Manual of Extracorporeal Membrane Oxygenation (ECMO) in the ICU Poonam Malhotra Kapoor
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1MANUAL OF Extracorporeal Membrane Oxygenation (ECMO) in the ICU2
3MANUAL OF Extracorporeal Membrane Oxygenation (ECMO) in the ICU
EditorPoonam MalhotraKapoorMD DNB MNAMS FIACTA FTEE FISCU Additional Professor Department of Cardiac Anesthesia Cardiothoracic and Neurosciences Center All India Institute of Medical Sciences, New Delhi, India Secretary, Society of Cardiac Anesthesia, New Delhi and NCR Branch Coordinator, IACTA Education and Research Cell Co-editor, Annals of Cardiac Anesthesia ForewordsNavin C Nanda Naresh Trehan Balram Airan Steven A Conrad Yatin Mehta
4
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Manual of Extracorporeal Membrane Oxygenation (ECMO) in the ICU
First Edition: 2014
9789350906330
Printed at
5Dedicated to
My father and family
Dr KK Malhotra (4.7.1929–4.1.2011)
My mentor, guide and inspiration in life
An extraordinary physician and human being with boundless affection, witty, hardworking and godly qualities
6
7CONTRIBUTORS 9FOREWORD
It is a pleasure to write a foreword for Manual of Extracorporeal Membrane Oxygenation (ECMO) in the ICU edited by Dr Poonam Malhotra Kapoor. ECMO represents a modern day challenge in every cardiac and noncardiac ICU and is unique in that it requires in medical professionals from different disciplines to act as one team in providing the best care to the patient. She is to be commended on producing this manual which provides an overview of this important subject. Many aspects of ECMO such as its use in ARDS, sepsis and bronchopulmonary fistula are comprehensively covered. Since ECMO may be the last hope for survival in some patients, all technical intricacies in its operation including timing of weaning from ECMO are clearly and lucidly detailed in this work. The manual emphasizes the need for patient-centered care at every stage of ECMO and to provide an easily assimilable knowledge of the subject, narratives are followed by questions and answers. This format which also includes multiple choice questions will be particularly helpful to students preparing for examinations. This practical manual will be of immense benefit to all health care professionals whose work brings them into contact with patients in the intensive and critical settings. This includes not only intensivists but also anesthesiologists, surgeons, cardiologists, pediatricians, trainees, students and paramedical personnel such as nurses and perfusionists.
Dr Poonam Malhotra Kapoor as an experienced anesthesiologist in one of India's premier medical institutions is well suited to take this onerous task of editing and writing this manual and she has done this most admirably. I highly recommend this manual and I am confident it will garner the success it deserves.
Navin C Nanda
Distinguished Professor of Medicine and Cardiovascular Disease
University of Alabama at Birmingham, Birmingham, Alabama, USA
President, International Society of Cardiovascular Ultrasound (ISCU)
10FOREWORD
Extracorporeal membrane oxygenation (ECMO) has come a long way from early days in 1971 when it was used for prolonged respiratory support in a case of post-traumatic acute respiratory distress syndrome (ARDS).
The initial use remained in cardiac surgery for refractory cardiac failure post-CPB and was later on extended to pediatric patients and in patients in cardiogenic shock not responding to conventional cardiac supportive measures like inotropes, vasopressors/dilators or IABP. Earlier days, it was a rescue procedure for the cardiac surgeons, in order to buy time so that the original insult leading to refractory cardiac failure is reversed with improvement in patients’ own cardiac function before weaning off the ECMO. The domain was restricted to perioperative cardiac surgery, with all the venous and arterial cannulae being inserted by the cardiac surgeon either through the open chest or percutaneously through the groin/neck and monitored and managed by the perfusionist under the supervision of the cardiac surgeons/anesthesiologists.
Over a period of time, the indications and users of ECMO has extended beyond the boundaries of cardiology and cardiac surgery and worldwide the usage is increasing with evidence coming out in its favor in relatively large trials.
This book edited by Professor (Dr) Poonam Malhotra Kapoor has contribution of renowned professionals, is timely, very well written and would be a valuable addition to any medical library.
Naresh Trehan
Chairman and Managing Director
Medanta—The Medicity
Gurgaon, Haryana, India
11FOREWORD
ECMO with ELSO in the USA and also in many other parts of the world is now a far advanced medical therapy. In India too, ECMO started 11 years back at our center (CN Center) AIIMS, New Delhi, and has picked up more in the last four to five years, after introduction of the role of “Integrated ECMO” in congenital cardiac disease like TGO, ALCAPA, obstructed TAPVC and all cardiac surgeries having a failing heart and lung. Under the experienced hands of Professor Usha Kiran, Professor Sandeep Chauhan, and other cardiac anesthetists, experienced cardiac surgeons and an experienced team of perfusionists “The ECMO Team” at AIIMS has nurtured and rescued many patients with the use of “Integrated ECMO”. Venoarterial ECMO state of the art is the tribute and experience from CN Center AIIMS. We have reached and learnt a lot together and have lots more to achieve in this field, chiefly the control of bleeding and infection during ECMO.
