The technique of extracorporeal membrane oxygenation, or ECMO, may seem sometimes like a “bridge to nowhere” or a “Hail Mary” attempt to prolong life when there’s no hope.
But the Grand Rounds presentation on January 22 by Daniel Herr, MD, FCCM, portrayed ECMO as anything but futile. Dr. Herr is Associate Professor of Medicine at the University of Maryland School of Medicine, the home of the famous R. Adams Cowley Shock Trauma Center, where he directs surgical critical care services including ECMO.
Speaking on the topic, “ECMO: What we have learned and what we are learning”, Dr. Herr advised listeners to get rid of “hospital legends” and outdated beliefs about managing ECMO and deciding which patients might benefit. His main points: ECMO is not just for the dying, and there are “lean” ways of implementing ECMO that can reduce costs and improve outcomes at the same time.
Commonly-held beliefs Dr. Herr debunked in his talk:
“Get that patient out of bed,” Dr. Herr urged, showing a photo of a patient walking outdoors with his ECMO system.
For patients with ARDS, Dr. Herr said research supports instituting VV (veno-venous) ECMO first, and reserving conversion to VA (veno-arterial) ECMO only if there is refractory hypotension. He also advised early tracheostomy for any patient who requires ECMO for more than a few days, as it increases patient comfort and reduces the need for sedation.
Dr. Herr spoke in detail about the Maryland experience with patients who suffer cardiovascular collapse due to poisoning, many of whom had ingested overdoses of cardiovascular agents such as beta blockers or calcium channel blockers. He advocated more aggressive use of ECMO for these patients, pointing out that the average duration of ECMO was less than three days and over half of their patients were successfully discharged home.
Dr. Herr also supported more aggressive use of extracorporeal CPR for adult patients in refractory cardiac arrest after cardiac surgery, percutaneous coronary intervention, or pulmonary embolus. He predicted that as more experience is gained, the future will see earlier use of ECMO in septic shock accompanied by cardiac failure.
“Prevention, not just rescue,” should be the goal, Dr. Herr said.