ECLS supported transport of ICU patients: does out-of -house implantation impact survival?
Journal of Cardiothoracic Surgery, Ausgabe 1/2021
Extracorporeal life support (ECLS) is a potentially life-saving technique applied to critically ill patients with severe cardiac and/or pulmonary failure, and its use has increased over the past decades [ 1, 2].
Generally, two forms of ECLS are available: venous-venous (v-v) support for hypoxic respiratory failure and acute respiratory distress syndrome (ARDS), and venous-arterial support for cardiac failure/cardiogenic shock [ 3].
The use of ECLS is expanding, and with growing experience and availability of reliable devices, this treatment option is no longer limited to large, tertiary centers but is also available in some smaller, secondary centers. However, an increasing number of tertiary centers are now offering mobile ECLS teams to transport severely ill patients from smaller secondary and primary centers with the possibility of ECLS cannulation on-site. Since the first report of a successful ECLS transport in 1986, this potentially life-saving treatment option has gained widespread use [ 4]. In recent years, a number of single center studies have been published on the experience with mobile ECLS teams. Here, we present our experience with the mobile ECLS team and compare its outcome to our extensive in-house experience. We aim at answering the question whether extra-hospital ECLS implantation has an influence on mortality and morbidity.
We retrospectively analyzed all extracorporeal membrane oxygenation implantations performed in-house at our center and at outside hospitals from 2012 until 2018.
During this time, a total of 978 ECLS implantations were performed, of which 243 were performed on-site in tertiary hospitals for ECLS supported transportation. Contact was usually initiated by the referring clinic to the cardiac surgery department by telephone. After careful consideration with the collaborating departments, the patient was selected for either v-v or v-a support. Patients eligible for v-v ECLS support were critically ill patients with potentially reversible respiratory failure or indication/candidate for lung transplant with a peak inspiratory pressure > 32 mmHg, refractory hypercarbia (pH < 7.2) despite optimal respiratory maneuvers. Indications for v-a support were patients in cardiogenic shock with treatment options (reversible/VAD/transplant/surgery candidate) with acedemia, lactatemia, under high doses of catecholamines.
The mobile ECMO team consists of a cardiac surgeon and a perfusionist. Transport was carried out as appropriate, either ground based or via helicopter/airplane for longer distances (> 150 km). We used the CARDIOHELP-System (Getinge, Getinge, Sweden) console and a variety of cannulas (Novaport, Avalon, BioMedicus, Twinport, HLS) at the surgeon’s discretion. Based on our experience with femoral v-a cannulation, we have a mandatory approach to establish distal limb perfusion. If not possible on-site, distal limb perfusion is performed either through open surgery or ultrasound-guided after arrival at our center. V-v support is either performed via cannulation of the femoral vein and the jugular vein or by a twin-port canula via the femoral vein if hypercarbia is the main reason for respiratory failure.
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