Table Of ContentECMO Retrieval
Program
Foundation
Anton Sabashnikov
Thorsten Wahlers
Editors
123
ECMO Retrieval Program Foundation
Anton Sabashnikov • Thorsten Wahlers
Editors
ECMO Retrieval Program
Foundation
Editors
Anton Sabashnikov Thorsten Wahlers
Department of Cardiac Surgery Department of Cardiac Surgery
Intensive Care Medicine and Thoracic Intensive Care Medicine and Thoracic
Surgery Heart Center Surgery Heart Center
University Hospital Cologne University Hospital Cologne
Cologne, Germany Cologne, Germany
ISBN 978-3-031-17148-2 ISBN 978-3-031-20260-5 (eBook)
https://doi.org/10.1007/978-3-031-20260-5
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Preface
This book should not only represent a comprehensive overview on current evidence
and expert experiences in extracorporeal membrane oxygenation (ECMO) but also
serve as a guideline for launching a structured and well-functioning ECMO pro-
gram. Whereas this book covers all relevant clinical and research topics on ECMO,
it is mainly focused on particularities and special features of planning, setting up,
developing, structuring, and maintaining of ECMO support program for instable
patients with the need of transportation from peripheral hospitals to an experienced
ECMO center for further treatment.
Authors have condensed both the current evidence and guidelines on ECMO and
eCPR support and have highlighted in detail the issue of planning, setting up, devel-
oping, structuring, and maintaining this program with the view to helping other
centers launching this life-saving service taking into account their experience in this
important field of medicine. In this context, the main benefit of this book is the out-
standing and particular aim to educate the reader in developing and maintaining a
large-spectrum ECMO program.
The volume, richly illustrated and written by KOLs using an expository writing
style to promote the readability, will appeal to intensivists, anesthesiologists, and
cardiologists, as well as cardiac and thoracic surgeons and pneumologists.
Köln, Germany Anton Sabashnikov
Köln, Germany Thorsten Wahlers
v
Synopsis
Extracorporeal membrane oxygenation (ECMO) has been proven to be a very valu-
able life-saving therapeutic strategy for both refractory cardiogenic shock and
severe respiratory failure over the last decades [1]. The complexity of this young
treatment sector is currently not only associated with still constantly evolving and
transforming clinical scope but is also justified by organizational, financial, and also
ethical issues. Moreover, significant educational requirements over the course of
permanently increasing evidence and research on strategies to improve outcomes
pose an additional liability of the entire system.
Dramatic increases in proportion of patients with cardiac or pulmonary failure
treated using ECMO have indeed been seen in recent years, despite increasingly
stricter patient selection. While in earlier times, ECMO therapy used to be the last
resort “ultima ratio” option for patients in extremely poor conditions when once had
nothing to lose, the indication logics was gradually shifted towards a more aggres-
sive implantation frequently in less severely ill patients that would require more
than optimal conservative treatment to be able to recover in terms of organ function
rather than to survive at all. Therefore, the increase in numbers over the last decades
was related to consequentially more decent outcomes over the course of consis-
tently improving cost-benefit-risk balance and support if all else fails, however
when the chances of survival are still considerable.
During the period of initial clinical confrontation with this technically challeng-
ing treatment strategy amidst rapid development and general intricacy, ECMO ther-
apy was naturally limited to the local use in large centers with experience with
cardio-pulmonary bypass (CPB) and solid intensive care unit (ICU) capacities.
However, with advances in theoretical knowledge and also technical progress,
increasing evidence and expanding need for support of critically ill patients who
would benefit from more than conservative treatment pushed the limits of high-
volume center use only and opened up new frontiers of this life-saving approach
spreading the boarders of large institution exclusivity.
The first step towards decentralization and attainability of ECMO support for a
wider spectrum of indigent population became the scenario of distant supply in
patients that were not likely to survive transport from local hospitals without ECMO
vii
viii Synopsis
experience with subsequent transportation to centers with expertise for further treat-
ment. This mobilization of already established standard of care would have not been
feasible without remarkable technical advances in the area of ECMO that took place
over the certain period of time among other things resulting in the development and
launching of a new category of miniaturized but still fully functioning devices,
especially designed for interhospital transportation on ECMO support. Since then
the era of the so-called ECMO retrieval service began and whereas the number of
experienced centers providing this service has been permanently growing till
date [2, 3].
