SCCM Resource Library-Extracorporeal Membrane Oxygenation Support: A Bridge to Palliation in Single-Ventricle Physiology

Video Transcription

Hello, my name is Jim Lantry, and I'm coming to you from a hospital right outside Washington, D.C.,  Totonova, Fairfax, and I was asked to speak on the topic of extracorporeal life support. What's here, what you need to know, and what's coming.  So I'll talk briefly about the past, and by that, the immediate past of ECMO, focus mainly on the present and what COVID-19 has done to the field of ECMO,  and then spend a few slides talking about the future of ECMO, and what's coming down the path. So in 2018, it was a year before the world was even introduced to COVID-19,  when the Eoletra was released. Now this was the greatest, and probably the greatest RCT we're ever going to see for the use of EV ECMO in the acute respiratory failure population.  Now it had its flaws, as most RCTs do, but it was the best we're probably ever going to see to prove that in select ARDS patients, EV ECMO is superior to conventional therapy.  And following in its heels, we found that, you know, worldwide, there was a global survival of 60% plus for EV ECMO of any population.  So you name what the cause of the ARDS, or respiratory failure, and ECMO was the answer for it.  Cases were on the rise, and following suit, a lot of centers were starting to begin their own ECMO programs. It was actually a really good time to get into ECMO at that point,  especially as late 2019, early 2020, we were hit with COVID-19. It was devastating worldwide, but the ECMO world stepped up.  No matter where you were, the teams donned their PPE, stepped into the room, and placed patients onto ECMO. They used whatever resources were available, and did the job.  Now, as most organizations do, ELSO, which is the governing body for ECMO, released guidelines, and those guidelines for ECMO use were quite similar  to what we were expecting of the generic ARDS patient. Certain oxygenation, ventilation goals, but it was, you know, what we were using before.  And by using them, we had tremendous results. In a short period of time, ECMO became the go-to therapy for the advanced COVID-19 ARDS patient. And the trend was seen worldwide.  You know, ECMO had a tremendous outcome compared to conventional therapy.  And a very large study out of the Lancet showed that, you know, as we had expected before, there was a 60-plus percent survival for the ARDS patient placed on VVECMO  that was suffering from COVID-19 pneumonia. And then something happened, and that something occurred in the summer of 2020.  And what happened is that where we were expecting a survival of 60 percent, we're actually now seeing a mortality of 60 percent. The script had been flipped, if you will.  And I thank Dr. Dalton for this information out of the COVID Consortium. But it was seen across the globe. You know, no matter who was doing ECMO, you know, we would call around,  and everybody had this steep drop-off for survivors. It was pretty profound. And again, the Lancet did another study looking at the same survival population matched  pre-May 1st going on ECMO and post at the same exact hospital. And they saw a tremendous difference in mortality, a 10-15 percent increase in mortality.  They went on to also explain that if you were a center that was late in the game and put patients on for the first time post-May 1st, you actually had the worst results.  Now, this was approaching a 55-60 percent mortality. If you look deeply at that study and you match the centers,  if you look at centers that put patients on the first time after May 1st that had equal volume of ECMO population compared to those that were doing it the entire time,  say pre-May 1st, the outcomes were about the same. So the story was, you know, what you would expect in medicine.  If you weren't good at doing it before and you started doing it during a crisis, you were not going to have the same outcomes as those who were experts in the field.  But I digress. There still is a problem. Like, what happened pre-May 1st and post-May 1st? Well, there are several theories out there, and the Lancet paper actually gives you a few.  And I'm going to go over the top three theories. First off, when we first attacked ECMO, when we attacked it, we had seen crisis like this before. We had all been through H1N1.  We had all been through ECMO for that population, and we had amazing results. All we had to do was stay firm and weigh out the tide.  Well, the tide decreased, but it never went away. The emergency departments kept filling up, no matter what we did. And the ICUs ensued, followed, constantly full.  You know, there were times when we didn't even know if we'd have enough PPE for the next day. We were recycling things, autoclaving what we could.  And this became a very scary situation. Now, this was pre-vaccine. People became exhausted. You know, my team, we worked double-time, if not triple-time most of the days,  just to cover the expansive ECMO population we were handling. And leave it to nursing literature, when you stretch people thin, when you cause burnout, complications occur.  