The path to success in ECMO seems to be getting steeper every year. ECMO involves a huge infrastructure in the ICU and operation room and it is difficult to know whether the institute doing ECMO has garnered all the necessary facts and reached the right standard of patients monitoring during ECMO. That is precisely where this book comes in, written by experienced ECMO physicians, who have toiled their way doing ECMO on patients in the ICU. This manuscript will give the reader an opportunity to know the depth and breadth of ECMO in different case scenarios. Right knowledge at the right time in the right hands is essential.
This manual of ECMO is an advance in that the content has been enriched by short questions and answers with multiple choices in the last section and good explanatory illustrations in all the sections. It is, of course, particularly gratifying to me that this initiative has been designed and delivered by a CN Center AIIMS faculty Dr Poonam Malhotra Kapoor, who has edited the manuscript and I congratulate her and all the contributory authors of different chapters for bringing about a timely book on a futuristic ECMO. I wish this book all the success it deserves.
Balram Airan
Head, Department of CTVS
Chief CTC
CN Center AIIMS, New Delhi, India
12FOREWORD
Among the central themes of critical care is support of failing organs, and it has long been the dream to be able to provide artificial organ support in anticipation of recovery of function. Renal replacement therapy is now routinely applied in the intensive care unit, enabling time for return of renal function. Support of the failing circulation with ventricular assist devices is rapidly maturing, and several options are available for short-and long-term support. We are lacking good support modalities for liver failure, but current research into bioartificial and other technologies is encouraging.
Developing support technologies for severe acute respiratory or combined cardiorespiratory failure has been a journey of nearly half a century. The early technological barriers were seemingly insurmountable, with severe hemolysis, platelet activation and systemic inflammation limiting the initial applications to short periods of time. Technological improvements, notably the more biocompatible silicone artificial lung and cannulas for peripheral vascular access permitted successful support for up to weeks at a time, allowing the slow diffusion of ECMO into specialized centers around the world. More recent developments in hollow fiber technology and centrifugal pump technology have made for an equally important jump in efficacy and safety. While it would be irresponsible to suggest that ECMO is a mature technology, it clearly has reached a stage for more widespread application.
Perhaps, the next barriers for ECMO to overcome are adoption and education. It is past time to assume that our current applications of mechanical ventilation and pharmacologic circulatory support represent true organ support. To the contrary, they are as likely to cause harm as to help, and the earlier institution of what is now a reasonably safe support modality should be incorporated into our practice as ordinary and not extraordinary care.
This timely text will help overcome these barriers with its broad treatment of relevant topics in ECMO along with a self-study section. This comprehensive compendium of current information includes the fundamentals of ECMO equipment and physiology, practical steps in initiation and maintenance of support, monitoring and management of patients, and applications in a variety of clinical settings, including ‘new’ indications such as sepsis. It stands as an important resource in the hands of those dedicated to providing care for the most critically ill and injured.
Steven A Conrad
Shreveport, Louisiana, USA
13FOREWORD
Extracorporeal membrane oxygenation (ECMO) has come a long way from the earlier days when it was used as a desperate measure when the patient was not able to come off CPB despite maximal therapy. The techniques, circuitry and oxygenators were primitive with poor biocompatibility, excessive hemolysis and platelet destruction; ultimately, leading to death in majority of patients.
The indications for ECMO have increased not only from the disease spectrum point of view but also with respect to the type of ECMO used, i.e. venoarterial (VV) to venovenous (VV).
ECMO started with VA for cardiac surgery and has spread to medical ICU as VV-ECMO. ECMO now is an addition to the supplementing cardiac function which is being used more and more to support the lungs particularly in ARDS.
Worldwide ECMO numbers are going up with ELSO registry data adding to our knowledge base.
ECMO is being used more and more in different centres in India but the knowledge, familiarity and expertise is lacking.
This book by Prof (Dr) Poonam Malhotra Kapoor is a significant contribution to the reduction of this lacuna.
Yatin Mehta
Chairman
Medanta Institute of Critical Care and Anesthesiology
Gurgaon, Haryana, India14
15PREFACE
The process of extracorporeal membrane oxygenation (ECMO) for the failing heart and lung is the last straw of hope and life. When all other modalities fail, ECMO offers a ray of sunshine. The presence of ECMO in cardiac ICU brightens up the gloomy atmosphere with E-CPR.
