Dr. Landau from Critical Care Medicine and Vascular Surgery describes Extra-Corporeal Life Support and its considerations in Southwestern Ontario
As part of the South Western Ontario Critical Care Series (SWOCCS).
Please find more information at: https://forms.gle/zCogjMbBnvgVnQwu5
Or e-mail: SWOCritCareSeries@gmail.com
Oated uh blood from a parent uh instill it into the circulation of the child to allow the heart to be open to repair vssd uh and then complete the circuit back to the parent for uh for further gas exchange so from from that sort of biologic basis again there’s a lot of
Steps being skipped here and a lot of fast forward um but Gibbons invented this sort of first heart lung machine that facilitated what we would think of as modern cardiac or open heart surgery and from there a lot of technology and material design has sort of developed into what a membrane oxygenator
Cardiopulmonary bypass machine might look like to allow us to perform open heart surgery uh and in parallel it’s developed as a therapy as a form of life support for critically ill patients and intensive care so this is again not a dissimilar idea what this machine is doing compared to this machine but some
Of the technology and material design and sort of computer control the therapy has evolved in the background but really they’re all sort of Performing the the same task and that’s allowing gas exchange and a pump to move blood around and there’s there’s a sort of modern attempt at I modification of this type
Of technology to miniaturize it and put it in this small sort of briefcase size package to uh allow this therapy to use be used more efficiently uh when you’re thinking about transporting critically ill patients and having the the life support machine be more streamlined or bring it into auster environments for
Field retrieval of critically ill patients away from a major Hospital um so there’s a a very fascinating history behind the design and development of this technology at the end of the day in the world of critical care if we’re talking about ECMO we’ be talking about one of
Two things one is VV or venovenous ECMO which means that we’re draining deoxygenated Venus blood from the body oxygenating it through a membrane lung and returning it to the Venus circulation or VMO which is venoarterial EO which means draining deoxygenated blood from the Venus circulation oxygenating it and then returning into
The arterial circulation there’s ways to make this a lot more complicated but foundationally that’s really just what we’re talking about when we consider one of those two therapies um so talking about both of these sort of in series but what is vvecmo so again we’re we’re removing deoxygenated Venus blood
Performing gas exchange through a membrane lungs so adding oxygen to deoxygenated blood removing CO2 and returning it back into the Venus circulation from where it came so this is really a form of lung bypass so if we think about you know tradition gas exchange the deoxygenated blood from
Your organs goes to the right side of your heart gets pumped to your lungs to become oxygenated goes back to the left side of the heart and pumps the oxygenated blood back into your organs if we’re in a situation where your lung function is severely compromised and it’s not adequately performing those
Duties of gas exchange of oxygenation and clearance of carbon dioxide then addition of this membrane lung will allow the oxygenation to happen outside of the lungs and return that oxygenated blood back to the right side of the heart um and then there’s oxygenated blood actually being delivered through
The lungs back to the left sided circulation and if we look sort of uh mechanistically at how that’s happening we have a blender that’s sort of blending some fraction of air and oxygen very similar to a ventilator so is the gas being delivered to the lungs through
The ventilator 100% oxygen is it 50% oxygen very same thing and that’s placed into the membrane lung which just allows a semi-permeable membrane between the bloodstream and this fresh gas flow uh which will allow this um exchange of oxygen and carbon carbon dioxide to happen at that interface uh typical vvmo patient would
Be someone like this with ards with the sort of really bad heterogeneous infiltrates very challenging to ventilate patient and there are multiple different ways that we can sort of connect the plumbing of the circuit the specifics of that not tremendously important but some form of femoral Venus or internal jugular Venus access to
Drain the blood and return it and it can be done either sort of with two large single Lumin canulas or one larger double Lumin canula which if you look at it in cross-section has one large tube that has both the drainage and the return of the oxygenated blood through a single
AIS uh in parallel to that so VMO or Veno arterial EO will remove the deoxy Venus blood and then perform that gas exchange in the membrane lung but return it back to the arterial circulation and that really is sort of bypass for both the heart and the lungs and again
If we’re looking at that same sort of model of the deoxygenated blood going to the lungs becoming oxygenated returning to the body if you’re in a situation in severe cardiogenic shock where your forward flow from the heart is also extremely poor uh and your native lung
Function may or may not be uh affected by that at the same time what we end up doing is draining that deoxygenated blood from the body oxygenating it and returning it Direct directly to the organs through the arterial circulation and the Heart sometimes has very little
Native function at the uh at the onset of the need for vaco so we really sort of excluding largely both the heart and the lung function um through that type of setup uh two main ways that can be done either centrally which is very common after cardiac surgery or post
Cardiotomy need for VMO or peripherally through the femoral vessel so femoral arterial and Venus access and really those patients uh would be the ones that you look at that have sort of severe ventricular failure in this case an echo of someone with severe B ventricular failure where their hemodynamic monitors are suggestive of
Hypotension that likely looks um and smells exactly like cardiogenic shock so poor peripheral organ and tissue oxygenation and profusion on the basis of poor pump failure um but what these two things have in common is that we use some form of a pump to move the blood
Around and this membrane lung where the blood gas interface happens uh to allow that circuit to remove that deoxygenated blood and then return it to the patient in the arterial venus circulation this is kind of what one of the machines will look like so you can see the the tubing with
