How long can patient be in ECMO?

[Dock1234]

Just stupid pre-med here asking. I was just wondering how long could patient survive in ECMO in a situation where he has no function in his own heart and lungs? And what is the main reason for this limit?

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[europeman]

Just stupid pre-med here asking. I was just wondering how long could patient survive in ECMO in a situation where he has no function in his own heart and lungs? And what is the main reason for this limit?

I don't know the record, but we once had someone waiting for a lung transplant on ecmo for 6 months. She certainly had cardiac function though. It was just her lungs that were the issue.

 

[KLPM]

I don't know the record, but we once had someone waiting for a lung transplant on ecmo for 6 months. She certainly had cardiac function though. It was just her lungs that were the issue.

Out of interest is this adult or paeds? The local children's hospital has recently become quite interested in elective ECMO as a bridge to lung transplantation because from their limited n = 4 experience it works well.

 

[Stitch]

There isn't a set time limit, however every day you are on ECMO there is the risk of having a catastrophic bleed. So without any heart or lung function, you have ask what the goal of care is. Do you think the process is reversible. In peds, we generally say that myocardial stun from an ischemic event shouldn't last more than 3 days. We'll often give them five on VA ECMO before deciding on whether they would be a VAD or transplant candidate. If you're seeing significant myocardial depression from something like sepsis and are using ECMO for support, it's a different story. For severe ARDS on VV, that often takes a good deal of time to get better. ECMO just supports you, it doesn't fix the problem. Those patients can take several weeks to separate. And my feeling is they should be placed on ECMO earlier rather than later to avoid ventilator induced lung injury.

Using VV ECMO as a bridge to lung transplantation is becoming more popular, and Duke is about to publish data showing how getting the patient up and moving while on pump reduces deconditioning and improves survival. They can spend several weeks on ECMO. Cool stuff. Bleeding risks (complications in general) are a little higher for VA ECMO. The longest VA run I've seen at our institution was a neonate with hypertrophic cardiomyopathy too small for a VAD who was awaiting transplant. He stayed on for a little over 3 months, much of that time extubated, then went on to get a heart.

 

[Dock1234]

Why is it that CPB machine is more often used in surgeries than ECMO? I mean if you can be longer in ECMO, wouldn't it be more safe to use it in surgeries too? Or what are ECMOs disadvantages when compared to CPB machines?

 

[subtle1epiphany]

Just popping in to answer the basic portion of the question. The physiology and equipment is almost the same for both VA-ECMO and CPB, the difference is that cannulation is central in CPB and percutaneous in ECMO.

 

[BigRedBeta]

While I was interviewing for fellowship, one center had a teenager on ECMO for 90+ days, extubated, awaiting lung transplant with a significant fungal infection and so was going to be on for quite a bit longer.

As for the CPB/ECMO ?: There are a few other unique aspects to the CPB machines if I remember correctly while getting sternly lectured by a perfusionist as a 3rd year peds resident hanging out in the Cardiac OR and trying to make connections to ECMO that I had familiarity with (she was VERY clear that CPB and ECMO were not the same). They were all things most useful while in the OR - more rapid temperature regulation, inclusion of CellSaver lines into the circuit, the ability to rapidly empty the circuit into the patient for volume resuscitation, etc. I'm sure others can weigh in with more authority.

In the Peds Cardiac ICU's it is certainly not uncommon to have central ECMO cannulations through open chests.

 

[subtle1epiphany]

some other distinctions i can think of are that VA/VV-ECMO may be run by a trained CCRN, but rarely is CPB run by a non-perfusionist. other than these subtle distinctions i'm uncertain how they fundamentally differ. don't get me wrong, i completely hear you and i agree, they are different technologies. perhaps the line is just getting blurrier as we embrace these technologies and use them in different locations.

 

[sakata8242]

We had a patient who was on VV ECMO for at least a couple months..that I know of.

 

[Femtochemistry]

 

[idiot07]

The site of cannulation has nothing to do with the difference between ECMO and CPB. Patients can be peripherally or centrally cannulated on either. Most patients on ecmo are peripherally cannulated due to ease of access only and most patients on cpb are centrally cannulated because we have to open up their chest anyway to do the operation and central cannulation is associated with lower complications and better circuit performance, usually.

