Out of Hospital ECLS (Extracorporeal Life Support)

[silver]

In Resuscitation this month there were a couple articles about the use of ECMO out of hospital. In the last couple of years in hospital ECMO has been used for patients in refractory cardiac arrest. The results have been very promising, however not every hospital has teams capable of placing a patient on ECMO available.

Some European EMS systems are trialling deployable ECMO teams or using them on MICU ambulances staffed by physicians. The Resuscitation articles report two separate successful resuscitations (witnessed drowning and witnessed arrest) from asystole to sinus rhythm with field insertion of VA ECMO. Unfortunately, both had poor neurologic outcomes and did not survive to be discharged.

Although I don't ever see paramedics doing this, ECLS might become more common practice out of hospital.

Out-of-hospital extracorporeal life support for cardiac arrest-A case report.
http://www.ncbi.nlm.nih.gov/pubmed/21536364
"We report the use of out-of-hospital extracorporeal life support (ECLS) in cardiac arrest. We treated a 9-year-old girl with cardiac arrest after warm-water drowning with percutaneous venoarterial extracorporeal membrane oxygenation (ECMO) using a new portable Mini-ECMO system. A beating-heart circulation was reestablished on ECMO, but, unfortunately, our patient did not survive. This case shows that Mini-ECMO support can be used to restore an effective circulation and gas exchange in the out-of-hospital setting."



Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner.
http://www.ncbi.nlm.nih.gov/pubmed/21536365
"For patients who present with an out-of-hospital refractory cardiac arrest, in-hospital extracorporeal life-support (ECLS) initiation represents an alternative therapy which allows significant survival. We describe here the first case of out-of-hospital ECLS implantation in a patient presenting with a refractory cardiac arrest during a road race. ECLS was initiated within the MICU ambulance 60min after cardiac arrest and enabled restoration of cardiac output to 4.5lmin(-1). Coronarography revealed a severe isolated stenosis of the right coronary artery, which was treated by angioplasty. The cardiogenic shock resolved progressively, enabling ECLS weaning within 48h, while renal, hepatic, and respiratory functions recovered simultaneously."

 

[WTEngel]

I don't see paramedics (at least what we consider paramedics) using this.

Some specialty transport teams are already using this. Arkansas Children's comes to mind.

We have considered using it where I am (Children's Medical Center Dallas.) We already have one of the larger in-hospital ECMO programs in North Texas. We don't have the patient volume necessary to make it financially beneficial on transport yet. For us to say we do not have the patient volume is pretty telling, as we are one of the busiest pedi transport teams in the nation and as I mentioned earlier, one of the larger ECMO programs in North Texas.

I know the Army has a transport ECMO program in this region, based in San Antonio (I am almost certain, someone may correct me.) From time to time we will receive patients from them.

 

[usalsfyre]

Considering adult ECMO is still considered an "absolute last-ditch" effort by most and from my (very, very limited) understanding the outcomes are generally poor this isn't something I currently see making a widespread push out of the hospital, even in physician-run EMS systems such as most of Europe.

 

[WTEngel]

Correct. ECMO generally takes a surgeon to perform the cannulation, possibly an anesthetist, a perfusionist to run the circuit, along with a nurse for meds.

If you have the surgeon perform the cannulation at the referral, then you don't have to bring one with you, a highly trained and specialized RT or paramedic can run the circuit, and a well trained nurse or paramedic can take care of sedation and meds.

Keep in mind, well trained does not mean your typical "see one, do one, teach one" mentality seen in EMS. we are talking years dealing with highly complex patients with highly complex disease processes. Experience in the CVICU for a year is the BARE minimum I would think in my experience, and that is still pushing it. Most nurses and RTs don't get the chance to start training on ECMO until they hAve spent considerable time with less complex patients and assisting with pre ECMO evals, etc.

As USAL said, ECMO in many cases does have poor outcomes, however that is not to say that most patient's will not make it off. ECMO is so resource intensive that candidates are screened carefully for the likelihood that ECMO will improve their outcome, and placed on the unit accordingly.

We are just now getting around to making sure people do compressions for 90% of the code, ECMO is a long ways away!

