ECMO in the ED

[Cerberus]

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http://emcrit.org/podcasts/ecmo/

Interesting but I agree with the last commenter. This really needs to be focused on a select group of patients. We do enough heroic necromancy on nursing home patients as is.

 

[docB]

heroic necromancy

Excellent term. I'm gonna steal that one.

 

[KarlPilkington]

I can't imagine even trying to set up ECMO on a coding patient in my shop...this sounds great for the one guy in the video who survived, but I'll be amazed if this gains any traction on a bigger stage...in my experience the logistics of ECMO can be so difficult, I think it would be tough to even study this therapy in terms of survival benefit.
My biggest fear would be getting this off the ground and then we go from trying to decide whether to start CPR in that demented patient with unclear advanced directives, to calling in an ECMO team and loading up our ICU's with even more poor, suffering patients with little hope of recovery.
If I go down...nobody better throw me on ECMO, let me go in style.

 

[KYTNOH]

I've only ever seen it on pediatric patients in our department, and that was only once. Usually we wait until they get to the PICU before putting them on ECMO. ECMO in adults fairly rare as it isn't indicated all that often.

 

[Lawsonc]

This may be a dumb question, but how many hospitals have ECMO, and staff that know how to use it, readily available? I've seen it only once at a regional childrens hospital in the PICU, and even then they had an external team come in from across the country.

 

[xaelia]

If my hospital wanted to add ECMO, I would suggest to them that more lives would be saved by increasing nurse staffing instead.

 

[Venko]

We have ECMO 24/7 available and have implemented it about once or twice annually in the ED. There is a simple paging system that we just input the room of the patient and the team is mobilized to it. The patients we target are the massive PE, crashing asthmatic etc. The machine is based in the ED, the ED residents / staff we get guidewires in femoral vessels and the ECMO team mobilizes usually within 2-5 minutes and arrive to dilate and cannulate fully and initiate ECMO.

Its certainly a very slick thing but only available here because of how big the institution is. When you have these patients who you know can live and thrive if only you can oxygenate / ventilate their blood, its a great tool to have available to you.

TL

 

[Xerxes1729]

When I was in med school in the unit, we had a case almost exactly like the one described in the podcast, except the guy went on ECMO in the cath lab when the couldn't fix his V tach. The whole time he was on pump, I kept thinking that it was completely ridiculous, that there was no way this guy would get off the machine, and that even if he did, he would be neurologically devastated. Things dragged on for weeks with no real change, but in the end, I was wrong and he walked out of the hospital with no deficits.

 

[deleted92121]

I work at medium-sized hospital south of Pittsburgh and we have ECMO. Once I even heard the page overhead for the ECMO team to head for the OR. Would have never guessed we had it until that day.

I agree with xaelia though, more nursing and ancillary staff would be a safer bet.

 

[Stitch]

It's pretty interesting how ECMO use has changed and grown even in just the past few years. We initially viewed it as a support platform while a reversible process healed. Now we put just about anyone on, and use ECMO to determine whether that process is actually reversible.

We have 24/7 coverage and can have somewhere around a max of 6-8 circuits going in the hospital at any one time between the PICU and the NICU. It's especially useful in the setting of congenital heart disease, where CPR may not be as effective, and we've used eCPR (putting a kid on while you code him) numerous times with decent survival (supposing there's no delay in CPR and such). I don't know of any data looking at larger populations, though getting people on circuit early (ideally within 20 minutes from initiation of arrest) seems key.

 

[B-Bone]

We have ECMO 24/7 available and have implemented it about once or twice annually in the ED. There is a simple paging system that we just input the room of the patient and the team is mobilized to it. The patients we target are the massive PE, crashing asthmatic etc. The machine is based in the ED, the ED residents / staff we get guidewires in femoral vessels and the ECMO team mobilizes usually within 2-5 minutes and arrive to dilate and cannulate fully and initiate ECMO.

