Perioperative extracorporeal membrane oxygenation (ECMO) in liver transplantation - bridge to transplantation, intraoperative salvage and postoperative support: outcomes and predictors for survival in a large volume liver transplant centre.

Data on peri-operative extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) are scarce. ECMO has been used pre-, intra-, and postoperatively for a variety of indications at our centre. This retrospective, single centre study of ECMO use peri-LT aimed to describe predictors for successful outcome in this highly select cohort of patients. Demographics, support method and indication for LT were compared between survivors and non-survivors. Twenty-nine patients received: veno-venous (V-V) (n=20); veno-arterial (V-A) (n=8); and veno-arteriovenous (V-AV) (n=1) ECMO. Twelve (41.4%) patients were bridged to emergency LT (ELT) for acute liver failure (ALF), and emergency redo LT. Four (13.3%) patients required intraoperative V-A ECMO salvage: two necessitating extracorporeal CPR (ECPR). Thirteen (43.3%) patients were supported post LT: V-V ECMO (n=9); V-A ECMO (n=1); and ECPR (n=3) between postoperative day 2-30. Overall, 19 patients (65.5%) were successfully weaned off ECMO; 15 (51.7%) survived to ICU discharge. All patients who underwent intraoperative salvage ECMO, and all who were bridged to emergency redo LT died. Peri-LT ECMO is feasible. Post LT ECMO outcomes are encouraging, in particular for V-V ECMO. Intraoperative ECMO salvage, uncontrolled sepsis and graft failure are associated with poor outcomes.

Simulation training for extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a complex treatment. Despite this, there are a lack of training programs designed to develop relevant clinical and nonclinical skills required for ECMO specialists. The aim of the current study was to describe the design, implementation and evaluation of a 1-day simulation course for delivering training in ECMO. METHODS: A 1-day simulation course was developed with educational and intensive care experts. First, the delegates received a lecture on the principles of simulation training and the importance of human factors. This was, followed by a practical demonstration and discussion of the ECMO circuit, console components, circuit interactions effects and potential complications. There were then five ECMO simulation scenarios with debriefing that covered technical and nontechnical issues. The course culminated in a knowledge-based assessment. Course outcomes were assessed using purpose-designed questionnaires. RESULTS: We held 3 courses with a total of 14 delegates (9 intensive care nurses, 3 adult intensive care consultants and 2 ECMO technicians). Following the course, 8 (57%) gained familiarity in troubleshooting an ECMO circuit, 6 (43%) increased their familiarity with the ECMO pump and circuit, 8 (57%) perceived an improvement in their communication skills and 7 (50%) perceived an improvement in their leadership skills. At the end of the course, 13 (93%) delegates agreed that they felt more confident in dealing with ECMO. CONCLUSIONS: Simulation-training courses may increase knowledge and confidence in dealing with ECMO emergencies. Further studies are indicated to determine whether simulation training improves clinical outcomes and translates to reduced complication rates in patients receiving ECMO.