Now, this is going over UTIs and surgical site infections. Following suit, as you would expect, mortality was also increasing.  You know, it didn't matter if you were a larger hospital or a smaller hospital. The more burnt out and the more spread out your staff became, the worse the outcomes were.  And with the outcomes being bad and the burnout rates rising, exhaustion set in. Extensive exhaustion. Job dissatisfaction. People were leaving left and right.  Millions of nurses were either leaving the field or retiring early. And this mass exodus, not just nurses, not just RTs or docs,  but of all healthcare staff, led to a tremendous deficit. So we're looking at a population that is now going to be expected to have worsening complications.  Worsening mortality simply due to the low staffing ratio. Also now being staffed by a smaller population of clinicians. Bad outcomes at that point may be expected.  Second, I think you were just better at treating COVID-19. In the very early stages, we had really no weapons to attack COVID-19. We didn't have anything.  And we put people on ECMO who, in retrospect, maybe didn't need to be on ECMO. As time went on and more trials came out,  July of that year was the first digital printing of the dexamethasone study that basically revolutionized what we thought about treating COVID-19.  It was maybe an afterthought to rely on ECMO, only after these new therapies had actually kicked in. So did that play a role?  Because, thirdly, we do know the longer you wait to put people on ECMO,  the worse they do. And although it is a sequential worsening of outcome expected, most organizations agree that about a week is the max you should wait to put someone on ECMO.  And it didn't really matter which scoring system you used, you know, maximum 10 days. But what made COVID-19 so unique is all these large organizations  were basically telling us it's okay to wait to even intubate. So these individuals were being put on high flow and noninvasive  for a prolonged period of time, and we were waiting much longer to intubate them. Why? Because the studies panned out and said that it's okay to wait.  You know, the longer you wait, the less likely you are to expose your healthcare personnel within RSI intubation, where maybe they didn't need to be exposed in the first place,  and maybe the patient could have gotten by on high flow or noninvasive. And, you know, definitely when you put someone on the ventilator, you cause some amount of barotrauma.  You do. And when you have someone passively breathing, the barotrauma is definitively less than being on a ventilator,  but being on high flow and noninvasive, it's not a benign process. There's still some form of patient self-inflicted lung injury  that occurs due to the levels of PEEP that you're applying to those lungs. When you look at data, the barotrauma incidents for patients with COVID-19  placed on high flow and noninvasive were actually equal to older studies of ARDS populations placed on a ventilator. So were we causing barotrauma by ignoring the high flow  and the noninvasive time that these patients were on? And when we looked at that in my hospital, it did pan out.  Now, when you equalize the amount of time on the ventilator to about 3 1⁄2 days, and you look at whether you're on high flow and noninvasive less than 3 days  or 3 or more, there's a profound difference. Now, this is coming off ECMO and being discharged from the hospital.  We looked at mortality, and it was empowered to actually find a difference there, but there was a difference. There was a trend towards definitely a worsening mortality as well.  So we accommodated to the one thing we could control. We said, okay, we're going to keep them ventilated for definitively less than one week, but we're going to add on  whatever time they're on high flow and noninvasive, and then use that to stratify our patient population and then see if it actually has a change in our outcome. But that wasn't it.  That wasn't the only major change that COVID-19 did to the ECMO population, to the ECMO world. So there have been spikes, and I expect there to be another spike in COVID patients.  When you look at the early study at Ajama, looking at the Chinese Center for Disease Control, they basically said that of all hospitalized patients,  5% are expected to be severely ill, meaning they have critical organ failure that would require advanced therapies. Now a similar study published out of the United States data  showed a much lower number, 2%. Now if we average them out, let's say 3.5% are critically ill in need of some kind of rescue. Let's play an ECMO game.  So 100 patients are admitted to your hospital per day. And that's not unusual for my hospital. And three and a half of them are critically ill, three and a half a day.  