Mobile Extracorporeal Membrane Oxygenation Research Articles

Extracorporeal Membrane Oxygenation in Amniotic Fluid Embolism: A Systematic Review of Case Reports.

Amniotic fluid embolism (AFE) is an obstetric complication that can result in acute circulatory failure during and after labor. The effectiveness of extracorporeal membrane oxygenation (ECMO) in AFE patients has not been established, especially in the context of coagulopathy. This review aims to evaluate the efficacy of ECMO support in AFE patients. We conducted a systematic review of case reports following the Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Quality assessment was performed using a standardized tool. Out of 141 studies screened, 33 studies included 79 AFE patients. The median age was 34 years, and the median gestational age was 37.5 weeks. The majority of AFE cases occurred during cesarean section delivery (55.2%), followed by labor before fetal delivery (26.7%). Extracorporeal membrane oxygenation configurations included venoarterial ECMO (81.3%) and extracorporeal cardiopulmonary resuscitation (CPR, 10.7%). The maternal survival rate was 72%, with 21.2% experiencing minor neurological sequelae and 5.8% having major neurological sequelae. Rescue ECMO to support circulation has demonstrated both safety and efficacy in managing AFE. We suggest early activation of local or mobile ECMO as soon as an AFE diagnosis is established. Further studies are needed to assess the benefits and implications of early ECMO support in AFE patients.

ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients.

Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.

Impact of thrombocytopenia on short-term outcomes in patients undergoing mobile extracorporeal membrane oxygenation support.

The prolonged use of extracorporeal membrane oxygenation (ECMO) support is associated with increased consumption of platelets and hemolysis. The prognostic impact of thrombocytopenia prior to and during ECMO support on patient's short-, mid- and long-term outcomes has been critically evaluated and discussed over the last years. However, only few data have been published on thrombocytopenia caused by mobile ECMO support. The aim of this study was to evaluate the impact of thrombocytopenia on short-term outcomes and predictors of in-hospital mortality in patients supported by mobile ECMO for transportation and subsequent weaning in a tertiary centre. This retrospective single-centre study analyzed a total of 117 patients requiring mobile veno-arterial (va) ECMO support and subsequent transportation from referral hospitals to our department from January 2015 until December 2021. A total of 15 patients had to be excluded from the analysis for missing data regarding baseline platelet count. Patients were divided into two groups: thrombocytopenia group (<130 × 109/L, n = 44) and non-thrombocytopenia group (≥130 × 109/L, n = 58). The primary outcome was in-hospital mortality. Secondary outcomes were successful ECMO-weaning, and the incidence of associated complications (bleeding, acute hepatic failure, acute renal failure, dialysis, and septic shock). The dialysis rate before ECMO initiation was significantly higher (p = .041) in the thrombocytopenia group compared to the non-thrombocytopenia group. The rates of bleeding complications (p = .032) and limb ischemia (p = .003) were significantly higher in patients with low platelet count. Moreover, complication rates of acute hepatic failure (p < .001), acute renal failure (p < .001) and dialysis (p = .033) were significantly higher in the thrombocytopenia group. Also, in-hospital mortality was significantly higher (p = .002) in patients with low platelet count before initiation of ECMO support. Based on the results of the present study, patients with thrombocytopenia prior to mobile vaECMO support may be at significantly higher risk for associated complications and short-term mortality.

