Standardized nomenclature for peripheral percutaneous cannulation of the pulmonary artery in extracorporeal membrane oxygenation: Current uptake and recommendations for improvement.

The rising application of extracorporeal membrane oxygenation (ECMO) has emphasized the need for consistent and standardized terminology, especially concerning peripheral percutaneous cannulation of the pulmonary artery (PPC-PA). The Extracorporeal Life Support Organization (ELSO) Nomenclature Task Force produced the ELSO Maastricht Treaty for extracorporeal life support (ECLS) Nomenclature to address this challenge. However, adherence to nomenclature recommendations has been poor in publications describing PPC-PA. We aim to describe common nomenclature errors and provide a user-guide for abbreviations that can be used by authors, reviewers, and journal staff to ensure properadherence to standardized nomenclature in publications describing PPC-PA.

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19.

OBJECTIVES: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). DESIGN: Multicenter retrospective, observational study. SETTING: Ten tertiary referral university and community hospitals. PARTICIPANTS: Patients with confirmed severe COVID-19-related ARDS. INTERVENTIONS: Venovenous or venoarterial ECMO. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. CONCLUSIONS: The present findings suggested that about half of adult patients with severe COVID-19-related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. CLINICAL TRIAL REGISTRATION: identifier, NCT04383678.

The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization.

Extracorporeal life support (ECLS) was developed more than 50 years ago, initially with venoarterial and subsequently with venovenous configurations. As the technique of ECLS significantly improved and newer skills developed, complexity in terminology and advances in cannula design led to some misunderstanding of and inconsistency in definitions, both in clinical practice and in scientific research. This document is a consensus of multispecialty international representatives of the Extracorporeal Life Support Organization, including the North America, Latin America, EuroELSO, South West Asia and Africa, and Asia-Pacific chapters, imparting a global perspective on ECLS. The goal is to provide a consistent and unambiguous nomenclature for ECLS and to overcome the inconsistent use of abbreviations for ECLS cannulation. Secondary benefits are ease of multicenter collaboration in research, improved registry data quality, and clear communication among practitioners and researchers in the field.

Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) may be a lifesaving rescue therapy in refractory, severe respiratory, and/or circulatory failure. To provide the best cost efficiency to the population served and patient outcome, ECMO therapy should be provided by specialized high volume ECMO centers. This requires dedicated transport teams to organize and perform these complex transports. Concerning adverse events and complications during these transfers, only a minimal amount of data has been published. METHODS: To shed light on this matter, all medical transport records from transports on ECMO between January 2010 and June 2016 were analyzed. The data was classified in constituent groups and categorized to risk groups. RESULTS: During the study period, 536 transports on ECMO were performed. The transport records could be identified in 514 of these cases (95.9%). In 163 (31.7%) transports 206 adverse events occurred. In 34 transports two or more adverse events passed on the same trip. No deaths occurred during transport. Sixty-five percent (134) of the complications were Patient related; the most prominent was loss of tidal volume with or without fluid flooding of the lung (n = 57, 43%). Lack of control of equipment was the most common Staff related flaw. Causes due to Equipment/technical (n = 30) could be traced to 14.6% of the events. Vehicle/transportation related complications were reported from 26 transfers, a sub-group in which 50% of the reports concerned malfunction of Ambulance utility/electrical, or Wrong ambulance size at hospital or airport. CONCLUSIONS: If transporting on ECMO high-risk or sudden threat-of-life situations are inevitable and have to be dealt with immediately, sometimes within seconds. A well-trained staff and an experienced high-volume organization are recommended. Key words: extra corporeal membrane oxygenation; ECMO, transport; adverse event; complication.

The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation.

INTRODUCTION: In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenation (ECMO) may be a lifesaving procedure. Specialized departments provide ECMO, and these patients often have to be transferred for treatment. Conventional transportation is hazardous, and deaths have been described. Only a few centers have performed more than 100 ECMO transports. To date, our mobile ECMO teams have performed more than 700 transports with patients on ECMO since 1996. We describe 4 consecutive years (2010-2013) of 322 national and international ECMO transports and report adverse events. METHODS: Data were retrieved from our local databases. Neonatal, pediatric and adult patients were transported, predominantly with refractory severe respiratory failure. RESULTS: The patients were cannulated in 282 of the transports, and ECMO was started in these patients at the referring hospital and then they were transported to our ECMO intensive care unit. In 40 cases, the patient was already on ECMO. Of the transports, 60% were by aircraft, and the distances varied from 6.9 to 13,447 km. In about 27.3% of the transports, adverse events occurred. Of these, the most common were either patient-related (22%) or equipment-related (5.3%). No deaths occurred during transport, and transferred patients exhibited the same mortality rate as in-hospital patients. CONCLUSIONS: Long- and short-distance interhospital transports on ECMO can be safely performed. A myriad of complications can occur, but the mortality risk is very low. The staff involved should be highly competent in intensive care, ECMO physiology and physics, cannulation, intensive care transport and air transport medicine. They should also be skilled in recognition of risk factors involved in these patients.

Central Venopulmonary Extracorporeal Membrane Oxygenation: Background and Standardized Nomenclature.

This review highlights advancements in extracorporeal life support (ECLS), emphasizing the critical role of standardized terminology, particularly for extracorporeal membrane oxygenation (ECMO) in treating right ventricular and respiratory failure. Advocating for the adoption of the Extracorporeal Life Support Organization (ELSO) Maastricht Treaty for ECLS Nomenclature guidelines, it aims to resolve communication barriers in the ECMO field. Focusing on venopulmonary (VP) ECMO utilizing central pulmonary artery (PA) access, this review details surgical approaches and introduces a terminology guide to support effective knowledge exchange and advancements in patient care.

