Click here to add Header - Missouri Perfusion Society · Shift to Nurse ECMO Management • CVR Nursing team not trained in ECMO management • Reviewed options for training –Looked

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Click here to add sub-headMBMC ECMO Program

John Brooks

Perfusion Department ManagerMissouri Baptist Medical CenterSt. Louis, MO

Disclaimer: I have no financial interests in anything discussed.

Presentation Goals

• Review of MBMC VAD/ECMO History

• Available Resources

• Personnel Management Strategies

• A Shift in Volumes

• Administration buy-in

• Impact on Resources

• Catching up

What is ECMO?

ECMO - Extracorporeal Membrane Oxygenation.

Provide sufficient oxygen and blood flow when a patient’s heart and/or lungs cannot.

Patients on ECMO are constantly monitored. They require continuous monitoring of their vital signs, including their blood pressure, blood flow, temperature and oxygen levels.

Type of Patients Helped by ECMO

• Cardiogenic Shock

• Acute Respiratory Distress (H1N1 Flu virus)

• Post Cardiac Surgery heart failure

These are the sickest of the sick patients

ECMO vs VAD

• ECMO includes a pump to support blood flow and an oxygenator to support O2/CO2 gas exchange

• VAD – ventricular assist device - only includes a pump to support blood flow. (RVAD / LVAD / BiVAD) A VAD is usually cannulated centrally, in the chest.

• A VAD can become an ECMO or vice versa.

Cannulation Options

Arterial:Rt. AxillaryAsc. AortaFem. ArteryShunt

Venous:Rt. JugularVena CavaFem. VeinPulm.Artery

Prior to 1996

• MBMC Cardiac Surgery program

– Efficient

– Active (550 cases per year)

– 2 Cardiac Surgery Suites

– Essentially zero use of VAD or ECMO

– CABG –Valve-Combos-occasional Aorta

BJC Healthcare System

• Barnes Jewish Christian Healthcare System

– Merger of Barnes and Jewish Hospitals

• Acquisition of Dr. Nick Kouchoukos

– Instant increase in caseload of 40%

– Procedure types mimicked academic centers minus transplants

– Began to provide VAD support for the occasional post surgical patient ( 2-3 per year)

VAD Support Resources

• Medtronic Centrifugal pump and cart

• Disposable circuits heparin coated with Medtronic centrifugal head.

• Mostly RVAD or BIVAD support with central cannulation

• Perfusionist – insertion and 24/7 in-house coverage, transport

• Patient on 3-5 days• Perfusion contract service

with added bonus pay for VAD hours (till 2005)

• Worked from 1996 – early 2014

Shift in VAD systems

• Using Jostra (Maquet) rotaflow centrifugal pumps for some cardiac cases

• Smaller pump head with built in flow probe

• Replaced aging Medtronic 540 pumps

• Needed new carts, but no capital $ available

• Developed rolling shelving with homemade cabinet below (under $200)

• Allowed for all equipment to fit on the cart

Home grown VAD Carts

• Wire rack rolling shelving

• Homemade under-cabinet

• Originally had two older Jostra(Maquet) rotaflowpumps that were not ICU friendly

• Had two carts

• No pre-made tubing sets

Making Perfusion pump ICU friendly

VAD Cannulation Needs

LVAD:Asc. AortaLA Dome

RVAD:Pulm. ArteryVena Cava

New Young Surgeon Hired 2014

• New young surgeon from MGH in Boston hired mid-2014 to eventually replace the soon to retire as a primary cardiac surgeon, Dr. K.

• Discussed our perfusion practice patterns, including our sparse VAD program with new surgeon. Was honest about our limited experience with VAD & especially ECMO

• We had no warning of the impending escalation of extended support service needs

• 1st ECMO Early Nov 2014, last approx. 6 days

Flood gates are Opened Jan 2015

• Jan 2015, our 2nd ECMO that month lasts 14 days. The team, covering the ECMO 24/7 in-house is crying uncle.

