ECMO Retrieval Program Foundation

Preface
Synopsis
References
Contents
About the Editors
Part I: Scientific, Technical and Clinical Background of Extracorporeal Membrane Oxygenation (ECMO) Therapy
Chapter 1: History of Extracorporeal Life Support: From Cardiopulmonary Bypass Towards ECMO
1.1 Introduction
1.2 History of Blood Pumps
1.3 History of Oxygenators
1.4 From the Early Days of ECMO up to Present
References
Chapter 2: Variety and Classification of ECMO Systems and Cannulation Strategies
2.1 Classification
2.1.1 Standard ECMO
2.1.2 Less Commonly Used ECMO Types
2.1.2.1 Pulmonary Artery-Left Atrium (PA-LA Novalung)
2.1.2.2 The Extracorporeal CO2 Removal (ECCO2R)
2.1.2.3 RA-PA (Tandem Life Protek Duo)
2.1.3 Hybrid ECMO
2.1.3.1 Veno-Veno-Venous ECMO (vvvECMO)
2.1.3.2 Veno-Veno-Arterial ECMO (vvaECMO)
2.1.3.3 Veno-Arterial-Venous ECMO (vavECMO)
2.1.3.4 Veno-Veno-Veno-Arterial ECMO (vvvaECMO)
2.1.3.5 Veno-Veno-Arterio-Venous ECMO (vvavECMO)
2.1.4 Parallel ECMO
2.1.4.1 Dual vvECMO
2.1.4.2 Dual vaECMO
2.1.4.3 vv and vaECMO
2.2 Cannulation Techniques
2.2.1 Basic principles
2.2.2 Cannula types
2.2.3 Percutaneous Cannulation
2.2.3.1 vvECMO Cannulation
Dual Cannula Techniques
Femoro-Femoral Approach
Femoro-Jugular Approach
Double-Lumen Single Cannula Technique
2.2.3.2 vaECMO
Femoro-Femoral Approach
2.2.4 Surgical Cannulation
2.2.4.1 Central Cannulation for vaECMO
2.2.4.2 Peripheral Surgical Cannulation
Femoral Artery Cannulation
Femoral Vein Cannulation
Axillary Artery Cannulation
Axillary Vein Cannulation
2.3 Cannulae for Peripheral ECMO
2.3.1 Examples of Commercially Available Peripheral Cannulas
2.3.1.1 Single-Lumen Peripheral Cannulas
Maquet HLS Cannulae
Types of Medtronic Cannulae
Bio-Medicus™ NextGen Femoral Venous Cannulae
Bio-Medicus™ NextGen Femoral Arterial or Jugular Venous cannulae (Fig. 2.3)
DLP™ Femoral Venous Cannulae
DLP™ Femoral Arterial Cannulae
Types of Xenios Cannulae
Medos Arterial and Venous Femoral Cannulas
NovaPort One KU Single-Lumen Cannulas
NovaPort One KI Single-Lumen Cannulas
Types of LivaNova Cannulae
LivaNova Bi-Flow™ Arterial cannula (Figs. 2.4 and 2.5)
2.3.1.2 Double-Lumen Cannulae
Avalon Elite® Bi-Caval Dual Lumen Catheter (Figs. 2.6 and 2.7)
Crescent Jugular Dual Lumen Catheter
Xenios Novaport Twin
OriGen® Dual Lumen Cannula
LivaNova Tandem Life Protek Duo Cannula
2.4 Cannulae for Central ECMO
2.4.1 Arterial Cannulae
2.4.1.1 Types of Medtronic Cannulae
Soft-Flow® Extended Arterial Cannula
Soft-Flow® Straight Tip Arterial Cannula
Soft-Flow® Angled Tip Arterial Cannula
EOPA® Arterial Cannulae
EOPA™ 3D Arterial Cannulae
EOPA® (Elongated One-Piece) Arterial Cannulae
Select Series™ Straight Tip Arterial Cannulae
Select Series® Angled Tip Arterial Cannulae
Select 3D™ II Arterial Cannulae
DLP™ Straight Tip Arterial Cannulae
DLP™ Curved Tip Arterial Cannulae with One-Piece Wire-Wound Body
DLP™ Curved Tip Arterial Cannulae with Wire-Wound Body
DLP™ Curved Tip Arterial Cannulae
2.4.1.2 Types of Edwards Lifesciences Cannulae
OptiSite Arterial Cannulae
EZ Glide Aortic Perfusion Cannula
2.4.1.3 Types of Maquet Arterial Cannulae
TRANSMINAR Cannulae
Standard Arterial Cannulae
2.4.1.4 LivaNova Adult Arterial Cannulae
PureFlex™ Arterial Cannulae
2.4.2 Venous Cannulae
2.4.2.1 Types of Medtronic Venous Cannulae
DLP™ Single Stage Venous Cannulae
DLP™ Malleable Single Stage Venous Cannulae
VC2™ Venous Cannulae
MC2™ Two Stage Venous Cannulae
MC2X™ Three Stage Venous Cannulae
2.4.2.2 Types of Edwards Lifesciences Venous Cannulae