 

[MedicBender]

We had a very brief intro to ECMO during out PICU rotations in medic school. Johns Hopkins has an ECMO transport team that runs around the area. Pretty incredible stuff to consider doing in the field

http://www.hopkinschildrens.org/ecmo-transport-now-at-hopkins-childrens.aspx

 

[bstone]

It's a good idea, but I think this will have to wait until being a paramedic means you need a BA/BS and this sort of ultra-advance technique would be either a graduate certificate or a full on MS.

 

[redcrossemt]

Out-of-hospital ECLS is perhaps useful in extremely rural areas, but far fetched from my perspective. In our suburban area, very few hospitals (only tertiary care/regional centers) have ECLS now. One of our flight services can bring ECLS to an outlying hospital, but I am not sure this has ever been done at (or is allowed for) scene calls.

I foresee the near future of ECLS for emergency patients is the therapy being made available at more community/rural hospitals.

 

[CANMAN]

I can tell you from first hand knowledge that even though Hopkins has the ability to transport ECMO it is still a very rare transport, and a logistical nightmare.

 

[redcrossemt]

I can tell you from first hand knowledge that even though Hopkins has the ability to transport ECMO it is still a very rare transport, and a logistical nightmare.

With the advent of portable ECMO devices, I think that you'll see this become much more commonplace in the critical care transport arena in the next ten years or so... Right now I mainly see people referred to ECMO facilities and start on ECMO once they arrive.

Here's one such portable device that was recently FDA approved:

http://www.lifebridge.de/usa/medical-professionals/product-information/index.html

 

[Veneficus]

Considering adult ECMO is still considered an "absolute last-ditch" effort by most and from my (very, very limited) understanding the outcomes are generally poor this isn't something I currently see making a widespread push out of the hospital, even in physician-run EMS systems such as most of Europe.

In between hospitals now, so just a quick comment.

ECMO has been for some time been effectice in nonates and young peds. The studies in adults are still mixed.

As stated, it is generally considered a last effort, however, like any medical treatment I suspect who is using it, on whom, and under what circumstances is what will make it effective or not.

There is no one treatment that is useful for all patients or no patients. Only treatments to start with on most patients, with variances as needed.

Having a doctor follow a protocol without deviation is no more effective than anyone else doing it.

 

[medicdan]

First of all, do we have any studies showing real improvement in adults-- everything I've seen is greatly mixed? ECMO has been used effectively in infants and children for ten years or so, I just haven't seen much on adults. Please, please correct me if I'm wrong.

As redcrossemt said, we need to hit a few other milestones before thinking about realistic pre-hospital ECMO. First, we need to perfect and further expand ECMO inter-facility teams (call them MICUs if you'd like), and figure out that staffing which as previously mentioned would require some combination of RN/RT/MD/Perfusionist/?Paramedic.

The next step is basing these MICU teams at academic medical centers and "deploying" them to pick up unstable patients from tertiary or rural hospitals, and equipping or training these teams to initiate ECMO at the sending facility (which may require sending a surgeon for cannulation in addition to an intensivist). If they can successfully initiate the therapy in the controlled environment of a tertiary hospital, then transport to an academic center, we have completed the next step of this process.

Heck, if we determine that this therapy actually works and is worth the cost and risks (I doubt it), we could put a team and mini-ECMO machine on a chopper to rapidly deploy them in rural areas, and have the team return via ground (Are any flight services transporting ECMO patients??)

Only at this point could we consider field cannulation and initiation of ECMO treatment. I don't see the viability of this, even in rural areas, if we can deploy the teams to the closest hospital, and have EMS bring the patient to that facility. The risk of complications (infection, hemorrhage, etc.) and costs to maintain staff and equipment just don't seem worth it.


Is my logic making sense? There have been some discussions in the blogosphere recently about how it seems hospitals are focusing only on those areas that bring in the most profit (cardiac stenting, CRT, ECMO), often with little discussion of quality of life or chance of recovery. Maybe we need to not only train the population to talk about end-of-life decisions early and support DNRs for the chronically unstable, but also build incentives for hospitals to "do the right thing" even if that means forgoing a procedure or intervention. The articles Silver cited make clear that while this was cool to do in the field, neither patient survived to discharge and both had significant neuro deficits. </policy rant>

 

[Brandon O]

Craziness. I love it.

One wonders if there might be better luck focusing solely on circulatory support rather than oxygenation, on the same "C before B" principle that brought us compressions-only. Something along the lines of an LVAD but as non-invasive as we can dream up.