Despite the aforementioned evidence-based tendency towards more aggressive
and early support in relatively stable patients with high recovery potential where
medical treatment is not fully sufficient, a significant group of instable patients
requiring cardio-pulmonary resuscitation (CPR) further spread the mindset of in-
hospital approach. Several groups with both local and mobile ECMO experience
showed benefits of ECMO use in patients who required immediate cardio-p ulmonary
support due to sudden cardiac failure for various reasons being out of hospital.
Despite the higher risk of infectious complications due to obviously not pristinely
clean street, train station, supermarket, or even Louvre conditions as well as lacking
cutting-edge technical equipment and familiar surroundings of a modern operating
room or ICI, not only the patient but also the ECMO team are definitely dragooned
to leave the comfort zone. However, we do not need to talk about risk-benefit evalu-
ation of such valiant approach when someone’s life is in acute fatal danger. This is
the life and death struggle and the life-saving potential of the technical edge and
clinical know-how must be utilized to their full capability, never mind the expense.
And this is more than just justified—everyone would agree. However, despite being
“thrown into the deep end” and chasing the idea of saving lives as bail-out concept,
there are always alternative ways of handling any situation as we know it from
real life.
Our retrieval service was initially focused on support and transportation of
patients with severe pulmonary failure requiring veno-venous ECMO. After posi-
tive experience with good outcomes and permanently increasing numbers of
implantations in peripheral hospitals performed by trained colleagues of the depart-
ment of internal medicine specialized in pulmonology, and considering large expe-
rience in veno-arterial ECMO implantations and management on-site in our
department for cardiothoracic surgery, we decided to expand the spectrum of the
service adding veno-arterial ECMO support for patients with heart or combined
heart-lung failure. After several years of growing ECMO retrieval experience, our
team also inevitably faced the stage of getting goose pimples from the first out-of-
hospital implantation request under CPR. Indeed, on the first impression and on the
basis of the first assessment of the clinical information provided, this strategy ini-
tially seemed to be the most reasonable approach in that particular situation. While
for several reasons in detail described in this book this out-of-hospital ECMO run
had to be abandoned, our team began to wonder about the purposefulness of out-of-
hospital interventions, at least taking into consideration the logistic conditions we
had achieved at that stage of our ECMO retrieval program. Being mostly involved
Synopsis ix
in usual day-to-day life of one of the largest departments for cardiac surgery, inten-
sive care medicine, and thoracic surgery in the country, our team is not exclusively
employed for ECMO support. Moreover, this initially not founded activity that by
and large was driven by inspiration and enthusiasm of our motivated surgeons,
intensivists, and perfusionists, appeared as kind of ancillary service rather than the
main job. ECMO consoles borrowed from the industry and expensive disposables
are located in our hospital and all technical equipment along with hospital based
trained staff has to be transported to the scene by our city fire department after usual
logistic organization and preparations, such as priming of the circuit and packing all
medical utensils required. It is not uncommon that one of the trained surgeons or
perfusionists scheduled for surgery has to be replaced in the operating room to be
able to attend the ECMO run. Therefore, it obviously seems to be more rational to
move a patient under CPR to our catheterization laboratory in order to save time and
maintain in-hospital conditions during implantation. In that way, our program natu-
rally expanded including extracorporeal cardio-pulmonary resuscitation (eCPR) of
patients with out-of-hospital cardiac arrest with great support of colleagues of our
in-house department for cardiology and round the clock availability of catheteriza-
tion laboratories for implantation and further diagnostics.
On the one hand, in this book we tried condensing the current evidence and
guidelines on ECMO and eCPR support, on the other hand, we highlight in detail
the issue of planning, setting up, developing, structuring, and maintaining of this
program with the view to helping other centers launching this life-saving service
taking into account our experience in this important field of medicine.
References
1. Sabashnikov A, Djordjevic I, Deppe AC, Kuhn EW, Merkle J, Weber C, Sindhu D, Eghbalzadeh
K, Zeriouh M, Liakopoulos OJ, Rahmanian PB, Kuhn-Régnier F, Choi YH, Madershahian N,
Wahlers T. Managing traps and pitfalls during initial steps of an ECMO retrieval program using
a miniaturized portable system: what have we learned from the first two years? Artif Organs.
2018;42(5):484–92.
