ARDS management with ECMO

MomRN0913 · Sep 16, 2011

I worked in a community based ICu, so we never saw that. Proning a patient on one of those KCI beds is a big thing. We had to prone the patient once without the bed. That was interesting.

The idea of ECMO sounds pretty logical when you think about it. I would love to hear about who is doing this and how it has worked.

EricJRN, MSN, RN · Sep 16, 2011

I work in a children's hospital connected to an adult hospital and we do neonatal, pediatric and adult ECMO. I was an ECMO specialist briefly, before my current nurse educator opportunity arose. I will tell you all I know (so it will be brief :) ).

Adults make up, by far, our smallest set of patients. Part of that has to do with the decades-old belief that adult ECMO never works. An NIH trial from the 70's showed disappointing results, but those patients were not treated in high-volume ECMO centers and ventilation was mismanaged, as many of the ECMO patients were not placed on rest ventilator settings after starting ECMO.

For a long time after that trial, studies weren't aggressively pursued in adults. I think that has led to a terrible cycle in some places. Since ECMO "never works" in adults, they use it infrequently, and only as a last resort when the patient has one foot in the grave. Nothing that you do once or twice a year is likely to go well, especially if you save it for pretty-much-already-dead patients, so, of course, adult ECMO "never works" in those places.

On the neonatal side, we're getting better at optimizing conventional therapies, which has led to a steady decline in babies who need ECMO over the last couple of decades. It could be a coincidence, but it seems like the drop in baby numbers may have provided some of the incentive for centers to explore ECMO's use in adults again. The results this time are a little more encouraging. If you're interested in some data, look at the CESAR trial (which stands for Conventional vs ECMO for Severe Adult Respiratory Failure, I think).

Our center is slowly expanding the number of adults we place on ECMO, but these are some of the factors at work in the resistance to adult ECMO. I'm interested to hear from anyone else who is more experienced with it.

FIREMEDIC-CCRN · Sep 17, 2011

I wonder if the reason the military is having so much success with ECMO is because their patient population are soldiers who are young, healthy, and fit with limited medical conditions, I would imagine it has decreased success the older the patient is and the more medical conditions one already brings to the table.

Pediatric Critical Care Columnist · Sep 17, 2011

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"...

catamounts303 · Sep 19, 2011

Outstanding reponses. I've been thinking lately when cases do arise would this adult patient event benefit? So many are lung transplant receipients, ILD, and in full blown septic shock on Levo and fluid resuscitattion. But we still see a steady flow of the acute lung injury and somewhat stable ARDS patient so I do hope there is a push. 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!

Pediatric Critical Care Columnist · Sep 19, 2011

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.

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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.

Advanced Practice Columnist / Guide · Sep 25, 2011

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

CCRNDiva, BSN, RN · Oct 2, 2011

We were hit pretty hard by the flu last year. Our sickest patients were in the 25-45 age group. We don't have ECMO so we have to transfer to U of Michigan or U of Chicago. Our outcomes were not that good though, I think we had 2 survive. I think they did better because we were able to transfer them w/in 24 hrs. I also think ECMO is something a facility has to do often in order to do well.

On a side note, all of the patients we had to transfer for ECMO were mismanaged outpatient prior to crashing and requiring ICU admission. One young lady had been to an urgent care center affiliated with our hospital 3 times over the two wks prior to her admission to the unit. By the time she was admitted her WBC was 3 and she did not have any reserve left to fight the infection. Thankfully, she was one who was transfered within 24 hrs of admission and did survive.