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 - PowerPoint PPT PresentationTRANSCRIPT
ECMO application: ruled implementation or free diffusion?
Milan2012
Palle Palmér
ECMO Centrum Karolinska
Karolinska University Hospital, Stockholm Sweden
If we look at Stockholm development
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ECMO is a simple technic
But not that simpleYou 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
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One doctor has to be totally responsibleThe 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.
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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.
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v.cava.sup low saturation
v.cava.inf high saturation
MRI Jonas A Lindholm
Multistage cannulae
Respiratory ECMONeeds 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
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Burn patient consuming 450 ml of oxygen per minute
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68 days run with saturation of 65% in 45 days
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Arterial satVenous sat
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
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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
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In normal or thoracical ICUHigh 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.
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ELSO reports July 2012
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The big well developed ECMOcentersReports 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.
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Mean p/f ratio 1995 – 2008
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A new indication
Septic shockSAPPS 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 fieldNo heparin until they stop bleeding
The Problem is that the major trauma cases don’t die within 1-2 hours.
They are still alive 10 hours later, and we empty the blood bank,and the surgeons are tired
You can pack the thoracic cavity, to stop bleedings
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10 million people per ECMO centerYou will have respiratory ECMO
40 -50 adult patient per year mean 15 days ( 7-60 days)
30-40 pediatric patient mean 15 days ( 7-60 days)
30-40 neonates mean 7 days ( 4-30 days)
You need an ECMO transport organization that can transport 24/7
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An high volume centerCan 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
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Pneumothorax
Don’t hurt the patient
First choice - stop ventilation in 2-3 days
Pleura drainage - Seldinger or Surgeon
A very small pleuradrainage - 20 liter of blood and 4 operations
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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
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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 carefulBe patientBe trainedDon’t solve problems that doesn’t have to be solved
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