Out of Hospital ECLS (Extracorporeal Life Support)

[mycrofft]

Thank you USAF and ECMODoc

USAF: caught me. Pesky except to the owner-operator how all those giblets are fastened so they don't just tumble around, usually.

ECMODoc, I get your point. Hard to isolate causes for what might or might not be delayed sequelae, especially when your control group (no bypass machine) would be around 100% dead. After the enlightenment regarding Roux-en-Y gastric bypass surgery M&M reporting (initial researchers were stakeholders, and the 18 month f/u was cherry picked), I think each and every new procedure higher than topical wart removal ought to be retrospectively checked for efficacy, AND for whether or not in real life it is being taught, learned, and done safely and effectively.

The whole prehospital ECMO sounds like good fodder for Stephen King , but then so would have field cardioversion many years ago.

 

[MedicPatriot]

Funny, years ago I always said they should come out with a machine that artificially oxygenates RBC's outside of the body. Last year I find out it exists, and it has very poor outcomes.

Many people die of brain bleeds from all of the meds

 

[usafmedic45]

Funny, years ago I always said they should come out with a machine that artificially oxygenates RBC's outside of the body. Last year I find out it exists, and it has very poor outcomes.

Many people die of brain bleeds from all of the meds

Care to back up those contentions? I don't believe it is generally poor outcomes because of the technology or associated medications. It's because we (in EMS) tend to try to look at stuff like this in settings where it's not necessarily helpful because the patient's pathology is already sufficient that there is going to be a poor outcome regardless no matter what is done.

 

[ECMODoc]

"Funny, years ago I always said they should come out with a machine that artificially oxygenates RBC's outside of the body. Last year I find out it exists, and it has very poor outcomes.

Many people die of brain bleeds from all of the meds"

Not sure where you got that idea. Survival among neonates with meconium aspiration is about 80%. In adults with acute hypoxemic respiratory failure (who have about a 60-80% chance of dying) survival is about 60%.

 

[systemet]

......

 

[ecmotoo]

ECMO INFO and MISINFO

I've enjoyed reading all these posts. It's clear that there is a lot of misinformation regarding ECMO. Some of what has been discussed in this thread regarding ECMO is correct.
I have been active in the ECMO community since mid 1990's. So I am an supporter of advancing ECMO modalities when it's appropriate. I can tell you that the survival rates for Adults CAN be as good as pediatric patients, which has improved over the years. But you must keep in mind ECMO is a life support modality. It isn't a treatment. So if there is nothing viable...the patient outcome will be bad. If there is viable tissue/organs/life at initiation of ECMO, then there is a pretty good chance of positive outcome.
I am personally involved in ECMO transport. It is cumbersome and requires significant resources and logistics. However, with newer technology such as the Cardiohelp and Lifebridge devices, the potential for it to be simpler and more widespread is greater now and will continue to improve over the next couple of years.
I know there are processes underway right now to make rapid deployment of small portable ECMO systems WITH an experienced ECMO Specialist available for initiation of ECMO and transport of patients on ECMO to established ECMO centers...but not from the field. Response will be to a hospital setting. But I can see that if this effort is successful, it will spread to field response. We are also working to educate and help transport teams build ECMO transport capabilities.
So it's coming. But it will require significant education, training, and technology.
Keep doing all the good work you do! It Matters!!

 

[mycrofft]

Thanks, and thanks or helping lift the level of discussion and knowledge here!

 

[ecmotoo]

I received a PM but as a new user I can not respond to PM yet. So thought others may want this info also.

I am not a doctor. I grew up a Respiratory Therapist...then obtained my Nursing degree. I have been working as an ECMO Specialist for most of the last 18 years. I currently own a company called ECMO Advantage. We provide ECMO consulting, ECMO Staffing, ECMO Specialist Training Programs, ECMO Transport, and ECMO Equipment rental. I provide that as a method of hopefully establishing some level of expertise in ECMO...not as an advertisement.

