ECMO application:
ruled implementation or free diffusion?
Milan
2012
Palle Palmér
ECMO Centrum Karolinska
Karolinska University Hospital, Stockholm Sweden
If we look at Stockholm development
140
120
100
80
Neonatal
Pediatric
60
Adult
Total
40
20
0
Days on ECMO
1400
1200
vårddygn
1000
800
Europa
Sverige
Stockholm
600
400
200
0
1999
2000
2001
2002
2003
2004
2005
År
ECMO Centrum Karolinska
2006
2007
2008
2009
2010
ECMO is a simple technic
But not that simple
You need to know a lot of
Cannulas, oxygenators, oxygen delivery and consumption,
carbon oxide, coagulation
Interrelation between ECMO circuit, the ventilator and the
CVVHDF machine
The doctor and nurses in charge has to know this 24/7
4 ECMO Centrum Karolinska
One doctor has to be totally responsible
The week has 168 hours
In Saturday morning at 4 am you have to have one experienced
doctor to handle problems.
It not enough with one interested doctor in the ward daytime for
40 hours a week. At least he/she has to be dedicated to come
in the other 128 hours too.
ECMO is not run by itself for 128 hours a week.
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We have to make a different between
Cardiac and Respiratory ECMO
Cardiac ECMO should probably be done in all thoracic surgical
departments.
Most of these patients comes from the operation table and
need a short term assistance.
If the patient get a lung edema it will be complicated and take
much more time.
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Multistage cannulae
v.cava.sup low saturation
v.cava.inf high saturation
MRI Jonas A Lindholm
Respiratory ECMO
Needs volume and centralization
Long run ECMO 15- 60 days
Much more maintenance – circuit change and clotting problems
Totally whiteout lungs makes the safety marginal to 30 seconds
Low saturation
How to ventilate
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Burn patient consuming 450 ml of oxygen per minute
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68 days run with saturation of 65%
in 45 days
120
100
80
Arterial sat
60
Venous sat
40
20
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67
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Multi-Organ-failure
Decreased urine output
Increasing liver values
Low blood pressure
RIGHT SIDED HEART FAILURE -
Convert to V-A ECMO
Hemolysis – clotting in the circuit -
Solve that problem
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Does volume make different ?
In a low volume unit less then 10 patient per year , less then 150
days per year, you need much more assistance from
perfusionists.
It will be more expensive
Lack of perfusion capacity for the operation
Lack of beds in the thoracic intensive care
Less persistence
12 ECMO Centrum Karolinska
In normal or thoracical ICU
High volume center, at least one ECMO case every day of the
year in the ward. It’s a normal part of the ICU treatment.
The safety will be in the walls due to dedicated nurses and
doctors experience.
Much more persistence.
Possible to have the patients awake.
Possible to learn how to solve problems.
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ELSO reports July 2012
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The big well developed ECMOcenters
Reports survival rate of 70-80%, Stockholm and Leicester, even
with mean p/F ratios of 50 and 65.
That means that the smaller centers have an survival rate of
about 50%
It´s also possible that the experience centers takes more odd
cases.
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Mean p/f ratio 1995 – 2008
80
70
60
50
40
30
20
10
0
1
1995
2
3
4
5
6
7
8
9
10
11
12
13
14
2008
A new indication
Septic shock
SAPPS III scoring 2012
10 patient with septic shock mean 80 points
Mortality risk of 85%
Low leucocytes declining to < 2
”ALARM ALERT”
Inotropic index > 100
Cold sepsis in some of them - amputation
Survival rate 80%
V-A ECMO because of cardiogenic shock
Trauma is an undeveloped field
No heparin until they stop bleeding
The Problem is that the major trauma cases don’t die within 1-2
hours.
They are still alive 10 hours later, and we empty the blood bank,
and the surgeons are tired
You can pack the thoracic cavity, to stop bleedings
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10 million people per ECMO center
You will have respiratory ECMO
40 -50 adult patient per year
mean 15 days ( 7-60 days)
30-40 pediatric patient
mean 15 days ( 7-60 days)
30-40 neonates
mean 7 days ( 4-30 days)
You need an ECMO transport organization that can transport 24/7
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An high volume center
Can take the full advantage of the ECMO circuit
The goal is not to come off the machine
The goal is to have a healthy patient
20 ECMO Centrum Karolinska
Pneumothorax
Don’t hurt the patient
First choice - stop ventilation in 2-3 days
Pleura drainage - Seldinger or Surgeon
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A very small pleuradrainage - 20 liter of
blood and 4 operations
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Maybe we should look at survival
as something obvious
Why did they die and was it preventable
Last 2 years 78 adult patient Sapps III mortality rate of 85%
17 patient died (22%)
5 patient we didn´t have a chance from beginning
5 patient in pseudomonas and fungus
4 intracranial bleeding septic embolus pre ECMO
3 intracranial bleeding due to the ECMO treatment
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When you look at the pump and as your best
friend then you are a mature ECMO unit
Learn everything about the
pump oxygenators tubings and cannulaes
Train,train,train
Be careful
Be patient
Be trained
Don’t solve problems that doesn’t have to be solved
EURO-ELSO 2013
Precongress
8-9
May 2013
Congress
9-11 May 2013
Scientific programme
Deadline for Abstracts
15
Nov
2012
March
2013
Welcome to Stockholm 2013