Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

ECMORN, the photo I posted is several years old. We have upgraded our equipment since then and are using new technology. I think one of the reasons our outcomes for V-V are not as good is that we tend to get these kids late in the process of their illness... our catchment area covers 1.26 million square kilometers (783,000 square miles) of, for the most part, sparsely populated country and includes a large indigenous population. (It's the largest territory covered by any hospital in Canada.) We'd be more proactive if we could. I think I mentioned our severe asthmatic who has had ECMO twice who is maybe, finally, learning that his asthma isn't a joke. Another reason for our less-successful V-V runs could be the somewhat more vague indicators that ECMO should be considered. With our cardiac kiddies, we have fairly clear-cut indicators and electively cannulate them more often.

We're definitely expanding our capacity, at least in the human resources area. Our PICU is running an ECMO training course at the beginning of October; we usually train 8-10 new providers each course. Our team is fairly evenly distributed between our RNs and RRTs but since the team leader is an RRT, there's a little favoritism in the selection process. Ultimately that isn't an issue... unless you're one of the RNs who wasn't selected.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

I have to disagree with oramar here...at least partially...

Originally Posted by oramar

The short answer to the question that heads this thread is "NO". The long answer is that is a very specialized medical procedure that will be offered at only a small number of very high tech facilities. During this summer's herald event it is feasible to transfer people across state lines for this treatment. However, when this thing peaks this winter the big medical centers will have all their machines tied up with locals and when people from out of state call the answer will be "NO". So their you have the long and short of it.

There are nearly 100 ECMO programs in the United States that report to ELSO (Extracorporeal Life Support Organization) which is a relatively small number compared to all the hospitals in the U.S. However it is a rather large number compared to the rest of the world. The 10 largest ECMO programs in the US have the ability to support anywhere from 3-8 patients at one time. The other 85-90 or so can usually support at least 2 at one time. It is very specialized...but the biggest problem will be that the overwhelming majority of ECMO centers are ONLY pediatric and neonate. So the Adults will have very limited support at experienced centers.

But...there are a significant number (still trying to identify exactly how many) of Adult hospitals that are supporting ECMO patients by using their perfusionists and a "non-traditional" (in many cases) ECMO system to provide this much needed support often on somewhat of an emergent or last ditch effort basis. Problem with this is that the OR has to shut down for cardiac surgeries because the perfusionists are sitting at an ECMO pump 24/7.

There are also a couple of independent agencies that are trying to beef up ECMO System rental capability as well as ECMO Specialist staffing contracts to help support the hospitals that don't have established ECMO programs. You can google ECMO staffing/ECMO equipment/ECMO Specialists etc. and find a couple of different groups at least offering some type of help.

I know there are also groups trying to partner with manufacturers to make sure that there are plenty of ECMO systems available in the U.S. this fall.

So will we be ready?...probably not as ready as we would like to be...but it won't be as bad as it could be.

As for who is doing ECMO...at least those who report to ELSO can be found on the ELSO web site. www.elso.med.umich.edu (I am not associated with the U of M...just happen to know this info is available on this site)

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Originally Posted by ECMORN

But...there are a significant number (still trying to identify exactly how many) of Adult hospitals that are supporting ECMO patients by using their perfusionists and a "non-traditional" (in many cases) ECMO system to provide this much needed support often on somewhat of an emergent or last ditch effort basis. Problem with this is that the OR has to shut down for cardiac surgeries because the perfusionists are sitting at an ECMO pump 24/7.

ELSO is now tracking H1N1 statistics on their website. Our hospital is on four of their five lists of providers, all except the adult pulmonary. My guess is that the adult side will utilize the expertise of the children's side to enable capacity there.

Every once in awhile we transport children on ECMO for great distances (800 miles) after a surgeon there has cannulated and their adult perfusionist has run the pump. Our transport team nurses have all been trained so they can limit the number of personnel having to travel. All but one of the kids we've transported has survived. But what I really wanted to comment on here is the "non-traditional) angle. In 2007, the Winnipeg Children's Hospital cut an oxygenator into a CRRT circuit and saved a neonate's life. My friend who works there called it "FakeMO". www.hsc.mb.ca/press_release22.doc

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Originally Posted by ECMORN

But...there are a significant number (still trying to identify exactly how many) of Adult hospitals that are supporting ECMO patients by using their perfusionists and a "non-traditional" (in many cases) ECMO system to provide this much needed support often on somewhat of an emergent or last ditch effort basis. Problem with this is that the OR has to shut down for cardiac surgeries because the perfusionists are sitting at an ECMO pump 24/7.

This is how my hospital does it... We do have enough perfusionists available to continue a regular OR schedule, but they are frazzled after a few days of this.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Originally Posted by c0ntagion

This is how my hospital does it... We do have enough perfusionists available to continue a regular OR schedule, but they are frazzled after a few days of this.

I would imagine that all will be very stressed after a fall and winter full of these types of cases if they decide to use ECMO. I wonder if decisions will be made on how costly and labor intensive it is to use this mode of tx as most do not seem to survive.

