Family and Patient Helpline

Background

Till date, the most common mode of death in death certificates is cardiorespiratory failure. Even, if rest of the system and the body is intact, cardio/respiratory arrest is synonymous with cessation of life. Over the years, it was quite frustrating, to watch helplessly, our patients succumbing untimely, to cardiac and / or respiratory in sufficiency, after all machines and medicines fail to assist the heart and / or the lung to minimum efficiency.

ECMO: principles of treatment

Upto recent past, all modalities of critical cardiorespiratory management were assist therapy whether it may be IABP or ventilator or inotropes. They were to support the existing organ and improve its performance. If the organs are damaged beyond a particular limit, they require absolute rest for recovery. Further step up in assist mechanism will create more harm than good. Also, if rest to the organ is not given timely, it will lead to cumulative and collateral damages. At this particular stage of advanced organ damage or malfunction, the mainstay of recovery is rest and substitution. Since, respiration and circulation can not take rest throughout life, ECMO appears as the only makeshift arrangement in this juncture. It is always wise to take a timely decision to switch over to temporary replacement treatment after assist therapy has failed and before secondary multiorgan failure has set in.

Definition

ECMO stands for Extracorporeal Membrane Oxygenation. ECMO comes under the auspices of ELSO (Extracorporeal life support organization) is a useful modality of mechanical circulatory/ventilatory support (MCS) for refractory cardiorespiratory failure. ECMO is a form of replacement therapy from extracorporeal route for a defined period of time.that can support the patient’s body when his own heart and/or lung function is inadequate. The technology of ECMO is similar to the heart-lung bypass techniques used in cardiovascular surgery.

ECMO Setup

ECMO is a set of machines used for temporary replacement treatment of heart and/or lung function by mechanical means via extracorporeal route. Blood drains from the patient through a tube (catheter) placed in a large vein. This blood passes through a plastic pouch, or bladder, and then in pumped by a mechanical pump which serves as a artificial heart . This heart pump provides the necessary force (blood pressure) for the blood to circulate without and within the body. The blood is then diverted inside the tubings to a artificial lung (respiratory filter) for oxygenation and removal of carbon dioxide. The blood then passes through a heat exchanger that maintains the blood at normal body temperature. Finally, the blood re enters the body through a large catheter placed in an artery in the neck or leg with pressure and oxygen to perfuse and ventilate the cells of the body.

Types of ECMO

There are two different ways for ECMO to support a patient. The first method is called venoarterial or VA bypass. VA ECMO will support the heart and lungs. One cannula is placed in the right atrium of the heart (filling chamber) and a second cannula in the aorta (main artery of the body). The second method is called veno-venous or V V bypass. This is used for lung support only. This type of ECMO requires only one / two catheters to be place through large vein in leg and /or neck.

Other applications of ECMO

We feel, there is a great future of ECMO due to its wide applications, like rescue circuit, first line short term replacement therapy in all refractory acute heart or lung failure, e-CPR, organ preservation in brain dead donors and switch over therapies.

ECMO: advantages and challenges

It is a simple percutaneous procedure which can be initiated in short time. It can be done at bed side in any ICU without the need of any specialised machines. It is portable system and allows patients to be shifted across great distances by any transport and can be combined with other support systems. It has great flexibility and various combinations can be designed to support only heart / only lungs or both heart and lungs.

ECMO Logistics

Management of the ECMO circuit is done by a team of ECMO specialists that includes intensive care unit (ICU) physicians, pulmonologist, cardiologist and intensivist, perfusionists, respiratory therapists, Medical Laboratory Technologists and registered nurses that have received training in this speciality. ECMO has shown great utility in all age groups from pediatrics to geriatrics. With increasing usage and indications, the results are promising and life rewarding.

There is lot of physiology involved about hematology and haemorheology, physics of cannulae and pump, chemistry of respiratory membrane and hemofiltration, biology of the living, dying and dead cells, pathology of the disease process and overall medical management of the entire corpus. Thus, entire science is at work and the operator has to master of all and not jack of one. The challenge is worth taking and success is gratifying to the extent of playing GOD.

