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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

Maquet Cardiohelp portable device.
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Figure 3: Maquet Cardiohelp portable device.

Mentions: Improved engineering designs have significantly reduced the footprint of ECMO units and circuits, making travel much easier and more convenient [31]. Transport of ARDS patients, especially in military conflict can be challenging, let alone moving a small child or infant any distance. In centers with limited ECMO expertise, inter-hospital transfer may be a necessity. Optimally, patients who may require ECMO should be identified early and transported to a referral center (or center of excellence) that provides ECMO expertise. The practitioner must always be aware that the new transport technologies present a significant cost that may or may not necessarily be of benefit to the patient [32]. For example, in the Maquet Cardiohelp (22 pounds) portable device (Figure 3), the oxygenator and pump are one unit and can “clot” together, which may be problematic. Other modular ECMO may be used, such as the Lifebridge devices (the B2T model weighs 36 pounds), but always recognize the logistics of transport are exceedingly cumbersome [33]. Other devices include the configuration of the older Medtronic system, the Maquet Rotoflow, and the Thoratec CentriMag system.


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)

Maquet Cardiohelp portable device.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: Maquet Cardiohelp portable device.
Mentions: Improved engineering designs have significantly reduced the footprint of ECMO units and circuits, making travel much easier and more convenient [31]. Transport of ARDS patients, especially in military conflict can be challenging, let alone moving a small child or infant any distance. In centers with limited ECMO expertise, inter-hospital transfer may be a necessity. Optimally, patients who may require ECMO should be identified early and transported to a referral center (or center of excellence) that provides ECMO expertise. The practitioner must always be aware that the new transport technologies present a significant cost that may or may not necessarily be of benefit to the patient [32]. For example, in the Maquet Cardiohelp (22 pounds) portable device (Figure 3), the oxygenator and pump are one unit and can “clot” together, which may be problematic. Other modular ECMO may be used, such as the Lifebridge devices (the B2T model weighs 36 pounds), but always recognize the logistics of transport are exceedingly cumbersome [33]. Other devices include the configuration of the older Medtronic system, the Maquet Rotoflow, and the Thoratec CentriMag system.

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