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Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies.

Tulman DB, Stawicki SP, Whitson BA, Gupta SC, Tripathi RS, Firstenberg MS, Hayes D, Xu X, Papadimos TJ - BMC Anesthesiol (2014)

Bottom Line: Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual.Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected.There are challenges that still must be overcome.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA.

ABSTRACT

Background: Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected.

Discussion: Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices.

Summary: Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.

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Related in: MedlinePlus

Example of ECMO ambulation: (A) extubated, bed-ridden patient on ECMO; (B) patient on ECMO and able to sit up in bed and ambulate.
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Figure 2: Example of ECMO ambulation: (A) extubated, bed-ridden patient on ECMO; (B) patient on ECMO and able to sit up in bed and ambulate.

Mentions: There are both advantages and disadvantages to the BCDL catheter [28]. Advantages include (a) single insertion site, which decreases risk of bleeding and infection, (b) ability to ambulate patients (FigureĀ 2), (c) posterior lateral position that is optimal for thoracic surgery, (d) permits prone positioning more easily, and (e) facilitates aeromedical transport. In contrast, the disadvantages include (a) limited range of catheter sizes with limited flows if inappropriate size inserted, (b) radiographic and/or echocardiographic guidance needed for insertion, (c) instability of catheter after placement, (d) insertion of a large, double lumen cannula into the internal jugular artery may result in cerebral venous congestion; an additional cephalad drainage line may be worth considering, and (e) the need for expertise in ECMO management for optimal outcomes. We use the BCDL frequently because we try to keep our ECMO patients ambulating and using a stationary bicycle type device whenever possible, recovery permitting.


Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies.

Tulman DB, Stawicki SP, Whitson BA, Gupta SC, Tripathi RS, Firstenberg MS, Hayes D, Xu X, Papadimos TJ - BMC Anesthesiol (2014)

Example of ECMO ambulation: (A) extubated, bed-ridden patient on ECMO; (B) patient on ECMO and able to sit up in bed and ambulate.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4126084&req=5

Figure 2: Example of ECMO ambulation: (A) extubated, bed-ridden patient on ECMO; (B) patient on ECMO and able to sit up in bed and ambulate.
Mentions: There are both advantages and disadvantages to the BCDL catheter [28]. Advantages include (a) single insertion site, which decreases risk of bleeding and infection, (b) ability to ambulate patients (FigureĀ 2), (c) posterior lateral position that is optimal for thoracic surgery, (d) permits prone positioning more easily, and (e) facilitates aeromedical transport. In contrast, the disadvantages include (a) limited range of catheter sizes with limited flows if inappropriate size inserted, (b) radiographic and/or echocardiographic guidance needed for insertion, (c) instability of catheter after placement, (d) insertion of a large, double lumen cannula into the internal jugular artery may result in cerebral venous congestion; an additional cephalad drainage line may be worth considering, and (e) the need for expertise in ECMO management for optimal outcomes. We use the BCDL frequently because we try to keep our ECMO patients ambulating and using a stationary bicycle type device whenever possible, recovery permitting.

Bottom Line: Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual.Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected.There are challenges that still must be overcome.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA.

ABSTRACT

Background: Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected.

Discussion: Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices.

Summary: Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.

Show MeSH
Related in: MedlinePlus