ARDS management with ECMO

ECMO should be reserved only for those with a reversible cause for their cardiac or respiratory failure. Because ECMO doesn't CURE anything. All it really does is rest the injured organ(s) for a time. It may be legitimately used as a bridge to transplant, cardiac transplant that is. Most lung transplant programs will not perform transplantation on an ECMO patient; morbidity is much too high - lung transplant recipients must be in good physical condition otherwise in order for survival and a decent quality of life.

Our unit does a lot of ECMO. It's not uncommon for our 17 bed unit to have three or four pumps running at one time, and the runs are prolonged. Our experience with it for ARDS in children of any age is rather mixed. We've had kids with the RSV/adenovirus double whammy on ECMO for up to 8 weeks who have ultimately died. And we've had kids with severe ARDS from other viral or bacterial sources/TRALI/asthma who have needed only a few days of rest and they've bounced right back. During the H1N1 panic, our hospital trained a large number of new pediatric specialists to accommodate an expected spike in cases requiring ECMO, adult and peds - which never happened.

I agree with Eric that self-fulfilling prophecy will never be disproven until someone has the gumption to challenge it. The military has undertaken that task and the results will be very important. Naturally, comorbidities will have an impact on outcomes. And ECMO cannot be undertaken on a whim. There are certain risks that go hand in hand with the placement of garden-hose-sized cannulae into anybody, regardless of their underlying health status. Infection, bleeding and thromoembolic complications are very real and very serious. As the adult cases are analyzed, more clear-cut criteria for offering ECMO to adults will become available and it may become an option for a significant population. Having said all that, let me show you the tattoo I have on my right neck that says, "Do Not Cannulate"...

I'm yet to see the machine I figure the concept is similar to the heart lung machine? That is a wild store having to prone the patient without the kci bed!

There are some significant differences between the bypass system used in the OR and an ECLS circuit. CPB uses a series of reservoirs and centrifugal pumps whereas ECMO uses one pump and one reservoir - the patient. ECMO is "portable" (we take our ECMO patients to CT, the cath lab or the OR fairly often) and CPB is not.

As for proning patients without a specialized bed... we do it ALL the time - we don't have anyof those specialized beds. Our administration figures people are less costly than equipment. So we gather up a group of strong backs and turn, q12h. Six of us can prone an average adult-sized patient in about 10 minutes or less. It's all about planning and teamwork. We've even proned an adolescent with an open chest, complete with retractors. Believe it or not, that patient recovered completely and is doing well 11 years later.

hi everyone

on our unit we've been seeing a lot of ards lately for multiple reasons. usually things like aspiraton pneumonitis, fibrotic lung disease, acute lung injuries, trauma, etc. one of the treatments we have done has been of course the kci bed that turns the patient upside down etc. however recently i've been hearing about putting a patient on ecmo allowing the lungs to heal while the machien can perfuse the body.

i was wondering if any of your centers have used ecmo? i have heard a lot of the military hospitals have been using it. just curious about the success rates etc. maybe even some nicu nurses could chime in on what its like to manage a patient on ecmo therapy. the idea seems awesome. wonder if and when or if it is in fact going on in some of your hospitals?

i work in adult critical care as an np and our cardiothoracic surgery service have been using ecls or ecmo in the adult population for acute lung injuries (especially during the first year h1n1 broke out) and as a bridge to lung transplantation in cases of ild and cf. our surgeons prefer early referral to our center and cannulation early in the course of h1n1. we do have a modest success with the h1n1 population but have not seen many severe cases requiring ecmo in subsequent years. this is obviously a case where the consensus was that the reversibility of lung injury, hence the chances of success, warrants the high cost of the therapy.

we do still see quite a few pre-lung transplant patients (already worked up and determined suitable candidate) who present with severe hypoxemic and hypercarbic respiratory failure who end up getting cannulated and getting transplanted later. in these cases, the lung pathology is obviously irreversible and ecmo is used in an analogous manner to a patient being on vad while waiting for a heart tranplant. being on ecmo does bump up the lung allocation score for patients. a recent trend, that probably warrants a formal study, is that we are finding patients who were bridged from ecmo have less incidence of rejection after transplantation.

if you're interested in the use of ecmo for ards, read the cesar trial. it's a british study that somewhat re-energized the concept of using ecmo on adults. a simple google search will yield tons of stuff:

http://www.cesar-trial.org/

http://www.medscape.com/viewarticle/569740

http://www.thelancet.com/journals/lancet/article/piis0140-6736(09)61630-5/fulltext

there are published data and articles on ecmo use in h1n1:

http://jama.ama-assn.org/content/302/17/1888.full

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0710a1.htm

http://www.medscape.com/viewarticle/710348