The power of ECMO under ELSO (USA), RVCC (Mumbai) and the largest cardiac series in India at All India Institute of Medical Sciences (AIIMS) has come a long way. It adds years to a shortened life whether you are a postgraduate or an intensivist, a perfusionist, a cardiologist, a pediatrician, a cardiac surgeon, a cardiac or general anaesthetist or a nurse, you will find a body of enjoyable and useful information within the cover of this book as ECMO is a teamwork. The 40 chapters in 11 different sections within this book expound upon our learned knowledge of nature's gift to humanity–that of every cell “thriving to live despite complications”. This book is simple reading of a complicated subject. In last 24 years, through various clinical trials, ECMO has been modified by technology and the medical profession's ability to discover, synthesize, modify and use this technology has enabled most of us to reach the stage of using advanced ECMO in a simple manner to decrease the morbidity and mortality in the cardiac and respiratory ICU.
The inspiration for this book arose from the desire to enlighten and instill a greater appreciation of the subject within the medical fraternity—and to inspire to the physicians and the young students to explore more into the fascinating and almost infinite applications of ECMO. For most, the mere mention of the word “ECMO” conjures up images of tubes, bulky heart-lung apparatus and a bleeding patient. The reality of ECMO is far more exciting and rewarding, once these unfortunate and distressing images are dispelled.
ECMO has brought together many medical disciplines. A few other recent technologies have evoked such an impact from its usage in almost all ICUs as has ECMO. Section 10 of this book is a treatise to the reader in the form of multiple choice questions—some with explanation and some without explanation. It will also help in preparing for the examination.
There is so much yet to be discovered and invented by the younger generation of doctors who choose to use this technology judiciously with their minds and aim to chisel “ECMO” to its finest glory. The ball has been set rolling.
I hope the reader will enjoy reading this book as much as I have loved writing and editing it.
Happy Reading.
Poonam Malhotra Kapoor
16
17ACKNOWLEDGMENTS
Manual of Extracorporeal Membrane Oxygenation in the ICU is the first book of its kind in India. At the outset, I would like to thank my senior “Gurus” from All India Institute of Medical Sciences – Professor P Venugopal, Professor Sampath, Professor Balram Airan, Professor Neeta Saxena, Professor S Kale, Professor Usha Kiran, and Professor Sandeep Chauhan, for their guidance and support throughout the past few years have been nothing but inspirational. It was at AIIMS, under their farsighted leadership that ECMO started in India. I feel privileged to be a part of AIIMS faculty, wherein, I have observed and put the patients on ECMO in the cardiac OT and ICU, on a weekly basis in last 10 years. I am particularly thankful to each one of them and to all other co-faculty and perfusion colleagues at AIIMS for their constant support.
This book which started as an MCQs book and took the shape of a Textbook/Manual, is possible because of its contributors— each one of the authors who could come out with chapters in such short time should be applauded for their efforts. My heartfelt gratitude to them. My office team member, Mr Sandeep, Mr Manoj Mishra, Mr Pardeep, Mr Sachin Balyan, and Miss Poonam, are to be specially thanked for their data and reference input and typing and preparation of this manuscript along with their long working hours without a grimace, all of which added to my confidence in a big way to finish this manuscript in time!
I am heartily thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India, and their highly professional publishing team is whom I am most grateful for, for their second time speedy work in such a professional manner.
I am grateful to my mother, sisters, husband and son for their untiring emotional support, affection and love along with their constant encouragement which was the good like a safety net! Thank the God above for a family of mine and all of them being in my life. The book is an ode to “ECMO India 2013” under the auspicious of SCA – Delhi & NCR branch, ELSO Registry & ECMO Society of India, who all come together under Dr Steve Conrad, Dr Yatin Mehta, Dr Venkat Goyal and Dr Pranay Oza, respectively.
I thank all these leaders and am freely indebted to them for their commitment and leadership and exceptional cooperation and motivation in making this “ECMO Manual” possible. This book is under the aegis of these three societies.
Thanks to Dr Steven A Conrad, Dr Navin C Nanda, Dr Naresh Trehan, Dr Balram Airan and Dr Yatin Mehta for writing foreword(s) to this book and encouraging me with expert suggestions.18
25Introduction of Extracorporeal Membrane Oxygenation in a Layman's Language
CHAPTER OUTLINE
  • □ What is Extracorporeal Membrane Oxygenation?
  • □ Who Goes on Extracorporeal Membrane Oxygenation?
  • □ How does Extracorporeal Membrane Oxygenation Work?
  • □ What is Principle behind Extracorporeal Membrane Oxygenation?
  • □ What is the Basic of ECMO?
  • □ What is the Goal of Extracorporeal Membrane Oxygenation?
  • □ Cannulae Placement
  • □ Respiratory (Lung) Support Only
  • □ Cardiac (Heart) Support
  • □ Venovenous Extracorporeal Membrane Oxygenation
  • □ Venoarterial Extracorporeal Membrane Oxygenation
  • □ What Happens during this Time?
  • □ What can we Do during this Time?
  • □ What are the Risks?
  • □ What About Blood Transfusion Risks?
  • □ What Kind of Medications are Used on Extracorporeal Membrane Oxygenation?
  • □ What About Nutrition during Extracorporeal Membrane Oxygenation?
  • □ Why are Patients on Extracorporeal Membrane Oxygenation, So Puffy?
  • □ How do You Know if they are Getting Better?
  • □ What Happens Once they are Off ECMO?
  • □ What Happens if they do not Get Better?
  • □ What is Urgent Extracorporeal Life Support?
  • □ How did ECMO Get Started?
AN OVERVIEW OF ECMO—IN A LAYMAN'S TERMINOLOGY
 