P69: ECMO mobilizing device

Extracorporeal Membrane Oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients suffering from severe respiratory and/or cardiac failure. Studies have demonstrated the feasibility of mobilization in ECMO patients within the hospital during their bridge to recovery or transplantation. Ambulatory ECMO is a comprehensive form of mobilization aimed at preventing neuromuscular weakness and impaired physical functioning during and after treatment. Despite more compact and mobile ECMO devices, the implementation of ambulatory ECMO remains a labour-intensive, complex, and challenging operation. Ambulatory ECMO requires a large multidisciplinary team to carry all the equipment, to monitor and physically support the patient, and to provide a back-up wheelchair in case of patient fatigue. Additionally, current device configuration contributes to unnecessary device transport. Moreover, there is no adequate solution for ensuring the stability of the patient’s cannula and circuit management during ambulation. We developed a system that contributes to the improvement and innovation of current ambulatory ECMO patient programs and combines: (1) A modular cart-in-cart system (A) consisting of two distinct carts - the stationary cart (B) and the ambulatory cart (C). The stationary cart carries the devices (e.g. heater-cooler) not required during ambulation and remains in the ICU next to the patient’s bed. The ambulatory cart carries all the necessary devices during ambulation and features an extendable walking frame (D) that ensures safe walking support for the patient. A foldable seat (E) allows the patient to sit and facilitates transport back to the ICU in case of patient fatigue. Additionally, a safety brake system prevents unintentional movement of the ambulatory cart. Devices on both carts can be (dis)connected through a multi-connector hub, enabling easy configuration of necessary fluids, gases, and electricity. The connection between the stationary and ambulatory cart is maintained by a foot pedal-controlled lift mechanism that prevents accidental disconnection of the multi-connector and enables transport of both carts simultaneously. The system also features a gas switching device that allows for convenient switching between wall-mounted gas and bottled gas. (2) A universal-sized shoulder brace (F) with integrated blood tubing connector that can be adjusted to the patient via Velcro closure, facilitates secure fixation of the blood tubing, and minimizes strain on the cannula. At the time of writing, the project is undergoing design optimization. Subsequently, a physical prototype will be constructed and subjected to verification and validation processes. Internal testing will be performed to assess compliance with the user requirements. The prototype will then be evaluated in a simulated ICU environment to determine its suitability for use in a clinical setting. The patent for this invention has been filed and is currently pending.

Transfer of Veno-venous Extracorporeal Membrane Oxygenation Patients With COVID-19 Associated Acute Respiratory Distress Syndrome.

Interhospital transport of acute respiratory distress syndrome (ARDS) patients bears transport-associated risks. It is unknown how interhospital extracorporeal membrane oxygenation (ECMO) transfer of COVID-19 patients by mobile ECMO units affects ARDS mortality. We compared the outcome of 94 COVID-19 patients cannulated in primary care hospitals and retrieved by mobile ECMO-teams to that of 84 patients cannulated at five German ECMO centers. Patients were recruited from March 2020 to November 2021. Twenty-six transports were airborne, 68 were land-based. Age, sex, body-mass-index, Simplified Acute Physiology Score (SAPS) II, days invasively ventilated, and P/F-Ratio before ECMO initiation were similar in both groups. Counting only regional transports (≤250 km), mean transport distance was 139.5 km ± 17.7 km for helicopter (duration 52.5 ± 10.6 minutes) and 69.8 km ± 44.1 km for ambulance or mobile intensive care unit (duration 57.6 ± 29.4 minutes). Overall time of vvECMO support (20.4 ± 15.2 ECMO days for transported patients vs. 21.0 ± 20.5 for control, p = 0.83) and days invasively ventilated (27.9 ± 18.1 days vs. 32.6 ± 25.1 days, p = 0.16) were similar. Overall mortality did not differ between transported patients and controls (57/94 [61%] vs. 51/83 [61%], p = 0.43). COVID-19 patients cannulated and retrieved by mobile ECMO-teams have no excess risk compared with patients receiving vvECMO at experienced ECMO centers. Patients with COVID-19-associated ARDS, limited comorbidities, and no contraindication for ECMO should be referred early to local ECMO centers.

Risk of COVID-19 infection among mobile extracorporeal membrane oxygenation team.

The transport of coronavirus-2019 (COVID-19) patients on extracorporeal membrane oxygenation (ECMO) is a challenging situation, especially for healthcare workers (HCWs), due to the risk of cross-infection. Hence, certain precautions are needed for their safety. The study aims to evaluate the risk of COVID-19 transmission to HCWs who transport COVID-19 patients on ECMO device. A retrospective review of adult patients with COVID-19 infection supported with ECMO and transported by ground route to the Medical Intensive Care Unit (MICU) at Hamad General Hospital (HGH) and a survey of HCWs involved in those cases. A total of 63 HCWs of the mobile ECMO team were exposed to COVID-19-positive patients on 199 occasions. HCWs exposure time was nearly 110 h, and the total transport distance was 1018 km. During the study period, only two of the mobile ECMO HCWs tested positive for COVID-19. There was zero incidence of transfer-associated injuries or accidents to HCWs. The risk of COVID-19 cross-infection to the mobile ECMO team seems to be very low, provided that strict infection prevention and control measures are applied.

