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Running head: Extracorporeal Membrane Oxygenation
Use of Extracorporeal Membrane Oxygenation in Emergent Situations
Kevin P. Doan
Ferris State University
ENGL 321
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Extracorporeal Membrane Oxygenation
Use of Extracorporeal Membrane Oxygenation in Emergent Situations
Table of Contents
Abstract
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Introduction
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Traditional Uses
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Emerging Uses
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Interview
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Contraindications
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Literature Review
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Conclusion
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Glossary
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References
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Appendix A Interview
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Appendix B Outline
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Appendix C Reviews
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Abstract
This paper addresses the use of extracorporeal membrane oxygenation as an adjunct therapy in the
treatment of respiratory failure and cardiac arrest. The history and traditional use of ECMO therapy
are discussed, as well as contraindications to the therapy. An interview was conducted with Jill
Hammond, a Mechanical Circulatory Support Specialist with Spectrum Health, discussing her
experience using ECMO in emergent situations.
Keywords: Extracorporeal Membrane Oxygenation, ECMO,
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Use of Extracorporeal Membrane Oxygenation in Emergent Situations
Introduction
Extracorporeal Membrane Oxygenation (ECMO) is “a method of life support used to
oxygenate the blood in newborn babies [, children, and adults] with lung failure, using a machine
incorporating membranes that are impermeable to blood but permeable to oxygen and carbon
dioxide.” (collins) The ECMO machine can just aid the heart and lungs or completely bypass
them. This therapy is used in solely controlled situations, with one of the largest applications
being on the operating room during open-heart surgeries. This form of the technology was
successfully used for the first time in 1953, in a Philadelphia hospital by Dr. John H. Gibbon,
“using total cardiopulmonary bypass for 26 minutes, closed a large atrial septal defect in an 18year-old woman.” (Cohn, 2003) This technology can also be performed as short to long-term
therapy in emergency situations for patients in respiratory failure or cardiac arrest. It is the use of
ECMO as a first line treatment in these situations that may lead to improved patient outcomes.
Traditional Uses
Currently, when ECMO is used for the patient with respiratory failure, it is implemented
after all other available treatments have been exhausted. These treatments include inhalers,
intravenous steroids, and all forms of mechanical ventilation. This rational follows the tradition
of beginning with the least invasive treatment and moving up to more aggressive therapies as
needed. However, in certain situations when patients are unable to adequately maintain
circulation or oxygenation to vital organs, the most invasive treatment may need to be initiated
first.
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Emerging Uses
This therapy show great promise for patients who experience abrupt, life-threatening
situations where there is a breakdown in the body’s ability to provide blood and oxygen to
organs. An example of such an event is cardiac arrest, where there is “sudden, unexpected loss of
heart function, breathing and consciousness.” (Mayo Clinic) By placing patients who have
suffered a witnessed cardiac arrest on ECMO, we can be certain that the patient will be receiving
adequate blood and oxygen supply to vital organs. During this time, physicians can determine the
source of the problem and find a solution to restore the patient’s own breathing and circulation.
The brain is the most sensitive organ when it comes to oxygen supply; cells in the brain will
begin to die after five minutes with lack of blood flow. While good quality chest compressions
and supplemental oxygen therapy can extend that time, they are extremely labor intensive, and
whether or not they are effective may not be able to be determined until after the patient’s own
circulation has returned. In 2008, a study was completed comparing traditional CPR to CPR
augmented with ECMO therapy. Researchers found that “of the 975 patients with in-hospital
cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the
conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched
patients who underwent extracorporeal CPR had a higher survival rate to discharge” (YihSharng, et al., 2008). ECMO’s capacity of enhanced monitoring and patient assessments makes
it unique and unparalleled when compared to other rescue treatments.
Interview
In order to gain a greater understanding of this subject matter, an expert interview was
conducted on April 24, 2013 with Jill Hammond, a Mechanical Circulatory Support Specialist
with Spectrum Health. As a Mechanical Circulatory Support Specialist, she is “trained to operate
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the various forms of ECMO circuits” as well as “assist the physicians in the set up and initiation
of the system”. In this interview, Hammond discussed her experience with four specific patients
who were placed on ECMO after suffering cardiac arrest. Two of those patients survived and
were discharged from the intensive care to rehabilitation facilities. One of the patients, a recent
case, remains in critical condition and is still on ECMO. The fourth patient, unfortunately, did
not survive. Even with a limited number of patients, Hammond states, “So far it is hard to tell,
but the results look promising”.
