Ecmo application ruled implementation or free diffusion
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ECMO application : ruled implementation or free diffusion?. Milan 2012 Palle Palmér ECMO Centrum Karolinska Karolinska University Hospital, Stockholm Sweden. If we look at Stockholm development. ECMO is a simple technic. But not that simple You need to know a lot of

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ECMO application : ruled implementation or free diffusion?

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ECMO application:ruled implementation or free diffusion?

Milan

2012

Palle Palmér

ECMO Centrum Karolinska

Karolinska University Hospital, Stockholm Sweden


If we look at Stockholm development


ECMO Centrum Karolinska


ECMO is a simple technic

  • But not that simple

  • You need to know a lot of

  • Cannulas, oxygenators, oxygen delivery and consumption, carbon oxide, coagulation

  • Interrelation between ECMO circuit, the ventilator and the CVVHDF machine

  • The doctor and nurses in charge has to know this 24/7

4 ECMO Centrum Karolinska


One doctor has to be totally responsible

  • The week has 168 hours

  • In Saturday morning at 4 am you have to have one experienced doctor to handle problems.

  • It not enough with one interested doctor in the ward daytime for 40 hours a week. At least he/she has to be dedicated to come in the other 128 hours too.

  • ECMO is not run by itself for 128 hours a week.

5 ECMO Centrum Karolinska


We have to make a different between Cardiac and Respiratory ECMO

  • Cardiac ECMO should probably be done in all thoracic surgical departments.

  • Most of these patients comes from the operation table and need a short term assistance.

  • If the patient get a lung edema it will be complicated and take much more time.

6 ECMO Centrum Karolinska


Multistagecannulae

v.cava.suplowsaturation

v.cava.inf high saturation

MRI Jonas A Lindholm


Respiratory ECMO

  • Needs volume and centralization

  • Long run ECMO 15- 60 days

  • Much more maintenance – circuit change and clotting problems

  • Totally whiteout lungs makes the safety marginal to 30 seconds

  • Low saturation

  • How to ventilate

8 ECMO Centrum Karolinska


Burn patient consuming 450 ml of oxygen per minute

9 ECMO Centrum Karolinska


68 days run with saturation of 65% in 45 days

10 ECMO Centrum Karolinska


Multi-Organ-failure

  • Decreased urine output

  • Increasing liver values

  • Low blood pressure

  • RIGHT SIDED HEART FAILURE - Convert to V-A ECMO

  • Hemolysis – clotting in the circuit - Solve that problem

11 ECMO Centrum Karolinska


Does volume make different ?

  • In a low volume unit less then 10 patient per year , less then 150 days per year, you need much more assistance from perfusionists.

  • It will be more expensive

  • Lack of perfusion capacity for the operation

  • Lack of beds in the thoracic intensive care

  • Less persistence

12 ECMO Centrum Karolinska


In normal or thoracical ICU

  • High volume center, at least one ECMO case every day of the year in the ward. It’s a normal part of the ICU treatment.

  • The safety will be in the walls due to dedicated nurses and doctors experience.

  • Much more persistence.

  • Possible to have the patients awake.

  • Possible to learn how to solve problems.

13 ECMO Centrum Karolinska


ELSO reports July 2012

14 ECMO Centrum Karolinska


The big well developed ECMOcenters

  • Reports survival rate of 70-80%, Stockholm and Leicester, even with mean p/F ratios of 50 and 65.

  • That means that the smaller centers have an survival rate of about 50%

  • It´s also possible that the experience centers takes more odd cases.

15 ECMO Centrum Karolinska


Mean p/f ratio 1995 – 2008

2008

1995


A new indicationSepticshock

  • SAPPS III scoring 2012

  • 10 patient with septic shock mean 80 points

  • Mortality risk of 85%

  • Low leucocytes declining to < 2 ”ALARM ALERT”

  • Inotropic index > 100

  • Cold sepsis in some of them - amputation

  • Survival rate 80%

  • V-A ECMO because of cardiogenic shock


Trauma is an undeveloped field

  • No heparin untilthey stop bleeding

  • The Problem is that the major trauma casesdon’tdiewithin 1-2 hours.

  • Theyare still alive 10 hours later, and weempty the blood bank,and the surgeonsaretired

  • Youcan pack the thoraciccavity, to stop bleedings

18 ECMO Centrum Karolinska


10 million people per ECMO center

  • You will have respiratory ECMO

  • 40 -50 adult patient per year mean 15 days ( 7-60 days)

  • 30-40 pediatric patientmean 15 days ( 7-60 days)

  • 30-40 neonatesmean 7 days( 4-30 days)

  • You need an ECMO transport organization that can transport 24/7

19 ECMO Centrum Karolinska


An high volume center

  • Can take the full advantage of the ECMO circuit

  • The goal is not to come off the machine

  • The goal is to have a healthy patient

20 ECMO Centrum Karolinska


Pneumothorax

  • Don’t hurt the patient

  • First choice - stop ventilation in 2-3 days

  • Pleura drainage - Seldinger or Surgeon

21 ECMO Centrum Karolinska


A very small pleuradrainage - 20 liter of blood and 4 operations

22 ECMO Centrum Karolinska


Maybe we should look at survival as something obvious

  • Why did they die and was it preventable

  • Last 2 years 78 adult patient Sapps III mortality rate of 85%

  • 17 patient died (22%)

  • 5 patient we didn´t have a chance from beginning

  • 5 patient in pseudomonas and fungus

  • 4 intracranial bleeding septic embolus pre ECMO

  • 3 intracranial bleeding due to the ECMO treatment

23 ECMO Centrum Karolinska


When you look at the pump and as your best friend then you are a mature ECMO unit

  • Learn everything about the

  • pump oxygenators tubings and cannulaes

  • Train,train,train

  • Be careful

  • Be patient

  • Be trained

  • Don’t solve problems that doesn’t have to be solved


EURO-ELSO 2013

Precongress8-9 May2013

Congress9-11 May 2013

ScientificprogrammeNov 2012

Deadline for Abstracts 15March2013


Welcometo Stockholm 2013


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