And about a third, based on recent data, actually meet your ECMO criteria. So 1.15 a day. And now let's assume, based on most studies,  that they're going to be on ECMO for a little over two weeks, 15.1 days. Now if you're blessed with a larger ICU, like most urban ICUs, you're at capacity in just under three weeks.  Sooner, if you don't have the discharges or the transfers out or the success on ECMO that you expected. But if you're like thousands upon other ICUs in the country,  and you have 10 or less, then you're at capacity in under a week. And this means you're bypassing surgical cases, you're bypassing other emergencies,  you're bypassing a lot of people who would standardly be in those ICUs, summer, fall, winter, et cetera. So what accommodations did the ECMO world make?  Well, we dropped the age by five years compared to previous studies. So the average ECMO patient with COVID-19 pneumonia is five years younger than those of the large eolia trial.  Secondly, certain centers adopted differential eligibility, like the Alfred, Melbourne, Australia, basically saying that we'll take your age  and add on a few other comorbidities for a scoring system and use this to determine eligibility for ECMO. CHEST released a tiered structure  looking at the patient population and pathology and then used this to stratify patients for triage, giving ECMO only to those with the expected outcome  that was the most beneficial for the entire population. The guidance from ELSO was simply to have a contingency plan, to know that there are going to be some times  when you're more liberal with ECMO resources and there's definitive times when you don't have that many beds or machines available and times are tough and you must be more strict.  And your consultants and your referring hospitals have to also buy in on this. Ethically, this can be very difficult. If you were to ask the average ECMO clinician pre-pandemic  how often are they thinking about future patients as they're cannulating the person in front of them, rarely would they say that they had. However, during the pandemic,  this hypothetical patient is on everyone's mind, especially as resources become tight and beds dwindle away. Furthermore, it would have been unheard of  to think about taking a failing patient off of ECMO pre-pandemic in order to put a new patient on. But during COVID-19, this became almost a normal conversation.  So I'll end you with a slight update. So where are we now? So this data was pulled from ELSO about a week ago and it shows that despite the pandemic,  this Omicron variant lessening in numbers, we're still seeing a decent amount of people on ECMO. And on a monthly basis, we're putting more and more on ECMO than we ever had before  and more and more centers are starting to do ECMO than ever had before. And we're starting to look at the future and facing an impending crisis. What happens after ECMO?  All these individuals who had mild, moderate, especially those with severe disease, they're expected to have some long-term pulmonary complications.  Will that increase the need for VV ECMO down the line, even outside the world of COVID-19 pneumonias? Will we be prepared to face that crisis?  When you look at ECMO fellowships, sampling 103 of them, a decent amount had ECMO exposure and a majority had some ECMO didactic training,  but only 1 in 20 programs felt that they prepared their graduates appropriately to, quote, independently manage ECLS, meaning go out there and handle ECMO  without any kind of oversight. So, you know, there are certain organizations, ELSO being one of them, SCCM also stepping up, that's using whatever resources possible,  online learning, hands-on sessions, et cetera, to prepare the future clinicians to handle this new impending crisis. And we have some optimistic outcomes with some studies.  Now, these are mainly VA ECMO studies, but these should be coming out relatively soon. You know, should maybe change not the way we see VV ECMO,  but the way we use ECMO for cardiac arrest patients, building off of the RESUSCITATE study and the CHEER trial from prior years. And we're looking at a world, perhaps,  with heparin-free ECMO, you know, where you can get the same gas exchange and longevity of circuit without the after effects or complications seen with overuse of heparin.  And finally, you know, even further down the line, and I think this is the most exciting, is the use of ambulatory VAD-like ECMO support devices outside the ICU,  whether it's a long-term rehab nursing home center with ECOR for CO2 removal for patients who simply need some form of augmented ventilation,  or if it's just take this machine, go home, use it whenever you're hypoxic, turn it up, and then wait on a lung transplant, just like a VAD is for a heart transplant.  So, you know, a lot of exciting things coming down the wire. And I'll leave this slide with you and leave my email inbox open for questions,  and hopefully can participate live during this session in order to answer questions immediately. Thank you very much.

