Mobile Extracorporeal Membrane Oxygenation Research Articles

First Berlin Heart EXCOR Pediatric VAD Interhospital Transports of Nonambulatory Patients with the Ikus Stationary Driver

Ventricular assist devices (VADs) are increasingly being used in pediatric patients to support cardiac failure. As more centers adopt this technology, there may be a need to transport these patients over long distances to facilitate patient care and organ transplantation. Food and Drug Administration indications for use state only that the patient must be a candidate for transplantation and does not place restrictions on the transplant capabilities of the implanting medical center. Nontransplanting institutions are able to use this technology with a predetermined agreement to transfer the patient to a partnering transplant center. We report the first two cases of interhospital air and ground transport of nonambulatory or intubated pediatric (<13 kg) patients supported by Berlin Heart EXCOR pediatric VADs and Ikus stationary drivers. We present our protocol for transporting this delicate patient population. In addition, we discuss important challenges encountered on these operations regarding vehicle transfers and the management of vehicle power supply. These two cases demonstrate that the transportation of pediatric patients on Berlin Heart VADs is feasible and safe and should be considered a treatment option in certain situations.

International Retrieval of Adults on Extracorporeal Membrane Oxygenation Support

A retrieval service was established in New South Wales to provide mobile extracorporeal membrane oxygenation support to patients with severe, acute cardiac or respiratory failure. This service has also retrieved four adult patients from Nouméa, New Caledonia to Sydney on extracorporeal membrane oxygenation support, which are the first international retrievals of this type from Australia. We discuss our experience with these patients, three of whom survived to hospital discharge. However, one patient referred from New Caledonia died before extracorporeal membrane oxygenation could be established.

Session UMAC/UMAR : point de vue du SMUR, évaluation des coûts

Since the 1970s, it has become possible to handle patients with serious pulmonary and cardiac failure with extracorporeal membrane oxygenation (ECMO) when conventional treatment fails, but only in specialized centers. When the latter were too far away, the risks of such transport were considered too high until the Mobile Cardiac Assistance Unit (MCAU) and Mobile Respiratory Assistance Unit (MRAU) were created. We are first going to expose the point of view of the pre-hospital Emergency Medical Services (EMS). The M.D. in need of such assistance should call the cardiac surgeon of the reference center : if the indication is confirmed, they will call the EMS (Service d’Aide Médicale Urgente, SAMU), and decide together which means is the most appropriate for a quick transportation of the team and the ECMO to the patient's bedside, and then back to the ECMO center, depending on the problems raised by ground vehicles on the one hand and aircrafts or helicopters on the other. Then, we are going to evaluate the cost of such transportation, which is quite considerable. As a conclusion, because of its high cost, the mobile inter-hospital ECMO. service should only be used when the patient is considered too ill to be transported on conventional therapy : in that case, this procedure represents huge progress.

Mobile cardio-respiratory support in prehospital emergency medicine

Serious pulmonary and cardiac failure may be treated with extracorporeal membrane oxygenation (ECMO) when the conventional treatment fails. Improvements in extracorporeal circulation devices have allowed us to set up two specialized mobile units: a mobile cardiac assistance unit (MCAU) and a mobile respiratory assistance unit (MRAU). Their role is to provide ECMO at patient's bedside, and then to ensure inter-hospital transport (IHT). The aim of this study was to evaluate our experiences with the transportation of patients on ECMO. We performed two prospective observational studies, the first on IHT requiring MCAU during 3 years and the second on IHT requiring MRAU during 6 months. Thirty-two patients needed MCAU. The median age is 40 years. The median distance travelled is 45 km. The median time of arrival at patient bedside is 49 min. Causes of cardiac shock were: myocarditis (28.1%), acute heart failure of unknown aetiology (21.9%), drug-induced cardiovascular failure (18.8%), post-infarction cardiac failure (12.5%), post-cardiac surgery (12.5%) and refractory cardiac arrest (6.2%). Thirty days mortality was 40%. Eleven patients needed MRAU. The median age was 33 years. The median distance travelled is 40 km; the median time of arrival at patient bedside is 47 min. All patients had severe acute respiratory distress syndrome complicating severe H1N1 virus infection. Thirty days mortality was 65%. In both the cases, all transportations were uneventful. This study shows that mobile ECMO system can be successfully and quickly established at patient's bedside, and that transportation of patients on ECMO can be performed safely and without technical difficulties.

