Centers where intensivists perform ECMO cannulations.

[dna105]

Advertisement - Members don't see this ad

Apart from ECPR in ED, I'm gathering information of places where intensivists perform cannulations in the ICU.

Looks like the Australians (e.g. Alfred) and Europeans have been doing this for a while but I've only found one study from a US center -

Checking your browser - reCAPTCHA

Can anyone tell me of other centers where intensivists perform VV and VA ECMO cannulations? Feel free to DM me. Would appreciate it.

 

[POW16]

They do it at Penn for VV ECMO.

 

[inspirationmd]

They do it at East Carolina University for VV ECMO

 

[The kitchen sink]

Montefiore in the Bronx, NYC use to have a program where they cannulated for VV ECMO

 

[MelMcT2009]

LSU Shreveport - CC fellows do all cannulations

 

[bigdan]

Michigan - anes CCM and surgical CCM
CCF - cardiac surgeons and CCM

 

[pccmbound]

I believe Cooper in NJ recently transitioned to this as well

 

[gro2001]

Outside of ECPR it tends to be a hard case to make to have people other than CT surgeons cannulate for VA.

Mount Sinai Hospital (New York) has an interventional cardiologist cannulating for VA, but he is the only non-CT surgeon in the group.

 

[SpacemanSpifff]

Outside of ECPR it tends to be a hard case to make to have people other than CT surgeons cannulate for VA.

Mount Sinai Hospital (New York) has an interventional cardiologist cannulating for VA, but he is the only non-CT surgeon in the group.

Why?

 

[vector2]

Outside of ECPR it tends to be a hard case to make to have people other than CT surgeons cannulate for VA.

Mount Sinai Hospital (New York) has an interventional cardiologist cannulating for VA, but he is the only non-CT surgeon in the group.

Why?

Pretty much anyone is capable of placing cannulae with seldinger technique and serial dilation. The value of ICs/vascular/CT surgeons (procedurally) stems primarily from when vascular complications occur, or when it's time to remove cannulae since they have familiarity with perclose devices and/or cutdowns to primarily close arteriotomies etc when simply holding pressure is insufficient.

 

[gro2001]

Pretty much anyone is capable of placing cannulae with seldinger technique and serial dilation. The value of ICs/vascular/CT surgeons (procedurally) stems primarily from when vascular complications occur, or when it's time to remove cannulae since they have familiarity with perclose devices and/or cutdowns to primarily close arteriotomies etc when simply holding pressure is insufficient.

Agree with all of that. Cannulation for VA ECMO/ECPR is something that could totally be learnable by emergency physicians and intensivists. In fact, for ECPR specifically, I think that's the future. The only way to have scalable success with it will be to have a large pool of people, constantly available on site, who know how to place lines with POCUS/Seldinger technique cross trained to cannulate for VA.

But outside of ECPR, when you do have 30-40 minutes to spare, it just makes sense to have the CT surgeons do it, for exactly that reason that they have more options in case of complications/unexpected difficulty (converting to central, for example). I think this is one of the two reasons VA cannulation is usually done by CT surgeons at most places. I think the other reason is that at most places I've seen ECMO tends to be extremely political, primarily because of the large amount of revenue involved (to say nothing of the egos). That's the other reason it's usually hard for someone not from a CT surgeon background to make their way. Not unheard of, but not common.

 

[lunaire]

Agree with all of that. Cannulation for VA ECMO/ECPR is something that could totally be learnable by emergency physicians and intensivists. In fact, for ECPR specifically, I think that's the future. The only way to have scalable success with it will be to have a large pool of people, constantly available on site, who know how to place lines with POCUS/Seldinger technique cross trained to cannulate for VA.

But outside of ECPR, when you do have 30-40 minutes to spare, it just makes sense to have the CT surgeons do it, for exactly that reason that they have more options in case of complications/unexpected difficulty (converting to central, for example). I think this is one of the two reasons VA cannulation is usually done by CT surgeons at most places. I think the other reason is that at most places I've seen ECMO tends to be extremely political, primarily because of the large amount of revenue involved (to say nothing of the egos). That's the other reason it's usually hard for someone not from a CT surgeon background to make their way. Not unheard of, but not common.

Speaking of revenue, generally the lion share of billing comes from the initial cannulation, with daily management being a diminishing return proposition; especially for the hospital. I imagine a really slick intensivist program that is able to cannulate and maintain a sensible length of stay/complication rate would be making bank.

To answer OP - Lots of places has the intensivist doing VV cannulation, with CVT surgery backup. A couple places I am aware of -- Orlando Health, Cleveland Clinic, and Mayo Clinic Jacksonville. I think Mayo in general is ok with intensivist VV cannulation. Lots of smaller private practice programs affiliated with the Mayo clinic network also adopts the same stance.

