ECMO and ARDS

[VentMonkey]

For any of the many ICU folks on here, does anyone have any experience implementing ECMO for patients with severe ARDS in an ICU setting? Obviously, my understanding is that it's typically v-v ECMO unless there's also cardiac failure/ involvement as well, in which it may be va-ECMO.

I'm just curious as to what the average mortality is like with these patients at this stage in the ARDS/ sepsis/ MODS game when dealing with these patients first hand. I know, generally speaking these are very sick individuals, and I also understand that this may be a relatively new treatment for this sort of patient.

Any insight that anyone would love to share, as always, is very much appreciated.

 

[gonefishing]

For any of the many ICU folks on here, does anyone have any experience implementing ECMO for patients with severe ARDS in an ICU setting? Obviously, my understanding is that it's typically v-v ECMO unless there's also cardiac failure/ involvement as well, in which it may be va-ECMO.

I'm just curious as to what the average mortality is like with these patients at this stage in the ARDS/ sepsis/ MODS game when dealing with these patients first hand. I know, generally speaking these are very sick individuals, and I also understand that this may be a relatively new treatment for this sort of patient.

Any insight that anyone would love to share, as always, is very much appreciated.

I had an ARDS case last year. Patient lasted 2 days and expired. They were family.

Sent from my SM-G920P using Tapatalk

 

[VentMonkey]

I had an ARDS case last year. Patient lasted 2 days and expired. They were family.

Sent from my SM-G920P using Tapatalk

Sorry to hear that, thanks for sharing.

 

[TXpeds16]

I cannot speak for adults; however, from what i've learned and experienced, pediatrics tend to do quite well on ecmo. The two I remember particularly were transported on high freq/nitric and were crashed onto ecmo on our arrival to the ICU. Both were decannulated a few days later with full recoveries. One was a PPHN, the other was a mec. aspiration, both were VV. VV is used more frequently in our hospital I believe, with VA being reserved for cardiac patients.

 

[VentMonkey]

I cannot speak for adults; however, from what i've learned and experienced, pediatrics tend to do quite well on ecmo. The two I remember particularly were transported on high freq/nitric and were crashed onto ecmo on our arrival to the ICU. Both were decannulated a few days later with full recoveries. One was a PPHN, the other was a mec. aspiration, both were VV. VV is used more frequently in our hospital I believe, with VA being reserved for cardiac patients.

I was talking to our daughters pediatrician about NO sometime ago, as he also happens to be a neonatologist/ intensivist, and heads a NICU back home, and he swore by this for neonates with certain CHD's. For those unfamiliar with this, please feel free to read this:

http://pediatrics.aappublications.org/content/106/2/344

@TXpeds16 any experience with "da bey-bez" and Prostaglandins?

 

[CANMAN]

Really is a guessing game in my opinion. I have seen a bunch of patients do really well and walk out of the hospital neurologically intact, and seen just as many do poorly. Crash ECMO deployment is all the rage around my area lately. We have a center which will rapid deploy right in their bay if need be for HEMS transfers and EMS patients vs. going to the O.R. if time is an issue. We also have seen an increase in ECMO transports in the area, which I don't personally agree 100% with but it's happening none the less.

On a side note my father who is 62 years old and lives in TX, with only a HX of HTN had a bout with ECMO recently and did exceptionally well. He was sick with what they thought was bronchitis vs. pneumonia. Super frustrating events leading up to the need for ECMO but ended up arresting on a medical floor due to hypoxia and CHF. Was coded twice for 12 minutes each, and later I got him transferred to an ECMO center. He arrived maxed on 5 pressors with an EF of 10%. Ended up being rapidly deployed on ECMO, spent 3 days on, needed a heart transplant vs. BiVAD placement, and we ended up getting super lucky and he got a heart within a day of being listed as a 1A on the transplant list. 3 months later he is home, driving, 100% neurologically intact and back to his old self. Had it not been for the ability to wean him off of almost all the pressors and allow ECMO to completely support him as a bridge to transplant he would have passed from MODS. After a complete heart biopsy they never determined a cause. Still thinking some undetectable virus myocarditis. They ruled out giant cell myocarditis and hypertrophic cardiomyopathy early on, so we are still puzzled but glad to still have him with us. So I am an ECMO believer....

 

[VentMonkey]

Really is a guessing game in my opinion. I have seen a bunch of patients do really well and walk out of the hospital neurologically intact, and seen just as many do poorly. Crash ECMO deployment is all the rage around my area lately. We have a center which will rapid deploy right in their bay if need be for HEMS transfers and EMS patients vs. going to the O.R. if time is an issue. We also have seen an increase in ECMO transports in the area, which I don't personally agree 100% with but it's happening none the less.