Triple Stage Venous Cannula
Dual Stage Venous Cannula
Single Stage Venous Cannula
2.4.2.3 Types of Maquet Venous Cannulae
Single Stage Venous Return Cannulae
Venous Two Stage Cannula
References
Chapter 3: Is it Time to Move on? Discrepancies Between Official Guidelines and Real Life Clinical Scenarios
3.1 Existing Guidelines for ECMO Therapy
3.2 General Indications for Initiation of ECMO Therapy
3.3 “Classic ECMO Indication”: The Patient with Refractory Cardiogenic Shock
3.4 Adult Respiratory Distress Syndrome (ARDS)
3.5 Indications Beyond the Current Guidelines
3.6 Influenza H1N1 (“Swine Flu”) Pandemic
3.7 SARS-CoV2 Pandemic
3.8 Mendelson Syndrome
3.9 Accidental Hypothermia
3.10 Extracorporeal Cardio-Pulmonary Resuscitation (eCPR)
3.11 Pulmonary Embolism (PE)
3.12 Is it Time to Move on?
References
Chapter 4: Left Ventricular Decompressing and Venting Strategies: The Game Changers in ECMO Support
4.1 Introduction
4.2 Pathophysiology of Left Ventricular Distension Under Femoral Veno-Arterial ECMO
4.3 Central Cannulation Strategies for Left Ventricular Unloading
4.4 Intra-Aortic Balloon Pump for Left Ventricular Unloading
4.5 The ECMELLA Concept
4.6 ECMELLA Therapy with Axillary Implanted Impella 5.0/5.5 Devices and Bridging Options
4.7 Conclusion
References
Chapter 5: ECMOlogy as the New Medical Discipline: The Way Towards Interdisciplinary Approach of ECMO Therapy
5.1 Who Can Become ECMO Specialist?
5.2 How to Become ECMO Specialist?
5.3 ELSO Guidelines for Training and Continuing Education of ECMO Specialists
5.3.1 Training Outline for Education According to ELSO [9]
5.3.2 Continuing Education of the ECMO Specialist According to ELSO [9]
5.4 ECMOlogy: Do we Need a New Medical Discipline?
References
Part II: From Zero to Hero: Matters and Challenges of Launching an ECMO Retrieval Program
Chapter 6: Teamwork Makes the Dream Work: Creating Interdisciplinary Synergies Among Cardiothoracic Surgery, Cardiology, Pulmonology, and Anesthesiology
6.1 Introduction
6.2 History of Extracorporeal Membrane Oxygenation
6.3 Extracorporeal Membrane Oxygenation in Respiratory Disease
6.4 Extracorporeal Membrane Oxygenation for Hemodynamic Support
6.5 The Use of ECMO in Special Situations
6.5.1 Mechanical Circulatory Support in the Emergency Room
6.6 Extracorporeal Support During Pregnancy
6.7 Conclusions
References
Chapter 7: ECMO Retrieval Program Foundation Financial Aspects and Negotiations with Manufactures
7.1 Introduction
7.2 Program Volume
7.2.1 Initiation and Management
7.2.2 Retrieval Scope
7.2.3 Expenditure
7.2.4 Personal Requirements
7.2.5 Equipment and Machinery
7.2.6 Negotiations with Manufacturers
7.3 Reimbursement
7.3.1 Financial Effectiveness
7.3.2 DRG Case Flat Rate
7.3.3 Ventilation Duration and ICU-Day Flat Rate
7.3.4 Additional Billing Modalities
7.3.5 Unique Settings in Individual Countries
7.4 Special Requirement for Prolonged Therapy
7.4.1 Device/Oxygenator Change and DRG Encoding
7.4.2 Supportive Therapies and Rehabilitation
7.5 Lessons Learned from the COVID-19 Pandemic
7.6 Summary
References
Chapter 8: Add-on Modules, Quality Assessment Issues, and Specific Arrangements in Intensive Care Units (ICU) Sector: Demand of Infrastructure and Staff
8.1 Infrastructure
8.1.1 Stabilization
8.1.2 Decision
8.1.3 Termination
8.2 Staff
8.3 Summary
References
Chapter 9: Brainstorming: Personnel Education and Planning Stage of the Service
9.1 General Considerations of Personnel Education