WHAT IS EXTRACORPOREAL MEMBRANE OXYGENATION?
ECMO stands for extracorporeal membrane oxygenation the term ECLS or extracorporeal life support are also synonymous to ECMO is a special procedure that takes over the work of the heart and/or lungs when they are too sick to properly support the body. ECMO allows the heart and/or lungs time to rest and heal. ECMO does not cure these organs, but allows them time to rest. ECMO is very similar to the machine used for open heart operations. While those patients are on the machine for only hours, ECMO patients can be on from days to weeks.
 
WHO GOES ON EXTRACORPOREAL MEMBRANE OXYGENATION?
This treatment for newborns through adults. The patients that meet our criteria and progress to ECMO generally have a mortality rate (chance of dying) of 80 to 90 percent without 90 The patient must have a reversible process and have good brain function. Some of the reasons that pediatric patients need ECMO are:
Fig. 1: ECMO system
 
HOW DOES EXTRACORPOREAL MEMBRANE OXYGENATION WORK?
Cannulae are placed into large vessels that lead directly into the heart. The patient's size, age, weight, and reason for ECMO will determine the size of cannulae used and where they are placed. These cannulae allow blood to be drained (by gravity) from the heart and through the ECMO circuit. The blood will be given oxygen, carbon dioxide will be removed, and it will be warmed before it is given back to the body/heart through another cannulae.
Fig. 2:
 