ECMO SOCIETY OF INDIA

ECMO is widely applied in specific indications all over the western hemisphere for more than silver jubilee years. We have been quite late in adopting this power of science i.e. ECMO due to its complexity and logistics. It is a multidisciplinary project requiring a team approach. It is a novel technology and should be adopted with utmost meticulousness and sincerity because your results grows with experience.

Since the patient population reaching ECMO criteria are limited. We should learn from other mistakes. This has led us to start the “ ECMO society of India ”. The root motive of this national registry is to maintains uniformity of data entry. Every one should contribute to streamlining the methodology of working protocols and record upkeeping, and thus, reach valuable statistical inferences at the end of the day.

Every country has their own ECMO society which follows advise and instructions at international level. Thus, every member have an access to large and valuable international registry data of more than 50,000 patients which is not possible for an individual in his lifetime.

We seek your suggestions on the same and invite you to join the group if you are interested in starting a ECMO programme at your centre.

Acknowledgments:

Dr. Robert Bartlett, MD is considered the founder of ECMO, and the University of Michigan’s ECMO program is the largest in the country. We at the RVCC ECMO Center are deeply grateful to Dr. Bartlett for the use of this guide on our website.

Dear Family & Friends,
Having a very sick family member being treated in the strange and overwhelming environment of an intensive care unit is an extremely stressful situation. This booklet will provide you with information, to answer some important questions you may have. Feel free to ask questions or express your concerns. There are many people to help you cope with this difficult period.

Sincerely,

What is ECMO?

ECMO stands for ExtraCorporeal Membrane Oxygenation. It is the use of an artificial heart-lung machine for patients whose heart or lungs are failing despite all other treatments. The ECMO equipment functions as a heart (pump) and lung (providing oxygen). It takes over the work of these organs so they can rest and heal.

Why ECMO?

ECMO is used for children and adult patients with severe, but reversible heart or lung disorders that have not responded to the usual treatments of mechanical ventilation (ventilator), medicines, and extra oxygen.

• Adults who need ECMO usually have one of the following problems:
• Pneumonia
• Respiratory failure from trauma or severe infections
• Cardiac failure

ECMO will not cure these conditions; it does give support and allow time for the lungs/heart to heal.

We believe this recovery may lead to the survival of your loved one.

How Long Will ECMO be Needed?

EMCO is continued until the heart or lungs recover or until treatment is not effective; it may be a period of days or weeks. The length of time on ECMO may be affected by: the type of lung or heart disease, the amount of damage to the lungs before ECMO, and other illnesses or complications.

What Are the Risks of ECMO?

Any person who requires ECMO is very ill and will usually die without it. However, there are risks with this procedure. The ECMO physician will discuss these with you:

• Bleeding: A drug called Heparin is given to prevent the blood from clotting while it travels through the ECMO circuit. The amount of heparin given is monitored closely, but sometimes bleeding occurs. Bleeding can occur anywhere in the body but is most dangerous when it occurs around the brain. This could result in permanent brain damage.
  If the bleeding becomes too great, any of the following actions may be necessary:
  
  • Frequent blood transfusions
  • Other operations to control bleeding
  • Discontinue ECMO therapy
• Blood Clots: Small blood clots may be introduced into the blood stream of the patient. These clots can cause serious injury to the patient, damaging vital organs such as the brain or kidneys.
• Malfunction of ECMO Equipment: Although rare, the equipment required for the ECMO system may fail. An ECMO specialist, at the bedside 24 hours a day, is trained to respond quickly to any malfunction.
• Stroke: Stroke may occur from bleeding, or blood clots into the brain. If cardiac support is needed, a surgical procedure that involves permanently tying off one carotid artery (blood vessel) is performed. Although there are two carotid arteries that supply blood flow, brain injury, including stroke has occurred in some cases.
• Other: An operation is needed to attach theECMO machine to the patient. This may lead to infection, bleeding, or vocal cord injury. The function of the heart or lungs may not improve during the time of ECMO support. Some patients develop severe blood stream infections that cause irreversible damage to vital organs.
• Possible Risks- Blood Transfusion: Very rarely, serious reactions can occur, including shock, kidney failure and even death. In addition, there is a slight risk of acquiring an infectious disease, such as hepatitis, and a remote risk of AIDS. Improved donor screening and blood testing procedures make such problems unlikely.