Its certainly a very slick thing but only available here because of how big the institution is. When you have these patients who you know can live and thrive if only you can oxygenate / ventilate their blood, its a great tool to have available to you.

TL

I've been involved with many ECMO cases at this institution, and had one where we put a baby on ECMO in the ED. Not good results, as a whole. The only ECMO cases i've ever personally had live to discharge were relatively young previously healthy people who were already in the OR when we decided to try ECMO as a last resort after inability to separate from CPB during cardiac surgery. Even with a giant ECMO team "instantly" available the mortality rate between when you decide to try it and are able to implement it in an emergency approaches 100%. Perhaps things have changed, but when I was around, ECMO cannulas were placed by cardiac surgeons, and they weren't in-house when I was a resident. Who's getting there in 5 minutes to place the cannulas?

Certainly I've read of success stories, but I think the ratio of quality life years attained to dollars spent is probably one of the worst in all of medicine.

 

[Xerxes1729]

Perhaps things have changed, but when I was around, ECMO cannulas were placed by cardiac surgeons, and they weren't in-house when I was a resident. Who's getting there in 5 minutes to place the cannulas?

In the hospital in the podcast that started the thread, the cannulas are placed by the ED physicians. The ECMO machine is brought down by nurses who run it for 45 minutes until the perfusionist shows up.

 

[Venko]

I've been involved with many ECMO cases at this institution, and had one where we put a baby on ECMO in the ED. Not good results, as a whole. The only ECMO cases i've ever personally had live to discharge were relatively young previously healthy people who were already in the OR when we decided to try ECMO as a last resort after inability to separate from CPB during cardiac surgery. Even with a giant ECMO team "instantly" available the mortality rate between when you decide to try it and are able to implement it in an emergency approaches 100%. Perhaps things have changed, but when I was around, ECMO cannulas were placed by cardiac surgeons, and they weren't in-house when I was a resident. Who's getting there in 5 minutes to place the cannulas?

Certainly I've read of success stories, but I think the ratio of quality life years attained to dollars spent is probably one of the worst in all of medicine.

Certainly, resources and mobilization are key. We have cardiac and vascular surgeons available in house 24/7. You are right that if it doesn't happen quickly, it is a useless intervention.

To the OP, I dont believe that it is a wasted step if you have a crashing asthmatic whose disease process will resolve over time, or the massive PE who can then have embolectomy, lytics etc based on the case.

It is certainly always possible to end life-sustaining measures, but for these very severe, but very uncommon (thankfully) cases if the resources are available it would be a shame not to use them; if it is conclusively futile, these discussions can be had at another time.

 

[Cerberus]

Certainly, resources and mobilization are key. We have cardiac and vascular surgeons available in house 24/7. You are right that if it doesn't happen quickly, it is a useless intervention.

To the OP, I dont believe that it is a wasted step if you have a crashing asthmatic whose disease process will resolve over time, or the massive PE who can then have embolectomy, lytics etc based on the case.

It is certainly always possible to end life-sustaining measures, but for these very severe, but very uncommon (thankfully) cases if the resources are available it would be a shame not to use them; if it is conclusively futile, these discussions can be had at another time.

Well, that was exactly my point. I don't want to see this end up as something we do on everyone (i.e. the 100 yr old, who should be DNR, whose family demands you do everything). There are cases where I'd like to have this at my disposal (the young, healthy pt with a reversible pathology).

 

[docB]

Well, that was exactly my point. I don't want to see this end up as something we do on everyone (i.e. the 100 yr old, who should be DNR, whose family demands you do everything). There are cases where I'd like to have this at my disposal (the young, healthy pt with a reversible pathology).

But therin lies the problem. This is very expensive infrastructure. If it's not getting used frequently enough to justify its expense it can't last as a modality. If you're using it often enough to justify it then it's probably being applied incorrectly.

We have been experiencing similar issues with our therapeutic hypothermia program.