
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Gillian Grafton
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Henry Kim
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Crystal Jones
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Gerald Koenig
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Akshay Khandelwal
- Department of Cardiovascular Medicine, Allegheny Health Network & Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Hassan Nemeh
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Brian O’Neill
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Daizo Tanaka
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Celeste Williams
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Pedro Villablanca
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - William O’Neill
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Khaldoon Alaswad
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
| | - Mir Babar Basir
- Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan
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Duffin SC, Askew JH, Southwood TJ, Forrest P, Plunkett B, Totaro RJ. An intensivist-led ECMO accreditation pathway and safety data over the first 4 years. CRIT CARE RESUSC 2024; 26:41-46. [PMID: 38690187 PMCID: PMC11056391 DOI: 10.1016/j.ccrj.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 05/02/2024]
Abstract
Objective To describe the training and accreditation process behind an intensivist-led extracorporeal membrane oxygenation (ECMO) cannulation program, and identify the rate of complications associated with the ECMO cannulation procedure. Design A narrative review of the accreditation process, and a retrospective review of complications related to cannulation during the first four years of the intensivist program. Setting Royal Prince Alfred Hospital, a quaternary referral hospital in Sydney. Participants All patients initiated onto ECMO during the first four years of the intensivist cannulation program (August 2018 to August 2022).Main outcome measures: All cases were reviewed for identification of 14 pre-defined adverse events which were classified as low, medium or high clinical significance complications. Results A total of 402 cannulations were attempted by the intensivist group in 194 separate cannulation episodes involving 179 patients. This included 93 V-V initiations, 69 V-A initiations (36 of these ECMO-CPR), 3 V-AV (veno-arteriovenous) initiations, 25 ECMO reconfigurations and four patients cannulated for peripheral cardiopulmonary bypass in cardiothoracic theatre. One of the 402 cannulations was halted as resuscitation was ceased, and one was halted and the patient transferred to theatre for central arterial cannulation. 394 out of the remaining 400 cannulations were successful (98.5%). Of 402 total cannulations, 32 complication events occurred (7.96% event rate), of which 15 (3.7% event rate) were low significance complications, 10 medium significance (2.5% event rate), and seven high clinical significance (1.7% event rate). Conclusions Our experience of the first four years of an intensivist-led ECMO service demonstrates that our training process and cannulation technique result in the provision of a complex therapy with low levels of complications, on par with those in the published literature.
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Affiliation(s)
| | | | | | - Paul Forrest
- Royal Prince Alfred Hospital, Sydney Medical School, Sydney, Australia
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Condella A, Simpson NS, Bilodeau KS, Stewart B, Mandell S, Taylor M, Heather B, Bulger E, Johnson NJ, Prekker ME. Implementation of Extracorporeal CPR Programs for Out-of-Hospital Cardiac Arrest: Another Tale of Two County Hospitals. Ann Emerg Med 2024:S0196-0644(24)00005-2. [PMID: 38323952 DOI: 10.1016/j.annemergmed.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is a form of intensive life support that has seen increasing use globally to improve outcomes for patients who experience out-of-hospital cardiac arrest (OHCA). Hospitals with advanced critical care capabilities may be interested in launching an ECPR program to offer this support to the patients they serve; however, to do so, they must first consider the significant investment of resources necessary to start and sustain the program. The existing literature describes many single-center ECPR programs and often focuses on inpatient care and patient outcomes in hospitals with cardiac surgery capabilities. However, building a successful ECPR program and using this technology to support an individual patient experiencing refractory cardiac arrest secondary to a shockable rhythm depends on efficient out-of-hospital and emergency department (ED) management. This article describes the process of implementing 2 intensivist-led ECPR programs with limited cardiac surgery capability. We focus on emergency medical services and ED clinician roles in identifying patients, mobilizing resources, initiation and management of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the ED, and ongoing efforts to improve ECPR program quality. Each center experienced a significant learning curve to reach goals of arrest-to-flow times of cannulation for ECPR. Building consensus from multidisciplinary stakeholders, including out-of-hospital stakeholders; establishing shared expectations of ECPR outcomes; and ensuring adequate resource support for ECPR activation were all key lessons in improving our ECPR programs.
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Affiliation(s)
- Anna Condella
- Department of Emergency Medicine, University of Washington, Seattle, WA; Trauma & ECLS Programs, Harborview Medical Center, University of Washington, Seattle, WA.
| | | | - Kyle S Bilodeau
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Barclay Stewart
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Samuel Mandell
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Mark Taylor
- Trauma & ECLS Programs, Harborview Medical Center, University of Washington, Seattle, WA
| | - Beth Heather
- Critical Care Nursing, Hennepin County Medical Center, Minneapolis, MN
| | - Eileen Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; Department of Medicine, Hennepin Healthcare, Minneapolis, MN
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Teixeira JP, Larson LM, Schmid KM, Azevedo K, Kraai E. Extracorporeal cardiopulmonary resuscitation. Int Anesthesiol Clin 2023; 61:22-34. [PMID: 37589133 DOI: 10.1097/aia.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Lance M Larson
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Kristin M Schmid
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Keith Azevedo
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Erik Kraai
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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