Characteristics and outcomes in extracorporeal membrane oxygenation support in COVID-19 patients: A nationwide cohort-study in Argentina

IntroductionOne of the great challenges during the COVID-19 pandemic was the management of ventilatory support. Extracorporeal membrane oxygenation (ECMO) was the main strategy for the management of refractory acute respiratory distress syndrome. ObjectiveRetrospective, multicentre cohort study of adult patients who required extracorporeal membrane oxygenation (ECMO) in participating centers. Clinical and paraclinical characteristics were recorded. A comparison was made between surviving and non-surviving patients. In addition, time from symptom onset to ECMO placement, time from mechanical ventilation, and cannulation were analyzed. Material and methodsRetrospective, multicentre cohort study of adult patients who required extracorporeal membrane oxygenation (ECMO) in participating centers. Clinical and paraclinical characteristics were recorded. A comparison was made between surviving and non-surviving patients. In addition, time from symptom onset to ECMO placement, time from mechanical ventilation, and cannulation were analyzed. ResultsTwenty-six patients were included in the analysis. Mortality during ECMO was 42.3% (n=11) and overall hospital mortality was 65.3% (n=17). The patient cohort did not differ in terms of sociodemographic characteristics and predictors of mortality at ICU admission between survivors and non-survivors. Mobile ECMO was performed in 10 patients, while 16 were cannulated in situ at the participating centers. The median time from symptom onset to ECMO was 14.5 days (IQR 10.7–21.5), 11 days (IQR 9.5–15.5) in the survivor group, and 17 days (IQR 12.5–27) in non-survivors. The median IMV time was 28.5 (IQR 13–38.25) days. Driving pressure (12 vs 10cmH2O; p<.01), compliance (37.2 vs 21.4ml/cmH2O; p<.01), and mechanical power (17.4 vs 11.3J/min; p=.051) of the respiratory system showed statistically significant differences when comparing survivors and non-survivors, during the 3rd day of ECMO support. ConclusionIn our cohort, mortality after ECMO and after 30 days of hospital stay, was 42.3%, similar to that stated on the extracorporeal life support organization (ELSO) COVID-19 registry dashboard. Information about patients with COVID-19 who required ECMO during the first wave in Argentina was provided in this analysis.

Interhospital Aircraft/Ground Extracorporeal Membrane Oxygenation Transportation by a Mobile Extracorporeal Membrane Oxygenation Team: First Turkish Pediatric Case Series.

Extracorporeal membrane oxygenation is a life-saving treatment for patients with circulatory and respiratory failure refractory to standard therapy. However, safe and timely patient transport to the referral extracorporeal membrane oxygenation center is critical for better patient outcomes in patients with acute cardiogenic shock. This study aimed to describe children's features who were transferred to our center under extracorporeal membrane oxygenation by aircraft/ground vehicle and demonstrated the importance of extracorporeal cardiopulmonary resuscitation for transported children. We report the first Turkish pediatric case series of patients with acute cardiogenic shock transported by aircraft and ground ambulances on extracorporeal membrane oxygenation support to a referral extracorporeal membrane oxygenation center between January 2016 and January 2021. Overall, 6 patients on venoarterial extracorporeal membrane oxygenation support were transported by aircraft and ground vehicles to our pediatric intensive care unit. Transport was achieved by fixed-wing aircraft in 5 patients and commercial aircraft in 1. Our mobile extracorporeal membrane oxygenation team cannulated 3 patients, and 3 patients were cannulated by the team at the hospital they applied to. The median age was 112 (range: 14-204) months and the median weight was 28.6 kg (range: 8.6-57.2 kg). The etiology of acute cardiogenic shock was fulminant myocarditis in 4 patients, dilated cardiomyopathy in 1, and transposition of great arteries and atrial flutter in 1. The median distance of travel for the patients to our hospital was 618 (407-955) km. No adverse events were detected during aircraft or ground vehicle transport. Mobile pediatric extracorporeal membrane oxygenation transport teams may provide safe aircraft and ground vehicle transportation in high-risk patients with acute cardiogenic shock bridging to survival or long-term circulatory support.

