ECMO

Pediatric Critical Care Columnist · Feb 15, 2008

We try to reconstruct all the vessels, because some of our kids are going to be back many times before they either grow out of their cardiac issues or die. Decannulation often takes a couple of hours while they do the reconstruction. With our little ECMO frequent flyer, she had a clot in her internal jubgular and the external jugular wasn't big enough. She ahs also had femorla clots with multiple collaterals. Her family knows that ECMO and CPB are both out of the question for her now but aren't willing to believe that she's going to die. They've agreed to a modified DNR (no intubation, no compressions, no push drugs) but insist that we do everything up to that point. So we'll keep her in an ICU bed for however long it takes. Sad.

My AACN presentation will be an oral one. I think I'll do a Power Point to go with it. Maybe I'll run my abstract by you before I submit it.

elizabells, BSN, RN · Feb 16, 2008

I'll be happy to read it!

I think the hardest part of our jobs (as we've discussed in other threads) are the kids who we KNOW aren't getting better, but we can't seem to communicate that to the families. Up in our PICU we had a toddler on ECMO for 38 days, which is unHEARD of in our hospital. She had adenovirus, and ended up with 8 chest tubes, was on the oscillator the entire time she was on ECMO (again, unheard of for us, don't know about anyone else) and saddest of all, in a way, no ears. They just couldn't stop the skin breakdown. At one point her entire skull was covered in Duoderm. Even after she came off ECMO she took a really long time to pass. We had runs going in the NICU the whole time she was on, and the perfusionists started showing up earlier and earlier so they could come to us instead of the PICU, because it was just too sad.

ECMOismygame · Feb 16, 2008

I'll be happy to read it!
I think the hardest part of our jobs (as we've discussed in other threads) are the kids who we KNOW aren't getting better, but we can't seem to communicate that to the families. Up in our PICU we had a toddler on ECMO for 38 days, which is unHEARD of in our hospital. She had adenovirus, and ended up with 8 chest tubes, was on the oscillator the entire time she was on ECMO (again, unheard of for us, don't know about anyone else) and saddest of all, in a way, no ears. They just couldn't stop the skin breakdown. At one point her entire skull was covered in Duoderm. Even after she came off ECMO she took a really long time to pass. We had runs going in the NICU the whole time she was on, and the perfusionists started showing up earlier and earlier so they could come to us instead of the PICU, because it was just too sad.

thats horrible :crying2:

Pediatric Critical Care Columnist · Feb 16, 2008

Our longest run to date was 56 days, same kind of patient... a toddler with adeno. She didn't survive, and we knew pretty much from the start that she wouldn't. The family situation was very sad; her sister had been murdered the month before and the parents were still reeling from that when she got sick. Our infectious diseases doc told the family that recovery from adeno would take six to eight weeks, and they took that to mean that we'd keep her on ECMO for that long. Because of the family's psychological needs we did just that. Every day she'd fail her oxygen challenge and we'd just keep going. Then on the 56th day it was agreed that she'd come off. She was moved off the bed and onto her mother's lap and the bridge was clamped; she died in minutes. She too had many areas of skin breakdown, no matter what we did. It was terrible.

Polednice · Feb 17, 2008

That's really very sad, about the kids in your ICUs!! ...I really admire what you do for your little patients!!

...and I am also interested in that abstract of your lecture, Janfrn!

califalcon · Mar 20, 2008

Hi to all: I am new to the forum but with a very extensive service as an RN both in military and civilian sections.

ECMO started catching my interest when in 1995 I arranged for an ECMO transport from Kapiolani to Orange County California and had to deal with rearranging flights with the US Coast Guard because the ECMO unit would not fit in the Gulfstream we were using.

The modality has grown considerably...the Air force at Wilford Hall, UM and Arkansas are the only known centers to do Mobile ECMO in the US. However, they self limit their transports to patients who are referred to their facilities or in the case of WHMC, to military and their dependents. I only know of two or three transports that were done externally.

I have been in the aeromedical world since the beginning of the aeromedical development flying the injured under fire in a Huey and went on to develop my own aeromedical service and international development company.

Now, after getting calls to transport ECMO patients and being basically refused by the current Mobile providers, I have contacted the Pentagon and received the assurance of support to develop and promote Mobile ECMO services that will also be used by the USAF .....without any hospital affiliation that will eliminate the need to search for the means to get a patient from one center to the other or deal with hospital politics.

I will be very happy to hear what needs exist and what it is we need to do to plug the holes.

We will be placing a LearJet in service for this....which will eliminate the need for large military cargo aircraft and imagine....minimize the costs to the taxpayers.

thanks for the opportunity to participate in this forum

Manny

Pediatric Critical Care Columnist · Mar 21, 2008

Our transport team has successfully provided mobile ECMO for four children now. The first transport was a logistical nightmare; it was Canada Day and the military transport planes were all tied up with fly-pasts and other events that had been prearranged to which they'd deployed earlier in the week. The air ambulance was too small, so we chartered a Lear to go pick up the child, an 11 year old post arrest. The referring hospital had the expertise to cannulate but not the resources or manpower to follow through. Another hospital closer to the referring center had been approached but they refused. Our team flew out with our pump and equipment; getting the kid switched over went well, but the only elevator accessible to the PICU there was too small to contain all the equipment so the pump and oxygenator had to be taken off the cart and put on the bed between the kid's legs for the elevator ride. The city had no ambulance that could accommodate the equipment and crew, so the fire department dispatched a flat-bed and a dozen strapping firefighters to dead lift the stretcher, circuit and pump onto the truck. We have video tape of the whole process, entertaining to watch, but I can only imagine the anxiety the crew was feeling!

