1. ECMO application: ruled implementation or free diffusion? Milan 2012 Palle Palmér ECMO Centrum Karolinska Karolinska University Hospital, Stockholm Sweden

2. If we look at Stockholm development

3. ECMO Centrum Karolinska

4. ECMO is a simple technic But not that simple You need to know a lot of Cannulas, oxygenators, oxygen delivery and consumption, carbon oxide, coagulation Interrelation between ECMO circuit, the ventilator and the CVVHDF machine The doctor and nurses in charge has to know this 24/7 4 ECMO Centrum Karolinska

5. One doctor has to be totally responsible The week has 168 hours In Saturday morning at 4 am you have to have one experienced doctor to handle problems. It not enough with one interested doctor in the ward daytime for 40 hours a week. At least he/she has to be dedicated to come in the other 128 hours too. ECMO is not run by itself for 128 hours a week. 5 ECMO Centrum Karolinska

6. We have to make a different between Cardiac and Respiratory ECMO Cardiac ECMO should probably be done in all thoracic surgical departments. Most of these patients comes from the operation table and need a short term assistance. If the patient get a lung edema it will be complicated and take much more time. 6 ECMO Centrum Karolinska

7. v.cava.sup low saturation v.cava.inf high saturation MRI Jonas A Lindholm Multistage cannulae

8. Respiratory ECMO Needs volume and centralization Long run ECMO 15- 60 days Much more maintenance – circuit change and clotting problems Totally whiteout lungs makes the safety marginal to 30 seconds Low saturation How to ventilate 8 ECMO Centrum Karolinska

9. Burn patient consuming 450 ml of oxygen per minute 9 ECMO Centrum Karolinska

10. 68 days run with saturation of 65% in 45 days 10 ECMO Centrum Karolinska

11. Multi-Organ-failure Decreased urine output Increasing liver values Low blood pressure RIGHT SIDED HEART FAILURE - Convert to V-A ECMO Hemolysis – clotting in the circuit - Solve that problem 11 ECMO Centrum Karolinska

12. Does volume make different ? In a low volume unit less then 10 patient per year, less then 150 days per year, you need much more assistance from perfusionists. It will be more expensive Lack of perfusion capacity for the operation Lack of beds in the thoracic intensive care Less persistence 12 ECMO Centrum Karolinska

13. In normal or thoracical ICU High volume center, at least one ECMO case every day of the year in the ward. It’s a normal part of the ICU treatment. The safety will be in the walls due to dedicated nurses and doctors experience. Much more persistence. Possible to have the patients awake. Possible to learn how to solve problems. 13 ECMO Centrum Karolinska

14. ELSO reports July 2012 14 ECMO Centrum Karolinska

15. The big well developed ECMOcenters Reports survival rate of 70-80%, Stockholm and Leicester, even with mean p/F ratios of 50 and 65. That means that the smaller centers have an survival rate of about 50% It´s also possible that the experience centers takes more odd cases. 15 ECMO Centrum Karolinska

16. Mean p/f ratio 1995 – 2008 1995 2008

17. A new indication Septic shock SAPPS III scoring 2012 10 patient with septic shock mean 80 points Mortality risk of 85% Low leucocytes declining to < 2 ”ALARM ALERT” Inotropic index > 100 Cold sepsis in some of them - amputation Survival rate 80% V-A ECMO because of cardiogenic shock

18. Trauma is an undeveloped field No heparin until they stop bleeding The Problem is that the major trauma cases don’t die within 1-2 hours. They are still alive 10 hours later, and we empty the blood bank, and the surgeons are tired You can pack the thoracic cavity, to stop bleedings 18 ECMO Centrum Karolinska

19. 10 million people per ECMO center You will have respiratory ECMO 40 -50 adult patient per year mean 15 days ( 7-60 days) 30-40 pediatric patientmean 15 days ( 7-60 days) 30-40 neonatesmean 7 days( 4-30 days) You need an ECMO transport organization that can transport 24/7 19 ECMO Centrum Karolinska

20. An high volume center Can take the full advantage of the ECMO circuit The goal is not to come off the machine The goal is to have a healthy patient 20 ECMO Centrum Karolinska

21. 21 ECMO Centrum Karolinska Pneumothorax Don’t hurt the patient First choice - stop ventilation in 2-3 days Pleura drainage - Seldinger or Surgeon

22. A very small pleuradrainage - 20 liter of blood and 4 operations 22 ECMO Centrum Karolinska

23. Maybe we should look at survival as something obvious Why did they die and was it preventable Last 2 years 78 adult patient Sapps III mortality rate of 85% 17 patient died (22%) 5 patient we didn´t have a chance from beginning 5 patient in pseudomonas and fungus 4 intracranial bleeding septic embolus pre ECMO 3 intracranial bleeding due to the ECMO treatment 23 ECMO Centrum Karolinska

24. When you look at the pump and as your best friend then you are a mature ECMO unit Learn everything about the pump oxygenators tubings and cannulaes Train,train,train Be careful Be patient Be trained Don’t solve problems that doesn’t have to be solved

26. EURO-ELSO 2013 Precongress8-9 May2013 Congress9-11 May 2013 Scientific programmeNov 2012 Deadline for Abstracts 15March2013 26

27. 27 Welcome to Stockholm 2013