An International Survey of Extracorporeal Membrane Oxygenation Education and Credentialing Practices.

Background: The use of extracorporeal membrane oxygenation (ECMO) has grown rapidly over the past decades because of evolving indications, advances in circuit technology, and encouraging results from modern trials. Because ECMO is a complex and highly invasive therapy that requires a multidisciplinary team, optimal education, training, and credentialing remain a challenge. Objective: The primary objectives of this study were to investigate the prevalence and application of ECMO education and ECMO practitioner credentialing at ECMO centers globally. In addition, we explored differences among education and credentialing practices in relation to various ECMO center characteristics. Methods: We conducted an observational study of ECMO centers worldwide using a survey querying participants in two major domains: ECMO education and ECMO practitioner credentialing. Of note, the questionnaire included ECMO program characteristics, such as type and size of hospital and ECMO experience and volume, to explore the association with the two domains. Results: A total of 241 (32%) of the 732 identified ECMO centers responded to the survey, representing 41 countries across the globe. ECMO education was offered at 221 (92%) of the 241 centers. ECMO education was offered at 105 (98.0%) high-ECMO volume centers compared with 136 (87.5%) low-ECMO volume centers (P = 0.005). Credentialing was established at 101 (42%) of the 241 centers. Credentialing processes existed at 52 (49.5%) high-ECMO volume centers compared with 51 (37.5%) low-ECMO volume centers (P = 0.08) and 101 (49.3%) Extracorporeal Life Support Organization centers compared with 1 (2.7%) non-Extracorporeal Life Support Organization center (P < 0.001). Conclusion: We found significant variability in whether ECMO educational curricula are offered at ECMO centers. We also found fewer than half of the ECMO centers surveyed had established credentialing programs for ECMO practitioners. Future studies that assess variability in outcomes among centers with and without standardized educational and credentialing practices are needed.

Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting.

Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.

The Association of Oxygenation, Carbon Dioxide Removal, and Mechanical Ventilation Practices on Survival During Venoarterial Extracorporeal Membrane Oxygenation.

Introduction: Oxygenation and carbon dioxide removal during venoarterial extracorporeal membrane oxygenation (VA ECMO) depend on a complex interplay of ECMO blood and gas flows, native lung and cardiac function as well as the mechanical ventilation strategy applied. Objective: To determine the association of oxygenation, carbon dioxide removal, and mechanical ventilation practices with in-hospital mortality in patients who received VA ECMO. Methods: Single center, retrospective cohort study. All consecutive patients who received VA ECMO in a tertiary ECMO referral center over a 5-year period were included. Data on demographics, ECMO and ventilator support details, and blood gas parameters for the duration of ECMO were collected. A multivariable logistic time-series regression model with in-hospital mortality as the primary outcome variable was used to analyse the data with significant factors at the univariate level entered into the multivariable regression model. Results: Overall, 52 patients underwent VA ECMO: 26/52 (50%) survived to hospital discharge. The median PaO2 for the duration of ECMO support was 146 mmHg [IQR 131-188] and PaCO2 was 37.2 mmHg [IQR 35.3, 39.9]. Patients who survived to hospital discharge had a significantly lower median PaO2 (117 [98, 140] vs. 154 [105, 212] mmHg, P = 0.04) and higher median PaCO2 (38.3 [36.1, 41.1] vs. 36.3 [34.5, 37.8] mmHg, p = 0.03). Survivors also had significantly lower median VA ECMO blood flow rate (EBFR, 3.6 [3.3, 4.2] vs. 4.3 [3.8, 5.2] L/min, p = < 0.001) and greater measured minute ventilation (7.04 [5.63, 8.35] vs. 5.32 [4.43, 6.83] L/min, p = 0.01). EBFR, PaO2, PaCO2, and minute ventilation, however, were not independently associated with death in a multivariable analysis. Conclusion: This exploratory analysis in a small group of VA ECMO supported patients demonstrated that hyperoxemia was common during VA ECMO but was not independently associated with increased mortality. Survivors also received lower EBFR and had greater minute ventilation, but this was also not independently associated with survival. These findings highlight that interactions between EBFR, PaO2, and native lung ventilation may be more relevant than their individual association with survival. Further research is indicated to determine the optimal ECMO and ventilator settings on outcomes in VA ECMO.