Extracorporeal Membrane Oxygenation for Respiratory Failure Related to COVID-19: A Nationwide Cohort Study.

Background:Despite expanding use, knowledge on extracorporeal membrane oxygenation support during the COVID-19 pandemic remains limited. The objective was to report characteristics, management, and outcomes of patients receiving extracorporeal membrane oxygenation with a diagnosis of COVID-19 in France and to identify pre-extracorporeal membrane oxygenation factors associated with in-hospital mortality. A hypothesis of similar mortality rates and risk factors for COVID-19 and non–COVID-19 patients on venovenous extracorporeal membrane oxygenation was made.Methods:The Extracorporeal Membrane Oxygenation for Respiratory Failure and/or Heart failure related to Severe Acute Respiratory Syndrome-Coronavirus 2 (ECMOSARS) registry included COVID-19 patients supported by extracorporeal membrane oxygenation in France. This study analyzed patients included in this registry up to October 25, 2020, and supported by venovenous extracorporeal membrane oxygenation for respiratory failure with a minimum follow-up of 28 days after cannulation. The primary outcome was in-hospital mortality. Risk factors for in-hospital mortality were analyzed.Results:Among 494 extracorporeal membrane oxygenation patients included in the registry, 429 were initially supported by venovenous extracorporeal membrane oxygenation and followed for at least 28 days. The median (interquartile range) age was 54 yr (46 to 60 yr), and 338 of 429 (79%) were men. Management before extracorporeal membrane oxygenation cannulation included prone positioning for 411 of 429 (96%), neuromuscular blockage for 419 of 427 (98%), and NO for 161 of 401 (40%). A total of 192 of 429 (45%) patients were cannulated by a mobile extracorporeal membrane oxygenation unit. In-hospital mortality was 219 of 429 (51%), with a median follow-up of 49 days (33 to 70 days). Among pre-extracorporeal membrane oxygenation modifiable exposure variables, neuromuscular blockage use (hazard ratio, 0.286; 95% CI, 0.101 to 0.81) and duration of ventilation (more than 7 days compared to less than 2 days; hazard ratio, 1.74; 95% CI, 1.07 to 2.83) were independently associated with in-hospital mortality. Both age (per 10-yr increase; hazard ratio, 1.27; 95% CI, 1.07 to 1.50) and total bilirubin at cannulation (6.0 mg/dl or more compared to less than 1.2 mg/dl; hazard ratio, 2.65; 95% CI, 1.09 to 6.5) were confounders significantly associated with in-hospital mortality.Conclusions:In-hospital mortality was higher than recently reported, but nearly half of the patients survived. A high proportion of patients were cannulated by a mobile extracorporeal membrane oxygenation unit. Several factors associated with mortality were identified. Venovenous extracorporeal membrane oxygenation support should be considered early within the first week of mechanical ventilation initiation.

Mobile Extracorporeal Membrane Oxygenation for Covid-19 Does Not Pose Extra Risk to Transport Team.

Previous experience has shown that transporting patients on extracorporeal membrane oxygenation (ECMO) is a safe and effective mode of transferring critically ill patients requiring maximum mechanical ventilator support to a quaternary care center. The coronavirus disease 2019 (COVID-19) pandemic posed new challenges. This is a multicenter, retrospective study of 113 patients with confirmed severe acute respiratory syndrome coronavirus 2, cannulated at an outside hospital and transported on ECMO to an ECMO center. This was performed by a multidisciplinary mobile ECMO team consisting of physicians for cannulation, critical care nurses, and an ECMO specialist or perfusionist, along with a driver or pilot. Teams practised strict airborne contact precautions with eyewear while caring for the patient and were in standard Personal Protective Equipment. The primary mode of transportation was ground. Ten patients were transported by air. The average distance traveled was 40 miles (SD ±56). The average duration of transport was 133 minutes (SD ±92). When stratified by mode of transport, the average distance traveled for ground transports was 36 miles (SD ±52) and duration was 136 minutes (SD ±93). For air, the average distance traveled was 66 miles (SD ±82) and duration was 104 minutes (SD ±70). There were no instances of transport-related adverse events including pump failures, cannulation complications at outside hospital, or accidental decannulations or dislodgements in transit. There were no instances of the transport team members contracting COVID-19 infection within 21 days after transport. By adhering to best practices and ACE precautions, patients with COVID-19 can be safely cannulated at an outside hospital and transported to a quaternary care center without increased risk to the transport team.