• Looking at all options…

– Discuss added pay for ECMO shifts.. no precedent

– How about adding another perfusionist… no

– Director asks for VAD/ECMO history… 2-3 per year

– Informed the Director our ECMO caseload is ramping up… as you might expect she did not believe me

Reviewing logistics & resources

– Discuss issues with director & surgeons…

• Team of 5 perfusionists (only 4 60% of the year)

• Covering 3 cardiac OR’s, IABP’s in cath lab, Cell saver & PRP in gen. surg. 24/7 on-call support for all services

• ECMO requires one full time perfusionist covering, and one perfusionist sleeping, leaving 2-3 covering scheduled cases… may have to cancel cases

• Coverage from other perfusion group in BJC– Other groups in system cannot help and cover their own

service

– Outsource to local Perfusion service group Salyer Perfusion…

Looking for nightshift & weekends

• By the end of March, we’ve done 4 ECMO’s and are discussing nightshift & weekend coverage with Salyer Perfusion. Finally get approval for coverage… greatly reduces strain on MBMC Perfusion team.

• 12 hr. nightshift coverage allowed us to have our full team complement on days

• Weekend coverage allowed us to have a life

Shift to Nurse ECMO Management• CVR Nursing team not trained in ECMO management

• Reviewed options for training– Looked at ELSO training and another ECMO training option

– Very expensive to bring in a team to do the training – would have taken months to come up with the funds

• Discussed with our new, young MGH surgeon, Dr. Baker– He felt he could do the background training for the nurses in bedside

patient management

– He had me do the Perfusion and equipment training• Initial training included education assistance from Maquet clinical specialist

• Once multiple training classes were complete, we continued with outsourced coverage for a couple of months to let the nurses achieve some ECMO management experience Dr. Baker and Perfusion would be available for assistance 24/7 for any ECMO issues for nursing. Goal is to refresher train about every 6 months with nurses

• Eventually phased out our outsourced perfusion coverage and have been nursing ECMO coverage ever since. They continue to do an excellent job

• One area that still needs education is our Respiratory Therapy team. They do not have the staff to support ECMO like other larger institutions.

ECMO History

MBMC had 21 ECMO pts 20169 ECMO pts ytd 2017

Adult Patients Surviving to Transfer or Discharge

Nat’l Avg = 41%*MBMC = 61%

*National data per ELSO Registry

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ECMO History

National MBMC

Majority of MBMC ECMO Patients are Bridge to Recovery

VA ECMO

Full cardio-pulmonary support

Salvage approach

VV ECMO

Catheter placement is important to avoid shunting oxygenated blood back into the venous line.

Both the Right and Left heart function must be adequate to support life

Used primarily for acute pulmonary support

Avalon bicaval cannula

Inflow needs to be precisely positioned to properly direct inflow into right atrium

Centrimag Console & Monitor

Why Rotaflow?

Do you transfer your EMCO patients to a transplant center?

Will your ECMO system transport OK?

Does the accepting hospital use the same ECMO circuit?

ECMO Heater

Carts

Diagnostic Monitoring

Immediate access to data Non-Invasive Real-Time

Alarms allow for faster RN response time

Heads up display enables truly continuous monitoring of the patient

ECMO to Go Bags

ECMO Insertion Locations

• Cath Lab –Hybrid

• Cardiac OR

• ICU

• General OR

• ER

ECMO Complications(normally not seen with conventional bypass)

• Air in the circuit

• Clots in the circuit

• Poor cannulation

• Poor vascular access

• Hypovolemia

• Bleeding

• Arterial tear or dissection

• Hemolysis

Clot formation in oxygenator

Impella vs ECMO

• Impella:

– Left heart support only (currently)

– CP Impella limited to 4 LPM (also 2.5LPM option)

– Surgical Impella 5 LPM

– Insertion approach: femoral or right axillary

– Requires fluoroscopy for proper insertion

– Like ECMO it is volume dependent

Concomitant Support

• Impella – concurrent, in a addition to or as replacement (left side only)

• IABP – replaced by, concurrent or as replacement

MBMC ECMO JOURNEY2014 1 patient 1 Transferred to BJH, Expired

2015 16 patients 7 Discharged to Home

6 Expired

3 Transferred to BJH, Expired

2016 21 patients 9 Discharged to Home

7 Expired

1 Transfer to BJH

1 Transfer to extended care

2 multiple procedures

Avg patient age is 58 Avg days on ECMO = 4Min=1 hr, Max = 17days

2017 YTD10 ECMOs9 Patients

15% Expire rate

Cardiac Emergency Rapid Response

Effective ECMO support can Save Lives