On a side note my father who is 62 years old and lives in TX, with only a HX of HTN had a bout with ECMO recently and did exceptionally well. He was sick with what they thought was bronchitis vs. pneumonia. Super frustrating events leading up to the need for ECMO but ended up arresting on a medical floor due to hypoxia and CHF. Was coded twice for 12 minutes each, and later I got him transferred to an ECMO center. He arrived maxed on 5 pressors with an EF of 10%. Ended up being rapidly deployed on ECMO, spent 3 days on, needed a heart transplant vs. BiVAD placement, and we ended up getting super lucky and he got a heart within a day of being listed as a 1A on the transplant list. 3 months later he is home, driving, 100% neurologically intact and back to his old self. Had it not been for the ability to wean him off of almost all the pressors and allow ECMO to completely support him as a bridge to transplant he would have passed from MODS. After a complete heart biopsy they never determined a cause. Still thinking some undetectable virus myocarditis. They ruled out giant cell myocarditis and hypertrophic cardiomyopathy early on, so we are still puzzled but glad to still have him with us. So I am an ECMO believer....

Thank you for sharing, @CANMAN; glad to hear he's okay.

You mentioned they had initially thought he had a bout of bronchitis turned pneumonia. Could it have been possible this lead to some form infection in his myocardium?

This article here is what prompted my question (yes, I know, another AMJ citing):

http://www.airmedicaljournal.com/article/S1067-991X(16)30096-7/abstract?showall=true=

 

[CANMAN]

Thank you for sharing, @CANMAN; glad to hear he's okay.

You mentioned they had initially thought he had a bout of bronchitis turned pneumonia. Could it have been possible this lead to some form infection in his myocardium?

This article here is what prompted my question (yes, I know, another AMJ citing):

http://www.airmedicaljournal.com/article/S1067-991X(16)30096-7/abstract?showall=true=

I will have to read through that article in depth later on tonight. By briefly scanning the article it sounds scary close to his presentation. I coordinated all of his care via phone from MD until I could get on the next flight down there. Originally he was in a small community hospital with limited resources, and I was extremely unimpressed with both the Cardiologist and Intensivist who I spoke with on the phone while at the airport. It was at that time I insisted they move him to UT Southwestern in Dallas.

He basically was sick with non-productive dry cough, DX with bronchititis, got worse and was sent to pulm MD who put him on Prednisone as well. Three weeks later from initial symptoms he had severe orthopnea and pedal edema, which prompted his ED visit. He was afebrile throughout his entire illness. He's stubborn so for him to go to the ED I know he was feeling like crap. ED MD doesn't even draw a b-type natriuretic peptide and admits him under a pneumonia pathway even with patchy atelectasis on his CXR and the above symptoms SMH ....He was admitted to a medical floor where he developed A-flutter and some hypotension, and later that day he further decompensated and arrested... At this point whatever caused his function to be almost non-existent on ECHO wasn't going to be corrected but just the complete lack of putting the symptoms together as textbook heart failure is frustrating to say the least.

I will have to read the article in full when I can view/print it but sounds like it's spot on with what happened. Their best educated guess at UT was some type of viral illness which caused the myocarditis. He also had some coag issues, ended up with a large clot in his LV of the old heart etc so he was super tough to manage but long story short having worked at one of America's top hospitals for years, I was completely blow away with the caliber treatment and compassion he got at UT in Dallas. They also treated me like a part of their healthcare team once they found out where I worked/did HEMS which was helpful in dealing with sharing info with family etc.

 

[VentMonkey]

ED MD doesn't even draw a b-type natriuretic peptide and admits him under a pneumonia pathway even with patchy atelectasis on his CXR and the above symptoms SMH ....

This alone seems like a HUGE red flag, IMHO.
Patchy infiltrates/ atelectasis should be at least a concern for ARDS, even if only mild.

My understanding is ARDS is a result of another more serious problem, most often sepsis, or (blunt) traumatic chest wall injuries. I would hope if it was me, the treating physician would have his "thinking cap" on and run a full panel, and/ or be somewhat more aggressive in their treatment modalities.

And FWIW, he sounds like a helluva tough guy.

 

[CANMAN]

This alone seems like a HUGE red flag, IMHO.
Patchy infiltrates/ atelectasis should be at least a concern for ARDS, even if only mild.

My understanding is ARDS is a result of another more serious problem, most often sepsis, or (blunt) traumatic chest wall injuries. I would hope if it was me, the treating physician would have his "thinking cap" on and run a full panel, and/ or be somewhat more aggressive in their treatment modalities.

And FWIW, he sounds like a helluva tough guy.

Thanks man! Yeah he's tough as nails. He's got young kids to live for so we are glad he pulled through. On a side note, which is super creepy, he remembers alot of the events to include arresting, the sending MD's talking about the transfer, etc. Has completely changed my eyes on talking around patients you think are out of it. Sorry to derail the topic. Back to the OP post...