What You Can Expect?

• Starting ECMO: Placing the tubes (catheters) into the blood vessels requires a procedure done at the bedside by a surgeon and an operating room team.
• Your family member is given medications ahead of time for pain control and sedation. The catheters are connected to the ECMO system.
• While your family member is being supported by ECMO, the ventilator will remain on at very low settings in order to “rest” the lungs.
• Pain medication is given on a regular basis to prevent any discomfort. Attempts are made to maintain your family member in an alert, awake state. However, this is not always possible. Many patients do require heavy sedation and paralyzation to decrease the amount of oxygen used by the muscles.
• ECMO patients are placed on a special bed. You will notice the bed rotate side to side. This decreases pressure on the skin to prevent damage and helps move the secretions in the lungs. It is elevated because gravity plays a part in the amount of blood that can safely travel through the ECMO system.
• We follow a daily routine that includes a morning chest X-ray and blood tests at different times throughout the day. The ECMO circuit is used for drawing blood and for giving medications. The lungs are suctioned regularly since the patient’s cough mechanism is not effective.
• Nutrition is provided through specially formulated solutions administered through the veins or through a tube into the stomach.
• As the heart or lungs improve, the amount of ECMO support will be decreased over a period of time. As signs of improvement continue, a “trial off” ECMO is begun. If this is successful, then ECMO is discontinued. The patient will remain on the ventilator for support for several days or weeks, until further improvement takes place.

The ECMO Team

We understand that this is a very stressful time for you and you may not remember all of our explanations. Please don’t be afraid to ask us the same question more than once. We are here to help:

• Attending Physician: The primary physician in charge of your family member’s care. Our physicians are known worldwide for their research and for the development of ECMO.
• ECMO Fellow: This surgeon is specializing in the treatment of severe respiratory failure and is the primary manager of patients requiring ECMO, under the guidance of the attending physician.
• ECMO Specialists: The management of ECMO equipment the minute-to-minute monitoring of ECMO patients is done by these specially trained nurses and respiratory therapists.
• Critical Care Nurses: Nurses provide care and comfort for your loved one. They will often be your first line of information for the many questions that you have.
• Respiratory Therapists: These professionals are specialists in ventilator management, make recommendations to other team members and assist with procedures.
• Resident Physicians: Surgical residents are medical doctors who are obtaining specialty training in surgery. Much of the around-the clock-bedside medical care, under the supervision of the attending physician and ECMO fellow, is carried out by the resident physicians.
• Social Worker: The social worker can help you with:
  • Accommodations or lodging
  • Financial concerns: Insurance, parking, or meals.
  • Emotional issues such as coping with a life threatening illness.
• Clinical Care Coordinator: The clinical coordinator is a nurse who serves as a resource for you during and after a hospital stay. She will help answer any questions or concerns about the plan of care, prepare you to go home, and be available for follow-up.

How ECMO Works

ECMO substitutes for the function of the lungs and heart by pumping blood out of the body; oxygen is added to the blood and carbon dioxide is removed before it is returned to the patient. This process allows the heart and lungs to rest and recover.

Types of ECMO:

There are two types of ECMO therapy; venoarterial (V-A) and venovenous (V-V). The terms V-A and V-V refer to the blood vessels used during the ECMO procedure:

• V-A ECMO is used in people with blood pressure or heart functioning problems. A catheter is placed in both a Vein and an Artery. This method gives excellent support for the heart in addition to the lungs.
• In V-V ECMO, catheters are placed so that blood travels from a Vein & back to another Vein. The advantage of VV is that the carotid artery does not need to be tied off as in V-A. Occasionally, patients start out on V-V and need to be changed over to V-A ECMO.