The dark red deoxygenated blood going through the membrane long and then being moved through with the pump and then there’s the the console and the heat exchanger attached to it on the stand there are more streamlined versions of it that are uh a little bit more sort of
Efficient in their setup and more compact as well which can sometimes make transport a little bit easier um but that’s ultimately kind of what the technology is doing and how it works so if that’s kind of what the setup is like who should we be referring for consideration for emo as a therapy
So ultimately the the guiding principle is that it would be a patient in severe acute heart or lung failure with one of the following destinations in mind so it’s either will be functioning as a bridge to Ultimate native organ recovery bridge to receiving a transplant so harder lung transplant bridge to another
Bridge so someone in heart failure that might get a more durable implantable mechanical support device or uh sort of temporizing as a bridge to a decision about what you might do next and if you have someone that’s an extremist and endstage organ failure that you don’t expect recovery wouldn’t be wise to add
It as another machine on the way out as a patient has sort of an unrecoverable trajectory so we should be anticipating some form of recovery or destination treatment to allow stabilization or recovery of their organ failure so as a guiding principle um from a global consensus pattern the extraoral life
Support organization or Elso uh has a set of guidelines for consideration uh of both VV and VMO and I think important to keep in mind that these are sort of guidelines it’s not um a strict objective hard indication contraindication um but if you look at their indications and contraindications for adult vvecmo
Um the specific clinical conditions that are usually involved in referral uh in canulation for vvmo are airds or acute respiratory distress Syndrome from things like viral bacterial pneumonia from aspiration pneumonia aspiration pneumonitis acute EOP eosinophilic pneumonia diffuse Al Hemorrhage or pulmonary Hemorrhage interestingly which seems a bit counterintuitive sometimes
In a therapy that requires an coagulation but can be used quite successfully for that um patients with severe refractory asthma significant lung injury from thoracic trauma um severe inhalational injuries either sort of chemical or thermal large Bronco plural fistulas where patients are sort of further compromised by positive pressure ventilation uh and patients
That are Parry lung transplants uh either with sort of failing native lungs as a bridge to transplant or with primary lung graft dysfunction after lung transplant um the sort of physiologic indications that are sort of classically described from some of the previous trials are patients with hypoxemic respiratory failure
Uh that have a PF ratio of less than 80 after your best attempt at Optical medical management um and that really includes sort of climbing the ladder that we usually consider for evidence-based therapies um so high peep low tital volume ventilation as per the sort of ards net protocol attempts at
Proning neuromuscular blockade and if you’ve trying those things and they’re not working then another thing to consider that’s in the sort of evidence of generating Spectrum would be considering EO for their hypoxemia in that patient population but also less often considered as patients that have hypercapnic respiratory failure uh so
Severe respiratory acidosis despite your best attempts at ventilator titration and that can be in the absence of concominant hypoxemia um and in fact the uh membrane oxygenators are more efficient at clearing CO2 than they are infusing oxygen um so that is another strong indication for referral in consideration
And then again ventilator support is a brid to lung transplantation or primary graph dysfunction after you have a lung transplant which again less less relevant outside of the lung transplant center of Toronto but also just something to be aware of um when we think about contraindications so is there really an underlying organ
Dysfunction that’s going to give them a poor prognosis at Baseline or do they have a very dismal neurologic prognosis are kind of the main things to consider so previous known CNS Hemorrhage or traumatic brain injury significant central nervous system injury let’s say like a stroke irval and incapacitating central nervous system ology otherwise
Patients with systemic bleeding uh who would bleed more with anticoagulation or other contraindications to anticoagulation uh patients that are severely immunosuppressed that might be at significant risk of opportunistic infection um older age is always one but it’s really hard to use that as a strict criteria in the sort of age ain’t
Nothing but a number type of concept you know there’s 65 year olds that look 95 and they’re 95 year olds that look 30 uh they’re can’t really stick to a specific age as a cut off um mechanical ventilation for more than 7 days which is a very important thing to consider um
Ultimately this is a surrogate for the fact that one of the main benefits of venovenous ECMO and sort of severe acute lung failure is that it helps us prevent further ventilator induced lung injury so uh avoiding a prolonged pre-referral timeline of mechanical ventilation uh is just a surrogate for
That when you look at the contraindications so in patients where you’re of struggling to ventilate them and they have severe ards with a chest x-ray that might look like this you’ve tried neuromuscular blockade and prone positioning still having significant challenges with hypoxemia hypercapnia those are the types of patients to
Consider uh again when we think about who should be referred for Veno arterial ECMO these are generally patients that are in cardiogenic shock uh or have some form of primary heart failure um and again the Elso guidelines for vao if we review them there have been multiple
Different trials in the past past and not all of them using EO was a therapy that have different sort of physiologic criteria for cardiogenic shock um more recently the sky classification or stages of cardiogenic shock this consensus St that came out in 2019 tried to frame this as this nice sort of ABCDE
Neonic of at risk beginning classic deteriorating and extremis in terms of the stages of cardiogenic shock and also have it broken down into very easy to sort of understand and frame your understanding of those stages by physical exam by chemical markers and hemodynamics and these are sort of