I have much interest in the possibilities for "suspending" our arrest patients until reversible causes can be addressed. At the moment our idea of reversible is slim because the time window is so small, but if we could stretch it out long enough that might change.

 

[usafmedic45]

Something along the lines of an LVAD but as non-invasive as we can dream up.

Once again the problem being that sticky one of "vascular access" not to mention the issues inherent with priming such a device.

"suspending" our arrest patients until reversible causes can be addressed.

While laudable, you have to remember that "reversible causes" are an extreme minority of cases. People generally don't just code....they have gone pretty far down towards the completely :censored::censored::censored::censored:ed end of the pathophysiology continuum before it gets to that.

Perhaps it's better to realize that we are largely just flogging a corpse in most cases and that maybe the best that can be done is what we see being done now. It's nice to dream but I doubt the technical and chronological issues inherent with plans such as yours will ever be overcome.

 

[mycrofft]

Extracorporal life support even in a hospital?

I give you the word "pump-head", and I've seen it. I have been told that people on heart-lung machines or cardiac bypass machines have a strong tendency towards prolonged periods of declined mentation versus before, sometimes beginning immediately, sometimes after a couple months. WHere to blow the whistle and say "Frankenstein", versus "Frontiers of Science"?
A MD I worked with was on bypass during cardiac surgery. It took him two months to get back into the saddle at all, over the next two years he regained some of his old bite and decisiveness, then he started declining and retired four years total after the op. He had a heart valve replaced.

 

[Brandon O]

Once again the problem being that sticky one of "vascular access" not to mention the issues inherent with priming such a device.

Indubitably, but -- insurmountable problems? Hard to know...

While laudable, you have to remember that "reversible causes" are an extreme minority of cases. People generally don't just code....they have gone pretty far down towards the completely :censored::censored::censored::censored:ed end of the pathophysiology continuum before it gets to that.

Well, yes and no.

People die for a reason, and sometimes it neither can be nor should be opposed. If there's been a long battle with cancer, it's now widely metastasized and terminal, and the patient finally dies at home, then whether or not we "save" them, it won't set them any further back along that timeline than resetting the very last notch. If they don't go there today, it'll be another day soon.

But there are also plenty of people who drop a long way with that last click, and who could be restored a long way if we can undo it. This means the classic otherwise-well 40-year-old who manages to throw a thrombus into his LAD... but it could also mean an end-stage renal patient who happens to spike his K+ and goes to pieces, yet has every desire to keep living for however long he otherwise may.

Anyone who hasn't literally signed a DNR deserves, IMO, whatever life we can give them. And what gets me is that, although the cause of arrest may be overwhelming or insurmountable (as in that CA patient), in and of itself, SCA is not an inherently complex problem. It's not like the difficult problems of, say, sepsis or TBI, where multiple, multiplying, and sometimes conflicting issues run away from you. At least in the acute phase, it's simple, and the goal is simple; that goal is difficult to achieve, but difficult in a basic mechanical way. (Right now the biggest problems are psycho-social -- how to get people to do certain things, so we can achieve those goals -- not medical.) That's why I have some hope that we could get to a point where the only limitation on our ability to fix the proximate cause becomes the time constraints, and where we have the ability to manipulate that window.

But, hey. Pipe dreams. Right now we're lucky if someone pushes on their chest for a bit.

 

[Veneficus]

I think in this thread, somewhere along the line, we lost sight of what it actually takes to run en ecmo/bypass machines.

In order to maintain perfusion it is more than just hooking up some pipes and plugs.

The "techs" who do this as well as the anesthesiologists who oversee it, have a bit more education and experience than hooking this up and fixing some dials prior driving around the block.

In the cardiac surgery center here, there are 3 operating theatres that do 3-4 bypass or valve replacements a day. That can be between 3 and 12 applications a day. (some of the surgeons perform off pump bypass.)

Most EMS providers simply don't have what it takes to apply these machines.

I am not saying they are incapable of getting it. Only that there are significant hurdles to implementation of such therapies. Not least of which is lack of education.

Don't forget in European countries, the senior care provider on the ambulance is most often a doctor.

 

[silver]

I think in this thread, somewhere along the line, we lost sight of what it actually takes to run en ecmo/bypass machines.

In order to maintain perfusion it is more than just hooking up some pipes and plugs.

