ECMO

[VFlutter]

Seems to have been some recent discussions on the forum regarding ECMO so I figured this could be a thread for general questions and information.


I currently work for a commuity based Rotorwing service that transports ECMO patients as well as have some bedside CVICU experience. We see a decent volume of both VA and VV ECMO patients on a variety of devices ranging from modified CPB circuits/pumps to TandemLife and CardioHelp. Previously VV was most common however recently we have been doing predominantly ECLS and CT surgical VA. VV will likely pick back up with flu season.

 

[CANMAN]

Seems to have been some recent discussions on the forum regarding ECMO so I figured this could be a thread for general questions and information.


I currently work for a commuity based Rotorwing service that transports ECMO patients as well as have some bedside CVICU experience. We see a decent volume of both VA and VV ECMO patients on a variety of devices ranging from modified CPB circuits/pumps to TandemLife and CardioHelp. Previously VV was most common however recently we have been doing predominantly ECLS and CT surgical VA. VV will likely pick back up with flu season.

What type of airframe are you flying in? We are an all 135 program and have been flying ECMO (Rotaflow & Cardiohelp) for a good while now. I often get contacted by people in other 135 programs that are looking to break into ECMO transport but encounter alot of logistics they need help with due to the airframe and configuration. So much so I am thinking about submitting to present on it @ AMTC 2020.

 

[GMCmedic]

What type of airframe are you flying in? We are an all 135 program and have been flying ECMO (Rotaflow & Cardiohelp) for a good while now. I often get contacted by people in other 135 programs that are looking to break into ECMO transport but encounter alot of logistics they need help with due to the airframe and configuration. So much so I am thinking about submitting to present on it @ AMTC 2020.

Ive never done it be we figured that we would have to remove the forward facing seat and spare supplies to load the patient, then replace it to secure equipment.

We strictly do ECMO by ground and take the perfusionist with us. We so rarely do Impellas and Balloon pumps that we determined training on ECMO also was not in our best interest.

 

[CANMAN]

Ive never done it be we figured that we would have to remove the forward facing seat and spare supplies to load the patient, then replace it to secure equipment.

We strictly do ECMO by ground and take the perfusionist with us. We so rarely do Impellas and Balloon pumps that we determined training on ECMO also was not in our best interest.

Your last statement is fair and I applaud your program for determining that based on an honest evaluation. If you're not doing them on a consistent basis it does take a good amount of training to get smooth with these type of transports. IMO they are 90% logistics and 10% actual actual medical care and the safe movement of these patient's who often are on multiple infusions, vented, chest tubes, possible Impella or IABP, etc. is something that not all crews or programs will excel at, especially with a lack of training.

The aircraft configuration will largely determine the best way to load, transport, unload and that is the biggest factor that I find when people reach out to find out how we do it. We are always 3rd seat down configured, biggest variable is which pump we have. A Cardiohelp will get loaded first after wheels on deck, load patient, then stow remainder of gear and button up. Rotaflow is a bit more of a pain in the rear and gets stowed directly behind the drop down seat after the load, facing in towards the cabin so access can be made to controls in flight if absolutely needed.

One of the biggest factors we find is also training with perfusion. They aren't used to being outside the hospital environment and we try to spend a decent amount of time training, and often have to remind them that most of our interventions such as fluids, blood, albumin, etc should ideally be done before we depart the bedside so we are minimizing time at the back of the A/C and not trying to do a ton in flight if possible. I find that when crews get bogged down or encounter a hang up where they lose forward motion/progress that's where the wheels start to come off the wagon.

 

[Peak]

My ECMO experience comes from our congenital heart program, we surgical and medical management of congenital heart disease from birth (including preemies as long as they are big enough for ECLS, otherwise they start in the NICU) through geriatrics. We own the ECMO program but will offer it up to outside groups in our hospital (typically other PICU, NICU, adult ICU, and OB/GYN patients), but we bring them into our unit for managment.

The vast majority of our runs are VA, most of our patients in the program have too much cardiac disease/failure to make VV an option (even if they are cardiac stable during their initial cannulation we have had to transition from VV to VA many times before).

Our perfusion group also offers services in other hospitals and our surgeons and perfusionists will go out to cannulate and assist with transport, unless we are transporting patients outside of the state we only run ground and then we will do fixed wing, rotor is too complex for all of the equipment we need. We also don't really want to par down the equipment we need for transport, and we'd rather have a slower transport than start cutting down what drips and other support we keep.