Working their way into some of the considerations for a framework or consideration for possible referral for ECMO but ultimately the uh you know Central source of pathology is always going to be some form of cardiogenic shock and these darker gray circles here are sort of the classic indications so acute myocardial
Infarction myocarditis often viral myocarditis um postcardiac arrest or postart transplant bad patients um postcardiotomy failure after cardiac surgery or hypothermia with cardiac instability but other I think more recent less classical situations where patients have had success in isolated cases and case Series where vaco has been used as acute pulmonary embolis and
I think there’s a number of uh situations where we’ve used that successfully as rescue at lhsc in the last year uh trauma postpartum acute cardiomyopathy um from things like Amic fluid embolis or just idiopathic per cardiopathy uh certain drug intoxications like extreme calcium channel or beta blocker overdoses um patients with sepsis with
Terrible septic cardiomyopathy uh arhythmic storms or sometimes backup support for certain Interventional Cardiology procedures um again the sort of consideration of this therapy early is another Hallmark of the recommendations from this document in line with sort of the VVC mode guidelines as well VC mode should be considered within six hours of
Occurrence of cardiogenic shock that’s refractory to Conventional pharmacologic and fluid therapy uh with patients that have a reversible idiology or eligible for some sort of alternative cardiocirculatory assistance like other form of mechanical support of heart transplant um the they shouldn’t have any contraindications and there’s some sort of anatomic and physiologic
Contraindications like severe aortic regurgitation or aortic insufficiency where If you’re sort of using a machine to push blood backwards towards the heart if your aortic valve is not working the heart will then distend and become traumatically injured by that um but a poor life expectancy or severe liver disease acute brain injury imuno
Compromise uh those are part of the exclusion criteria in the same way that they were for vvecmo um again the Contra indications uh that are objectively defined in this document are both sort of anatomic and physiologic but if you are have severe peripheral vascular disease to the point where you can’t get
The device in if your AIC valve is not functional to the point where where countercurrent blood flow will be injurious or you have an overall poor life expectancy from some fixed anatomic or physiologic enstage disease or reason for poor neurologic prognosis those are all generally contraindications but again I think the
North Star if we’re thinking about a patient that’ be appropriate to refer to in the same way that you have that horrible chest x-ray and a patient not responsive to proning if we’re still having this terrible looking point of care ultrasound at the bedside of our patient that’s on 11 different IV pumps
That are trying to manage their cardiogenic shock and they remain hypotensive and in shock those are the types of patients to consider early the next question is you know why does it work and what is the physiologic basis for this and how does it help as a
Form of life support and is there evidence to support it or is this just sort of an expensive thing that we’re doing just because um so like I mentioned earlier um vvma was helpful for these patients primarily because it minimizes ventilator induced lung injury um and we know that in uh in patients
With significant lung disease we’re at risk of things like barot trauma volut trauma Adel trauma diaphragm myot trauma oxygen toxicity uh and in patients that were really struggling to ventilate vvmo can really help facilitate lung rest um and if we look at again the evidence that we’ve generated in terms of
Protecting lungs and patients with lung failure um the arset trial in the year 2000 showed that uh low volume low pressure ventilation decreased mortality versus the traditional approach proa that we know about as well to provide a objective basis for considering prone ventilation in these people I showed ventilation the prone position decreases
Mortality versus the traditional supine approach as for their protocol um more recently things like the driving pressure starts to show us an inflection point where if that Delta P starts to become higher and higher we see a fairly strong inflection that that begins to represent more and more injurious lung
Ventilation uh that increases in hospital mortality for these patients so ultimately the the sum forces of sort of overall biot trauma and lung trauma that can happen as a result of injurious mechanical ventilation in some ways in certain patients can be avoided uh by turning on an extra corporeal circuit to
Provide gas exchange and to a large degree turning off the ventilator to avoid further injurious ventilation to those patients and if we look at our own local guidelines of how to ventilate someone who is on vvmo we can look at I think most shockingly the sort of tital
Volumes are what we would classify as ultr low lung protective ventilation strategy between zero and four milligrams per kilogram we’ve seen patients with extremely poor lung compliance and severe ards getting you know functionally almost just like the dead space in and out with every breath that they’re getting from the ventilator
During the most extreme phase of their VV EO run and that really again is just a surrogate that we’re not just going to let the lungs sit there and collapse we want to cycle them during the inspiratory and expiratory phase but they’re really participating very minimally in gas exchange at that point
Due to the severe extent of their lung disease and we’re really just allowing the circuit to take over the job of gas exchange while the lungs heal themselves so our primary goal using this as a therapy is not necessarily just to sort of supercharge the blood with oxygen and
Clean the carbon dioxide if we can but it’s to prevent further lung injury on the basis of ventilator induced lung injury uh and await lung recovery uh and again I think sometimes the most challenging thing is to avoid complications that are iatrogenic related to both the circuit and and patient related
Complications and these complications include both bleeding and clotting um difficulties with mobility and literally everything else you can possibly think of so if we look at this nice summary slide from a publication from Dan Brody the types of complications that are often present in patients receiving vvecmo include intcal Hemorrhage or