The ECMO circuit is in essence a stripped down cpb circuit. There is a big line that drains blood from the venous side, a pump pushes it through a membrane oxygenator, there may or not be a heat exchanger somewhere, and then oxygenated blood is pushed back into the arterial line and into the patient (arterial system for va, venous system for vv). CPB does the exact same thing except there is a reservoir that can be used to drain volume from the patient and temporarily helps stabilize flows if venous return drops. There's always a heat exchanger. And then there's a lot of extra intake lines that can be used as vent's from the the heart or to recapture blood from the surgical field (cardiotomy suction, not quite the same as cell saver, since cell saver filters everything out except the red cells, the pump suction returns whole blood into the pump reservoir). There's also usually an extra line that the perufsionist can use to pump cardioplegia into the patient to stop the heart. Finally, there may be some technical differences between the actual pump (roller vs centrifugal) and the type of membrane oxygenator's used (the one's designed for ecmo tend to last longer and are less thrombogenic but cost more) but these can be institution dependent, ask your friendly neighborhood perfusionist.

The advantage of cpb is its versatility. You can stop the heart, vent different chambers, open the heart, the circuit can deal with some air coming in the venous side and suckers, cool faster and slower, control the patients volume status, etc. You can't do that stuff with ecmo, if any air get's in the venous line it's probably going to the arterial side and out into the arterial circulation which is bad. The drawback of cpb is that the circuit is more thrombogenic so they need much more heparin (Goal ACT for cpb is > 400, while va ecmo 180-200ish again institution dependent) while they're on it, bleed more, and they're is a very significant systemic inflammatory response. So if somebody needs a little cardiopulmonary support in the icu, ecmo is the way to go. ECMO is also occasionally used ifor operations causing hypoxia or hd instability from cardiac manipulation, so you need some support but not everything else cpb does, i.e. airway surgery or lung transplant, with the thought you have less bleeding and inflammatory response. However, this too is institution and surgeon dependent.

 

[subtle1epiphany]

Those are excellent points that I hadn't considered due to lack of familiarity with the CPB circuits, but now that you mention it I recall to a degree. Thanks!

 

[chocomorsel]

I know this is old but at my place it's quite common to have them on for months. They mostly die though when it's getting into the months scenario. There was a recent one who needed lungs that was on for eight months. Never made it and it was sad as I would see him walking around all the time. I heard of one in the past that got decanulated after six months and got transferred out then died in step down from PE or something catastrophic. That would really suck.
We just decannulated one successfully after almost two months.
Also, we hardly use heparin for our circuits.
It's possible that if government cuts funding we won't be that aggressive and prolonged in the future. At least I've heard that sentiment from one attending.

 

[cardsguy2017]

Funny I saw this as I was just talking to a friend about this. They work at a hospital that's aggressive in care and doing ecmo for months isn't unheard of. The hospital has supposedly been in a financial bind the past few years, cutting staff, services, etc. I do wonder how much aggressive care, it's resource utilization and reimbursement all play into this.

 

[chocomorsel]

Funny I saw this as I was just talking to a friend about this. They work at a hospital that's aggressive in care and doing ecmo for months isn't unheard of. The hospital has supposedly been in a financial bind the past few years, cutting staff, services, etc. I do wonder how much aggressive care, it's resource utilization and reimbursement all play into this.

Our mortality on ECMO is high but I think it’s cuz we are putting poor candidates on it to begin with. Patients on the bridge to nowhere who should go to palliative instead. It sucks.

 

[Instatewaiter]

We had a patient on V-V ecmo for 11 months. She was transiently on VAV ecmo for a week but spent the rest on VV. I saw her in clinic last month. She walked in under her own volition.

Where I was before we had someone on VA ECMO for 1.5 months (centrimag). That guy didn't live in the end and he had tons and tons of complications over that month (multiple pneumonias, ischemic complications etc). The most we've kept a patient on VA where I am now is about 2-3 weeks. If they can't come off we'll place a durable VAD Unless the RV is shot too...

 

[Instatewaiter]

Funny I saw this as I was just talking to a friend about this. They work at a hospital that's aggressive in care and doing ecmo for months isn't unheard of. The hospital has supposedly been in a financial bind the past few years, cutting staff, services, etc. I do wonder how much aggressive care, it's resource utilization and reimbursement all play into this.

The reimbursement got slashed this year (like by 60% -so the pencil pushers tell me). Will be interesting to see what hospitals decide. ECMO became a lot less financially viable .

Wonderful what happens when the govt tries to save some money...

 

[CCM-MD]

Off the ELSO website.

 

[chocomorsel]

The reimbursement got slashed this year (like by 60% -so the pencil pushers tell me). Will be interesting to see what hospitals decide. ECMO became a lot less financially viable .

Wonderful what happens when the govt tries to save some money...

ECMO can be a money dump full of futile care. Let’s be real. The mortality I suspect in many programs is sky high. This is America. Plenty of people want everything done even when there is no hope because they don’t have to pay for it and many doctors are scared to pull back.