First experience with the ultra compact mobile extracorporeal membrane oxygenation system Cardiohelp in interhospital transport

In patients with severe cardiopulmonary failure extracorporeal assist devices are to support patients during resuscitation, for transportation, until organ recovery, and as bridge to further therapeutic modalities. We report on our first experience with the new Cardiohelp system for interhospital transfer of cardiopulmonarily compromised patients. The Cardiohelp system was used for transportation and in-house treatment in six male patients with a mean age of 41±17years. Five patients suffered respiratory failure; one patient with acute myocardial infarction was in profound cardiogenic shock. Accordingly, the Cardiohelp system was implanted as a venovenous extracorporeal membrane oxygenation (ECMO) in five patients and as a venoarterial system in one patient. The preECMO ventilation time was 0.5-4days. The patients were transported to our institution by car (n=1) or helicopter (n=5) over a distance of 80-5850km. The subsequent in-house ECMO support was continued with the Cardiohelp and lasted for 5-13days. PostECMO ventilation was one to 25 days. A 100% survival was achieved. The portable Cardiohelp system allows location-independent stabilization of cardiopulmonary compromised patients with consecutive interhospital transfer and in-house treatment. The integrated sensors, which register arterial and venous line pressure, blood temperature, hemoglobin as well as SvO(2), greatly alleviate its management and considerably increase safety.

MRI of the Brain and Thorax during Extracorporeal Membrane Oxygenation: Preliminary Report from a Pig Model

Early diagnosis of cerebral hypoxic ischemic complications during extracorporeal membrane oxygenation (ECMO) is important to guide further treatment. However, diagnostic methods available during ECMO are limited, especially in adults and older children. Magnetic resonance imaging (MRI) is a sensitive and noninvasive method for assessment of vessel patency and brain parenchymal changes, and for measurement of brain perfusion. The use of MRI during ECMO has, to our knowledge, never been reported. We report the first animal experiment with MRI examination during ECMO. After a preliminary test with the mobile ECMO system in the MRI environment, a healthy pig was put on venoarterial ECMO, transported to the MRI department, and examined with sequences for anatomy and function of the brain and thorax. The results showed that the ECMO system was not adversely affected by the magnetic field at a distance from the camera where positioning and examination of the animal was possible. High-quality anatomical and functional images of the brain, heart, and thoracic vessels were acquired. The results suggest that MRI may be used for early diagnosis of cranial complications in patients on ECMO. MRI may also provide a useful tool for further research on flow dynamics and brain perfusion during ECMO.

CT in the evaluation of patients on ECMO due to acute respiratory failure.

In patients with acute severe respiratory failure (ARF) treated with extracorporeal membrane oxygenation (ECMO) the radiological evaluation has until now almost exclusively relied on bedside radiography and US. At St. Göran/Karolinska ECMO centre CT has become a routine complement to bedside examinations. To review retrospectively the frequency, indications and findings on CT of patients with ARF on ECMO and to evaluate the risk of complications associated with transportation for CT examinations. One hundred twelve neonates, children and adults were treated with ECMO from May 1994 to January 2001. Forty-six per cent of these patients had CT examinations on one or more occasions during ECMO, giving a total number of 238 examination sites on 104 occasions. All CT examinations were performed in the Paediatric Radiology Department and included a 10-min transport using a mobile ECMO system. CT was more often performed in older patients and in patients with long ECMO runs. The main indications were suspected complications of ECMO and/or the underlying disease or a delay in clinical improvement. In 57% of the CT occasions, significant findings affecting treatment were revealed. There were no complications associated with the examinations or transport. CT is safe and useful in evaluation of patients with ARF during ECMO.

Inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation--national and international experience.