 

[eefen]

There's a multidisciplinary ecmo grop at OHSU where intensivists cannulate for VV and come from variety of primary residency backgrounds (medicine, EM, anesthesia, surgery). Similar at Legacy system in Portland.

 

[mudderMD]

Cooper in Camden, NJ

 

[CrpDstr]

I don't think it's been mentioned, but Emory does. At least the fellows. They really really tout it as one of the pros for coming there (at least for anesth CCM)

 

[la2la2im]

I don't think it's been mentioned, but Emory does. At least the fellows. They really really tout it as one of the pros for coming there (at least for anesth CCM)

Emory doesn’t do all that much ECMO, tbh; at least not compared to some centers. I know their PCCM fellows occasionally will help/ cannulate for VV. I’m from the medicine side of things, so perhaps the anesthesia residents do help with both over there.

VA ECMO is an entirely different beast than VV though. Any one can get large bore access, but learning proper access sites, technique, bail outs, and who and where not to cannulate is really a skill you’re not going to get in a 1 - 2 year CCM program. Anyone can dilate, but god help you if you made a mistake or need to place or replace a reperfusion sheath, ripped a femoral or (worse) ripped an iliac, dislodged a plaque, left a bubble, etc. You’ve potentially made problems far worse and you have no way of solving them while your patient bleeds out. The value of having fluoroscopy when placing these systems is also key and there’s very little reason to not take a crashing patient to the suite where someone who knows how to use it can use it. The bottom line being—it may be worth learning in some cases for ECPR, but it’s hard to imagine you’ll get enough volume to truly be comfortable and good with the skill if your a PCCM/ IM-CCM trained person (or honestly even anesthesia-trained). Hence would say it’s best left for CT or vascular surgery, perhaps interventional cards.

Speaking of which, there are a bunch of shock-heavy interventional cardiology programs that do lots of peripheral ECMO and do it well, but it’s a very small number of places that truly train you how to do this with sufficient volume. The number of complications I’ve seen from less experienced sites with even small-ish devices like impella are pretty horrific. Limbs get lost, inappropriate people get cannulated, RP bleeds, etc.

So yes, it’s pretty cool, but not necessarily a skill you want to have when there are enough people out there who can potentially do it safer and better.

 

[SpacemanSpifff]

Emory doesn’t do all that much ECMO, tbh; at least not compared to some centers. I know their PCCM fellows occasionally will help/ cannulate for VV. I’m from the medicine side of things, so perhaps the anesthesia residents do help with both over there.

VA ECMO is an entirely different beast than VV though. Any one can get large bore access, but learning proper access sites, technique, bail outs, and who and where not to cannulate is really a skill you’re not going to get in a 1 - 2 year CCM program. Anyone can dilate, but god help you if you made a mistake or need to place or replace a reperfusion sheath, ripped a femoral or (worse) ripped an iliac, dislodged a plaque, left a bubble, etc. You’ve potentially made problems far worse and you have no way of solving them while your patient bleeds out. The value of having fluoroscopy when placing these systems is also key and there’s very little reason to not take a crashing patient to the suite where someone who knows how to use it can use it. The bottom line being—it may be worth learning in some cases for ECPR, but it’s hard to imagine you’ll get enough volume to truly be comfortable and good with the skill if your a PCCM/ IM-CCM trained person (or honestly even anesthesia-trained). Hence would say it’s best left for CT or vascular surgery, perhaps interventional cards.

Speaking of which, there are a bunch of shock-heavy interventional cardiology programs that do lots of peripheral ECMO and do it well, but it’s a very small number of places that truly train you how to do this with sufficient volume. The number of complications I’ve seen from less experienced sites with even small-ish devices like impella are pretty horrific. Limbs get lost, inappropriate people get cannulated, RP bleeds, etc.

So yes, it’s pretty cool, but not necessarily a skill you want to have when there are enough people out there who can potentially do it safer and better.

In an ideal world CTS or vascular would be the primary cannulators for VA, given the skill set required to manage every conceivable procedural complication. I suspect that some, if not many, centers will be moving towards an intensivist-centered approach. There are data that suggest intensivists with proper training and imaging guidance cannulate safely. Certainly agree that VV is a different game, although wires in the RA and large bore access should never be taken lightly. I also totally agree that it’s hard to imagine many centers providing enough volume to allow for many cannulators to be proficient.

ELSO has published a curriculum & certification for providers that they are hoping to make the standard of care - I’m sure a cannulator curriculum/certification is not far behind. Whether that will lead to widespread adoption, who knows.

