Establishing extracorporeal membrane oxygenation team increased number of patients and improved data recording

Implementing an Adult Extracorporeal Membrane Oxygenation Program During the COVID-19 Pandemic

BACKGROUND

In response to the needs of patients infected with COVID-19, an interdisciplinary team was assembled to implement an adult extracorporeal membrane oxygenation (ECMO) program in the surgical ICU of a West Texas tertiary care hospital. Use of Extracorporeal Life Support Organization (ELSO) guidelines was essential to the development of this effort.

AIM

The aim of this project was to develop, implement, and evaluate an adult ECMO program.

METHODS

A logic model was used in designing and evaluating the adult ECMO program. A 35-hour ECMO specialist training course was developed, and training began in August 2020, a month before implementation of the project began. Patient outcomes were measured between September 2020 and December 2021. Descriptive statistics were used to measure the clinical outcomes of interest.

RESULTS

Seventeen newly trained ECMO specialists included experienced critical care nurses and respiratory therapists. Protocols were developed for the initiation of ECMO, and tracked patient outcomes included survival off ECMO, survival to discharge, major and minor complications, and length of stay. Nine patients had COVID-19 and demonstrated an 11.11% mortality rate after adult ECMO program implementation.

CONCLUSIONS

Use of the ELSO professional guidelines to design and develop this project led to the achievement of a sustainable ECMO program. Hospital leaders can now implement adult ECMO programs amid other demands for resources that may be created by future pandemics.

[Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest]

Objectives

Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown.

Objective

We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA.

Materials and methods

. We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume.

Results

Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups.

Conclusions

After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

Effect of Portable, In-Hospital Extracorporeal Membrane Oxygenation on Clinical Outcomes

The time between onset of cardiogenic shock and initiation of mechanical circulatory support is inversely related to patient survival as delays in transporting patients to the operating room (OR) for venoarterial extracorporeal membrane oxygenation (VA ECMO) could prove fatal. A primed and portable VA ECMO system may allow faster initiation of ECMO in various hospital locations and subsequently improve outcomes for patients in cardiogenic shock. We reviewed our institutional experience with VA ECMO based on two time periods: beginning of our VA ECMO program and from initiation of our primed and portable in-hospital ECMO system. The primary endpoint was patient survival to discharge. A total of 137 patients were placed on VA ECMO during the study period; n = 66 (48%) before and n = 71 (52%) after program initiation. In the second era, the proportion of OR ECMO initiation decreased significantly (from 92% to 49%, p < 0.01) as more patients received ECMO in other hospital units, including the emergency department (p < 0.01) and during cardiac arrest (12% vs. 38%, p < 0.01). Survival to hospital discharge was equivalent between the two groups (30% vs. 42%, p = 0.1) despite more patients being placed on ECMO during ongoing cardiac arrest. Finally, we observed increased clinical volume since initiation of the in-hospital, portable ECMO system. Developing an in-hospital, primed and portable VA ECMO program resulted in increased clinical volume with equivalent patient survival despite a sicker cohort of patients. We conclude that more rapid deployment of VA ECMO may extend the treatment eligibility to more patients and improve patient outcomes.

Establishing a New ECMO Referral Center Using an ICU-Based Approach: A Feasibility and Safety Study

Background: A high-volume center with a multidisciplinary team is regarded as the optimal place for providing extracorporeal membrane oxygenation (ECMO). We hypothesize that an ECMO center can also be successfully created and subsequently developed entirely by intensivists in a mid-size mixed intensive care unit (ICU). Methods: A model was created for setting up a new ECMO referral center within the structure of an existing mixed ICU in a tertiary hospital. A retrospective analysis was carried out of the first 33 patients treated in the initial period of the center’s activity, from mid 2018 to the end of 2020. Results: An ECMO center was established and developed entirely based on the resources of an existing mixed ICU. Thirty-three patients were treated. They had an overall survival rate at 90 days of 60.6%. In veno-venous (VV) mode ECMO duration, ICU length of stay, and SOFA score were significantly higher than in veno-arterial mode. No significant differences in clinical characteristics were observed between survivors and non-survivors on VV-ECMO. Conclusions: A regional ECMO center can be set up as an integral part of a mixed ICU in a tertiary hospital. Extracorporeal therapy, such as continuous renal replacement therapy and mechanical ventilation can be managed entirely by intensivists. Further studies are needed to show that the ICU-based approach to setting up a new ECMO center is no less effective than the multidisciplinary approach.