9.2 Leaning Theories
9.3 Subjects of ECMO Training
9.4 Maintenance of ECMO Competency
9.5 Special Considerations Regarding an ECMO Retrieval Program
9.6 Summary
References
Chapter 10: Assign the Parts: Aspects of ECMO Team Building
References
Chapter 11: Checklists, Retrieval Protocols, and Internal Guidelines
11.1 Checklists
11.2 Patient Status
11.3 Monitoring (Technical Preparations)
11.4 Medication
11.5 Bedside ECMO Safety Checklists
11.6 Retrieval Protocol
11.7 Code of Conduct
11.8 ECMO Transport Process
11.9 Transport Modalities
11.10 Indications for Mobile ECMO Therapy
11.11 Door-to-Implantation Time
11.12 Internal Guidelines
11.13 Contraindications for ECMO Therapy
11.14 Prognostic Factors for Patients Receiving eCPR
References
Chapter 12: As Little As possible and As Much As Necessary: Supplementary Equipment and “ECMO suitcase” for Retrieval Service
12.1 Preface
12.2 General Utensils
12.3 ECMO Implantation
12.4 Connectors
12.5 Adapters
12.6 Surgical Material
12.7 ECMO Accessories
12.8 ECMO Cannulas
12.9 Alternative ECMO Cases and Stabilization Tools
References
Chapter 13: Do you Really Need an ECMO Coordinator? Strategies to Optimize Communication
13.1 General Principles of Communication Strategies
13.2 Strategies for ECMO Communication
13.3 Conclusion
References
Chapter 14: Round-the-Clock Operation: Trips and Tricks to Help Achieve Flexibility and Realizability
14.1 Patient Population and Selection
14.2 Human Resources
14.3 The ECMO Team
14.4 Supportive Staff
14.5 Training
14.6 Equipment and Disposables
14.7 Location and Infrastructural Features
14.8 Transportation
14.9 Ground Transport Via Ambulance
14.10 Preparing for Transport to the ECMO Center
14.11 Air Transportation
14.12 Adverse Events During Transportation
References
Part III: Specifics of the Propaganda Machine: How to Get Referrals and What Is the Best Way to Draw Attention to the Program
Chapter 15: Professional Web Presence as an Indispensable Module of the Current Information Dissemination
15.1 Impact of Web Presence on Success of Medical Programs: Scientific Background
15.1.1 Why Is a Web Presence Useful for ECMO Programs?
15.1.2 Purposes and Benefits of Web Presence: General Considerations
15.1.3 Quality of Website: What Is Essential?
15.2 Social Media as an Additional Tool to Present the Program
15.3 Recommendations on Structuring an ECMO Center Website
15.4 What Should Centers Keep in Mind to Appropriately Present the Program?
15.5 Conclusion
References
Chapter 16: Are Printed Media Still Holding Their Own Against the Electronic Competition?
16.1 Printed Media Against Electronic Media
16.1.1 Media during the COVID-19 Pandemic
16.1.2 Behavioral Trends during the Pandemic
16.1.3 Media by Age
16.1.4 Media by Country
16.1.5 ELSO Presence in Print and Electronic Media
16.1.6 ECMO Team Presence in Printed and Electronic Media
16.1.7 ECMO Team Web Presence, Posters, and Flyers
16.1.8 “Das Kölner Herzzentrum”
16.2 Conclusion
References
Chapter 17: Show Your Face: Personal Introduction and Direct Communication with Referring Colleagues
17.1 Interdisciplinary Communication: Discussion on Eye Level
17.2 Interprofessional Communication: Scientifically Provable Impact on Patient Treatment
17.3 Specifics of Communication between ECMO Teams and Referring Colleagues
17.4 Advantages of Face-to-Face Education
17.5 Conclusion
References
Chapter 18: Meet the Experts: Scientific Exchange and Academic Performance through Symposiums and Peer-Reviewed Publications
