Palmer: Long run ECMO, The Stockholm experience

Today it is a privilege to welcome Kenneth Palmér, MD, Director of the Extracorporeal Membrane Oxygenation Center (ECMO) at Karolinska Hospital located in Stockholm, Sweden. In his tenure at Karolinska he started the world’s first ECMO center in 1986, has perfected the use of awake ECMO support, and has assisted in creating one of the three biggest ECMO centers in the world! In addition, Dr. Palmér has been invited to give over 200 international lectures on the topic of ECMO. In addition to perfecting ECMO use for inpatients, Dr. Palmér has also perfected the use of extracorporeal membrane oxygenation in transport. Today he was kind enough to stick around after the 28th Annual Extracorporeal Life Support Organization Conference and discuss all he has learned over a lifetime of ECMO practice.

Clinical Pearls

  • #1: All pearls learned after 30 years of awake patients on VV-ECMO!
    • First dedicated ECMO ICU in the world
    • Covering all of Sweden means ECMO transport is key
  • Septic shock is a very common reason for ECMO (many VA) in Stockholm
    • Loss of SVR
    • Loss of peripheral oxygen consumption on a cellular level
    • Coagulation issues
    • Cardiogenic shock is common (EF < 20%)
      • Used often as the second inotropic drug
    • Most common issue: waiting too long due to too strict indications!
  • Prolonged aortic valve closure on VA-ECMO is worrisome for LV stagnation and clotting
    • No true time table to placement of decompression catheter/intervention
    • Some centers wait for 3 days before addressing
  • Cannulation
    • #1: Find the blue blood!
      • Flow is everything, recirculation is simply secondary
    • VA-ECMO goal: Drain the right IJ and return to the right femoral artery
    • VV-ECMO goal: Drain the right IJ and return to the right femoral vein
      • Thought process: brain consumes most of the oxygen and thus this is the bluest blood
    • Femoral artery cannulation tips
      • Place arterial catheter in dorsalis pedis BEFORE cannulation
      • 17 Fr short cannula in FA by Seldinger (15 Fr felt to be too small for full Flow)
      • Measure BP in leg, want > 35 mmHg
        • If flow is not sufficient, place retrograde cannula
    • Multistage cannula
      • Great Flow, BUT all blood comes from holes 1-3 with the rest of the cannula being wasted (same as a short cannula)
  • Saturation
    • We do not worry about low saturation if we drive up to a proper hemoglobin!
      • When you evaluate Hgb x 1.34 x saturation (basic equation), a patient with a hgb of 12 g/dL and 55% SpO2 has the same oxygen content as a patient with hgb of 7 and 90% SpO2!
    • Can live with VERY low saturations (45%), but circulation and physiology must otherwise be perfect
      • Hypoxemia (low O2 in blood) is common, hypoxia (low O2 in tissues) is uncommon
  • Oxygen Delivery
    • There is a limitation to how much an oxygenator can deliver
      • Normal adult oxygenator delivers ~ 280-300 ml/min
      • Often will need two oxygenators in parallel
    • Rated flow: capacity to increase saturation from 75% to 100%
  • Unique Issues
    • Things are different on ECMO
      • PTX: #1 Don’t harm the patient
        • 1st choice- stop ventilation 2-3 days
        • 2nd choice- pleural drainage by Seldinger technique
      • Long run ECMO
        • Multiple days of nearly zero tidal volume, then the lungs open
          • A relative rare occurrence in the ELSO registry
    • Bad heart + Bad lungs
      • Do we increase Flow and oxygenate brain (at expense of LV stagnation and pulmonary edema) OR do we accept hypoxia to brain with preserved CO?
        • Is it better to slow down pump, add CRRT with UF, and then wean both! No answer is known.
    • Ventilation strategy 
      • Optimum ventilator settings still unknown
        • Diurese the wet lung, wait out the consolidated lung
      • Bigger TV does not mean healthy lung, however, healthy lung means larger TV
        • Patients will fix themselves
      • Pt’s do not die from lung failure, but from other complications (bleeds, infections)
    • Sedatives
      • Best sedative is a low PaCO2 (< 35 mmHg)
      • Decrease all other sedatives as much as possible
        • Morphine, Precedex, etc.

Suggested Reading

  1. Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The “baby lung” became an adult. Intensive Care Med. 2016 May;42(5):663-73. [Pubmed Link]
  2. Holzgraefe B, Andersson C, Kalzén H, von Bahr V, Mosskin M, Larsson EM, Palmér K, Frenckner B, Larsson A. Does permissive hypoxaemia during extracorporeal membrane oxygenation cause long-term neurological impairment?: A study in patients with H1N1-induced severe respiratory failure. Eur J Anaesthesiol. 2017 Feb;34(2):98-103. [Pubmed Link]
  3. Combes A, Brodie D, Bartlett R, Brochard L, Brower R, Conrad S, De Backer D, Fan E, Ferguson N, Fortenberry J, Fraser J, Gattinoni L, Lynch W, MacLaren G, Mercat A, Mueller T, Ogino M, Peek G, Pellegrino V, Pesenti A, Ranieri M, Slutsky A, Vuylsteke A; International ECMO Network (ECMONet). Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med. 2014 Sep 1;190(5):488-96. [Pubmed Link]
  4. Wiktor AJ, Haft JW, Bartlett RH, Park PK, Raghavendran K, Napolitano LM. Prolonged VV ECMO (265 Days) for ARDS without technical complications.
    ASAIO J. 2015 Mar-Apr;61(2):205-6. [Pubmed Link]
  5. Posluszny J, Rycus PT, Bartlett RH, Engoren M, Haft JW, Lynch WR, Park PK, Raghavendran K, Napolitano LM; ELSO Member Centers. Outcome of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) ECMO. Ann Surg. 2016 Mar;263(3):573-81. [Pubmed Link]
  6. Broman LM, Holzgraefe B, Palmér K, Frenckner B. The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation. Crit Care. 2015 Jul 9;19:278. [Pubmed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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