Primary transport on extracorporeal membrane oxygenation: Two Indian center experience

Aims: Extracorporeal membrane oxygenation (ECMO) can be a lifesaving modality for patients with severe reversible pulmonary and/or cardiac failure, but its use remains restricted to a few highly equipped referral centers. Conventional transports to an ECMO center can be hazardous. Transport teams are usually trained to transfer stable patients across hospitals. As ECMO patients are extremely sick, specially trained critical care teams to deal with all possible complications in these critically ill patients will be required. Therefore, many ECMO centers have developed transport programs with the mobile ECMO team. In this study, we aim to present a brief account of the two-center experience of ECMO transport from India. Methods: Retrospective observational study is depicting the data of two mobile ECMO teams over 4 years, where 21 patients (16–74 years) were evaluated. Analysis was done for the transport arrangements, different characteristics of ECMO retrieval patients, their outcomes, and predictors of mortality of a total of 21 patients from two different referral centers of India. As it is a retrospective observational study, hence institutional ethical committee approval was waived off. Results: The mean distance of travel was 87.24±104.5 km (range 2–250 km) and transportation was by road in all cases. About 38% (n=8/21), patients had suffered from complications during transport like hypotension, cardiac arrest. There were no deaths in connection with transportation. The overall mortality rate was 33.3% with no difference over gender, age, duration of pre-ECMO ventilation, or duration of transport. The most common indication associated with ECMO transport was H1N1 infection. Conclusion: We found that patient transfer if done with proper protocols by a prepared team with full knowledge of problem areas to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients.

Safety of transport and retrieval of patients on extracorporeal membrane oxygenation during the peak of COVID-19 pandemic in the State of Qatar

Background: Transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) support can be hazardous with complications reported for up to 27% of patients1. Transport of COVID-19 patients on ECMO requires appropriate training, resource allocation, meticulous planning, effective communication and co-ordination. Strict adherence to infection control procedures and appropriate use of personal protective equipment is recommended2. The Extracorporeal Life Support Organisation registry reports 43% in-hospital mortality of COVID-19 patients supported on ECMO. This includes in-house and retrieval ECMO cases3. Methods: Between March 1st and September 30th 2020, 32 confirmed COVID-19 positive patients underwent peripheral cannulation followed by transportation to the Medical Intensive Care Unit (MICU) at Hamad General Hospital. Mobile ECMO is complex and time consuming. Following arrival at the bedside and thorough clinical assessment, the ECMO consultant may decline, recommend optimisation of the care provided, or opt for cannulation and initiation of ECMO. Cannulation can be performed at the bedside or in the operating room. Following stabilisation, the patient is transferred for computed tomography imaging and then transported by ambulance to hospital (Figure 1). Finally, another transfer from hospital entrance to the MICU takes place. All these phases pose risks for errors and complications unless vigilance, teamwork and continuous effective monitoring and co-ordination is observed. Patients were evaluated for age and severity of illness (Table 1). In addition, all major transport-related adverse events were reported and analysed. Major transport events are cardiac arrest, ECMO emergencies (membrane or mechanical failure, air embolism, accidental decannulation, or significant cannula dislodgement), significant arrhythmia, severe bleeding or cardio-respiratory instability, and vehicle breakdown/malfunction. Findings: The majority of our patients were critically ill with high probability of mortality as depicted by SOFA and APACHE2 score. 29 out of 32 patients were male. None of our patients suffered major complications during transportation. Conclusion: This small case series demonstrates transport and retrieval on ECMO for COVID-19 positive patients can be safely undertaken provided appropriate expertise, protocols and resources are used.