2. Forrest P, Cheong JY, Vallely MP, Torzillo PJ, Hendel PN, Wilson MK, Bannontt PG, Bayfield
MS, Herkes R, Walker SW. International retrieval of adults on extracorporeal membrane oxy-
genation support. Anaesth Intensive Care. 2011;39(6):1082–5.
3. Edelman J, Wilson MK, Vallely MP, Bannon PG, McKay G, Robertson SJ, Hislop R, Wong C,
Cartwright BL, Forrest P, Torzillo PJ. The expanding role of extracorporeal membrane oxygen-
ation retrieval services in Australia. Anaesth Intensive Care. 2017;45(1):92–3.
Anton Sabashnikov
Thorsten Wahlers
Contents
Part I Scientific, Technical and Clinical Background of
Extracorporeal Membrane Oxygenation (ECMO) Therapy
1 History of Extracorporeal Life Support: From
Cardiopulmonary Bypass Towards ECMO . . . . . . . . . . . . . . . . . . . . . . 3
Daniele Camboni and Christof Schmid
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 History of Blood Pumps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3 History of Oxygenators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4 From the Early Days of ECMO up to Present . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2 Variety and Classification of ECMO Systems and Cannulation
Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Muhammad R. Arab, Oliver J. Liakopoulos, Yeong-Hoon Choi,
and Mohamed Zeriouh
2.1 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.1.1 Standard ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.1.2 Less Commonly Used ECMO Types . . . . . . . . . . . . . . . . . . . 18
2.1.3 Hybrid ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1.4 Parallel ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2 Cannulation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.1 Basic principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.2 Cannula types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.3 Percutaneous Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.4 Surgical Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3 Cannulae for Peripheral ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.3.1 E xamples of Commercially Available Peripheral Cannulas . 27
2.4 Cannulae for Central ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.4.1 Arterial Cannulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.4.2 Venous Cannulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
xi
xii Contents
3 Is it Time to Move on? Discrepancies Between Official
Guidelines and Real Life Clinical Scenarios . . . . . . . . . . . . . . . . . . . . . 45
Wolfgang A. Wetsch
3.1 Existing Guidelines for ECMO Therapy . . . . . . . . . . . . . . . . . . . . . . 45
3.2 General Indications for Initiation of ECMO Therapy . . . . . . . . . . . . 47
3.3 “Classic ECMO Indication”: The Patient with Refractory
Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.4 Adult Respiratory Distress Syndrome (ARDS) . . . . . . . . . . . . . . . . . 47
3.5 Indications Beyond the Current Guidelines . . . . . . . . . . . . . . . . . . . . 48
3.6 Influenza H1N1 (“Swine Flu”) Pandemic . . . . . . . . . . . . . . . . . . . . . 49
3.7 SARS-CoV2 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.8 Mendelson Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3.9 Accidental Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3.10 Extracorporeal Cardio-Pulmonary Resuscitation (eCPR) . . . . . . . . . 52
3.11 Pulmonary Embolism (PE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.12 Is it Time to Move on? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4 Left Ventricular Decompressing and Venting Strategies:
The Game Changers in ECMO Support . . . . . . . . . . . . . . . . . . . . . . . . 57
Oliver D. Bhadra, Jonas Pausch, Hermann Reichenspurner,
and Alexander M. Bernhardt
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
4.2 Pathophysiology of Left Ventricular Distension Under
Femoral Veno- Arterial ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4.3 Central Cannulation Strategies for Left Ventricular Unloading . . . . . 59
4.4 Intra-Aortic Balloon Pump for Left Ventricular Unloading . . . . . . . . 60
4.5 The ECMELLA Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.6 ECMELLA Therapy with Axillary Implanted Impella
5.0/5.5 Devices and Bridging Options . . . . . . . . . . . . . . . . . . . . . . . . 62
4.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
5 ECMOlogy as the New Medical Discipline: The Way Towards
Interdisciplinary Approach of ECMO Therapy . . . . . . . . . . . . . . . . . . . 67
Asmae Gassa, Veselina Ninova, and Thorsten Wahlers
5.1 Who Can Become ECMO Specialist? . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2 How to Become ECMO Specialist? . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5.3 ELSO Guidelines for Training and Continuing Education
of ECMO Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5.3.1 Training Outline for Education According to ELSO . . . . . . . 72
5.3.2 Continuing Education of the ECMO Specialist
According to ELSO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.4 ECMOlogy: Do we Need a New Medical Discipline? . . . . . . . . . . . 73
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