 

[la2la2im]

In an ideal world CTS or vascular would be the primary cannulators for VA, given the skill set required to manage every conceivable procedural complication. I suspect that some, if not many, centers will be moving towards an intensivist-centered approach. There are data that suggest intensivists with proper training and imaging guidance cannulate safely. Certainly agree that VV is a different game, although wires in the RA and large bore access should never be taken lightly. I also totally agree that it’s hard to imagine many centers providing enough volume to allow for many cannulators to be proficient.

ELSO has published a curriculum & certification for providers that they are hoping to make the standard of care - I’m sure a cannulator curriculum/certification is not far behind. Whether that will lead to widespread adoption, who knows.

My issue is really that a hospital where you don’t have these people, you shouldn’t be offering ECMO. The survival rate in the most optimal conditions for ECPR is just under 50%. In most cases, with a tertiary care facility with lots of experience and a more general patient population, you’re looking at 20%— optimistically. Now translate that to a community center with no CTS, no 24/7 vascular, and a limited cath lab, and you’re looking at pouring in a ton of resources into something that realistic will result in a very limited benefit (<<10% survival? A guess but not an inaccurate one). I guess, as you said, we will see.

 

[McPoyle]

Emory doesn’t do all that much ECMO, tbh; at least not compared to some centers. I know their PCCM fellows occasionally will help/ cannulate for VV. I’m from the medicine side of things, so perhaps the anesthesia residents do help with both over there.

Not really true, they do a fair amount of both VV and VA. The PCCM fellows really only rarely get involved compared to the anesthesia fellows who leave training and (especially with COVID) able to be credentialed for the procedure.

I will say though… it’s a marginally marketable skill outside some specific institutions. I think the bigger benefit is that the CC group OWNED the VV program which meant learning much more about about patient selection, daily management, weaning, managing complications, etc.

 

[chessknt]

My issue is really that a hospital where you don’t have these people, you shouldn’t be offering ECMO. The survival rate in the most optimal conditions for ECPR is just under 50%. In most cases, with a tertiary care facility with lots of experience and a more general patient population, you’re looking at 20%— optimistically. Now translate that to a community center with no CTS, no 24/7 vascular, and a limited cath lab, and you’re looking at pouring in a ton of resources into something that realistic will result in a very limited benefit (<<10% survival? A guess but not an inaccurate one). I guess, as you said, we will see.

Yea we got to see what happened during the pandemic--regions without ecmo had a lot of people die because there was no availability. I think the general principle that ecmo should only be performed in high volume centers is true but the trade off for optimal outcomes in those people is that there is another group of people who will die never even having the chance of survival even if it wasn't optimal. It is a kind of calculus that you don't understand until you have worked somewhere far from an ecmo center (like 2+ hours by air far) which I am assuming you have never done.

I'll never forget the 43 year old healthy woman who presented with covid myocarditis with an ef under 10 struggling to stay alive on 4 pressors while I was on the phone for hours trying to find literally any place with an ecmo circuit that would take an outside transfer. Eventually I had to hang up the phone to go intubate her and she died later that night.

 

[la2la2im]

Not really true, they do a fair amount of both VV and VA. The PCCM fellows really only rarely get involved compared to the anesthesia fellows who leave training and (especially with COVID) able to be credentialed for the procedure.

I will say though… it’s a marginally marketable skill outside some specific institutions. I think the bigger benefit is that the CC group OWNED the VV program which meant learning much more about about patient selection, daily management, weaning, managing complications, etc.

I suppose it’s relative! But not the place to go I think for a medicine/CCM person to be comfortable with VA ECMO. A friend of mine is doing the CCM year there and has 2 weeks in 5E. Definitely not enough.

100% agree with your latter point.

 

[la2la2im]

Yea we got to see what happened during the pandemic--regions without ecmo had a lot of people die because there was no availability. I think the general principle that ecmo should only be performed in high volume centers is true but the trade off for optimal outcomes in those people is that there is another group of people who will die never even having the chance of survival even if it wasn't optimal. It is a kind of calculus that you don't understand until you have worked somewhere far from an ecmo center (like 2+ hours by air far) which I am assuming you have never done.

I'll never forget the 43 year old healthy woman who presented with covid myocarditis with an ef under 10 struggling to stay alive on 4 pressors while I was on the phone for hours trying to find literally any place with an ecmo circuit that would take an outside transfer. Eventually I had to hang up the phone to go intubate her and she died later that night.

Awful. I’m sorry. You’re quite right about where I work.

To tread lightly but push back on your very valid point, survival rates outside of literature certainly don’t have to be optimal in all hospitals at all times, but they have to be reasonable and there has to be a net reduction of harm to the patients. I love MCS, but I fully believe that ECMO used improperly is one of those things that can quite literally be worse than death.

 

[McPoyle]

I suppose it’s relative! But not the place to go I think for a medicine/CCM person to be comfortable with VA ECMO. A friend of mine is doing the CCM year there and has 2 weeks in 5E. Definitely not enough.

