Interhospital transport of patients requiring extracorporeal membrane oxygenation (ECMO)
*Piotr Knapik1, Roman Przybylski2, Jarosław Borkowski1, Rafał Koba1, Dawid Borowik1, Tomasz Maciejewski1, Marcin Borowicz2, Grzegorz Włoczka2
1Department of Cardiac Anaesthesia and Intensive Therapy, Medical University of Silesia, Silesian Centre for Heart Diseases in Zabrze
2Department of Cardiac Surgery and Transplantation, Medical University of Silesia, Silesian Centre for Heart Diseases in Zabrze
Background. The recent outbreak of AH1N1 influenza was associated with an increased number of respiratory complications. There were some extremely severe cases of ARDS, in which conventional therapy could not secure adequate gas exchange. These patients fulfilled ECMO criteria, however, due to late referral, were not suitable for transportation. To solve this problem, a portable ECMO system, providing for safe management of these patients, has been introduced in our institution.
Case report. We reviewed five adult ARDS patients, who were transported by an ambulance for a distance ranging from 2 to 95 km, over 35 to 120 min. In four cases, a veno-venous ECMO system was used, and one patient had an arterio-venous circuit. All circuits were implanted before transportation by a dedicated team from the reference hospital, comprising an anaesthesiologist, a cardiac surgeon and a perfusionist. All transportations were successful and no complications and/or technical problems were observed. During the subsequent ITU treatment, three patients survived and two died (one because of uncontrollable bleeding from the ECMO cannula, and one because of sepsis and multiple organ failure).
Conclusion. We conclude that safe use of ECMO during transportation is possible, and does not require very sophisticated and expensive equipment. A standard ambulance is sufficient for the purpose.
The AH1N1 influenza pandemic opened the doors to extracorporeal membrane oxygenation (ECMO) to be used in modern intensive therapy in many countries, including Poland. After the first experiences of 2009/2010 influenza, the recommendations of the specialist surveillance and the National Consultant of anaesthesiology and intensive therapy explicitly suggested that such an invasive and expensive therapy as ECMO should be carried out professionally, without heroism or improvisation involved . To support the use of ECMO, the Ministry of Health recognized the therapy as a payer-refunded therapeutic procedure and purchased the portable ECMO equipment for twelve centres of cardiac surgery . However, the optimal model for ECMO therapy in our country has not been determined yet.
The prerequisite of successful ECMO procedures is safe arrival of the patient to the reference centre where long-term ECMO support is possible. On referral to the reference centre, however, indications for ECMO can be already fulfilled and safe transport may not be achievable. Thus, ECMO should be instituted at the local hospital to provide suitable conditions for safe transport to the reference centre.
Such solutions have been well known and applied for a long time. The literature data suggest that transport ECMO in adults was already used in the nineties [3, 4, 5] and in children even earlier, i.e. in the eighties of the previous century [6, 7, 8]. At present, transport ECMO is routinely used in many centres, and involves adults [9, 10, 11, 12, 13, 14], children and newborns [6, 15, 16].
In Poland, the first patient undergoing ECMO was transported from Kępno to Wrocław in November 2009. The transport was long and difficult yet, thanks to high skills of the transporting team and their ability to deal with crises, the patient finally arrived at the reference centre in stable condition. According to the available data, no other patients have been transported on ECMO since that time .
We describe 5 cases of patients` transport with ECMO from the sending hospital to the reference centre.
The patients described were transported between January and March 2010 in the Silesian province. The time from the telephone qualification of patients to arrival of the reference centre team ranged from 4 to 8 h. Patients were transported to the ITU of the Silesian Centre for Heart Diseases in Zabrze from multi-profile ITUs in Zabrze, Częstochowa, Rybnik, Bytom and Gliwice. The distance between the reference centre and sending hospitals was 2-92 km, the arrival time was 10-90 min and transport time – 35-120 min. The detailed transport data are presented in Table 1.
In the analysed group, four patients developed fulminant ARDS in the course of AH1N1 infection; one female patient developed respiratory failure, which was likely to result from post-influenza bacterial complications. The patients` age ranged from 21 to 55 years. All patients met the ECMO criteria – for at least 2 h they were artificially ventilated, FIO=1.0, PEEP ≥10 cm H2O (1 kPa), PaO2 <70 mm Hg (9.3 kPa). They were haemodynamically stable, no catecholamine infusions were administered, except for one case. The patients’ characteristics on ECMO qualification are listed in Table 2.
During transportations, the same management scheme was used. After referral, the team, consisting of an anaesthesiologist, a cardiologist and a perfusionist, was sent to re-assess the patient condition; if the ECMO criteria were fulfilled and conventional transport was not possible, the team implanted the ECMO circuit, started extracorporeal oxygenation and transport. In five transports, 4 different anaesthesiologists were involved.
In three cases, the portable ECMO rotation pump, Maquet 2500s, and the Permanent Life Support oxygenator, 215 mL (Maquet, Germany) were used; in two cases, the Stockert (Sorin Group, Gernamy) or Levitronix (Levitronix, USA) pumps were applied as the transportation system was used in another patient. The system of an oxygenator and drains (total capacity of about 600 mL) was gravitationally de-bubbled and recirculated with the pump for about 5 min.