WHAT IS PRINCIPLE BEHIND EXTRACORPOREAL MEMBRANE OXYGENATION?
The principle: Extracorporeal membrane oxygenation is temporary support of heart and lung function by partial cardiopulmonary bypass (up to 75% of cardiac output). It is used for patients who have reversible cardiopulmonary failure from pulmonary, cardiac or other disease.
 
WHAT IS THE BASIC OF ECMO?
ECMO provides support, it does not Fix Anything Directly! Right therapy/right time. ECMO support allows time to heal, optimizing fluid status nutrition restoration of acid/ base status normalizing oxygen delivery. ECMO should be considered if the process is:
  1. Severe
  2. Acute
  3. Potentially reversible.
 
WHAT IS THE GOAL OF EXTRACORPOREAL MEMBRANE OXYGENATION?
Extracorporeal membrane oxygenation (ECMO) is used only after all other medical interventions have been attempted. ECMO allows the sick or injured organs a chance to rest and heal. Once the heart and/or lungs improve, then the patient can be weaned from ECMO. This can take days or weeks.
 
CANNULAE PLACEMENT
Extracorporeal membrane oxygenation (ECMO) cannulae can be placed either percutaneously (like an IV) or surgically (small operation). There are many variables that go into the decision for which type of cannulation is best for your child. Because we have such a diverse population of patients the following information is based on general ideals.
 
RESPIRATORY (LUNG) SUPPORT ONLY
 
Babies–Small Children
In the most noncardiac cases, the preference is that these patients be supported on VV (Venovenous) ECMO. This provides lung support only. At present, patients who weigh approximately 2 to 15 kg can be placed on VV-ECMO using only 1 cannulae. This is called a double lumen cannulae (DLC). This cannulae is placed into the right internal jugular vein (right side of the neck). If for any reason, this type of cannulae does not fit, then these patients will be placed on VA (Venoarterial). This requires a small operation on the right side of the neck. Two cannulae will be placed. The Venous cannulae will be placed directly into the right internal jugular vein and the arterial cannulae is placed into the right common carotid artery.
 
Children 1.5 to 5 Years
Children who fall into this age range will be placed on VA ECMO even if they only need lung support. At this time, there are no Double Lumen Cannulae that are big enough to support this size patient. Older Children and adults use 2 venous cannulae, one in the neck and on in the groin.
But for children less than approximately 5 years of age we do not use the groin vessels as they are not large enough.
 
Older Children
As stated above, these children can have 2 venous cannulae placed. One will be placed on the right side of the neck into27 the internal jugular vein, and the other will be placed into the right groin into the femoral vein.
There are three different ways to cannulate a patients on VA-ECMO.
 
CARDIAC (HEART) SUPPORT
All patients who require heart support will be placed on VA ECMO. There are three different ways we cannulate a patient on:
  1. VA-ECMO cannulae can be placed surgically in the right side of the neck. The venous cannulae are placed in the internal jugular vein, and the arterial cannula is placed in the common carotid artery.
  2. Directly into the chest. This is usually where the cannulae are placed for patients, who go on in the operating room or soon after their heart surgery. The thoracic surgeons will place the cannulae directly into the heart (through the side of the neck) and the patients chest will be left open. This means that a gortex patch will be sewn around the opening instead of the skin being sewn together.
  3. Older children, in an emergency situation (Urgent ECLS), cannulae can be placed into the groin only. A venous cannulae is placed into the femoral vein, and the arterial cannulae is placed into the femoral artery. There are many factors involved in the decision of where and how to place the ECMO cannulae. If you have any questions please feel free to ask us.
 
VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION
VA ECMO provides heart and lung support. Blood is drained from the Right Atrium of the heart. Oxygen is added, carbon dioxide is removed, the blood is warmed, and then returned to the Aortic Arch of the heart. This method allows us to “bypass” the heart and lungs so they can rest.
 
VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION
VV ECMO provides lung support only. The patients' own heart must work properly. If a double lumen cannula is used, we drain the blood from the right atrium of the heart through one lumen (side) of the catheter, oxygen is added, carbon dioxide is removed, the blood is warmed, and returned back to the right atrium through the second lumen of the catheter. The patient's heart then pumps the oxygenated blood to the body. If 2 cannulae are used, we will drain blood from the right atrium of the heart through the internal jugular vein, and return it through the femoral vein (in the groin) back to the right atrium.
On ECMO, the ventilator is put on the rest settings.
 
WHAT HAPPENS DURING THIS TIME?
Once the child is on ECMO, the ventilator will be turned down to rest settings. This means that the oxygen and pressures used to keep the lungs open will be reduced. This allows the lungs to rest and begin the healing process. An is take a X-ray to make sure the ECMO cannulae are in the proper position. The child have a chest X-ray each will day. There are routine blood samples all collected from the catheters already in place. The child will not be poked with needles while on ECMO. You may see us turn the child over onto their stomach (prone). This helps the lungs to heal. You may see us “clap” the child over the lung fields. This is called percussion. This helps to loosen the secretions in the lungs. We will suction the lungs every 2 to 4 hours. the child will get a bed bath and weight each night. The first couple of days may require the patient to be sedated and chemically paralyzed. The paralyzing drug reduces the amount of oxygen that the body uses. We will remove the paralyzing drug as soon as possible. The child will be given medication for pain and anxiety. Sometimes the patient will need a special procedure such as a CT scan, heart catheterization, or a trip to the operating room. The child will be weaned off from the paralyzing drug as soon as possible.
 
WHAT CAN WE DO DURING THIS TIME?
We encourage you to talk and touch the child. They may not be able to respond to you (pain medications, sedatives, or paralytics) but they can hear you! You may want to bring a favorite stuffed animal, blanket, or any other comfort item. Each bed in the PICU has a radio with a cassette player. Please bring in the child's favorite music or stories. Read them books or sing to them. Hearing your voice and feeling your touch can be very important to the child. There may be times that we ask you not to touch or talk to the child. This would be only in situations where we notice that the child does not tolerate this. Being this sick takes a lot of you.
Any part of the ECMO circuit can fail or rupture.
 
WHAT ARE THE RISKS?
The biggest risk with ECMO is bleeding. This is because in ECMO we use a medicine (Heparin) that thins the blood so clots take longer to form. It is very important that clots do not build up in the ECMO circuit. Bleeding can occur where the ECMO cannulae are placed, from old puncture sites (IV's, central lines), or other areas of the body. It is most dangerous when bleeding occurs in the brain. This occurs in less than 5 percent of ECMO patients. The risk is slightly higher for newborn babies. there is constantly be monitoring for signs of bleeding. Other risks include air or clots entering through the ECMO circuit to the patient. This is called an embolus. The ECMO specialist is also monitoring the circuit for this as well.28 The ECMO team is specially trained for these emergencies should they occur.
There is a constant monitoring for signs of bleeding.
 
WHAT ABOUT BLOOD TRANSFUSION RISKS?
Blood and blood products are needed often while on ECMO. The Blood Bank performs many tests on all the blood products to make sure they are as safe as possible.
 
WHAT KIND OF MEDICATIONS ARE USED ON EXTRACORPOREAL MEMBRANE OXYGENATION?
There are many different medications used while on ECMO. They may differ depending on the size of the patient, age, and diagnosis. The following list shows some of the drugs you may hear:
 
WHAT ABOUT NUTRITION DURING EXTRACORPOREAL MEMBRANE OXYGENATION?
While on ECMO, the child will receive all their calories by one of two methods. First they will be on TPN. This fluid contains vitamins, electrolytes, and sugar that the body needs. They will also receive Lipids. These are fats to increase the calories given. These fluids are given through an IV. The second way to receive nutrition is through a dobhoff tube. This is a tube placed through the nose. This allows Physician to deliver food directly to the intestines. Depending on the size on the child this food may be infant formula, or something similar to ensure.
 
