ecmo application : ruled implementation or free diffusion?
DESCRIPTION
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
![Page 1: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/1.jpg)
ECMO application: ruled implementation or free diffusion?
Milan2012
Palle Palmér
ECMO Centrum Karolinska
Karolinska University Hospital, Stockholm Sweden
![Page 2: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/2.jpg)
If we look at Stockholm development
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
0
20
40
60
80
100
120
140
NeonatalPediatricAdultTotal
![Page 3: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/3.jpg)
ECMO Centrum Karolinska
0
200
400
600
800
1000
1200
1400
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
vård
dygn
År
Days on ECMO
Europa
Sverige
Stockholm
![Page 4: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/4.jpg)
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
4 ECMO Centrum Karolinska
![Page 5: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/5.jpg)
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.
5 ECMO Centrum Karolinska
![Page 6: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/6.jpg)
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
![Page 7: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/7.jpg)
v.cava.sup low saturation
v.cava.inf high saturation
MRI Jonas A Lindholm
Multistage cannulae
![Page 8: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/8.jpg)
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
8 ECMO Centrum Karolinska
![Page 9: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/9.jpg)
Burn patient consuming 450 ml of oxygen per minute
9 ECMO Centrum Karolinska
![Page 10: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/10.jpg)
68 days run with saturation of 65% in 45 days
10 ECMO Centrum Karolinska
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 670
20
40
60
80
100
120
Arterial satVenous sat
![Page 11: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/11.jpg)
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
![Page 12: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/12.jpg)
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
![Page 13: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/13.jpg)
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.
13 ECMO Centrum Karolinska
![Page 14: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/14.jpg)
ELSO reports July 2012
14 ECMO Centrum Karolinska
![Page 15: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/15.jpg)
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.
15 ECMO Centrum Karolinska
![Page 16: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/16.jpg)
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Mean p/f ratio 1995 – 2008
1995 2008
![Page 17: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/17.jpg)
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
![Page 18: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/18.jpg)
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
18 ECMO Centrum Karolinska
![Page 19: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/19.jpg)
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
19 ECMO Centrum Karolinska
![Page 20: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/20.jpg)
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
20 ECMO Centrum Karolinska
![Page 21: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/21.jpg)
21 ECMO Centrum Karolinska
Pneumothorax
Don’t hurt the patient
First choice - stop ventilation in 2-3 days
Pleura drainage - Seldinger or Surgeon
![Page 22: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/22.jpg)
A very small pleuradrainage - 20 liter of blood and 4 operations
22 ECMO Centrum Karolinska
![Page 23: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/23.jpg)
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
![Page 24: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/24.jpg)
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
![Page 25: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/25.jpg)
![Page 26: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/26.jpg)
EURO-ELSO 2013
Precongress 8-9 May 2013
Congress 9-11 May 2013
Scientific programme Nov 2012
Deadline for Abstracts 15 March 2013
26
![Page 27: ECMO application : ruled implementation or free diffusion?](https://reader034.vdocuments.mx/reader034/viewer/2022051518/568164f0550346895dd75abd/html5/thumbnails/27.jpg)
27
Welcome to Stockholm 2013