Hospitals in some southern hemisphere countries have already been cancelling elective surgeries because of the numbers of flu victims being admitted as critical care cases.

Can the pediatric hospitals take adult cases? Many will be teens and young adults...My hospital offers ECMO, but only for neonates.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Hopefully this won't be a HUGE issue. But I agree it has great potential stress the system a bit. According to one report out of Australia, "2% of hospitalized patients and 6% of ICU (H1N1) flu patients go on to ECMO". The CDC is projecting a large number of total cases this fall in the US. And it is unclear as to whether we will have an effective vaccine...and if we do...how much and who will get it?

It is still uncertain what the overall survival rates are for these patients. Experts in Europe are saying 60% should survive. The data so far from Australia seems to be a little lower than that. The current experience in the States in the last 6-8 weeks is somewhere around that. It will be interesting to see what is reported from the ELSO database. Those who present with community acquired MRSA are not doing that well. But one thing that seems to be certain is that if you get sick enough to "qualify for ECMO" with an H1N1 related pneumonia, you're not likely to make it through without ECMO. So I'd say 40%-60% chance of survival vs. almost certain death might be worth whatever the cost. (In general ECMO costs much less than an organ transplant which is generally accepted in our society as a worthwhile expense.)

Maybe all the preparation in anticipation will make it all go smoother than it otherwise would.

We'll see...

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

There is some confusing info being posted.

1. You have to compare apples with apples. Percutaneous ECMO in several units in Australia is instituted by intensivists and used very early in the case, and they have excellent results (esp. The Alfred). In any case, the early and frequent institution of ECMO could give you skewed numbers.
2. Centrimag pumps are a very expensive way to run ECMO. Centrimag pumps cost around $8500-12000 dollars. Jostra or Biomedicus pumps only cost several hundred dollars. The Centrimag consoles are not cheap, and are also quite expensive to rent from Thoratec, because they are usually used for VADs. Biomedicus machines are a lot cheaper and widely available.
3. Not all big ECMO centres are listed on that ELSO website. In particular, UPMC in Pittsburgh is not listed and they do A LOT of VADs and ECMO. In addition, Children's Hospital of Pittsburgh also uses both ECMO and VADs for peds cases.
4. The limitation is really not the machines or equipment. It's the hospital CTICU/ICU beds, and the specialized staff to run the systems. There's no point sending 1 or 2 staff to outlying hospitals to run the ECMO, because you also need the capability to get back to the OR, change out circuits/oxygenators, etc etc. You need to be in a big center.
5. You do not need a surgeon to institute ECMO, unless it's centrally cannulated. Peripheral ECMO cannulae are reasonably easy (similar to an IABP) and quick to insert, and mean that support can be quickly initiated.
6. Another possible way to ramp up the ECMO capacity US-wide would be to adopt a model similar to The Alfred. ECMO is instituted either in OR or ICU, and managed by intensivists in ICU. The perfusionists handle in OR, but once in ICU, ECMO-trained RNs manage it. They have a formal ECMO course which is offered 1-2 times a year, and given by nurses, doctors and perfusionists. There is really no need to have a perfusionist bedside if you have trained ICU RNs - in an emergency, you need to be able to clamp the circuit. Routinely, you need to alter the sweep gas according to ABGs and supervise the circuit. We run Centrimags as VADs with no oxygenator and there's noone sitting bedside - we've even ambulated patients with Centrimag VADs! A lot of the insistence on 24/7 perfusionists with ECMO is the perfusionists creating job security, I think!

The answer to the thread is that we don't know. The percentage of H1N1 patients that end up requiring ECMO would be relatively minimal, so the impact is hard to estimate.

Originally Posted by ECMORN

I'd say 40%-60% chance of survival vs. almost certain death might be worth whatever the cost. (In general ECMO costs much less than an organ transplant which is generally accepted in our society as a worthwhile expense.)

Transplantation generally has a much better survival than 40-60%, though!!

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Here's the info for the Alfred ECMO clinical service and course:
http://alfredecmo.com.au/ECMO%20UNIT.html

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

http://alfredecmo.com.au/ECMO%20UNIT.html

This says almost 60% survive to discharge. That is more than I would have thought.

I wonder if there will be any change in case survival with H1N1.

Originally Posted by alfredecmo.com.au

To date (December 2008) the Alfred has performed 170 adult ECMO interventions with 129 occurring since 2003, an average of more than 20 per annum. Since the first use of ECMO in 1990, 65.9% of ECMO interventions have been associated with a successful wean from ECMO and 49.7% have survived to hospital discharge. Outcomes have improved since 2003 with this cohort of patients achieving a successful wean form ECMO 72% of the time and hospital discharge in 56.8%. Of the 42 patients that received ECMO support prior to 2003, only 28.6% survived to hospital discharge.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

If you take a look at their data though, the results for respiratory failure are worse, around 50%. Their good results in cardiac patients pushes the overall survival up. Also, as mentioned, they institute ECMO very early and do tend to get better results than those that just implant crash-and-burn patients - you can see the improvement in their results since 2003 when they started the percutaneous ECMO service.