Flow Dynamics and Mixing in Extracorporeal Support: A Study of the Return Cannula.

Cannulation strategies in medical treatment such as in extracorporeal life support along with the associated cannula position, orientation and design, affects the mixing and the mechanical shear stress appearing in the flow field. This in turn influences platelet activation state and blood cell destruction. In this study, a co-flowing confined jet similar to a return cannula flow configuration found in extracorporeal membrane oxygenation was investigated experimentally. Cannula diameters, flow rate ratios between the jet and the co-flow and cannula position were studied using Particle Image Velocimetry and Planar Laser Induced Fluorescence. The jet was turbulent for all but two cases, in which a transitional regime was observed. The mixing, governed by flow entrainment, shear layer induced vortices and a backflow along the vessel wall, was found to require 9-12 cannula diameters to reach a fully homogeneous mixture. This can be compared to the 22-30 cannula diameters needed to obtain a fully developed flow. Although not significantly affecting mixing characteristics, cannula position altered the development of the flow structures, and hence the shear stress characteristics.

Modeling sensitivity and uncertainties in platelet activation models applied on centrifugal pumps for extracorporeal life support.

Two platelet activation models were studied with respect to uncertainties of model parameters and variables. The sensitivity was assessed using two direct/deterministic approaches as well as the statistical Monte Carlo method. The first two, are linear in character whereas the latter is non-linear. The platelet activation models were applied on platelets moving within an extracorporeal centrifugal blood pump. The phenomenological, Lagrangian stress- and time-based power law-based models under consideration, have experimentally calibrated parameters and the stress expressed in a scalar form. The sensitivity of the model with respect to model parameters and the expression of the scalar stress was examined focusing on a smaller group of platelets associated with an elevated risk of activation. The results showed a high disparity between the models in terms of platelet activation state, found to depend on the platelets' trajectory in the pump and the expression used for the scalar stress. Monte Carlo statistics was applied to the platelets at risk for activation and not to the entire platelet population. The method reveals the non-linear sensitivity of the activation models. The results imply that power-law based models have a restricted range of validity. The conclusions of this study apply to both platelet activation and hemolysis models.

Flow-induced platelet activation in components of the extracorporeal membrane oxygenation circuit.

Extracorporeal membrane oxygenation (ECMO) is used for rescue in severe respiratory and/or circulatory failure. The patient's blood is pumped over artificial surfaces in the ECMO circuit. A platelet activation model was applied to study the potential thrombogenicity of ECMO circuit components: the centrifugal blood pump, cannulae, and tubing connectors. Based on the accumulated effect of the scalar form of the stress acting on the platelet over time, the activation model enables assessment of platelet activation and pinpoints regions of elevated activation risk in a component. Numerical simulations of the flow in different components of the ECMO circuit was carried out where the activation level is a function of the impact of local stress and its history along the path that the platelets follow. The results showed that the pump carried the largest risk for platelet activation followed by the reinfusion cannula and lastly the connectors. Pump thrombogenicity was mainly due to long residence time and high shear-rate while the connector showed a high level of non-stationary shear-rate that in turn may contribute to the formation of aggregates through direct platelet activation or through high shear-rate modulation of the vWF multimers.

Transportation of Critically Ill Patients on Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) may be a life-saving procedure for patients with severe reversible pulmonary or cardiac failure or for patients in need for a bridge to transplantation. ECMO is provided by specialized centers, but patients in need of ECMO are frequently taken care of at other centers. Conventional transports to an ECMO center can be hazardous and deaths have been described. For this reason, many ECMO centers have developed transport programs with mobile ECMO. After request, the mobile team including all necessary equipment to initiate ECMO is sent to the referring hospital, where the patient is cannulated and ECMO commenced. The patient is then transported on ECMO to the ECMO facility by road, helicopter, or fixed-wing aircraft depending on distance, weather conditions, etc. Eight publications have reported series of more than 50 transports on ECMO of which the largest included over 700. Together, these papers report on more than 1400 patient transports on ECMO. Two deaths during transport have occurred. A number of other adverse events are described, but without effect on patient outcome. Survival of patients transported on ECMO is equivalent to that of non-transported ECMO patients. It is concluded that long-, short-distance interhospital transports on ECMO can be performed safely. The staff should be experienced and highly competent in intensive care, ECMO cannulation, ECMO treatment, intensive care transport, and air transport medicine.

Double lumen catheter placement during VV ECMO in an infant with persistent left superior vena cava-important considerations.

Extracorporeal membrane oxygenation (ECMO) is a salvage therapy in acute cardiac failure and/or severe respiratory failure. In this case report the importance of cannula positioning during veno-venous ECMO is exemplified. The use of echocardiography and its advantages compared to plain chest radiograph will be shown. This case reflects a 5-month-old boy who acquired a severe viral pneumonia leading to respiratory failure and ECMO treatment. Extracorporeal membrane oxygenation was performed via a dual lumen cannula correctly placed in the right atria according to a chest radiograph. During the first day of treatment the patient's arterial saturation was not satisfying. Assessment revealed that a part of the ECMO flow was recirculating. Echocardiography was used to optimize the cannula position, and thus, rapidly improving the patient's oxygenation. A persistent left superior vena cava and its effect on the central hemodynamics were also objectified. This case illustrates important considerations in daily ECMO treatment: the benefit of direct echocardiographic competence at all times during the day, the importance of understanding central blood flow dynamics, to adjust the cannula-position accordingly, and to address situations outside the ordinary with a physiologic approach.