ECMO outcomes are very disease specific. And as I mentioned in the post...the patient must be viable. ECMO does not regenerate tisse/organs etc. If the damage is done...it won't be reversed. So of course there is always the balance between putting a patient on EARLY that some will argue didn't need ECMO vs the opposite senario where it's a last ditch effort and there isn't a viable patient. So the goal would be for appropriate ECMO use to reside somewhere in the middle. Patient selection is important for appropriate use of this life support modality.

There are several recent controversial ECMO outcome reports of interest. The CESAR Trial was reported out of Europe about 2 years ago now. It was specific to Adult Respiratory Failure patients.
ELSO also has their H1N1 database outcomes available to the public on their web site.

The ELSO database is probably the most comprehensive place to find reliable outcome information regarding ECMO patients. At least for survival. They do not have good "quality of life" information. CESAR did address quality of life.

Cardiac indications...especially post-op cardiac surgery and "E-CPR" (utilizing ECMO as CPR modality) have the poorest outcomes. But CPR in general also has relatively poor outcomes.
ECMO for Cardiac Bridge to Transplant, Bridge to Destination Therapy, and Bridge to Decision have better overall outcomes. This population may be great candidates for ECMO Transport and involve the EMT community more.

Unfortunately, good literature that definitively answer the questions related to ECMO are rare. and it's very difficult to design and carry out such studies. So we are often stuck with case reports, small volume studies, antidotal reports, and the rare reports such as CESAR Trial and the ELSO H1N1 data to pull from. So I am certainly not going to try to convince you that everyone should run out and provide ECMO support. But I would encourage you to continue to seek out the answers and remain open to the possibilities that ECMO may be a good choice for the patients you provide service to. There are close to 50,000 patients in the ELSO data base. I'm pretty sure the majority of them and/or their families are very glad ECMO was there to serve them.

I can tell you that ECMO, and especially Adult ECMO, is becoming more and more popular. Our greatest growth area is assisting Institutions establish Adult ECMO programs. In addition, we are getting more and more requests to provide Adult ECMO Transports from smaller rural hospitals in to major institutions that provide transplantation services or at least to hospitals that have established ECMO programs.

And with the advances we are seeing in technology, i.e. the Cardiohelp, Alung, NovaLung, etc...I do believe in the next few years we will see extracorporeal support expand to the point that it is available in most ICU's in the United States. Ok...so with that statement I probably just completely discredited myself. But store that thought away in the back of your mind and pull it back out 10 years from now. Will be interesting to see if I am correct.

 

[mycrofft]

Since the prime indication for CPR, unlike most other modalities, is "death", then that outcome is not surprising.

 

[ecmotoo]

Lol...yes. And we don't like that to be the prime indicator for ECMO. However, E-CPR is a subset of patients that, under the right conditions, are ECMO candidates. And for the purposes of the EMT discussion...we have still not made the successful jump from providing ECPR in the hospital to providing it in the field... yet. But I do believe it has the potential to be widely available in the not so distant future.

 

[mycrofft]

We as medical technologists and protocol writers are slicing the meaning and barrier of "dead" versus "alive" thinner by the year. With the drive to try to save everyone which make us more effective for all cases, we will produce a certain wedge of cases where we are playing for points and the pt outcome is going to be vegetative or nearly so. (I'll take "veg" over "nearly", please). As with our third-world traveling clinics' tendency to leave patients behind with no hope for adequate follow up care, we also produce domestic cases the outcomes of which have the same outcomes. I do not know the answer. Hopefully ECMO will address that.

 

[ecmotoo]

You highlight some very important aspects of advancing life support. Unfortunately we are increasing the ability to keep people "alive"...but can't always provide them with a measurable level of "Quality of Life". It's important to keep those discussions in the mix of advancement.

 

[ECMODoc]

Lifebridge

ecmotoo,

Do you have experience with the Lifebridge and Cardiohelp? If so how do they compare? I looked around briefly for Lifebridge info, but couldn't find much. I did find a schematic that seemed to be rather complicated (and included a resevoir (??) ).