18.1 ECMO Therapy: For Everyone and Everywhere?
18.2 Who Is an ECMO Expert? International Leading Centers
18.3 National and International Conferences
18.4 Literature Search on ECMO
18.4.1 Trials for ECMO Therapy in Cardiogenic Shock
18.4.2 Trials for ECMO Therapy in Acute Respiratory Failure (ARF)
References
Chapter 19: Make Your Global Debut: Benefits of Joining Extracorporeal Life Support Organization (ELSO)
19.1 Who and What Is ELSO?
19.2 Benefits of an ECMO Center Membership with the ELSO
19.2.1 ELSO Registry Database
19.3 Training in Advanced Life Support: Benefits of ELSO Membership
19.4 ELSO Registry COVID-19 Experience
19.5 ELSO Adult ECMO Practitioner Certification (E-AEC)
19.6 Conclusion
References
Part IV: From Start to Finish: Chronological Order and Safety Aspects of ECMO Retrievals from Local Hospitals
Chapter 20: Time Is Life: Optimization of Packing up the Equipment and Organizing Outward Journey
20.1 Receiving the Initial Phone Call and Implementations for Material Considerations
20.2 Hospital-Based Requirements of an Outward Facility for Receiving ECMO Support and for ECMO Center for Treat ECMO Supported Patients
20.3 Management and Organization of ECMO Team Members
20.4 Packing Things for Transport
20.4.1 ECMO Rack
20.4.2 Decision on Cannulation Strategy and Choosing Appropriate Equipment
20.4.2.1 Cannula Selection
Arterial Cannula
Venous Cannula
20.4.2.2 Guidewire
20.4.2.3 Distal Perfusion Cannula
20.5 Transport of the ECMO Team and its Equipment
20.5.1 “Rendez-Vous” System
20.5.2 Compact System
20.6 Putting it Altogether: Quick and Efficient Organization of Transport
References
Chapter 21: On the Road: Fast and Safe Transport of the Team and Equipment
21.1 Preface
21.2 Primary Transport
21.3 Preparation for Secondary Transport
21.4 Secondary Transport
21.5 Contraindications to Mobile ECMO
21.6 Transport Team
21.7 Transport Vehicle for ECMO Transport
21.8 ECMO Equipment for Mobile ECMO Transport
21.9 Medication
21.10 Summary
References
Chapter 22: On the Spot Check: Clinical Evaluation and Decision-Making
22.1 Introduction
22.2 Pathophysiology and Indications for Mechanical Cardiocirculatory Support
22.3 Clinical Evaluation
22.3.1 Confirmation Bias
22.3.2 Interpersonal Communication
22.3.3 Getting up to Date
22.3.4 Airway
22.3.5 Breathing
22.3.6 Circulation
22.3.7 Disability
22.3.8 Environment/Extremities/Extras
22.3.8.1 Core Temperature and Temperature Management
22.3.8.2 Vascular Access
22.3.8.3 Laboratory Analysis, Blood, and Blood Products
22.3.8.4 Room
22.3.8.5 Patients’ Will
22.3.8.6 Transport
22.4 Decision-Making
22.4.1 Does the Patient Still Meet ECMO Criteria?
22.4.2 What Are the Clinical Goals of the Individual Patient and how Can they Be Met As Best as Possible?
22.4.3 What Form of Mechanical Cardiocirculatory Support Is best Suited to Meet the Individual Goals of the Patient?
22.5 Peripheral vaECMO
22.6 Peripheral vvaECMO
22.7 Peripheral vavECMO
References
Chapter 23: Pearls and Pitfalls in ECMO Cannulation: Practical Tips to Minimize Complications
23.1 Percutaneous Cannulation: Femoral Vein and Artery
23.2 Open Femoral Cannulation
23.3 Role of Fluoroscopy
23.4 Percutaneous Vessel Closure
23.5 Bailout Strategies for Arterial Cannulation
References
Chapter 24: Save the Leg: Game Plans for Ensuring Distal Limb Perfusion
24.1 Introduction
24.2 Incidence of ALI in Peripheral vaECMO Patients
24.3 Pathophysiology and Risk Factors of ALI in Peripheral vaECMO Patients
24.4 Clinical Assessment and Diagnosis of ALI in Peripheral vaECMO Patients
24.5 Prevention Strategies of ALI in Peripheral vaECMO Patients
24.5.1 Arterial Cannula Size Selection, Cannulation Technique, and Cannulation Site Selection
24.5.2 Distal Perfusion Cannula (DPC)
24.5.3 Bidirectional Cannula