 

[VentMonkey]

Thanks man! Yeah he's tough as nails. He's got young kids to live for so we are glad he pulled through. On a side note, which is super creepy, he remembers alot of the events to include arresting, the sending MD's talking about the transfer, etc. Has completely changed my eyes on talking around patients you think are out of it. Sorry to derail the topic. Back to the OP post...

Seems completely relevant to me.

 

[Carlos Danger]

Glad to hear your dad is doing well, @CANMAN. That's a heck of an ordeal and story.

 

[CANMAN]

Glad to hear your dad is doing well, @CANMAN. That's a heck of an ordeal and story.

Thanks Remi. It's been a rough couple of months but we have been very fortunate and are very thankful. To get a heart literally in a day after being listed is just amazing. After the first year the hospital will notify us if the donor's family wants to release their contact information. We are hoping they do because my Dad surely would like to meet them and thank them for their incredible gift. My parents are divorced, and my Dad remarried. Like I said he has little kids to live for; 6,8, & 10 so it would have been devastating to lose him suddenly after being relatively healthy for all these years. The saying "tomorrow is never promised" has never hit so close to home as it did with this event. Appreciate all the thoughts and support guys.
Cheers,

 

[VFlutter]

Traditionally VV ECMO for ARDS was used as salvage therapy and did not have the best outcomes however it seems that many centers are being much more aggressive and early initiation is key. During Influenza season our local center put many patients on VV ECMO and had good outcomes.

 

[VentMonkey]

Traditionally VV ECMO for ARDS was used as salvage therapy and did not have the best outcomes however it seems that many centers are being much more aggressive and early initiation is key. During Influenza season our local center put many patients on VV ECMO and had good outcomes.

Is there an average turn around time for this group of patients from initial ECMO implementation, to decannulation, and discharge?

 

[VFlutter]

Is there an average turn around time for this group of patients from initial ECMO implementation, to decannulation, and discharge?

"ECMO was operated for a median of 10 days with short-term mortality ranging between 8% and 65% with a median intensive care unit stay of 25 days, and an overall median total length of stay of 37 days."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057025/

 

[VentMonkey]

Here's an interesting angle on ECMO from a trauma surgeon's perspective. While this article is a few years old, I can't help but wonder if the utilization of ECMO has gained any momentum since it's publication in this particular patient population.

http://journals.co-action.net/index.php/mcs/article/view/21599

 

[TXpeds16]

I was talking to our daughters pediatrician about NO sometime ago, as he also happens to be a neonatologist/ intensivist, and heads a NICU back home, and he swore by this for neonates with certain CHD's. For those unfamiliar with this, please feel free to read this:

http://pediatrics.aappublications.org/content/106/2/344

@TXpeds16 any experience with "da bey-bez" and Prostaglandins?

Ill have to talk to my team tomorrow and find out some more about its use. I know for our protocols it is used for PPHN, congenital diaphragmatic hernias(CHD, which causes PPHN) and MAS(which I am not familiar with, i'll have to do some reading later on). I don't know the percentage of patients who are placed on NO that are then placed on ECMO. Anecdotally, the two I can remember taking were both placed on ECMO upon arrival to our PICU/CVICU. Regardless, NO is pretty interesting.

We do regularly transport kiddos on PGE. Most of the time the sending facility has already initiated it, so we just continue it. Usually L&D/lower level nicu's are pretty good at picking up on cyanotic defects.

 

[VentMonkey]

Ill have to talk to my team tomorrow and find out some more about its use. I know for our protocols it is used for PPHN, congenital diaphragmatic hernias(CHD, which causes PPHN) and MAS(which I am not familiar with, i'll have to do some reading later on). I don't know the percentage of patients who are placed on NO that are then placed on ECMO. Anecdotally, the two I can remember taking were both placed on ECMO upon arrival to our PICU/CVICU. Regardless, NO is pretty interesting.

We do regularly transport kiddos on PGE. Most of the time the sending facility has already initiated it, so we just continue it. Usually L&D/lower level nicu's are pretty good at picking up on cyanotic defects.

Admittedly, high acuity NICU is yet another area I could stand to gain more knowledge from. I still struggle with discerning the ductal vs. non-ductal dependent lesions the most.

I will say, I find "TET babies" remarkably fascinating though. @TXpeds16 if, or when you feel the need to share your knowledge with this patient population, please by all, means feel free.

 

[TXpeds16]

Admittedly, high acuity NICU is yet another area I could stand to gain more knowledge from. I still struggle with discerning the ductal vs. non-ductal dependent lesions the most.

I will say, I find "TET babies" remarkably fascinating though. @TXpeds16 if, or when you feel the need to share your knowledge with this patient population, please by all, means feel free.

http://www.pted.org is an excellent resource for congenital heard defects.

I've only been doing it about a year, so I am far from an expert. I am trying to soak up everything I can though. Its still pretty amazing to me how little I knew/really still know about pediatrics.