Contraindications
As with most invasive treatments, ECMO proposes potential complications. The lines
needed to access the blood vessels are much larger than normal intravenous central lines. “The
most frequent limb complications from peripheral veno-arterial extracorporeal membrane
oxygenation are limb ischemia and localized bleeding” (Lamb, Hirose, & Cavarocchi, 2013).
This potential bleeding is due to the anticoagulant coatings inside of the system, as well as the
high doses of Heparin required to prevent the system from clotting. Other equipment-related
complications can include infections, blood clots, air in the circuit that could cause an embolus,
and mechanical failure (Miami Childrens Hospital, n.d.). Patient conditions that are
contraindicated include internal hemorrhage and vascular abnormalities, such as aneurysms.
There is also a significant cost factor associated with the use of ECMO. “Circuits cost around
five thousand dollars for the non-reusable portion” according to Hammond. In addition, patients
receiving this therapy must have an ECMO specialist in the room at all times to oversee their
care, so the manpower cost is a very expensive consideration.
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Literature Review
While we have yet to see the widespread use of ECMO as a first line treatment for
emergency situations, the theory of using it as such is almost as old as the technology itself.
Doctor John Kennedy observed in 1966 that “Heart-lung machines now used for cardiac surgery
should be considered for use as an extended form of cardiopulmonary resuscitation in selected
patients. Of eight patients in whom cardiac arrest had proved refractory to open- or closed-heart
cardiac massage, all but one were resuscitated and survived hours to days. One patient recovered
completely” (Kennedy, 1966). Still today, very few hospitals throughout the country have the
capabilities to offer ECMO as a treatment. Most of these are large urban hospitals that have an
open-heart surgery program, as well as special certifications from accrediting bodies. This makes
the odds of being at an ECMO-supporting facility when suffering a cardiac arrest very slim.
There is promising new research into the technology of ECMO that is underway. As Hammond
mentioned in our interview, “A lot of other [foreign] countries are ahead of the United States on
these kinds of emergency treatments”. One study out of Germany included testing a portable
ECMO circuit, which could be easily carried by a medic into the battlefield. During their study,
“Four patients were cannulated in the war zone, and six patients were cannulated at LRMC
[medical center] after evacuation to Germany. In all cases, both hypoxemia and hypercapnia
improved, allowing for decreased airway pressures. Nine patients were weaned from ECMO and
extubated. One soldier died from progressive multiple-organ failure.” (Bein, et al., 2012)
Conclusion
While the theory behind ECMO therapy is not new, recent research has indeed revealed
its validity. For some patients, the use of ECMO as a first line treatment has led to improved
outcomes as well as increased survival rates. Access to facilities who offer this treatment remains
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scarce, as few hospitals in the country currently have the capability. However, with emerging
technologies and continued research, ECMO therapy, as well as better patient outcomes, will
soon become more commonplace.
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Glossary
Atrial Septal Defect: A hole in the wall between the top two chambers of the heart.
Cannulation: Insertion of tube into the blood vessel. For the purpose of this paper it is meant as
the insertion of ECMO circuit tubing.
Diaphragmatic Hernia: A birth defect that results in a hole in the diaphragm. Most of these
children will be unable to breath at birth.
ECMO: Extracorporeal Membrane Oxygenation.
Fasciotomy: A procedure that involves cutting away the outermost layers of skin to relieve
pressure that is cutting off circulation.
In Utero: In the womb.
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Reference
Bein, T., Zonies, D., Philipp, A., Zimmermann, M., Osborn, E. C., Allan, P. F., . . . Graf, B. M.