100% agree with your latter point.

Oh yeah, for PCCM they definitely no rely don’t get enough experience unless they seek it out. Anes/EM have no shortage at all though.

 

[psychbender]

Awful. I’m sorry. You’re quite right about where I work.

To tread lightly but push back on your very valid point, survival rates outside of literature certainly don’t have to be optimal in all hospitals at all times, but they have to be reasonable and there has to be a net reduction of harm to the patients. I love MCS, but I fully believe that ECMO used improperly is one of those things that can quite literally be worse than death.

Too often I end up involved with someone cannulated as a hail Mary, with no exit plan other than, "Maybe they'll get better in a few days!" It was partly that **** in fellowship that initially made me go to a shop without MCS, before I came to my current job, as I hated seeing it abused. I am trying to change the culture where I am to be more cannulate, stabilize, send out, to minimize the opportunities for micromanaging patients to death.

 

[la2la2im]

Too often I end up involved with someone cannulated as a hail Mary, with no exit plan other than, "Maybe they'll get better in a few days!" It was partly that **** in fellowship that initially made me go to a shop without MCS, before I came to my current job, as I hated seeing it abused. I am trying to change the culture where I am to be more cannulate, stabilize, send out, to minimize the opportunities for micromanaging patients to death.

100% this

 

[Drangue]

There's a multidisciplinary ecmo grop at OHSU where intensivists cannulate for VV and come from variety of primary residency backgrounds (medicine, EM, anesthesia, surgery). Similar at Legacy system in Portland.

This sounds neat. Is there more information on this group?

 

[aafisahar]

Yea we got to see what happened during the pandemic--regions without ecmo had a lot of people die because there was no availability. I think the general principle that ecmo should only be performed in high volume centers is true but the trade off for optimal outcomes in those people is that there is another group of people who will die never even having the chance of survival even if it wasn't optimal. It is a kind of calculus that you don't understand until you have worked somewhere far from an ecmo center (like 2+ hours by air far) which I am assuming you have never done.

I'll never forget the 43 year old healthy woman who presented with covid myocarditis with an ef under 10 struggling to stay alive on 4 pressors while I was on the phone for hours trying to find literally any place with an ecmo circuit that would take an outside transfer. Eventually I had to hang up the phone to go intubate her and she died later that night.

We had ecmo and these types of patients always died.

VA ECMO is not an anti death machine. It's a bridge and if you don't have a destination other than hope they'll get better, then it's best not to get on that train.

 

[SpacemanSpifff]

This sounds neat. Is there more information on this group?

Neither group was hiring ECMO intensivists the last time I heard, although the Legacy group may be looking for people in the near future. Both are ELSO centers of excellence and have a good mix of training backgrounds. The Legacy group does cannulate for VA, while the cardiac surgeons cannulate for VA at OHSU for now.

 

[chessknt]

We had ecmo and these types of patients always died.

VA ECMO is not an anti death machine. It's a bridge and if you don't have a destination other than hope they'll get better, then it's best not to get on that train.

You didn't have a single survivor? I feel like the ecmo centers I still have contact with had survival rates in the 40-60% range. Either way it was 0% for my patients. Bridge to recovery was real for some people from the lung side but for myocarditis I assume transplant vs vad was happening during the pandemic but maybe not everywhere. Seems nuts to think an otherwise healthy 50 year old would just not be given a chance.

 

[aafisahar]

You didn't have a single survivor? I feel like the ecmo centers I still have contact with had survival rates in the 40-60% range. Either way it was 0% for my patients. Bridge to recovery was real for some people from the lung side but for myocarditis I assume transplant vs vad was happening during the pandemic but maybe not everywhere. Seems nuts to think an otherwise healthy 50 year old would just not be given a chance.

Meant more for VA ecmo, we had decent success for vv. VA ecmo in covid invariably meant heart-lung transplant or death from ecmo complications

 

[Siggy]

Seems nuts to think an otherwise healthy 50 year old would just not be given a chance.

::Laughs in community ICU::

Local ECMO centers never had any room, and when you consulted them the patient was either not sick enough or too sick to be transferred.

 

[The Knife & Gun Club]

Meant more for VA ecmo, we had decent success for vv. VA ecmo in covid invariably meant heart-lung transplant or death from ecmo complications

We definitely had a handful at our hospital during the first couple waves. It wasn’t common and we’re a high volume center, but they were good about candidate selection, and while many didn’t make it some did.

I had a lady who was 38, one of the X-ray techs, got covid in wave #2, august 2020. I was battle field deployed to our covid unit back then, as an intern. She got cannulated, stayed on circuit for 2 weeks, and recovered neuro intact. Recently saw her in the ED, AO x3, laughing and playing with her kids. Only lasting deficit was she lost half her fingers.