Video Summary

In this video, Jim Lantry discusses the past, present, and future of extracorporeal life support, specifically focusing on ECMO and its relation to COVID-19. Lantry notes that in 2018, ECMO was shown to be superior to conventional therapy for select ARDS patients. When COVID-19 hit in 2020, ECMO became the go-to therapy for advanced COVID-19 ARDS patients, with a global survival rate of over 60%. However, in the summer of 2020, a shift occurred, and instead of a 60% survival rate, mortality rates of 60% were observed. Lantry explores several theories for this change, including burnout and exhausted healthcare staff, better treatment options for COVID-19, and delays in initiating ECMO due to prolonged high flow and noninvasive ventilation. Lantry also discusses the future of ECMO, including advancements in training, heparin-free ECMO, and the use of ambulatory ECMO support devices.

Asset Subtitle

Cardiovascular, Procedures, 2022

Asset Caption

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) in congenital heart disease is mostly well established. ECMO has served as a bridge to recovery, decision or transplant in the setting of myocardial decompensation. ECMO has provided support for single ventricle patients at different postoperative stages of the palliation. Little is known regarding the use of preoperative ECMO support in this population. We aim to evaluate the outcomes of patients with single ventricle physiology supported with ECMO as a bridge to palliation. METHODS: Data was collected from the Extracorporeal Life Support Organization (ELSO) registry between 2016 to 2021. Patients were included in the study if they had single ventricle physiology and required ECMO support prior to their first stage palliation. Multiple variables including demographics, pre ECMO course, indications for ECMO, cannulation details, ECMO duration, course, complications and survival to hospital discharge data were collected. Descriptive statistics and student t-test was used to compare continuous variables. Dichotomous variables were compared using chi square and fisher tests. A p-value of 0.1 was considered as statistically significant in univariate analysis. RESULTS: Sixty-six patients met inclusion criteria. Of the 66 patients, 24 died on ECMO prior to first stage palliation (36%). Thirty-nine of the 66 patients died before discharge (59%). There was no significant difference in weight and age between patients who died and survived on ECMO. Patients who died on ECMO had significantly longer ECMO runs than those who survived (248 hrs vs. 115 hrs; p < 0.001) . Patients who died on ECMO were significantly more likely to have a higher initial paO2(49 mmHg vs. 40 mmHg; p=0.027) and oxygen saturation (77% vs. 69%; p=0.076) than those who survived. Patients who died on ECMO were significantly more likely to have more than four complications during their course than those who survived (63% vs. 17%; p < 0.001). CONCLUSIONS: A third of patients supported with ECMO prior to initial single ventricle palliation died on ECMO. Those who died on ECMO were significantly more likely to undergo a longer ECMO run, suffer more complications, have a higher initial paO2 and oxygen saturation than those who survived ECMO. This information may guide management in the future.

Meta Tag

Content Type Presentation

Knowledge Area Cardiovascular

Knowledge Area Procedures

Knowledge Level Advanced

Learning Pathway Cardiothoracic Critical Care

Membership Level Select

Tag Shock

Tag Extracorporeal Membrane Oxygenation ECMO

Tag Cardiac Arrest

Tag Heart Failure

Tag Cardiothoracic Critical Care

Year 2022

Keywords

extracorporeal life support

ECMO

COVID-19

ARDS patients

mortality rates

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