The veno-venous ECMO system was used in 4 cases and the arterio-venous circuit in one case due to coexisting symptoms of circulatory failure (converted into veno-venous system immediately after arrival to the reference centre when normal myocardial contractility was confirmed). In all veno-venous ECMO cases, the Biomedicus catheters, 19 and 23 (Medtronic, USA), were transcutaneously inserted respectively to the right internal jugular vein (outflow) and the left femoral vein (inflow). The extracorporeal membrane oxygenation was started at the pump output of 4.5 - 6 L min-1, with 100% oxygen supply to the oxygenator – 5-7 L min-1. The heparin infusion was initiated maintaining the values of activated clotting time within the range of 180-200 secs.
Vascular cannulation and preparation of the patient was carried out in the ITU of the sending hospital. Once the patient’s condition was stabilised and satisfactory oxygenation achieved, transportation to the reference centre was started.
Patients were transported by the reference centre ambulance specially prepared for such purposes. Since the size and weight of the ECMO transport system are large (over 50 kg), the use of a standard transport trolley and a gas mixer was abandoned. During transportation, the control panel was placed on the stretcher between the patient’s legs and secured with the belt preventing its movement. The oxygenator and the pump drive were fixed to the stretcher using the handles and the heat exchanger – thanks to small diameters of drains – was placed in the front part of the ambulance. Oxygen was initially taken from the 10-litre transport cylinder and then from the ambulance oxygen source. After arrival to the reference centre, the control panel, pump, oxygenator and heat exchanger were mounted on the transport trolley and gas was further supplied to the oxygenator using the gas mixer.
During transportation artificial lung ventilation using the Pneupac VR1 ventilator (Smiths Medical, GB) was administered to all patients; standard monitoring involved ECG, SpO2 and SAP/DAP (the invasive method).
In three cases, the treatment was successful; two women were discharged home in good general condition. Two patients did not survive – in one case due to massive haemorrhage from the inflow catheter insertion place on day 2; in the other one because of irreversible multi-organ failure during septic shock after 3 weeks of extracorporeal oxygenation (Table 3).
The use of ECMO during transport seems to be risky; meticulous analysis, however, shows that the procedure is safe. The idea of a mobile intensive therapy unit was introduced already in 1993 by the American College of Critical Care Medicine and the American Association of Critical Care Nurses, which presented the suitable standards for transportation of critically ill patients .
The above recommendations were followed by the authors planning the first uses of transport ECMO carried out in the years 1993-1995. A large-size ambulance was equipped with 220 V power supply, the extracorporeal circulation device with a heat exchanger, full-range haemodynamic monitoring, equipment for nitric oxide supply, high-quality ventilator and even a portable device for gasometry as well as haemoglobin and electrolyte determinations . During that period, eight patients were transported with ECMO. All of them tolerated transport very well; six survived and were discharged from hospital.
In the developed countries, transport with ECMO has become routine. In the first 'pandemic' season of 2009/2010 influenza, 38 patients were uneventfully transported from the sending hospitals to the reference centres in Australia and New Zealand . Some other literature reports show that such transports were carried out using helicopters  or military airplanes, which carried the entire ambulance transporting the patient .
In Poland, it would be extremely difficult to fulfil the mentioned standards. The majority of our ambulances have almost nothing in common with a mobile intensive therapy unit. It is difficult to transport in them patients with severe respiratory failure, not to mention the use of ECMO. Ambulances are small and cramped; most of them lack the ventilators, which could meet the requirements of ECMO transport. The devices for nitrous oxide supply are unavailable not only in ambulances but also in the majority of ITUs. Invasive haemodynamic monitoring, which is indispensible during such ECMO transport, is usually unavailable in ambulances. Skills of ambulance teams are varied. However, positive sides should also be stressed as some signals indicating improvement in this field are noticeable .
Being aware of the fact that occurrence of patients with respiratory failure in the course of pandemic influenza is only a matter of time, our centre started preparations for transporting such patients in 2009. It was assumed that once the patient for ECMO therapy is notified, the safest procedure is the so-called 'own transport'. Our own (typical, small) ambulance was equipped with safe 220V power supply and all necessary devices were prepared. The portable ECMO system was purchased, which supplemented portable invasive monitoring and the set for nitrous oxide supply not requiring mains power. It was decided that for insertion of ECMO, the 'ready-to-leave' transplantation team will be sent, which under normal conditions is used to transport organs for transplantation; such a team is suitably trained and insured.
A relevant inconvenience seemed to be the lack of a proper quality transport ventilator. However, based on our earlier experience, it can be explicitly stated that transport of critically ill patients with extreme hypoxia is much safer using ECMO than using the best-quality transport ventilator. This does not mean that the ambulance should not be equipped with such a ventilator as soon as possible.
It is worth noting that the first testing of the equipment and planned procedures was not stress-free as the system was put straight away in practice. Before the institution of the comparable system in Norway, all devices (ventilators, monitors, nitric oxide supply, medical gases and power, including ECMO system) had earlier been tested in animals (pigs) and the Hercules plane had had several acceptance flights . It is not known what preparations were carried out in other cases [7, 9, 12, 13].
The available data clearly indicate that transportation of patients with the use of ECMO is safe yet requires suitable preparations, skills and perfect organisation of the transporting team. Our experience shows that organization of safe transport is possible also under Polish conditions using relatively simple solutions. The observations collected by us are worth considering while designing the Polish model of protection of patients with severe respiratory failure using ECMO.
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