Why not put everyone that codes on ECMO?
This is certainly becoming more in vogue.
There are 2 forms: veno-venous ECMO (V/V) and veno-arterial ECMO (V/A). V/V requires cannulation of 2 large central veins, while V/A requires venous and arterial cannulation. V/V performs only the work of the lungs, and requires a heart that is pumping and not in failure. V/A is essentially cardio-pulmonary bypass, and also performs the pumping of the heart.
There are 3 big limitations, from my experience:
1. The ability of someone to quickly and efficiently cannulate 2 large vessels: a central vein and an artery. This is usually a surgeon, an anesthesiologist, or an intensivist. These providers aren't always just hanging around a hospital, and when you need them, you need them NOW. So this will predispose the larger hospitals, tertiary care centers, trauma centers, and academic centers to be able to do this.
2. The cost to keep the equipment around is likely prohibitive. Usually your hospitals that perform open heart surgery are most likely to have it.
3. The people to maintain the therapy once started. Generally this is a cardiovascular ICU with a perfusionist on staff. We have 2 large medical centers in town; one is university based and is a major transplant center. They put in VADs all the time. They are comfortable using ECMO. The other one is a large hospital, licensed for around 550 beds, an ED that sees over 100K patients a year, and does about 3X the cardiac work (caths and CABGs) that the university medical center does. They will occasionally put it in, but they transfer them across town, to the University hospital, because they just don't do it that often, and don't feel comfortable managing them.
They're a good idea, but they take a lot to initiate in reality.
