ECMO Transport without Physicians or Additional Clinicians

Cardiac arrest in critical care transport: A case-control study

OBJECTIVES

Numerous prior works have demonstrated the risk of clinical deterioration with movement and transport, and the higher the patient's acuity, the higher the risk and consequence of decompensation.

METHODS

We performed a descriptive study of patients with a cardiac arrest during critical care transport (CCT) October 2020 through September 2022. Inclusion criteria included all patients with arrest after the arrival of the CCT team. To analyze factors associated with arrest, we performed a case-control study. Exclusion criteria included scene transports, pediatric patients, patients who did not arrest en route, and patients not transported.

RESULTS

Over two years, 87 patients (0.7 %) had a cardiac arrest after arrival of the CCT team. The most common indications for transport were severe trauma, respiratory arrest, and aortic emergencies, and patients were commonly ED to ED transfers. In the case-control assessment, four variables were associated with arrest: mode of transport, OR 2.66 (95 % CI 1.05-6.75), number of vasopressors [1, OR 3.46 (95 % CI 1.05-11.39), 2, OR 6.67 (95 % CI 1.97-22.55), 3, OR 16.0, (95 % CI 3.77-68.0)], and initial MAP and SBP [both OR 0.98 (95 % CI 0.97-0.99)]. Of the 32 patients who arrested in transport, only 15 (46.9 %) had return of spontaneous circulation (ROSC).

CONCLUSIONS

In a case-control assessment, four variables were associated with arrest in CCT: mode of transport, the number of vasopressors, the initial MAP, and the initial SBP. While cardiac arrest was uncommon, the rate of ROSC was only 46.9 %. Future work should build upon this work to determine thresholds for which patients are at the highest risk for arrest in transport.

ECMO cannulation across New England

BACKGROUND

Over the last 15 years, clinicians have increasingly used extracorporeal membrane oxygenation (ECMO) as a rescue technique, including cannulating patients in community hospitals without ECMO capabilities, leading to secondary ECMO transports.

OBJECTIVES

The objective was to evaluate the changes in cannulations and the number of cannulating centers over time.

METHODS

This is a retrospective review of transports across New England to ECMO centers in Boston from 2011 to 2022.

RESULTS

Over the years studied, 202 patients were cannulated and transported. VA ECMO was the most common configuration. This was a high-acuity cohort, with 26.4 % of VA ECMO patients having undergone cannulation during cardiopulmonary resuscitation (ECPR) and 6.1 % having central cannulation. The number of cannulations per year increased from 6 patients in 2011 to 36 in 2019 (p = 0.055). Cannulating centers also increased from 3 in 2011 to 14 in 2022. ECPR showed a similar trend, with increases in both ECPR patients and ECPR sites per year (p = 0.055).

CONCLUSIONS

The number of ECMO cannulations in the community has increased, with a high-acuity cohort of many patients undergoing ECPR. The number of patients cannulated at non-ECMO centers highlights the need for transport organizations and ECMO centers to address the needs of this high-acuity patient population.

Extracorporeal Membrane Oxygenation Use in Fat Embolism Syndrome: Current Perspectives and Clinical Insights (A 20-Year Review)

Background/Objectives: Fat embolism syndrome (FES) is a rare but serious complication that may arise after long bone fractures, characterized by fat globules entering the bloodstream and causing multi-organ dysfunction, particularly respiratory failure. While initial treatment focuses on supportive care including oxygen therapy, fluid management, and hemodynamic stabilization, severe cases may require advanced life support, such as extracorporeal membrane oxygenation (ECMO). The aim of this study is to evaluate the role of ECMO in managing severe cases of FES with refractory hypoxemia and hemodynamic instability by analyzing patient outcomes. Methods: This mini-review explores the role of ECMO in managing FES by analyzing published case reports from the first documented case in 2004 and reviewing the broader literature. By examining the physiological principles, clinical applications, and reported outcomes of ECMO in FES, we aim to provide insights into its potential benefits and limitations. Results: A total of 12 case reports were identified and evaluated for eligibility. All 12 cases met the inclusion criteria and were included in the analysis. These cases involved patients who had FES-related refractory hypoxemia and required ECMO support. Conclusions: Our analysis of case reports presents supportive evidence that incorporating ECMO into the management of FES serves as a crucial bridge to recovery for patients who do not respond to conventional therapies.