Many lessons were learned from that experience. The next mobile ECMO came from the same hospital and went much more smoothly. The other two came from a small hospital about 600 miles from here; both were neonates and both survived the transport only to die later of severe neurological complications.

I'm considering sharing your web-site address with our ECLS coordinator and our transport coordinator. I'm sure there are great things to be exchanged!

califalcon · Mar 26, 2008

Hello to all in the forum and thanks janfran for giving us the credibility.

We had a meeting on Good Friday about the formation of this program. We have a bunch of people who for one reason or another had a hand in the development of high quality services but none could equal the scope of our new Mobile ECMO design.

With a Lear 35 that will be redesigned for an FAA approved (STC) ECMO cart, equipped with the latest ECMO items, the idea lit up like a Christmas tree and now we have several equipment manufacturers interested not only in R and D for newer ideas and to redesign the machines to fit the Mobile EcmoJet, but to be the first to demo their items aboard the Jet.

Investors are also looking at a very interesting business, but we are cautious about who we invite to the table. We need, a great team that could eventually be our partners/owners of this idea and we want to include Neonatologists, Neo nurses and RT's to become part of this program.

We will be working with several foreign facilities, the US Air Force and many of the ECMO centers that with the absence of a committed Aeromedical service, sometimes are not able to help some of the kids in need......mainly because some of the ECMO centers (3 only) that have their own aircraft....limit their transports to their own patients. We will break the mold.

thanks again...and if there are any ideas, questions or simple curiosity...please let us know.

Manny

Polednice · Apr 1, 2008

Hello!!

What an interesting topic with ECMO!! I'm sorry I can't contribute, just wonder... well, except a tiny bit. We had a 64 years old ECMO patient about two months ago. He was acutely admitted for massive ischemia of myocardium, with the major part of his heart out of work, and with 1 sqcm large hole in his ventricular septum. Those were just "our" diagnoses, cardiosurgical, further he suffered from severe renal failure and severe form of diabetes. They planned to operate on him, but first they wanted to find out what's in his head, so he had to be transported to CT within the area of our hospital. Our perfusionists managed to disconnect the pump and the oxygenator from the rest of the machine... and with only a source of oxygen...they fixed them to the pole of the patient's bed. Although they went just a few meters away, it cost the whole team nerves. Anyway, the patient had the brain's death diagnosed and soon afterwards his ECMO session was terminated.

I'm not sure this procedure is possible with all types of the machine and definitely not sure for how long can the patient cope without the ECLS heat exchanger / warming unit (Sorry, I don't know the exact term for this in English!)... but this one "survived" this transportation.

Pediatric Critical Care Columnist · Apr 1, 2008

Polednice, we take our ECMO patients on road trips all the time! We take them to CT when there's been a change in their neuro status, we take them to the cath lab to see if their hearts are recovering and we've even taken them to MRI. I haven't been on one of those and don't ever wish to! I can't even imagine the prep work required. On our road trips we usually take everything from the bedside except the vent, as is. Fitting everything into the elevator is always interesting... radiology is one floor below us. My last trip was to the cath lab. When everything that had to go with the patinet was in the elevator, along with two ECMO specialists, a cardiologist and two resp techs, I opted to take the stairs. I got there just as the doors opened.

With our new cardiac sciences building, we have a supersized elevator, but because the new building hasn't been commissioned yet, it hasn't been put into service. It would sure be nice to have it NOW!

califalcon · Apr 1, 2008

Hello!!
What an interesting topic with ECMO!! I'm sorry I can't contribute, just wonder... well, except a tiny bit. We had a 64 years old ECMO patient about two months ago. He was acutely admitted for massive ischemia of myocardium, with the major part of his heart out of work, and with 1 sqcm large hole in his ventricular septum. Those were just "our" diagnoses, cardiosurgical, further he suffered from severe renal failure and severe form of diabetes. They planned to operate on him, but first they wanted to find out what's in his head, so he had to be transported to CT within the area of our hospital. Our perfusionists managed to disconnect the pump and the oxygenator from the rest of the machine... and with only a source of oxygen...they fixed them to the pole of the patient's bed. Although they went just a few meters away, it cost the whole team nerves. Anyway, the patient had the brain's death diagnosed and soon afterwards his ECMO session was terminated.
I'm not sure this procedure is possible with all types of the machine and definitely not sure for how long can the patient cope without the ECLS heat exchanger / warming unit (Sorry, I don't know the exact term for this in English!)... but this one "survived" this transportation.

Thanks for the contribution....no matter how small it may seem now, in the future (Longer transports like from europe to the US) are possible (in a limited way now) but that is our intent...to make it available worldwide.

Manny (Califalcon)

gal220RN, BSN, RN · Apr 17, 2008

I have absolutely seen RT's running ECMO circuits. The RN usually is running CVVH at the same time along with doing patient care. Better hope for a good working relationship among the two!