 

[VFlutter]

What type of airframe are you flying in? We are an all 135 program and have been flying ECMO (Rotaflow & Cardiohelp) for a good while now. I often get contacted by people in other 135 programs that are looking to break into ECMO transport but encounter alot of logistics they need help with due to the airframe and configuration. So much so I am thinking about submitting to present on it @ AMTC 2020.

We have a BK117

We have been approached by 135 programs wanting to transport ECMO as well. Obviously it is possible but our clinical team discourages it due to the logistics and really recommends it be a BK117/EC145. Most of these programs are hospital based and will do what they wish tho.

One of the programs was contemplating removing the 3rd seat and flying with Nurse and Perfusionist only....

Perfusionist are a wealth of knowledge with cardiac assist devices but really are not necessary for transport in my opinion. They are usually not comfortable in-flight and do not offer much assistance. The management and interventions is usually exclusively done by the flight crew. If anything catastrophic occurs it is not going to be fixable in-flight regardless. Aside from the logistics of getting the perfusionist to go, still having coverage for the hospital, and returning them in a reasonable time. We have had a few flat out refuse.

We currently take Tandem without perfusion and are working towards it with other devices.

 

[Peak]

@VFlutter Do your perfusionists sit ecmo pump all of the time? Ours don't sit in the unit once the patient is set up or back from the OR, we train our BSN nurses and BS RRTs to do that.

 

[CANMAN]

@VFlutter Do your perfusionists sit ecmo pump all of the time? Ours don't sit in the unit once the patient is set up or back from the OR, we training our BSN nurses and BS RRTs to do that.

Same, our BS RRT sit pump and perfusion floats, but we also have multiple perfusionists on daily.

 

[VFlutter]

@VFlutter Do your perfusionists sit ecmo pump all of the time? Ours don't sit in the unit once the patient is set up or back from the OR, we train our BSN nurses and BS RRTs to do that.

Nope. 2:1 Nurse. Perfusionists floats

 

[Peak]

Nope. 2:1 Nurse. Perfusionists floats

Two nurses on the pump or to for the patient and they share responsibility for the pump?

 

[VFlutter]

Two nurses on the pump or to for the patient and they share responsibility for the pump?

Poorly worded. One nurse's primary (or sole) responsibility is the pump but usually also helps with patient care. Which is nice because the busy part of these patient's care really isn't the pump vs having a RRT sit with.

 

[Peak]

For most of our ECMO runs our patients score high enough to be a 2:1 regardless of the ECMO and we consider the pump to need it's own nurse or RRT. Typically we end up with three nurses or two nurses and an RRT in the room total. Our points are also quite a bit more generous than other ICUs so we usually have better ratios all around. From my understanding we also are changing our flows and sweep gasses much more than most of the other ECMO programs in the city so whoever is sitting pump is pretty much stuck doing that.

 

[Carlos Danger]

For most of our ECMO runs our patients score high enough to be a 2:1 regardless of the ECMO and we consider the pump to need it's own nurse or RRT. Typically we end up with three nurses or two nurses and an RRT in the room total. Our points are also quite a bit more generous than other ICUs so we usually have better ratios all around. From my understanding we also are changing our flows and sweep gasses much more than most of the other ECMO programs in the city so whoever is sitting pump is pretty much stuck doing that.

Two RN’s per patient, PLUS a person dedicated to the machine? Damn you guys are spoilt.

 

[Peak]

Two RN’s per patient, PLUS a person dedicated to the machine? Damn you guys are spoilt.

Idk how things are ran in the adult only units but our runs are insanely busy. The other pediatric hospital has a similar setup, but I don't know how most adult ICUs run their setups.

Typically our patients are on at least 15 continous drips, several of which we are titrating hourly. Potentially they are on biologics if they are a transplant. We have labs every 4 hours including a hemogram, CMP, and TEG; we give replacements based off or our interpretation of the TEG. Almost all of our ECMO runs and up on CRRT and we change our goal based on any changes to drips, product given, and what their output actually was in the past hour. We run ABGs at least hourly, typically much more often. Then there is all the normal unit care stuff.

I can't imagine trying to do care with fewer staff.