Outcomes and risk factors of transported patients with extracorporeal membrane oxygenation: An ECMO center experience

Background

Extracorporeal membrane oxygenation (ECMO) has been proven to be a support method and technology for patients with cardiopulmonary failure. However, the transport of patients under ECMO support is challenging given the high-risk technical maneuvers and patient-care concerns involved. Herein, we examined the safety of ECMO during the transport of critically ill patients and its impact on mortality rates, to provide more secure and effective transport strategies in clinical practice.

Method

To assess the safety of ECMO patient transport, this study conducted a retrospective analysis on critically ill adults who required ECMO support and transport at the intensive care unit (ICU) center between 2017 and 2023. The study utilized standard ECMO transport protocols and conducted a comprehensive statistical analysis of the collected clinical data and transport processes. The 28-day survival rate for ECMO patients was determined using Kaplan-Meier analysis, while logistic regression identified prognostic factors.

Result

Out of 303 patients supported with ECMO, 111 (36.6%) were transported. 69.4% of the transport group were male, mean age was (42.0±17.0) years, mean body mass index was (24.4±4.6) kg/m2, and veno-arterial-ECMO accounted for 52.5%. The median transportation distance was 190 (interquartile range [IQR]: 70-260) km, and the longest distance was 8100 km. The median transit time was 180 (IQR: 100-260) min, and the maximum duration was 1720 min. No severe adverse events including death or mechanical failure occurred during transportation. The 28-day survival rate was 64.7% (n=196) and ICU survival rate was 56.1% (n=170) for the entire cohort; whereas, the 28-day survival rate was 72.1% (n=80) and ICU survival rate was 66.7% (n=74) in the transport group. A non-significant difference in 28-day survival was observed between the two groups after propensity score matching (P=0.56). Additionally, we found that acute physiology and chronic health evaluation II score (odds ratio [OR]=1.06, P <0.01), lactate levels (>5 mmol/L, OR=2.80, P=0.01), and renal replacement therapy initiation (OR=3.03, P <0.01) were associated with increased mortality risk.

Conclusion

Transporting patients on ECMO between medical facilities is a safe procedure that does not increase patient mortality rates, provided it is orchestrated and executed by proficient transport teams. The prognostic outcome for these patients is predominantly influenced by their pre-existing medical conditions or by complications that may develop during the course of ECMO therapy. These results form the basis for the creation of specialized ECMO network hubs within healthcare regions.

Patient care during interfacility transport: a narrative review of managing diverse disease states

BACKGROUND

When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals (interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.

METHODS

We conducted searches from the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases up to June 2022. Two reviewers independently screened the titles and abstracts for eligibility. Studies that were not in the English language and did not involve critically ill patients were excluded.

RESULTS

The search identified 75 articles, and we included 48 studies for our narrative review. Most studies were observational studies.

CONCLUSION

The review provided the current evidence-based management of diverse disease states during the interfacility transfer process, such as proning positioning for respiratory failure, extracorporeal membrane oxygenation (ECMO), obstetric emergencies, and hypertensive emergencies (aortic dissection and spontaneous intracranial hemorrhage).

Interfacility Transport of Critically Ill Patients

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.

Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases

Extracorporeal membrane oxygenation (ECMO) employs vascular cannulation and a gas exchange circuit to provide support to patients with severely compromised cardiopulmonary function. ECMO is often the last intervention taken before death and thus presents a unique challenge to medical examiners. This study describes the characteristics of decedents on ECMO at the time of death, including clinical indications, types of circuit configurations, causes and manners of death, gross findings at autopsy, and therapeutic complications. Files of a regional medical examiner office within an academic medical center were searched for the period between 2013 and 2019. Nineteen cases were identified with a median age of 36 years. The circumstances surrounding the initial presentation included: sudden death, trauma, substance abuse, homicide, therapeutic complication, work-related injury, drowning, and hypothermia. The underlying causes of death included injury-related, as well as respiratory and cardiac-related natural diseases. The time spent on ECMO varied from less than 1 h to 10 months. Complications encountered due to ECMO included cannulation site bleeding, pneumohemopericardium, retroperitoneal hematoma, limb ischemia, clotting, and cannula dislodgement. The patient population likely to receive ECMO has significant overlap with death circumstances likely to be reported to the medical examiner. As ECMO therapy has become increasingly available, it is of importance for medical examiners and death investigators to be familiar with the procedure as well as its limitations. Familiarity with ECMO and its sequelae allows for the proper documentation of postmortem findings and fosters an informed determination of the cause and manner of death.