Inter-hospital transport on extracorporeal membrane oxygenation in various health systems

The feasibility and the recognition of the possibility to transport patients on extracorporeal membrane oxygenation (ECMO) aroused in the 1970s. The number of transporting facilities worldwide was less than 20 in the beginning of the second Millennium. In 2009 the H1N1 pandemic and a publication showing survival benefit for adult patients transported to a hospital with ECMO resource increased both awareness and interest for ECMO treatment. The number of transport organizations increased rapidly. As of today, the number of transport organizations increases world-wide, though some centers where ECMO is an established treatment report decreasing numbers of transports. Since the introduction of the more user-friendly equipment (ECMO-2 era) increasing numbers of low-volume ECMO centers perform these complex treatments. This overview is based on the current literature, personal experience in the field, and information from the authors’ network on the organization of ECMO transport systems in different settings of health care around the globe. Registry data since the entry into ECMO-2 shows that the number of ECMO treatments matter. The more treatments performed at a given center the better the patient outcome, and the better these resources are spent for the population served. A Hub-and-S poke model for national or regional organization for respiratory ECMO (rECMO) should be advocated where central high-volume ECMO center (Hub) serves a population of 10 to 15 million. Peripheral units (Spokes) play an important part in emergency cannulations keeping the patient on ECMO support till a mobile ECMO team retrieves the patient. This ECMO team is preferably organized from the Hub and brings competencies for assessment and decision to initiate ECMO treatment bedside at any hospital, for cannulation, and a safe transport to any destination.

Implementation and Outcomes of a Mobile Extracorporeal Membrane Oxygenation Program in the United States During the Coronavirus Disease 2019 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic began in the United States around March 2020. Because of limited access to extracorporeal membrane oxygenation (ECMO) in the authors’ region, a mobile ECMO team was implemented by April 2020 to serve patients with COVID-19. Several logistical and operational needs were assessed and addressed to ensure a successful program, including credentialing, equipment management, and transportation. A multidisciplinary team was included in the planning, decision-making, and implementation of the mobile ECMO. From April 2020 to January 2021, mobile ECMO was provided to 22 patients in 13 facilities across four southern California counties. The survival to hospital discharge of patients with COVID-19 who received mobile ECMO was 52.4% (11 of 21) compared with 45.2% (14 of 31) for similar patients cannulated in-house. No significant patient or transportation complications occurred during mobile ECMO. Neither the ECMO nor transport teams experianced unprotected exposures to or infections with severe acute respiratory syndrome coronavirus 2. Herein, the implementation of the mobile ECMO team is reviewed, and patient characteristics and outcomes are described.

Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study

BackgroundIn the Île-de-France region (henceforth termed Greater Paris), extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) was considered early in the COVID-19 pandemic. We report ECMO network organisation and outcomes during the first wave of the pandemic.MethodsIn this multicentre cohort study, we present an analysis of all adult patients with laboratory-confirmed SARS-CoV-2 infection and severe ARDS requiring ECMO who were admitted to 17 Greater Paris intensive care units between March 8 and June 3, 2020. Central regulation for ECMO indications and pooling of resources were organised for the Greater Paris intensive care units, with six mobile ECMO teams available for the region. Details of complications (including ECMO-related complications, renal replacement therapy, and pulmonary embolism), clinical outcomes, survival status at 90 days after ECMO initiation, and causes of death are reported. Multivariable analysis was used to identify pre-ECMO variables independently associated with 90-day survival after ECMO.FindingsThe 302 patients included who underwent ECMO had a median age of 52 years (IQR 45−58) and Simplified Acute Physiology Score-II of 40 (31−56), and 235 (78%) of whom were men. 165 (55%) were transferred after cannulation by a mobile ECMO team. Before ECMO, 285 (94%) patients were prone positioned, median driving pressure was 18 cm H2O (14−21), and median ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen was 61 mm Hg (IQR 54−70). During ECMO, 115 (43%) of 270 patients had a major bleeding event, 27 of whom had intracranial haemorrhage; 130 (43%) of 301 patients received renal replacement therapy; and 53 (18%) of 294 had a pulmonary embolism. 138 (46%) patients were alive 90 days after ECMO. The most common causes of death were multiorgan failure (53 [18%] patients) and septic shock (47 [16%] patients). Shorter time between intubation and ECMO (odds ratio 0·91 [95% CI 0·84−0·99] per day decrease), younger age (2·89 [1·41−5·93] for ≤48 years and 2·01 [1·01−3·99] for 49–56 years vs ≥57 years), lower pre-ECMO renal component of the Sequential Organ Failure Assessment score (0·67, 0·55−0·83 per point increase), and treatment in centres managing at least 30 venovenous ECMO cases annually (2·98 [1·46–6·04]) were independently associated with improved 90-day survival. There was no significant difference in survival between patients who had mobile and on-site ECMO initiation.InterpretationBeyond associations with similar factors to those reported on ECMO for non-COVID-19 ARDS, 90-day survival among ECMO-assisted patients with COVID-19 was strongly associated with a centre's experience in venovenous ECMO during the previous year. Early ECMO management in centres with a high venovenous ECMO case volume should be advocated, by applying centralisation and regulation of ECMO indications, which should also help to prevent a shortage of resources.FundingNone.