A large catheter drains blood out to a pump. This blood is dark because it contains very little oxygen.

A steady amount of blood is pumped through the ECMO machine each minute. This is referred to as the flow rate. As your family member improves, the flow rate can be decreased and more of the blood will get oxygen through the lungs.

The pump pushes blood through a membrane lung where gas exchange occurs; oxygen is added and carbon dioxide is removed. The size of the lung is based on the size of the patient. Sometimes two lungs are needed for adults.

The blood is then warmed by a heat exchanger , before it is returned to the body.

This blood is bright red because it contains oxygen.

You will also see other tubing and ports for blood withdrawal and drug administration, as well as safety features, such as a pump regulator or “bladder box” and a backup power supply.

INTRODUCTION TO ECMO FOR PARENTS
(ECMO = “Extra Corporeal Membrane Oxygenation”, meaning heart-lung bypass)

Who Needs ECMO?

Your child has a severe lung or heart condition that has not responded to our usual therapy of a respirator (mechanical ventilation), medicines, and extra oxygen. Infants and children who do not respond to this therapy could die, but ECMO could be successful if used to treat your child. The infants who require ECMO usually have one of the following problems: Meconium Aspiration Syndrome, Sepsis, Respiratory Distress Syndrome, Persistent Pulmonary Hypertension, Pneumonia, or a Congenital Diaphragmatic Hernia. Children with Pneumonia, Sepsis, Acute Respiratory Distress Syndrome, or certain heart conditions may benefit from ECMO therapy.Your child’s doctor will discuss with you the specific problems your infant or child has.

Important: ECMO is offered only to children whose lung and/or heart disease is thought to be reversible.

What is ECMO?

ECMO stands for Extracorporeal Membrane Oxygenation. The ECMO machine is very similar to a heart-lung bypass machine used for open-heart surgery. When your child is placed on ECMO, his/her blood receives oxygen from an artificial lung in the ECMO circuit (or system). The artificial lung in the ECMO circuit will provide your child’s blood with the oxygen needed to live until his/her lungs and/or heart are able to work on their own.

How does the ECMO circuit work

Dark blood (containing little oxygen) will drain by gravity from the patient through a tube (catheter) placed in a large vein (usually the neck in infants and the neck and/or groin in older children). The pump (which acts as an artificial heart) will push the blood through the rest of the ECMO system. Blood is pumped into the oxygenator (which acts as an artificial lung), where it will be cleansed of carbon dioxide and will pick up oxygen. Once the blood leaves the oxygenator, it is warmed and is returned to the patient through the arterial catheter. This oxygenated blood will look bright red in color. Blood is drained out and pumped back to the patient at the same rate so your child’s body does not know this is happening.

How is my child placed on ECMO?

The surgical procedure required to put the ECMO catheters into your child is usually performed by a surgeon and an operating room team. This procedure usually occurs at your child’s bedside. Your child is given medication for pain and sedation before the procedure begins. A medication to keep your child from moving during the procedure is also given. Your doctor or nurse may refer to this medication as “paralysis”. This paralysis is temporary and will wear off a short time after the last dose is given. The incision area at the neck or groin will also be given a numbing medication.

The catheter(s) is (are) inserted into the blood vessel, and advanced (threaded) into the heart. An x-ray will be taken immediately to make sure that the catheter(s) is (are) in the correct position. The catheter(s) will then be connected to the ECMO circuit. Even though your child is being supported be ECMO, he/she will remain on the ventilator. This will allow for removal of secretions from your child’s lungs and will give breaths to help keep the lungs inflated

Types of ECMO:

There are two types of ECMO therapy: venoarterial (VA) and venovenous (VV) ECMO. The terms VA and VV refer to the blood vessels used during the procedure.