(2012, Dec). Transportable extracorporeal lung support for rescue of severe respiratory
failure in combat casualties. Journal of Trauma & Acute Care Surgery, 73(6), 1450-1456.
doi:http://0-dx.doi.org.libcat.ferris.edu/10.1097/TA.0b013e3182782480
Cohn, L. H. (2003). Fifty Years of Open-Heart Surgery. Circulation(107), 2168-2170.
doi:10.1161/01.CIR.0000071746.50876.E2
Kennedy, J. H. (1966). The role of assisted circulation in cardiac resuscitation. Journal of the
American Medical Association, 197(8), 615-618.
doi:doi:10.1001/jama.1966.03110080055017
Lamb, K. M., Hirose, H., & Cavarocchi, N. C. (2013). Preparation and technical considerations
for percutaneous cannulation for veno-arteial extracorporeal membrane oxygention.
Journal of Cardiac Surgery, 28, 190-192. doi:10.1111/jocs.12058
Mayo Clinic. (n.d.). Sudden cardiac arrest. Retrieved April 25, 2013, from Mayo Clinic:
www.mayoclinic.com/health/sudden-cardiac-arrest/DS00764
Miami Childrens Hospital. (n.d.). Extra Corporeal Membrane Oxygenation Complication.
Retrieved April 23, 2013, from http://www.mch.com/page/EN/2057/Extra-CorporealMembrane-Oxygenation/Complications.aspx
Yih-Sharng, C., Jou-Wei, L., Hsi-Yu, Y., Wen-Je, K., Jih-Shuin, J., Wei-Tien, C., . . . Shu-Chien,
H. (2008, August 16-22). Cardiopulmonary resuscitation with assisted extracorporeal lifesupport versus conventional cardiopulmonary resuscitation in adults with in-hospital
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cardiac arrest: an observational study and propensity analysis. The Lancet, 372(9638),
554-561. doi:doi.org/10.1016/S0140-6736(08)60958-7
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Appendix A
Interview with Mechanical Circulatory Support Specialist, Jill Hammond April 24, 2013.
Q. What is the role of a Mechanical Circulatory Support Specialist?
A. We are trained to operate the various forms of ECMO circuits that we have at Spectrum
Health. We also assist the physicians in the set up and initiation of the system.
Q. In your experience have you seen much ischemia related to ECMO cannula sites?
A. “Minimal ischemia with newer techniques in cannulation. Now that the physicians have more
experience when a patient is at risk for losing their pulse to a limb, they are much more likely to
do a fasciotomy [which is a surgery to relieve pressure in a limb that is cutting off circulation] or
consult a vascular surgeon.”
Q. Recently there have been a few patients who were placed on ECMO emergently without
trying less invasive measures first. In your experience have those patients done better or worse
with this aggressive treatment?
A. “There have been three adult patients recently, two of them were treated then discharged to a
rehab facility. The third was quite recent, and is still in critical condition. We had a pediatric case
that was similar, unfortunately they did not survive but that was due to extenuating
circumstances before they made it to the ER. So far it is hard to tell but the results look
promising.
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Q. I understand that adult ECMO is new to your facility, but you have been doing pediatric
ECMO for a while now, are there major differences between adults and pediatrics?
A. “With pediatric cases they are very slow to place a patient on ECMO. I feel that children are
more apt to survive the insult without long-term deficits. They are more hesitant with all forms
of interventions in pediatrics though; some won’t even place a child on the ventilator until the
last possible moment. For certain diagnoses they do not hesitate though, such as Diaphragmatic
Hernia. There have been cases where it has been diagnosed in utero, for this situation they
actually have the ability to partially deliver the child, cannulate and place them on ECMO, then
complete the delivery. This is referred to as delivery-to-ECMO.”
Q. Is it normal for hospitals to do pediatric ECMO before doing adult cases?
A. “That is just the way that it worked out at this hospital. Since we have been doing open-heart
surgeries for so long we technically have been doing ECMO, just not in the same capacity as we
currently do. A few facilities around the United States have been doing this longer than us. Also a
lot of other countries are ahead of the United States on these kinds of emergency treatments.”
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Appendix B
Outline
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Appendix C
Reviewers
Devon Horvath, RN
Comment in the contraindications section. “You could mention the cost of having extra
staff to just run the ECMO.”
Jennifer Girton, RN
Comment in the literature review section. “You mention Jill and the interview but I don’t
see it introduced before in the paper.”
Beverly Doan, Teacher (Retired)
Edited for grammar and punctuation.
Delores Zebelian, Teacher (Retired)
Edited for sentence structure.