Ischemic stroke ventilator ventilator Associated pneumonia or pneuma thorax um dbts and pees renal failure requir re iring some form of real replacement therapy failure of the membrane lung or thrombosis of the circuit or pump failure requiring exchange of the circuit and then Hemorrhage either gastrointestinal spontaneous bleeding and canulation sites um outside of
Intracranial hemorrhage hemolysis of the blood trauma through the circuit and the need for circuit changes so many things can go wrong and part of the um success that you build around successfully managing a patient on ecos avoiding these complications as much as it is supporting them to allow recovery for their
Lungs uh the next question is is there evidence to support this and this has proven to be an extremely challenging thing to study um so historically I think many of us know about the Caesar trial from 2009 where uh referral for consideration for VV EO resulted in increased survival versus conventional
Ventilator management but interestingly as per that protocol that was referral to an ECMO capable Center and not necessarily everyone transferred their uh received vvmo as a therapy uh so there may be some signal that you know in an expert acute lung Injury center that’s capable of offering EO may
Actually be you know where the value is and not necessarily ECMO itself in isolation um the uh the eolia trial as well from 2018 um comparing vvecmo to sort of usual ards therapy did not show a significant reduction in 60-day mortality uh there was a signal that was
Very close to benefit that people like to fix a on but I think statistically remains non-significant regardless of your emotional feelings about that but uh interestingly 28% of the patients in the control group did cross over to EO for refractory hypoxemia so that is sort of interesting and sort of hypothesis
Generating for further study but regardless of the fact that we don’t necessarily have a very uh strong Global consensus slam dunk RCT level amount of evidence to support it if we look at registry data from the extraoral life support organization globally if we look at the the annual amount of respiratory
Adult ECMO runs between 1990 and 2020 over 30 years that’s gone from 20 a year to almost 8,000 a year um so clearly people are seeing some benefit to this therapy that we haven’t necessarily been able to fully demonstrate in the context of a clinical
Trial but uh I think again part of this comes from the fact that a lot of critical care literature does lump a lot of patients in that are very heterogeneous and if we start to extract some of the patients that do well from some of them that don’t uh if you look
At patients with aspiration pneumonia the survival is 77% all the way down to patients that have viral pneumonia or other respiratory ideologies where the survival is closer to 57 or 59% based on this registry data um so really the underlying ideology as as within many things in critical care does influence
The survival of the patient um which is important to consider in the context of them all receiving the same kind of therapy uh again I think more recently a thing that we think about is the the respiratory failure pandemic that we’ve all just been through very recently
There have been a number of studies mid pandemic looking at the overall mortality of use in vvmo for patients with severe covid-19 pneumonia that were refractory to Conventional um sort of ards management of prone ventilation and and lung protective ventilation strategies and the mortality in those studies has been ranged anywhere from
30% to 54% uh but the results have generally been quite good if you look at the um extracoporeal life support registry data again for this there have been about 17 a half thousand confirmed cases of covid-19 that have received emo and if we look at their overall chart of
Outcomes their mortality in general is around 50% uh but of the people that have survived their ECMO run we can see that a significant portion of those were discharged from hospital um many of them home or to a rehab center some of them to a long-term acute care setting uh and
Then others to a sort of Home Hospital for for further Rehabilitation um so certainly they’re alive and functional some of them obviously not back to their Baseline uh but the same can be said for many patients in critical care in general uh shifting over to I think the
Underlying basis of the why for VMO um but similarly patients in cardiogenic shock that have some sort of primary cardiac insult whether it’s sort of classically a myocardial infarction um right and possibly B ventricular failure as a consequence of severe acute pulmonary embolis um ultimately those patients will have a
Decrease in their cardiac output their blood pressure will decrease um the vasil constriction that can occur as a compensatory mechanism from that uh can cause injurious increase in their afterload and a failing heart which further decreases their cardiac output and the sort of death spiral of cardiogenic shock can then sort of
Spring off from there as a consequence of their decreased organ profusion uh and the esic and inflammatory Cascade that can happen from there which again has a a further negative feedback loop to your overall heart function in the context of your cardiogenic shock uh and if we look at
Uh again the classic Model of acute myocardial infarction in patients in cardiogenic shock the more organ failures you have and the more organ dysfunctions that you have in the context of that severe acute failing heart the higher your inhospital mortality is and that’s been well demonstrated in a number of different
Studies so in those patients uh with very poor native heart function that’s not profusing their organs um if we’re using this sort of pump oxygenator combination as a form of extracoporeal life support you can have a patient alive with really no pulsatility from their native heart whatsoever um it’s
Not necessarily a situation that you want to keep going for indefinite periods of time but sometimes when they’re an extremist and acutely presenting they’re really getting almost no native forward flow from their heart uh and once they get their bridge to Ultimate treatment or recovery then that
Can sort of slowly recover over time as their native heart function recovers but it can be very impressive to see the degree of sort of deranged human physiology that you can support with that type of therapy another nice visual of the concept of that is this patient
Who’s had a CT with arterial phase contrast while on vaco if we see the ascending aorta here there’s really no contrast in that whatsoever reflective of this being the sort of region of native cardiac output that’s reaching the body and this contrast uh enhanced blood is coming through the ECMO circuit