 

[SurfingDoctor]

VV ECMO for sepsis with vent support?

What’s the point of that? And why does that code higher than cardiogenic shock?

 

[Psai]

We had a patient on V-V ecmo for 11 months. She was transiently on VAV ecmo for a week but spent the rest on VV. I saw her in clinic last month. She walked in under her own volition.

Where I was before we had someone on VA ECMO for 1.5 months (centrimag). That guy didn't live in the end and he had tons and tons of complications over that month (multiple pneumonias, ischemic complications etc). The most we've kept a patient on VA where I am now is about 2-3 weeks. If they can't come off we'll place a durable VAD Unless the RV is shot too...

Place a centrimag rvad as well problem solved

 

[deleted547339]

Place a centrimag rvad as well problem solved

Ummm...rvads are the start of the problem, not the solution.

 

[Instatewaiter]

Place a centrimag rvad as well problem solved

temporary solution for a chronic, often permanent problem.

 

[jdh71]

View attachment 247975

Off the ELSO website.

looks like the key is to put in an impella too!!

 

[combatwombat]

Just stupid pre-med here asking. I was just wondering how long could patient survive in ECMO in a situation where he has no function in his own heart and lungs? And what is the main reason for this limit?

IIRC the record is something like 2 years, in a pediatric patient at Duke. I don't remember if it was VA or VV.

You might be interested in this meeting: Home - ASAIO American Society for Artificial Internal Organs

 

[deleted547339]

How long does it take to get HIT?

 

[Modanq]

So you need anti coagulate? Not always...

 

[chocomorsel]

How long does it take to get HIT?

We don’t use Heparin routinely on these patients. Depends on surgeon.

 

[deleted547339]

We don’t use Heparin routinely on these patients. Depends on surgeon.

1) that’s weird, I’m surprised you don’t have a ton of embolic issues, at least with VA.
2) your circuits are heparin bonded.

 

[chocomorsel]

1) that’s weird, I’m surprised you don’t have a ton of embolic issues, at least with VA.
2) your circuits are heparin bonded.

Well yeah, the circuits may be heparin bonded but not a bunch of drips running. These people tend to die of Sepsis and MODS. Not so much embolic issues. That's what I learned during my rotation with the ECMO team. It's surgeon dependent the heparin. Don't remember seeing any HIT while I rotated. I did see a lot of sepsis/renal failure/ and some dead legs. What's your definition of a ton?

I am not the expert, just did a month rotation with them. I don't do it daily. I do remember asking about the heparin though and getting that answer and observe that on the patients.

 

[deleted547339]

Well yeah, the circuits may be heparin bonded but not a bunch of drips running. These people tend to die of Sepsis and MODS. Not so much embolic issues. That's what I learned during my rotation with the ECMO team. It's surgeon dependent the heparin. Don't remember seeing any HIT while I rotated. I did see a lot of sepsis/renal failure/ and some dead legs. What's your definition of a ton?

I am not the expert, just did a month rotation with them. I don't do it daily. I do remember asking about the heparin though and getting that answer and observe that on the patients.

Most places anticoagulants most patients on ecmo. Not all, but most. Specifically VA for obvious reasons. I did a lot of ecmo in fellowship at a high volume center. You can run either dry if you have a compelling reason to, heck, I’ve given PCC to someone on va ecmo (hint: doesn’t go well). A lot also depends on your flow rates - 5lpm on VV? Almost certainly fine. 2.5lpm on VA makes me super nervous.

Specifically I’m talking about strokes and dead gut.

 

[psychbender]

Saw several cases of HIT on ECMO in fellowship. Fun times.

Most ECMO was anticoagulated with heparin, some at high flow rates with high bleeding risk were left without. Never gave PCC to stop bleeding while on, but where I am now tried it once...also didn't go well.

 

[Modanq]

1) that’s weird, I’m surprised you don’t have a ton of embolic issues, at least with VA.
2) your circuits are heparin bonded.

VV not VA. In VA you have to anticoagulate

 

[deleted547339]

VV not VA. In VA you have to anticoagulate

You don’t have to. I’ve done it without a handful of times. It should be done with full anticoagulants 99% of the time.

 

[Modanq]

You don’t have to. I’ve done it without a handful of times. It should be done with full anticoagulants 99% of the time.

Agree - Big area of research. Should we use anti platelets, anticoagulants, also what do we follow Xa, put counts, TEG, functional markers, wVF levels, Do we use heparin, argatroban, bival. Bottom line is more often than not its institutional specific and that means we don't have a full answer as of yet.