A young mother, admitted to a local hospital and treated for what she thought was strep throat, was not getting any better. “They called us when she looked really awful,” recalled Jacob T. Gutsche, MD, Associate Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania in a 2017 video interview. “She was coding in her own hospital, coding on the emergency transport helicopter, and [still] coding at Penn Presbyterian’s Intensive Care Unit (ICU). She got CPR the whole trip.”
Dr. Gutsche said his team always saw patients like her – with her Pa02/Fi02 in the high 40s. Her previous care team had not recognized the signs of acute respiratory distress syndrome (ARDS), an inflammatory lung condition that can complicate severe pneumonia [including influenza], trauma, sepsis, [and] aspiration of gastric contents. ARDS is commonly secondary to many other conditions, and is often unrecognized and underdiagnosed.
Mobilizing ECMO: A Plan In Motion
Penn’s existing ECMO program created a mobile ECMO team, which launched in 2014. The Mobile ECMO team transports (helicopter) patients in critical conditions to neighboring hospitals to assist other clinical teams without the resources to transport critically ill patients – like Dr. Gutsche’s patient, the young mother who was undergoing heart failure.
“The genesis of mobile ECMO at Penn came about from a dinner napkin discussion [about four years ago] between our colleagues in Critical Care and Cardiac Anesthesia,” Wilson Szeto, MD, Chief of Cardiovascular Surgery at Penn Presbyterian Medical Center, explained. “We were discussing how ECMO is lifesaving but how it was only available to a limited number of patients. We thought ‘Wouldn’t it be great if it were available to those outside of Penn?’”
Dr. Szeto said the timing was perfect. “The ECMO technology has recently undergone significant technological improvements, making the circuits smaller, allowing this life saving technology to be portable and able to be brought to patients outside of Penn.”
How ECMO Works
The ECMO machine is designed to support critically ill patients by providing cardiopulmonary functions normally performed by the patients’ hearts and lungs. ECMO can support the heart, lungs, or both.
For venoarterial ECMO, the venous cannula withdraws the dark, unoxygenated blood from the patient, and oxygenates it, and infuses red oxygenated blood back into the arterial system.. For isolated lung support, or venoveno ECMO, the venous cannula withdraws unoxygenated blood from the patient and infuses oxygenated blood back to the heart, to be pumped out to the rest of the body.
At its inception, the team initially thought they would see a few cases per month. In the first year, there were 106 calls for review; in the second, 140. By July of 2018, the team performed over 100 mobile ECMO transfers.
Mobile ECMO at Penn: The Components
Type of transport, provider team lineup, equipment, procedure and patient selection criteria are the standard logistical components of the Mobile ECMO program. Most decisions weren’t difficult for the organizing providers: When treating time-dependent conditions, like heart failure and ARDS, a helicopter choice was fairly obvious.
As for the clinical team, the physicians knew they wanted, among other experts, cardiologists, pulmonary anesthesiologists and perfusionists. “As a surgeon, I am accustomed to working with my anesthesia colleagues to care for patients and place them on ECMO,” said Dr. Szeto. “The perfusionist role is to make sure the ECMO machine is working properly. An additional requirement for us is imaging – we bring a portable ECHO machine to make sure the ECMO cannluae are in the right place.”
And all of this is done at the patient’s bedside. “If the patient is too unstable, they can’t go in a helicopter, they can’t go to the ICU,” Dr. Gutsche said. “We don’t want to deal with recirculation and hypoxia on the trip.” To that end, the team corrects for hypoxia; does a respiratory acidosis sweep and decreases mean pressure positive end-expiratory pressure, or PEEP.
Furthermore, Dr. Szeto added, the team adheres to streamline protocols and steps every time: all patients get cannulated; are stabilized; evaluated to ensure the cannulae are in the right position; stay connected to the machine; and everyone is sent to to Penn Presbyterian’s Heart and Vascular ICU.
When to Consult: Patient Inclusion Criteria
Success of the ECMO program, in large part, is due to the careful development of the inclusion and exclusion criteria when it comes to patient selection, the physicians said. “In general,” explained Dr. Szeto, “inclusion criteria would mean a patient less than 65 years, relatively healthy with a good baseline and lung function prior to the acute event requiring lung rescue.” He continued, “It should also be an acute, isolated event, and not the result of late-stage lung disease that the patient has had for a long time.” And there is another consideration: Treating patients with a terminal illness. “It’s not an ethical thing to do,” Dr. Szeto said. “Since the prognosis is poor, we don’t want to prolong suffering from a chronic terminal disease process.”
While the physicians continue to evolve the ECMO program, the one aspect that won’t change is its multidisciplinary make-up: Its success, said Dr. Szeto, is due to a strong belief in a team approach to patient care with their colleagues, including critical care nurses and intensivists, respiratory therapists, cardio anesthetists, etc. “The results we are seeing are because of strong team work at Penn.”
The Mobile ECMO Team published data on Penn Medicine’s Mobile ECMO program in the Journal of Cardiothoracic and Vascular Anesthesia in 2017.
Consult with Penn Medicine
To consult with Penn Medicine about your patient, call our 24/7 provider-only line to consult with a critical care physician: 877-937-7366. To refer a patient, visit our online referral form visit our online referral form.
Additional ECMO Resources from Penn Medicine