Itself so clearly it’s responsible for profusing all the major abdominal organs in the lower body and reaching up to the level the arch vessels so at least partially perusing the upper body and left arm and part of the brain as well it’s a fairly dramatic visual to again
Uh pair with that fairly impressive flat artline tracing on this monitor um and again is there evidence to support this as a therapy that we can consider uh this is an interesting review from cardiovascular revascularization medicine which is again largely sort of a mark cardial infarction Interventional Cardiology cardiac surgery context but
If they look they examine the 16-year national Trends in the United States in the use and outcomes of via ECMO and cardiogenic shock and between 2002 and 2018 uh the use of emo increased basically 300% over that time uh while the mortality decreased significantly uh again with a review like this at a
Population level there’s enormous risk for bias of reasons why that might be uh but certainly the use of it as a therapy and the overall mortality has uh has improved significantly over the last 20 or so years um the uh group in Toronto was actually involved in uh this large systematic
Review and meta analysis looking at the impact of ideology uh of outcomes in patients receiving VA EO in over 30,000 patients in the Journal of Heart and Lung transplantation um but again as you you know if you lump everyone together that receives VMO you may have some fairly dismal results that don’t look
Tremendously impressive but if we start to stratify it on the basis of the reason that they needed the therapy to be begin with um the short-term mortality in those patients uh can be again fairly sort of acceptable and worthwhile in the context of the critically ill patients that were used
To treating on a daily basis but on the best end of the spectrum patients that require rescue postart transplant with graph dysfunction have a 35% mortality when they again in the context of their systematic review and meta analysis at the other end of the spectrum patients with out of Hospital Cardiac Arrest
Would do worse and there’s a lot of reasons why we can consider why that Spectrum exists but then on the in between patients with acute cardiopulmonary collapse from pulmonary embolis the results are fairly reasonable with an overall mortality of 52% um so we really want to stratify it
On the basis of of why they needed the therapy to begin with more than just thinking about you know does this work as a machine or not um so ultimately if that’s how it works and why we do it and what the the justification or evidence behind the
Therapy might be I think the next question when we think about you know the referral centers that exist and patients that want to or uh centers that want to consider patients for referral when should we refer patients so uh very thankfully critical care services Ontario has a set of ECMO consultation
Guidelines which if you’re not aware of I can draw to your attention at the critical care services Ontario website but it’s a very well-designed document that’s actually currently undergoing uh a revision this year or I guess next year um at some point in 2024 and the working group has been assembled to
Review and update these guidelines uh especially to contextualize some of the things that have been learned with the use of vvxo during covid um but it does split it into sort of respiratory and cardiac reasons for referral uh so for respiratory failure you again very similar to some of the
Things were mentioned in those ELO guidelines but consider ECMO for patients with acute respiratory distress syndrome or hypoxemic respiratory failure patients with isolated hyperic respiratory failure uh bridge to lung transplant or patients with failing lung transplants as well as severe status asthmaticus um you should avoid considering ECMO in patients with hard
Contraindications of end stage malignancy end stage organ failures uh prolonged CPR without adequate tissue profusion uh known severe brain injuries or chronic pulmonary hypertension or any non-recoverable advanced comorbidity or terminal malignancy that might make their overall prognosis dire outside of the context of their acute lung failure relative contraindications
Again are related to their anti-coagulation Advanced age obesity but those are sort of to be considered on a case-by Case basis as well as pre-existing endstage renal disease uh and they do have this uh well-designed chart of mild moderate severe ards and recommendations for interventions for these uh which we’re
All very familiar with but if we look more towards the severe end of the ARs Spectrum uh at the very bottom you can look at the sort of hypoxemic and hypercapnic parameters uh where if those patients are being considered for lung protective ventilation by the artset protocol for proning for neuromuscular blockade you
Fail to have results with all of those things and consider to have refractory hypoxemia or hypercapnia we can consider referral for potential ECMO for those patients again for cardiac collapse they they do also have local ccso guidelines for considerations for referral as well and again these are all very similar to
The indications for referral that were outlined on the uh the ELO guidelines document which informed a lot of these and again very similar uh reasons to not consider ECMO for these people end stage uh pre-existing organ failures malignant disease um prognosis uh of some organ system or anatomic or phys physiologic pathology
That’s poor uh you know in isolation outside of the context of their acute heart or lung failure and then some of those anatomic and physiologic criteria that might make it unsafe like having an AIC dissection unrepaired having severe perov vascal disease having aortic regation or aortic insufficiency uh and then again relative
Uh contraindications being any sort of counter indication any coagulation Advanced stage or obesity uh or pre-existing endstage renal disease um I think the next question that comes up very often uh is how um so how do we get these patients to for consideration of emo or whatever your
Local emo Center might be for anyone outside of the Southwestern Ontario LC region um and I think very broadly just to consider patients who are sick on a context of alive to dead and the various shades of critical illness that happen in between there’s a window where patients are unwell and safe to
Transport and then it becomes a a window where they’re so unwell that they’re no longer safe to transport from hospital to hospital and on one other end of the spectrum it’s patients that are an extremists that are extremely unwell that would be reasonable candidates to consider for VV or VA EO that are