ECMO Retrieval over the Mediterranean Sea: Extending Hospital Arms.

The retrieval and transport of patients from peripheral hospitals to high volume extracorporeal membrane oxygenation (ECMO) centers aims to reduce complications and improve survival. In Sicily (Italy), our institute houses a mobile ECMO team that serves a population of around 10 million people for a vast area in southern Italy and Malta. This observational, descriptive study includes all patients that required veno–venous (V-V) ECMO and transport by a mobile team between October 2009 and May 2020. Linear and multiple logistic regressions were applied to explore the risk factors for mortality in the ICU. Kaplan–Meier estimates were generated to predict the survival in patients transported by helicopter or ambulance, and the two cohorts were compared according to their baseline characteristics. Of 122 patients transported, 89 (73%) survived to ICU discharge (50 (41%) patients were transported by ambulance, and 72 (59%) were transported by helicopter). Independent predictive factors associated with mortality in a stepwise multiple regression model were prone positioning, acute kidney injury, and the number of days spent on mechanical ventilation (MV). Kaplan–Meier estimates for survival favored the helicopter cohort (79%) rather than the ambulance cohort (64%). Patients transported by helicopter had better pre-ECMO profiles, with shorter hospital and ICU stays, a shorter duration of MV use, and higher RESP scores, which indicate better survival probabilities. ECMO transport can be carried out safely over long distances; in rural areas with underdeveloped roads, transportation via helicopter or ambulance can extend the arm of the hospital to remote areas. Early ECMO initiation can be crucial in improving survival outcomes, and when transportation is the limiting factor to starting ECMO support, it should be attempted at the earliest logistical stage possible.

Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization.

Disclaimer:This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19–related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19–related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.

Cardiohelp System use in school age children and adolescents at a center with interfacility mobile extracorporeal membrane oxygenation capability.

Cardiohelp System use for pediatric extracorporeal membrane oxygenation (ECMO) beyond the transport setting is sparsely described in literature. We report the use of Getinge's Cardiohelp System in children and integrated utilization of Mobile ECMO Retrieval Team (MERT) at an all-age specialized cardiorespiratory center. Electronic database of all patients under 16 years of age who received ECMO with use of the Cardiohelp System between January 2018 and March 2020 was retrospectively reviewed and analyzed for demographics, set-up, complications, and outcomes. Out of 41 patients, seven patients (four in middle childhood, three in early teenage) with median age of 10 years (range 8.8-15.6) were supported with use of Cardiohelp System. Median weight and height were 34 kg (range 28-53) and 145 cm (range 134-166) respectively. Initial ECMO deployment was veno-arterial (V-A) in five patients and veno-venous (V-V) in two. There were three interhospital transfers by our MERT, and 12 intrahospital transfers for interventions or imaging. The median ECMO therapy was 7 days (range 4-25), with standard 3/8-inch tubing and ECMO flow rate range at 56-100 mL/kg/min (1.89-5.0 LPM). There were two circuit changes and three reconfigurations of support. Two patients received continuous veno-venous hemofiltration via ECMO circuit. The 90-day and 180-day survival rates were 100% (including two heart transplants at day 7 and day 8). There were no transport-related or circuit-related complications during the 1750 h of Cardiohelp use. Cardiohelp System use is safe in pediatric patients for diverse application of ECMO support including inter- and intrahospital transfers.