• VA ECMO: In VA ECMO, a catheter must be placed in both a vein (veno) and an artery (arterial). VA ECMO is usually used in children with possible blood pressure problems and who need the added support the VA ECMO can give the heart. The advantage of VA ECMO is that this method gives excellent support for the heart in addition to the lungs. Therefore, if the heart function is a concern, VA ECMO will be used.
• VV ECMO: In VV ECMO, a single catheter with two tubes is placed in a vein. VV ECMO is used in children who have no significant heart function or blood pressure problems. There are a few children who start out on VV ECMO who need to be changed over to VA ECMO. This is usually due to low oxygen levels with VV ECMO or blood pressure problems in the child. The advantage of VV ECMO is that the carotid artery does not need to be tied off as in VA ECMO. Special cases and older children may need an individualized approach to cannulation for ECMO, using other vessels than described above. If this is the case for your child, your child’s doctor will describe this to you. Don’t be afraid to ask questions.

What are the risks for my child on ECMO?

Any child who requires ECMO therapy is very ill and usually will die without it. However, there are risks associated with this procedure:

1. The blood must be kept from clotting while it goes through the machine, so a drug called heparin (a blood thinner) is given to prevent clotting. Sometimes this can lead to bleeding. If bleeding of any kind occurs, the ECMO physician will discuss it in detail with you. The amount of heparin needed will be monitored closely and steps will be taken to minimize any bleeding that occurs. If bleeding becomes too great, ECMO therapy may have to be discontinued.

There aren’t any tests to determine if your child has had damage to his/her brain from the low levels of oxygen before ECMO. If this has occurred, there may be an unjured area in the brain that will bleed when the heparin is used for ECMO. Your child’s doctor will discuss this with you. In general, your child’s risk of dying without ECMO is greater than the risk for bleeding in the brain.

2. The ECMO surgical procedure may involve tying off the carotid artery. The carotid artery is one of the blood vessels that supplies blood flow to the brain. To date, this has not caused any complications because other blood vessels takeover and carry blood to the brain. Because ECMO is relatively new, the long-term risks of this surgery are not known; however, an increased risk of stroke must be considered as your child continues into adulthood.

3. Whenever a catheter is inserted into a blood vessel, there is an increased risk of infection. Your child will receive antibiotics as a precautionary measure, and will be watched carefully for signs of infection.

4. A child on ECMO will require frequent blood transfusions. As with any blood transfusion, there is always a risk of a blood reaction as well as hepatitis and HIV. The blood used from the blood bank is screened both for hepatitis and HIV; however, there remains a very small risk that such a disease could be acquired. Your child will be monitored for any signs of infection from blood transfusions.

5. Although every safety measure is taken, the ECMO circuit can malfunction or fail. If this occurs, steps will be taken to keep your child stable. Your child will be put back on ECMO therapy as soon as possible.

6. Small blood clots or air bubbles can get into the bloodstream from the circuit. This can be fatal in some circumstances. Every safety precaution will be taken so that this won’t happen.

How long will my child be on ECMO?

The average number of days a child is on ECMO will depend on the age of the child and his/her original diagnosis. For a newborn, the average number of days on ECMO is 5-7, but can be as many as 14 or more days. For an older baby or child, the average number of days on ECMO is 10- 30 days (these averages can differ from one institution to another). Each child is different and the length of the course of ECMO may be affected by these individual differences. Some of these differences include: the type of lung or heart disease, the amount of damage to the lungs before ECMO, and complications that may occur during ECMO. A steady amount of blood is pumped through the ECMO machine each minute. This is usually referred to as the “ECMO flow”. When your child is first placed on the ECMO machine, the flow is maintained high. This means that the ECMO machine is doing most of the work to provide oxygen to your child’s blood. As your child improves, the ECMO flow can be decreased and more of the blood will go to your child’s lungs to get oxygen.

Your child’s lungs are improving when the oxygen content in the blood increased consistently over time despite a decrease in ECMO support.