Appropriate EO candidates and those two things do not overlap 100% um so ultimately uh in the absence of having a sort of canulation transport team currently um that can go out and culate patients at another hospital and retrieve them to our Center always uh I think wise to consider a phone call
Early while we’re still in the safe to transport window where you’re Maybe considering that they might head in that direction or want to have a discussion about it early because there are cases where sometimes patients become so unwell that we lose the window for transport which can happen um and again
Sort of if you want to take stock of you know is this patient a reasonable EO candidate or not very reasonable just to review the ccso EO consultation guidelines um as a refresher uh and obviously if you’re trying to get in touch with somebody then getting in
Touch with us through criticall uh is the best way to to go about it um but I think if I had one piece of advice to give when it comes to the how uh don’t be afraid to call early because the worst thing that would happen is say
Like maybe not right now but in the future if these objective parameters are met or consideration for just transferring patients early to say that we acknowledge there may be potential decompensation or not but the safest thing to do would be to transfer them early before we lose that safe window for
Transport um acknowledging that I have seen a couple questions pop up in the chat um I think that was the bulk of what I wanted to review um okay good that’s just from Anton looking for a survey that’s great but I just wanted to have a pause for
Questions that anyone might have uh about again any of the the who what when where why and how uh that we’ve reviewed when it comes to to ECMO and the South Coast Ontario region hey John can you hear us over here in the conference room yes I can
Rob great we’ve now been joined by Neil as well as Scott and myself so we have so many questions we kind of I feel like the moderator of a session I don’t want to leave you Ma ask a few others get their sort of the thoughts together um
My first one’s very boring very specific but you know the hospital for sick children has had a canulation transport team REO for decades and decades um do you uh do you know um does the GTA tgh they have an adult Coral are as well a transport and canulation uh they do
Yes and do you have any sense just for the those in the call like how frequently it’s used what their scope is how many per year kind of thing I’m just thinking just to give us a very very you know Bird’s eyee view of what that service looks like yeah uh that’s a
Great question I actually don’t have granular objective data about how many patients that they sort of culate at the other hospital and return to tgh um I know it’s a service that they offer um obviously they’re the largest Center in on onario when it comes to volume uh and
They have a large volume of expertise and I think also they’re when it comes to anything if you’re comparing your department of surgery usually to the Uhn their their resources always end up having to be you know the largest based on their size and their their referral patterns and their uh their patient
Population that they’re treating um so they definitely are capable of a larger number of that than anyone else really is in the province of Ontario but I don’t have any specific numbers to give you about that yeah Neil and I just are talking in the side but yeah it’s it’s a mystery to
Us too I I remember we were talking about we had a a young guy in Bay 3 probably 10 years ago now but they brought the EO bus for him and him back to Toronto can’t here and they but they transported him on eoo bus and he
Survived and stuff so I know exists and but you’re right John it’s still out of a gray area or black box for they don’t go outside of Toronto to can not typically John they will definitely come here for for Pediatric patients um and I have not
Been part of any context of cases where they have had to come here specifically um and again obviously since it’s something that we can offer here the number one situation that I could think of is if there’s a patient that was uh a candidate for lung transplantation that
Happened to be in our hospital that needed as a bridge to lung transplantation that would be kind of the N number one thing but as a center that offers mechanical support and heart transplantation for people with acute cardiac failure there usually wouldn’t be need for the Toronto people to come
Here right and I see in the chat Anton did a bit of research with those guy those folks and he definitely has um has some dat can share which is cool my only other as I’m waiting I’m hoping others on the call have some questions uh here
You know we got one from uh oh just I’m not trying to answer your question there’s a question in chat from one of our bar intensivists that says the majority e folks are caned in Barry uh but that’s the farthest north it’s kind of like I guess um like the GO
Train you can’t get a GO train you can’t get an EO circuit the ru um no my my next comment I don’t know if it it helps others to just sort of think of questions they have it’s more of a Comm than a question but I just want to quote
Dr Ian Malcolm uh from the great film Jurassic Park when I said looking at your data it’s clear that we as the sort of medical scientists have answered the question whether we can do EO we definitely can uh the question we’re still trying to figure out whether we
Should and who should get a like your talk said so it’s a cool time to be in critical care because this is we’re in in this gap between the two goal posts of definitely being good at doing it um and then trying to figure out you know
Being good at deciding when to do it and that’s such an important time for all of us to have these rounds and have these discussions because it’s always going to be nuance and it’s always going to be um like we can’t say it doesn’t exist we can’t say it’s impossible it’s
Definitely possible but um but what’s the best way to deploy it is such a such a like living breathing question that changes every day and uh and it’s folks like you and these talks and these rounds are going to help us shape that for our region and for the whole world
Thanks John hey John hello hey John um there’s no doubt that if you want to make yourself you put healthy patients on ECMO and I mean if you talk to people at Uhn they brag so much we’re the biggest we’re the best we do so many well and