24.5.4 ECMO Weaning and Decannulation Strategy
24.6 Treatment Strategies of ALI in Peripheral vaECMO Patients
24.7 Compartment Syndrome
24.8 Conclusion
References
Chapter 25: Initial Management of Transported Patients After Arrival on ICU
25.1 Preface
25.1.1 Case Example—ECLS System
25.2 Intensive Care Monitoring Under ECLS
25.3 Hemodynamic, Catecholamine Therapy, and Perfusion Flow
25.4 Gas Exchange and Ventilation
25.5 Neurological Status
25.6 Leg Perfusion
25.7 Anticoagulation and Blood Management
25.8 Pharmacokinetic Aspects
25.8.1 Case Example—ECMO Weaning
25.9 Complications under ECLS
25.10 Summary
25.11 Key Points
References
Chapter 26: Ins and Outs of Extracorporeal Cardiopulmonary Resuscitation (eCPR) service
26.1 Extracorporeal Membrane Oxygenation (ECMO)
26.2 Extracorporeal Cardiopulmonary Resuscitation
26.3 Inclusion and Exclusion Criteria
26.3.1 Inclusion Criteria [7, 17]
26.3.2 Exclusion Criteria
26.4 Timing
26.5 Organization and Localization
26.6 Initial Rhythm
26.7 pH Value
26.8 Percutaneous Coronary Intervention (PCI)
26.9 Team Organization
26.10 Targeted Cardiopulmonary Resuscitation (tCPR)
26.11 Organ Donation
References
Part V: Pushing the Boundaries: Managing Out-of-Hospital Cardiac Arrest
Chapter 27: Out-of-Hospital Cardiac Arrest—Achilles’ Heel in Cardiovascular Medicine
27.1 Introduction
27.2 Etiology
27.3 Prognostic Factors
27.4 Hemodynamic Mechanisms
27.5 Pharmacologic Treatment
27.6 Percutaneous Coronary Intervention
27.7 Mortality and Neurological Outcomes
27.8 Termination of Resuscitation
27.9 Refractory Cardiac Arrest
27.10 Time to Change the Strategy?
References
Chapter 28: In- or Out-of-Hospital ECMO Implantation? Impact of Infrastructure, Logistic Conditions, and Legal Circumstances
28.1 Principles and History of In- or Out-of-Hospital ECMO Implantation
28.2 Technical and Logistic Aspects in eCPR
28.2.1 Vascular Access
28.2.2 Location
28.2.3 Transport
28.3 Evidence on Pre- and Early In-Hospital Use of eCPR
28.3.1 Pre-hospital Use
28.3.2 Early In-Hospital eCPR
28.3.2.1 ARREST
28.3.2.2 PRAGUE OHCA
28.3.2.3 EROCA
28.3.3 Case Series, Choi et al.
28.4 Conclusion
References
Part VI: Miscellaneous
Chapter 29: Ethical Considerations
29.1 Is the Patient Center of Therapy or the Therapy Itself?
29.2 Bioethical Issues: Ethical Limitations and Dilemma of ECMO Therapy
29.3 Ethical Considerations of ECMO Therapy in Regard to Medical-Scientific Aspects
29.4 Bioethical Aspects of ECMO Therapy with Focus on Christian-Theological Views
29.5 Anthropocentric and Christocentric View of Human Beings
29.6 Impact of Human Dignity
29.7 Understanding of Disease in Christian Theology
29.8 Is Quality of Life the Only Measure of Ethical Considerations?
29.9 Reflection of Scientific Knowledge in Terms of Patient Treatment
29.10 Conclusion
References
Chapter 30: From the View of a Patient and Next of Kin
30.1 Introduction
30.2 Initial Situation
30.3 Sudden Cardiac Arrest
30.4 Procedures at the University Hospital in Cologne
30.5 Further Progress and Current Condition
Chapter 31: Future Perspectives
31.1 The Role of Remodeling in Heart Failure
31.1.1 Introduction
31.1.2 The Road to Heart Recovery
31.1.2.1 Trigger of Remodeling
31.1.2.2 Inflammation and Remodeling
31.1.2.3 Structural and Functional Changes
31.1.3 The Role of Ventricular Unloading
31.1.3.1 Unloading in ECMO
31.1.3.2 Unloading Toward Recovery
31.1.4 The Future in Device Technology
31.2 A Growing ECLS World and the Next Frontier
31.3 ECLS Centers and Mortality
31.4 Staffing Challenges in Healthcare
31.5 Automation in the Modern World
31.6 Quantum Leap for ECLS
31.7 Automation for Initiation
31.8 Auto-sigh Feature
31.9 Using Technology to Address Staffing Challenges
31.10 Bridging the Gap
References
Index