Is ECMO Painful?

When the ECMO catheters are initially inserted, your child is given a numbing medicine in the skin, as well as a medication for pain and sedation. ECMO patients do not appear to be in pain while on ECMO; however, a pain medication will be available if the nurse or ECMO Specialist determines that your child is uncomfortable.

In addition to pain medication, we will be doing other things to make your baby comfortable. Infants may lie on a sheepskin to cushion the skin or on an eggcrate mattress to help prevent pressure areas on the skin. An infant’s eyes may be shaded to decrease the disturbance from overhead lights. Pacifiers and booties may also be used for comfort if your child’s condition allows. Older children may be on a special bed with a specific mattress that helps to prevent pressure areas on the skin. Regular diaper changes, bathing, and frequent repositioning are just a few of things that we will be doing to keep your child comfortable.

Will I be able to visit my child during ECMO therapy?

As a parent and/or family member, you play an important role in your child’s care and recovery. We encourage you to visit your child while he/she is on ECMO. Each unit has its own visitation policy and you will need to check with the nursing staff of your child’s unit. If you wish to stay in the hospital overnight, ask your child’s nurse for further assistance. Unfortunately, space in the hospital may be limited but the nursing staff will do their best to find you a place to stay. If you would like to stay near the hopsital and are unfamiliar with the area, ask your child’s nurse to contact the social worker for further assistance. While your child is on ECMO, there are some things you can do to help with your child’s care. Please ask your child’s nurse or ECMO specialist how you can participate in your child’s care. Some examples are:

1. Providing special toys or comfort items.

2. Touch your child. A reassuring touch and your voice are important and comforting; in fact, studies show that healing occurs faster in a child who is touched. If you are afraid to touch your child, ask the nurse or ECMO specialist for guidance.

3. Tape yourself reading stories or singing songs and bring them in for your child to listen to.

4. If your child has brothers and/or sisters, have them draw pictures that can be placed at your child’s bedside. It is important to include the other siblings and encourage them to participate so that they may feel as if they, too, are contributing to the care and recovery of their brother or sister. Some units have sibling visitation policies. Ask your child’s nurse regarding those specific guidelines.

5. Keeping a journal of your child’s progress may help when you speak with your child’s doctors and may be a way you can better understand what is happening with your child.

6. You must also take care of yourself. Make sure you eat properly and get some rest. Although you may want to be at your child’s bedside all of the time, it is important that you keep up your strength.

And, remember, you can call at anytime to check on your child when you are away from the bedside- we are always happy to talk with you.

How will my child receive nutrition during ECMO?

All nutrition needed for energy and growth will be provided to your child by intravenous (IV) therapy while your child is on ECMO. If you are currently breastfeeding or are planning to breastfeed your baby, talk to his/her nurse or doctor. Often, after a baby comes off of ECMO, breastfeeding can be started. Meanwhile, you can pump your breasts and store the milk. Ask your baby’s nurse for information regarding pumping and storing breastmilk.

Who will be taking care of my child?

Once the physician has decided that your child is a candidate for ECMO and you (the parent/guardian) have given permission, the ECMO physician will then be in charge of your child’s care. There may also be other consulting physicians involved in the care of your child such as a cardiologist, radiologist, pediatric surgeon, or neurologist.

Every day you will see ECMO Specialists involved in your child’s day to day care. The ECMO Specialists are a group of specially trained nurses or perfusionists who have prior experience in intensive care units. They have received special training that enables them to manage ECMO patents and ECMO equipment.

In addition, there are other people who are available to provide assistance to you and your family. Ask your child’s nurse to direct you to the social worker if you need assistance in dealing with practical things such as housing, meal tickets, and/or parking vouchers and/or emotional issues such as dealing with your child’s illness. A chaplain is available 24 hours a day. In addition, there are parents of former ECMO patients who are ready to offer the support of those who have already experienced with their own children the feelings you are feeling now.