To evaluate the experiences and results from inter-hospital transportation of patients with acute respiratory failure on extracorporeal membrane oxygenation (ECMO). Observational, descriptive study. Tertiary referral center in a University Hospital. When standard ECMO criteria were fulfilled and the patient considered too unstable for a conventional transport, the mobile ECMO team cannulated the patient for ECMO at the referring hospital. The patients were then transported to our ECMO center by ground ambulance, helicopter or fixed-wing vehicle. Patients were also transported on ECMO from our ECMO center to other centers due to shortage of available ECMO beds. 29 patients (15 neonates, seven pediatric, and seven adult patients) with acute respiratory failure were transported on ECMO on a total of 30 occasions. Median time from arrival of the ECMO team at the referring hospital until the patient was on ECMO (28 patients) was 2.2 h (range 1.25-4.25 h). The median time that the transport team was out was 10 h (range 5.5-36.5 h) and the median time with the patient was 6 h (range 3-30.5 h). The distance of transport ranged from 4-1,500 km. Six transports were international. No patient complications occurred during the transports. Two technical complications related to the transport vehicle were encountered. One ambulance compressor malfunctioned. During one helicopter transport, one out of two electric supply circuits malfunctioned. The patients were not affected. Twenty-one of the 29 patients survived to discharge (72%). None of the deaths was transport related. Tertiary intensive care units and ECMO centers require a dedicated transport team. ECMO transports can be performed safely for all age groups for long distances, probably throughout most of Europe.

Extracorporeal membrane oxygenation for transport of hypoxaemic patients with severe ARDS.

Conventional inter-hospital transfer of patients with severe acute respiratory distress syndrome (ARDS) in need of extracorporeal membrane oxygenation (ECMO) may be risky and in severe hypoxaemic patients may be associated with cerebral hypoxia and death. Therefore, we began a phase 1 study to evaluate the feasibility, complications and outcome of inter-hospital transport of these patients using veno-venous ECMO. Eight patients with severe ARDS and a PaO2/FIO2 < 6.7 kPa at a PEEP > or = 10 cm H2O were placed on a mobile ECMO at the referring hospital. The 495 (SD 123) km inter-hospital transport via a special ground ambulance took 341 (151) min. After transfer, blood-gas tensions were improved in spite of less optimal ventilator settings, compared with data before the start of ECMO. No significant complications occurred. Six patients survived and were discharged from hospital; two patients died because of multiple organ failure. We conclude that initiation of ECMO in hypoxaemic patients before inter-hospital transfer is feasible and enables safe transport to an ECMO centre.

Mobile Extracorporeal Membrane Oxygenation

Mobile extracorporeal membrane oxygenation (ECMO) is being offered by select ECMO centers in the United States. Mobile ECMO can be performed for the critically ill patient who is unable to be transported by conventional ambulance transport. This article discusses the logistics and safety considerations associated with mobile ECMO.

Inter-Hospital Transport of Neonatal Patients on Extracorporeal Membrane Oxygenation: Mobile-ECMO

To describe the equipment, personnel requirements, training, management techniques, and logistic problems encountered in the design and implementation of a mobile extracorporeal membrane oxygenation (ECMO) program. This is a report of a technique for the transport of patients on ECMO and a description of our retrospective case series. The study was conducted at a regional referral children's hospital and ECMO unit. Thirteen neonatal medical patients with acute respiratory failure were transported with mobile-ECMO. Over a 24-month period, we transported 13 neonatal patients with mobile-ECMO. The reason for transport with mobile-ECMO was inability to convert from high-frequency ventilation (4 of 13), patient already on ECMO (1 of 13), and patient deemed too unstable for conventional transport (8 of 13). Eleven of the 13 patients were transported from other ECMO centers. Of the 13, 9 survived. No major complications during transport were reported for any of the patients. Follow-up data were available on all nine survivors of neonatal mobile-ECMO. Eight of these had normal magnetic resonance imaging scans of the brain; the ninth had a small hemorrhage in the left cerebellum. Our limited series shows that patients can be safely transported with mobile-ECMO. This program does not replace the early appropriate transfer for ECMO-eligible patients to an ECMO center.

Mobile extracorporeal membrane oxygenation

Transport of critically ill neonates in need of extracorporeal membrane oxygenation can be risky. Their extreme cardiorespiratory instability may delay or even preclude convention transport to an extracorporeal membrane oxygenation center. We report the use of a UH-1 helicopter specially adapted for mobile extracorporeal membrane oxygenation support to transport a critically ill neonate.