WHY ARE PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION, SO PUFFY?
Most ECMO patients look puffy for the first few days. This is generally due to all the fluids/blood products that have been given before ECMO and the start of ECMO. We closely monitor the urine output and lasix will be given to help with this. If the child's kidneys are unable to produce enough urine or function properly, then the doctors will help them with dialysis. Physician will place an artificial kidney into the ECMO circuit to help remove excess fluid.
 
HOW DO YOU KNOW IF THEY ARE GETTING BETTER?
Physician are watching for improvements each day. We will monitor all aspects of lung function and heart function. We can see how much air is in the lungs, and how easily they fill with air with each breath, monitor blood gases, wean ECMO flow, and monitor daily chest X-rays. If all looks good we may decide to Trial Off ECMO. If the child is on ECMO for heart reasons, we may do a cardiac echo while we are trialing, this allows us to see how the heart is functioning without the support of ECMO. While we are off ECMO, we will be monitoring blood gases, blood pressures, urine output, and ventilator settings. If everything looks good, the physician may decide to remove ECMO support. The physician and staff caring for the child will keep you updated and explain everything we are looking at each day.
 
WHAT HAPPENS ONCE THEY ARE OFF ECMO?
Once the physicians have decided that the child is well enough to be taken off of ECMO, the doctors will cut our circuit away from the cannulae. The surgeons will remove (decannulate) the ECMO cannulae at this time. If the cannulae were placed surgically then the blood vessels used will be ligated (Tied off). Normally a backup system of blood flow (Collateral circulation) is developed on the side of the ligation. If the cannulae were placed percutaneously, then they will be pulled like an IV and pressure will be held for 20 to 20 minutes. This applies only to patients who were cannulated through the neck or groin. The child will remain on the ventilator until they are able to breath on their own again. This varies with neach child. It could take days or weeks before this happens. The child may require physical therapy and rehabilitation. This also varies depending on the age of the child and how long they were sick.
 
WHAT HAPPENS IF THEY DO NOT GET BETTER?
There is the chance that despite our best efforts, the child will not improve. We will talk to you each day about the29 condition of the child. If the physicians feel that the child is not improving, or getting worse, they will sit down and talk with the family about what your options are.
 
WHAT IS URGENT EXTRACORPOREAL LIFE SUPPORT?
This is our emergency ECMO system. We may receive a call from anywhere in the hospital for a patient, who is extremely unstable. The ECMO pump and circuit we use for urgent ECLS is different than for nonemergency ECMO. This system is smaller and made to be ready within minutes. Once the patient is stable, this temporary system will be replaced with the regular ECMO system.
 
HOW DID ECMO GET STARTED?
Dr Robert Bartlett is known around the world as the Father of ECMO. Dr Bartlett is the Director of our ECMO Program. The first time a heart-lung machine was used for cardiac surgery was in 1956 by Dr Gibbon. Modifications were needed for prolonged support. Extensive research was performed, and prolonged life support began in the late 1960s. The first successful ECMO case was in 1971 by Dr Hill. Dr Bartlett began his involvement in the early 1970s. ECMO research first began with adults, but quickly turned to newborns with respiratory problems. Dr Bartlett successfully treated the first newborn in 1975 in Irvine, California. He continued to research ECMO and brought the program to the University of Michigan in 1980. This was the only ECMO center in the World at that time. ECMO became standard treatment for sick newborns with respiratory failure. As ECMO programs started across the United States, we began using this treatment for pediatric and adult patients also. Currently, there are approximately 90 ECMO centers in the United States today. With a ELSO registry and about 6 ECMO centets in indication. There are also numerous ECMO programs outside the United States.