The "techs" who do this as well as the anesthesiologists who oversee it, have a bit more education and experience than hooking this up and fixing some dials prior driving around the block.

In the cardiac surgery center here, there are 3 operating theatres that do 3-4 bypass or valve replacements a day. That can be between 3 and 12 applications a day. (some of the surgeons perform off pump bypass.)

Most EMS providers simply don't have what it takes to apply these machines.

I am not saying they are incapable of getting it. Only that there are significant hurdles to implementation of such therapies. Not least of which is lack of education.

Don't forget in European countries, the senior care provider on the ambulance is most often a doctor.

Yep, which in those articles that I posted the team consisted of a cardiothoracic surgeon, anesthesiologist, and the perfusionist. The application to pre-hospital care will likely not be integrated into a system that is conceivable to any current American system, nor will the majority of members on this forum be working still...

No offense, but I think I rather die with dignity than have a medic attempt stick a 13F (4.3 mm) and 17F (5.6mm) cannulae in my femoral artery and vein, respectfully.

 

[usalsfyre]

No offense, but I think I rather die with dignity than have a medic attempt stick a 13F (4.3 mm) and 17F (5.6mm) cannulae in my femoral artery and vein, respectfully.

While I tend to agree with you about most medics, I would extend it to most nurses and juniors as well .

(We discussed just this morning the most dangerous place in Dallas on July 1st is Parkland Memorial Hospital...)

 

[Veneficus]

I don't really think this topic should reflect negatively on the ability of medics.

I pointed out the education and experience deficencies to illustrate the difficulties in bringing this therapy to the field, not to degrade medics.

As was pointed out, it is a system issue that has many obstacles to implementation.

I can say for myself, if I am in such bad shape I need an untrained provider to stick some catheters in me to have any chance, then give it a go, what could possibly happen? I might live?

While I absolutely champion the issue of bringing advanced therapy to both the emergency and field environments, I think we have to be realistic about what is valuable or practical.

Forget about provider issues, how much is it going to cost to put a bunch of these machines in play in EMS?

How often will it even be indicated?

Do the local hospitals have the capability to continue care?

Is it going to help in enough cases to justify the cost? (including provider education/training)

Will beneficial outcomes be negatively influenced by inexperience or occasional usage?

It would probably be cheaper, easier, and more effective more often to teach medics how to do an emergent thoracotomy (which is already basically next to never, in the US civillian world)

Long and short of it, you really can't fault field providers for not being able to proficently apply some of the most advanced therapies in medical science.

We are not talking about bringing an ED to a patient here, we are talking about bringing an ICU. That only works in specialty transport.

Could you imagine what the EMS protocol would look like?

Could you imagine some crazy cookiecutter provider deciding criteria had been met to initiate these thereapies? They can't even figure out when a backboard, fluid, or calling a helicopter helps!!!

 

[silver]

I don't really think this topic should reflect negatively on the ability of medics.

I pointed out the education and experience deficencies to illustrate the difficulties in bringing this therapy to the field, not to degrade medics.

As was pointed out, it is a system issue that has many obstacles to implementation.

I can say for myself, if I am in such bad shape I need an untrained provider to stick some catheters in me to have any chance, then give it a go, what could possibly happen? I might live?

While I absolutely champion the issue of bringing advanced therapy to both the emergency and field environments, I think we have to be realistic about what is valuable or practical.

Forget about provider issues, how much is it going to cost to put a bunch of these machines in play in EMS?

How often will it even be indicated?

Do the local hospitals have the capability to continue care?

Is it going to help in enough cases to justify the cost? (including provider education/training)

Will beneficial outcomes be negatively influenced by inexperience or occasional usage?

It would probably be cheaper, easier, and more effective more often to teach medics how to do an emergent thoracotomy (which is already basically next to never, in the US civillian world)

Long and short of it, you really can't fault field providers for not being able to proficently apply some of the most advanced therapies in medical science.

We are not talking about bringing an ED to a patient here, we are talking about bringing an ICU. That only works in specialty transport.

Could you imagine what the EMS protocol would look like?

Could you imagine some crazy cookiecutter provider deciding criteria had been met to initiate these thereapies? They can't even figure out when a backboard, fluid, or calling a helicopter helps!!!

That's a strong assumption to say that people (me) were degrading medics. The circumstances that you pointed out are the reason I rather not have a medic, nor a nurse or resident do it.