Impact of a Multidisciplinary Team Approach on Extracorporeal Circulatory Life Support-Bridged Heart Transplantation

Background

The number of heart transplantations (HTx) is increasing annually. Due to advances in medical and surgical support, the outcomes of HTx are also improving. Extracorporeal circulatory life support (ECLS) provides patients with decompensated heart failure a chance to undergo HTx. A medical approach involving collaboration among experienced experts in different fields should improve the outcomes and prognosis of ECLS-bridged HTx.

Methods

From December 2003 to December 2018, 1,465 patients received ECLS at Samsung Medical Center. We excluded patients who had not undergone HTx or underwent repeated transplantations. Patients younger than 18 years were excluded. We also excluded patients who received an implantable durable left ventricular assist device before HTx. In total, 91 patients were included in this study. A multidisciplinary team approach began in March 2013 at our hospital. We divided the patients into 2 groups depending on whether they were treated before or after implementation of the team approach.

Results

The 30-day mortality rate was significantly higher in the pre-ECLS team group than in the post-ECLS team group (n=5, 18.5% vs. n=2, 3.1%; p=0.023). The 1-year survival rate was better in the post-ECLS team group than in the pre-ECLS team group (n=57, 89.1% vs. n=19, 70.4%; p=0.023).

Conclusion

We found that implementing a multidisciplinary team approach improved the outcomes of ECLS-bridged HTx. Team-based care should be adapted at HTx centers that perform high-risk HTx.

Impact of an Extracorporeal Membrane Oxygenation Intensivist-Led Multidisciplinary Team on Venovenous Extracorporeal Membrane Oxygenation Outcomes

Objectives:

Venovenous extracorporeal membrane oxygenation is increasingly being established as a treatment option for severe acute respiratory failure. We sought to evaluate the impact of a dedicated specialist team-based approach on patient outcomes.

Design:

Retrospective cohort study.

Setting:

Single-center medical ICU in an academic tertiary hospital.

Patients:

Adult patients initiated on venovenous extracorporeal membrane oxygenation for severe acute respiratory failure.

Interventions:

Initiation of an extracorporeal membrane oxygenation intensivist-led multidisciplinary team; critical decisions on extracorporeal membrane oxygenation management were jointly made by a dedicated team of extracorporeal membrane oxygenation intensivists, together with the multidisciplinary team.

Measurements and Main Results:

Eighty-one patients (75%) and 27 patients (35%) were initiated on venovenous extracorporeal membrane oxygenation in the preextracorporeal membrane oxygenation intensivist-led multidisciplinary team (before January 2018) and postextracorporeal membrane oxygenation intensivist-led multidisciplinary team period (after January 2018), respectively. Inhospital (14.8% vs 44.4%, p = 0.006) and ICU mortality (11.1% vs 40.7%, p = 0.005) were significantly lower in the postextracorporeal membrane oxygenation intensivist-led multidisciplinary team period. On multivariate analysis correcting for possible confounding factors (ICU severity and extracorporeal membrane oxygenation-specific mortality prediction scores, body mass index, preextracorporeal membrane oxygenation vasopressor support, preextracorporeal membrane oxygenation cardiac arrest, and days on mechanical ventilation before extracorporeal membrane oxygenation initiation), management by an extracorporeal membrane oxygenation intensivist-led multidisciplinary team remained associated with improved hospital survival (odds ratio, 5.06; 95% CI, 1.20–21.28). Patients in the postextracorporeal membrane oxygenation intensivist-led multidisciplinary team period had less nosocomial infections (18.5% vs 46.9%, p = 0.009), a shorter ICU stay (12 days [interquartile range, 6–16 d] vs 15 days [interquartile range, 10–24 d]; p = 0.049), and none suffered an intracranial hemorrhage or nonhemorrhagic stroke.

Conclusions:

An extracorporeal membrane oxygenation intensivist-led multidisciplinary team approach is associated with improved outcomes in patients initiated on venovenous extracorporeal membrane oxygenation for severe acute respiratory failure.

Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome

Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.