I’m I’m not totally sure that if you ask them they don’t even think there’s equipoise here they think this is a required therapy that you must be doing and then they Pro themselves to be helpful useful and relevant by potentially putting any and everyone on the therapy and I think you’ll lose
Credibility if you do that uh so maybe a comment on that and my other question is we all know that when it to um devices uh the way that generally the course see these things is you need you need uh consent to withdraw a device and what is
Your thought on um when you offer this therapy and then the patient or the family changes their mind and never wants to come off the therapy I know there’s some places that try contracts and things like that it’s a scarce resource it’s it’s not you know
Limitless and we have to be careful that when we put on this therapy that we have a plan for how long and a way to get them off the therapy if it if it’s deemed to not work yeah uh those are two excellent points Scott I think uh to your first
One can you say that again John yeah uh two excellent points um the to your first one um I think my experience in other hospitals and other countries not just the United States uh and in other Health Care Systems I think you’re exactly right uh you know there are different thresholds and different
Incentives uh in the absence of something that’s as objective as a well- constructed randomized control trial to sometimes offer therapy because you can very easily make your outcomes look much better if you’re only treating patients that are healthier and there’s a lot of great literature about this in the
Orthopedic surgery literature that if you’re only doing you know healthy young athletes that all of the orthopedic surgeries you do is going to have outstanding outcomes and if you’re doing a lot of arthroplasty like elderly frail diabetic patients your outcomes will be much worse but someone has to be
Treating the elderly frail diabetic patients and I think a lot of centers want to declare themselves centers of excellence on the basis of their results without disclosing you know the patient population that they’re treating in that regard and I have seen people at other centers that I’ve done electives and
Experiences at uh you know have some form of uh you know code emo where the emo team shows up and by the time they’ve arrived and sort of brought their equipment they don’t really meet physiologic criteria anymore and they would just do it anyway because there are some form of incentives outside of
Necessarily what the patient needs whether it’s monetary or whether it’s academic or whether it’s clinical that might motivate them to do that uh so I certainly have seen versions of that that don’t necessarily have the is this the right thing for the patient driving the decision being made Andor people
Just believe so strongly in it that they think that people that are only sort of moderately unwell should getting EO anyway but there is definitely a large variability in practice which again I think to Dr Leer’s point it’s an exciting time because there’s not necessarily uh you know a concrete set
In seone set of guidelines about how to use it and that’s always very exciting in the process of discovery but I think it also is a is a call for you know thoughtfulness and responsibility when we’re considering patients for a therapy like that um I think to your second
Point about the end of life care and withdrawal of life support uh extremely important and I think uh there’s a lot of good sort of moral distress adjacent literature about this uh in critical care Publications and in nursing journals as well uh and I have seen
Patients that are sort of on emo for again over a hundred days and as soon as you turn the circuit off they just start to suffocate and they just have they’re sort of driven into a wedge with a road to nowhere and those are very complicated end of life discussions uh
And I have seen many different approaches to it uh whether it’s sort of like a um immediate involvement of the paliative care and ethics team of the hospital at the time of Ethics at the time of EO consultation to have them involved in a multidisiplinary discussion I have seen people uh you
Know include things like contracts to say that if you acknowledge that this is something that we’re advising you might be helpful I want you to also acknowledge that I will be responsible in a time to tell you when we’ve reached the end of the road and it’s no longer
Helpful and it’s now part of prolonging this patient’s natural dying process I don’t think there’s one right answer but I think those are all very important things to consider at the time of consultation uh is you know a thoughtful review of the patients’s appropriateness and their candidacy and their potential for
Overall recovery but then also to be objective about what the timeline for your next family meeting might be or when is enough enough as much as it is to say that this might be something that will help um again nobody has a a perfect answer to that otherwise
Everyone would all be doing the same thing but I think it’s uh you know as important a part of the consultation process as the physiologic basis and criteria that I talked about so I’m glad that you brought that up John do you ask questions geared at informing yourself
In terms of not specifically saying are you the kind of family that would never let me say the end is here but questions gear towards acquiring that information and would you reject the family if they say we want everything done forever no matter what we’ll never give up if they
Said that um would that dissuade you uh from offering it yeah that’s a great question um I think thankfully I have not personally been involved in a situation like that yet because that can often be very ethically challenging but I my immediate gut reaction to that exact phrase that you’ve
Mentioned would be that maybe this isn’t the right thing to consider because I’m worried about the injury this might cause this patient if they’re subjected to this forever because they have a window for recovery and once you pass the window for Recovery you’re artificially prolonging the dying
Process which is a phrase that I’ve taken from your end of Life Care discussions with people as one of your traines uh but I think I would absolutely fixate very strongly on the fact that at some point point we’re going to start causing harm and the most important part of our job
Is harm minimization as Physicians as part of the hypocrit oath so I I would absolutely not have any hesitations about um being skeptical about the value of offering it in a patient whose family has values the likes of which you describe yeah now you know what’s going
