ECMO Services

In this article, Dr Álvaro J. Roldán-Reina and Dr Alex Rosenberg, ECMO specialists at the Royal Brompton and Harefield Hospitals in London provide a look at their service and background to the technique…

• Extracorporeal membrane oxygenation (ECMO) is a temporary life support technique, used to treat respiratory or cardiac failure.
• There are two types of ECMO:

1. Veno-Venous (VV) to provide gas exchange, indicated for acute severe respiratory failure in patients whose primary disease is reversible and is only deployed when conventional therapies have failed to support the function of the lungs adequately.

2. Veno-Arterial (VA) which provides gas exchange and haemodynamic support.

It is common to use ECMO in neonatal intensive-care units, but the most common use in adults is in acute respiratory distress syndrome associated with pneumonia

• ECMO therapy requires a careful patient selection process and management of the patient’s overall condition, including the related technical issues.
• In most countries specialised ECMO retrieval services collect the patients and cannulate them in the referring hospital to transfer them with the ECMO circuit in situ. See more details in the video shown in the next step.

• The conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR) trial, published in 2009, showed that initiating ECMO in remote institutions followed by stabilisation and transfer to tertiary centres on ECMO had an improved survival rate.

A marked improvement in death rate and severe disability was shown when severe respiratory failure was treated with extracorporeal support

Inclusion Criteria

• Potentially reversible severe respiratory failure (e.g. PaO2/FiO2 <6.7 kPa for ≥3 hours or PaO2/FiO2 <10 kPa for ≥ 6 hours)
• Murray Lung Injury Score ≥3
• Uncompensated hypercapnia with a pH ≤ 7.20 despite respiratory rate > 35/min or due to life threatening airway disease (e.g. asthma or airway trauma, air leak)
• Failed trial of ventilation in the prone position for ≥ 6 hrs (unless contraindicated)
• Failed optimal respiratory management with lung protective ventilation after discussion with a national ECMO centre

Exclusion Criteria

• Refractory or established multi-organ failure
• Evidence of severe neurological injury
• Prolonged cardiac arrest (> 15 min)
• At least two ECMO centres must agree that it is appropriate to proceed to ECMO for patients meeting one of the following criteria:

1. Indices of low potential to recover such as RESP Score ≤ 3

2. Receiving invasive mechanical ventilation > 7 days

ECMO Landscapes

• The arrangement of ECMO services is very different in various countries.
• In the UK eight centres are commissioned for ECMO.
• In Germany, more than 500 hospitals have performed ECMO with a few outstanding centres concentrating most of the cases.

• The ECMO retrieval centres in the UK are:
  • Guy’s & St Thomas’s NHS Foundation Trust
  • Papworth Hospital NHS Foundation Trust
  • University Hospitals of Leicester NHS Trust (Glenfield Hospital)
  • University Hospital of South Manchester NHS Foundation Trust
  • Royal Brompton & Harefield NHS Foundation Trust
  • Aberdeen Royal Infirmary