VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) SUPPORT FOR PATIENTS WITH ACUTE RESPIRATORY FAILURE OR ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Extracorporeal Membrane Oxygenation (ECMO) has traditionally been used in the neonatal and pediatric patient population, with a survival-to-discharge rate of 50 percent.1 In recent years, ECMO has become more common for adult patients, especially following cardiac surgery and with pulmonology patients, since 2008. Christoph Brehm, M.D., intensivist at Penn State Hershey Heart and Vascular Institute, notes that adult patients at Penn State Hershey Medical Center (during the 2014 influenza season) with influenza (H1N1) pneumonia, causing severe ARDS, noted a 73 percent survival-to-discharge rate when ECMO was initiated.
To minimize risks, clinical staff must be proficient in performing ECMO support, as complications can occur frequently, hemorrhage being the most common.1“For adults, we insert a thick (25Fr- 31Fr) cannula in the right internal jugular vein, and it is possible to fatally perforate the patient’s heart,” Brehm confirms. “Also, ECMO patients are given heparin, and that can lead to heparin-induced thrombocytopenia or intracranial bleeding.”
ECMO experience is key, and sets Penn State Hershey apart, as the facility has used ECMO support on close to 300 patients in the last six years. (Figure) Penn State Hershey also uses advanced equipment, and started doing so in 2008. Many other facilities use older ECMO technology associated with a host of challenges. This early adoption gave Penn State Hershey the advantage of increased staff usage of the equipment, and therefore, greater experience as an organization.
Both experience and technology at the Heart and Vascular Institute were tested during the 2013- 2014 influenza season. Across the country, patients with severe H1N1 pneumonia or H1N1- related pneumonia caused a spike in demand for ECMO capacity.2 At Penn State Hershey, nineteen patients with H1N1-related pneumonia received veno-venous ECMO for severe respiratory failure during that influenza season. The majority of these patients were transferred from other facilities. Recalls Brehm, “We had limited space. All patients were admitted, but not all were placed on ECMO immediately. Patients were admitted to other medical and surgical ICUs and staff in those units exhausted all other options (inhaled nitric oxide and Flolan), first. Patients still in need of ECMO were then placed on the therapy.”
That is in alignment with what Brehm identifies as the most important factor when treating patients with severe respiratory failure: early intervention. Clinicians must determine when patients need the extra support of ECMO and either begin the therapy or transfer the patient to an ECMO center as early as possible to give those patients the optimum chance of survival.
Christoph Brehm, M.D.
Assistant Professor, Surgery
Residency: Cardiothoracic surgery, Ruhr-University Bochum, Bochum, North Rhine-Westphalia, Germany
Medical School: Phillips University of Marburg, Marburg, Germany
1. thoracic.org/clinical/critical-care/salvage-therapies-h1n1/pages/ecmo.php. Accessed August 14, 2014.
2. Michaels AJ, Hill JG, Bliss D, Sperley BP, Young BP, Quint P, et al. Pandemic flu and the sudden demand for ECMO resources: a mature trauma program can provide surge capacity in acute critical care crises. J Trauma Acute Care Surg. 2013 Jun;74(6):1493-7.