To happen next week right yes I’ll uh I’ll call you when it happens you can help me John can I Dr Lando can I just make a comment on that note yes please hi it’s Karen bosma um Scott Reese is really interesting point and I just wanted to
Um bring to everyone’s attention that last week at the cccf meeting in Toronto there was an ethicist from somewhere in the United States uh forgive me I’ll think of where it’s from um who gave a whole 20 minute or 30-minute talk on exactly this question on sort of the ethics around withdrawing
With holding stopping Care on patients on ECMO um who may or may not be conscious because a lot of patients are of course conscious on on ECMO um and if it’s meant to be a bridge to something else and there is no Bridge um how do you handle that medically legally
Ethically it was a very good session um and I think that those that talk might be available online um so just I just want to make that comment because it was explored in depth and it it’s a really a good point about someone who’s clearly thought about it and about this a
Lot thank you very much Karen yeah I I would love to check that out because again I think those are everyone gets very excited about the machines and the therapy but I think this is as important if not more important than that to consider in the context of those
Patients that we’ll be taken care of John it’s Paul Cameron if I have another question um converting this is May more Niche but converting femal J to like an Avalon catheter to promote mobilization waking up uh spontaneous breathing do you have a suggestion of how you would conceptualize making that transition
Like at what point would you consider it would you be putting an Avalon sort of or dual stage canels right away what are your thoughts on that yeah um and I’m noticing a lot of questions in the chat here as well but uh yeah I think from a plumbing perspective uh for
Conversions uh you know circuit changes can be dangerous they can be associated with mortality canulation changes can also be you know associated with Adverse Events as well so I think you want a very strong motivation to be doing it uh but again like the sort of physiotherapy
Ulation part of the critical eel can definitely be important so it it could very justifiably be a reason for doing so um often the access that you have established might be a contraindication to being able to switch over over the circuit uh to an Avalon canula but I’ve
Definitely seen it done I’ve seen people that are on sort of ephemeral J canulation strategy they have a tracheostomy they’ve shown some form of Recovery Place a subclavian inserted dumin venovenous EO catheter and just switch the tubes off of the femoral and J canulation over to the dumin catheter
Remove the other two uh make sure that they have hemostasis then the patients get up and start walking the next day so it’s definitely something that’s possible but I think ambulating an e patient is uh indicative of sort of like a higher level of care that EO centers
Can provide because not everyone is sort of capable or comfortable doing it um even sometimes the concept of ambulating someone who’s ventilated is uh you know a challenge in in certain uh scenarios so it’s definitely possible to do um as to your question but it does require heroic concerted efforts on the
Behalf of Physicians Allied Healthcare team respiratory therapists for fusionists physiotherapist ists to be able to do something like that but if it’s if if we think that there’s value there’s absolutely uh technical possibility for achieving something like that um Anton I just want to start going through some of these questions in the
Chat here just I’ve noticed them accumulating yeah we just have time for probably one more question here unfortunately we have to stop at 1M yeah no perfect uh I think um yeah lot of great questions uh so so maybe I can briefly Rachel your question about how much it costs um you
Know ultimately the cost of disposables for one ECMO circuit uh is around $10,000 to start um if you look at the cost of a lot of things in intensive care that’s in line with a lot of the costs of machines that we use and things that we do on a daily basis the
Consumables when it comes to taking care of patients is generally pretty much the same uh unless you need to start exchanging circuits or consider doing blood work more frequently or measuring sort of point of care activated clotting time those types of things but generally it just starts to fall into the millu of
The sort of daily cost of taking care of a critically ill patient um I think maybe just to answer Alex’s question about uh you know expanding lhsc’s ECMO presence uh I think my sort of youthful enthusiasm in participating uh as sort of a surgeon intensivist who is not a cardiac surgeon
Is largely just to add sort of more manpower and investment in trying to evolve the current implementation that we have right now and I think that involves a lot of focus on building education and simulation for our Intensive Care Group uh to help improve fluency in post canulation management
From our Intensive Care Group um and largely trying to make sure that we have slightly more autonomy of managing and adjusting and titrating EO as a therapy in concert with our Prof fusionists rather than sometimes exclusively relying on their advice so I think helping move things forward in that
Regard uh is sort of a main goal and then also I think the having a physical Presence at Victoria Hospital I think will sort of expand the resources available to have multiple EO patients being treated at once at lhsc in the sort of uh you know One hospital system
Two sites model that we have uh especially when we consider in the middle of the last respiratory pandemic we had the volume at one site uh may have been helped by having more capacity and availability a second site um so I think those among other things are the
Goals that we have right now in terms of trying to develop and expand things further based on my involvement um thanks again uh for the opportunity to speak I really appreciate it yeah and if anyone uh We’ve captured a couple of the questions and maybe we’ll send those on via email to people
Who are who asked them uh if we can get Dr lanard to weigh in we really appreciate everybody contributing we really appreciate all the excellent uh interaction that’s very much what we want this to be about um we will see you guys on January 25th January 25th we Dr
D robly talking about updates in and diag in diagnosis and management of cardiogenic shock and uh thanks for another great session thank you Dr Landau and here are the information for us and hopefully you guys got the form in the chat thanks everyone thanks chis thank you