Abstract 365: The Minnesota Mobile Extracorporeal Cardiopulmonary Resuscitation Consortium for Treatment of Out-of-hospital Refractory Ventricular Fibrillation: Program Description and Outcomes

Background: Extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation has been shown to improve the survival rate for patients with refractory VF/VT cardiac arrest. However, survival decreases as CPR duration increases and metabolic derangement progresses. We describe here a first of its kind multi-healthcare system consortium to rapid deploy ECMO-facilitated resuscitation to patients across a metropolitan area. Methods: This retrospective cohort study analyzed 58 consecutive patients prospectively enrolled in the Minnesota Mobile Resuscitation Consortium’s ECMO-facilitated resuscitation program. Inclusion criteria included: 1) age 18 to 75 years, 2) VF/VT as presenting rhythm, 3) refractory cardiac arrest despite 3 shocks, 4) body habitus accommodating a LUCAS mechanical CPR device, 5) estimated transfer time of &lt; 30 min from a cannulating center. The consortium included multiple healthcare systems, dispatch services, and emergency medical services. Essential components included EMS, selection of 3 ECMO cannulation sites in geographically favorable emergency departments, a centralized ECMO center for post-arrest care, and a 24/7 mobile ECMO cannulation team. The cannulation team provided ECMO cannulation and medical care until the patient reached the ECMO center. Results: From December 1, 2019 to April 1, 2020, 58 consecutive patients were treated by the mobile ECMO team. Mean age was 57 ± 1.8 years. Of these, 25/58 (43%) were discharged from the hospital with neurologically favorable survival. Patients were cannulated at all three cannulation sites with transport to the nearest site leading to mean professional CPR time of 52 min. Conclusions: This represents the first community-wide ECMO-facilitated resuscitation program in the United States. A consortium including multiple healthcare systems and emergency medical services coordinated efforts to rapidly deliver patients with refractory VF/VT cardiac arrest to a highly trained and equipped mobile ECMO cannulation team resulting in improved neurologically favorable survival.

The Minnesota mobile extracorporeal cardiopulmonary resuscitation consortium for treatment of out-of-hospital refractory ventricular fibrillation: Program description, performance, and outcomes.

BackgroundWe describe implementation, evaluate performance, and report outcomes from the first program serving an entire metropolitan area designed to rapidly deliver extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation to patients with refractory ventricular fibrillation/ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA).MethodsThis observational cohort study analyzed consecutive patients prospectively enrolled in the Minnesota Mobile Resuscitation Consortium's ECMO-facilitated resuscitation program. Entry criteria included: 1) adults (aged 18–75), 2) VF/VT OHCA, 3) no return of spontaneous circulation following 3 shocks, 4) automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System (LUCAS™), and 5) estimated transfer time of < 30 min. The primary endpoint was functionally favorable survival to hospital discharge with Cerebral Performance Category (CPC) 1 or 2. Secondary endpoints included 3-month functionally favorable survival, program benchmarks, ECMO cannulation rate, and safety. Essential program components included emergency medical services, 3 community ECMO Initiation Hospitals with emergency department ECMO cannulation sites and 24/7 cardiac catheterization laboratories, a 24/7 mobile ECMO cannulation team, and a single, centralized ECMO intensive care unit.FindingsFrom December 1, 2019 to April 1, 2020, 63 consecutive patients were transported and 58 (97%) met criteria and were treated by the mobile ECMO service. Mean age was 57 ± 1.8 years; 46/58 (79%) were male. Program benchmarks were variably met, 100% of patients were successfully cannulated, and no safety issues were identified. Of the 58 patients, 25/58 (43% [CI:31–56%]) were both discharged from the hospital and alive at 3 months with CPC 1 or 2.InterpretationThis first, community-wide ECMO-facilitated resuscitation program in the US demonstrated 100% successful cannulation, 43% functionally favorable survival rates at hospital discharge and 3 months, as well as safety. The program provides a potential model of this approach for other communities.FundingThe Helmsley Charitable Trust