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

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

If we look at Stockholm development


Ecmo application ruled implementation or free diffusion

ECMO Centrum Karolinska


Ecmo is a simple technic

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

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

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


Multistage cannulae

Multistagecannulae

v.cava.suplowsaturation

v.cava.inf high saturation

MRI Jonas A Lindholm


Respiratory ecmo

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

Burn patient consuming 450 ml of oxygen per minute

9 ECMO Centrum Karolinska


68 days run with saturation of 65 in 45 days

68 days run with saturation of 65% in 45 days

10 ECMO Centrum Karolinska


Multi organ failure

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

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

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

ELSO reports July 2012

14 ECMO Centrum Karolinska


The big well developed ecmocenters

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


Ecmo application ruled implementation or free diffusion

Mean p/f ratio 1995 – 2008

2008

1995


A new indication septic shock

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

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

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

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

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

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

22 ECMO Centrum Karolinska


Maybe we should look at survival as something obvious

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

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

EURO-ELSO 2013

Precongress8-9 May2013

Congress9-11 May 2013

ScientificprogrammeNov 2012

Deadline for Abstracts 15March2013


Ecmo application ruled implementation or free diffusion

Welcometo Stockholm 2013


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