Qatar Medical Journal - 1 - Extracorporeal Life Support Organisation of the South and West Asia Chapter 2017 Conference Proceedings, February 2017

Extracorporeal Life Support (ECLS) is saving an increasing number of lives worldwide,1 so it is a great pleasure to welcome for the first time in Qatar the South and West Asia Chapter (SWAC) of the Extracorporeal Life Support Organisation (ELSO). The conference organizing and scientific committees have worked tirelessly under the leadership of Dr Ibrahim Fawzy Hassan (2017 Conference Chair) to make ELSO SWAC 2017 an enriching event tha Read More

Introduction: The aim of the program was to establish a severe respiratory failure (SRF) service with mobile extracorporeal membrane oxygenation (ECMO) retrieval capability throughout Qatar. This was achieved through the collaboration of various Hamad Medical Corporation (HMC) entities (critical care, cardiothoracic surgery, vascular surgery, and ambulance services). The service was commissioned by the Ministry of Public Health in O Read More

Introduction: The H1N1 epidemic in 2009 caused a significant increase in the utilization of respiratory extracorporeal membrane oxygenation (ECMO) therapy for severe respiratory failure (SRF) patients who failed to improve following conventional ventilation therapy. Its use was linked to a high patient survival rate (more than 70%) reported from Australian and New Zealand1 as well as Canadian ECMO2 registries. It eventually led to the CES Read More

Introduction: Extracorporeal membrane oxygenation (ECMO) is an adaptation of conventional cardiopulmonary bypass techniques used for long-term support of respiratory and/or cardiac function. It provides physiologic cardiopulmonary support for patients with acute, reversible cardiac or respiratory failure. The term “extracorporeal life support” (ECLS) was proposed to describe prolonged but temporary (1–30 days) support of heart or lun Read More

Introduction: The provision of an effective extracorporeal membrane oxygenation (ECMO) service requires a dedicated unit with sufficient caseload and access to specialised resources.1 Moving unstable patients, with refractory respiratory failure on conventional mechanical ventilation, to the specialised centre for ECMO poses great risk to the patient.1,2 Therefore, there is a need to have mobile ECMO capabilities with specialised retrieval tea Read More

In the USA, trauma represents the leading cause of death between the ages of 1 and 46 years and contributed to 192,000 deaths in 2014.1 Major trauma is also responsible for significant disabilities and increased hospital length of stay (LOS), and represents a huge financial burden. Acute respiratory failure (ARF) is multifactorial in trauma patients with diverse underlying pathophysiological mechanisms. In a blunt thoracic injury, Read More

“Bringing ECMO simulation to life”: The main theme of the 4th Annual Conference of the Extracorporeal Life Support Organisation – South and West Asia Chapter (ELSO-SWAC), “Bringing ECMO Simulation to Life”, is meant to emphasise the growing role of simulation in healthcare and medical education at large and in the highly specialised and complex field of extracorporeal life support (ECLS), and in particular for extracorporeal membrane ox Read More

Extracorporeal life support (ECLS) is the prototype example of translational research. It began in laboratory studies to design, test, and characterize devices for prolonged extracorporeal circulation in the 1960s. The first clinical cases of ECLS for heart and lung failure were in the 1970s. These cases were met with skepticism, but the results in neonatal respiratory failure were encouraging. In the early 1980s, two centers conducted rando Read More

The South and West Asia Chapter of Extracorporeal Life Support Organisation (SWAC ELSO) was established in the year 2013 with the combined efforts of senior members from the ELSO and the ECMO society of India.1 It was established with the idea of improving the awareness and practice of ECMO in this part of the world. I am pleased to see the growth of the organisation in the next couple of years. This region is representative of the me Read More

The clarion call for setting up a Qatar adult extracorporeal membrane oxygenation (ECMO) program came during the MERS-CoV outbreak in the Arabian Peninsula region.1 This carried a high mortality rate in those presenting with severe respiratory failure, and recent data from the “CESAR Trial” showed that treatment in a severe respiratory failure center with ECMO capabilities improved severe respiratory failure (SRF) patient survival.2 Owin Read More

Rationale: Transport of critically ill patients on extracorporeal membrane oxygenation (ECMO) can be challenging; however, this has been demonstrated to be safe and feasible if undertaken by adequately trained teams,1–3 with appropriate equipment and a platform that can accommodate the team and allows full access to the patient. The ECMO retrieval service is a key component of the severe respiratory failure (SRF-ECMO) program. The H Read More

Quality and patient safety are core elements of a successful extracorporeal membrane oxygenation (ECMO) program. Patient survival, patient safety, and quality of life were the main considerations when establishing an ECMO service in Qatar, with the alternatives being death from refractory hypoxemia or permanent lung fibrosis and reduced quality of life as a result of harmful ventilation. The program strives to achieve these goal Read More

Introduction: Acute severe respiratory failure poses a major treatment challenge which stubbornly carries high mortality and morbidity rates. Here, we review PaO2/FiO2 (PF) ratio and disease severity, and discuss protective lung ventilation and the rescue therapies, and when to use what? PF ratio alone is not sufficient to determine disease severity: A recent study by Villar and colleagues demonstrated that only 38% of patients who were class Read More

The extracorporeal membrane oxygenation (ECMO) cannulae can be safely inserted into the jugular and femoral regions using a percutaneous dilation technique or by open surgical cannulation. Percutaneous dilation that avoids skin cutting can achieve a tight seal between skin, vessels and cannulae. This avoids bleeding associated with surgical dissection and limits tissue damage. Surgical dissection is also associated with additional risks of Read More

Temporary mechanical cardiopulmonary support may be used intraoperatively to facilitate cardiac surgery. Over the past decade, this intervention has been extended for prolonged use in the intensive care unit (ICU) as extracorporeal membrane oxygenation (ECMO).1 Two types of ECMO exist in clinical practice: veno-arterial (VA) and veno-venous (VV). VV ECMO provides support to the pulmonary system by extracting blood from the right atr Read More

The use of venovenous extracorporeal membrane oxygenation (VV-ECMO) for severe acute respiratory failure (ARF) has considerably increased worldwide. Therefore, extracorporeal membrane oxygenation (ECMO) teams called for practical guidelines with clear objectives on how to manage ECMO on daily basis.1 All classical topics of intensive care management have been put in perspective with the use of ECMO, opening multiple Read More

Introduction: Echocardiography (ECHO) plays a fundamental role in the management of patients supported with extracorporeal membrane oxygenation (ECMO).1 It is particularly useful for the detection of cardiac complications that may arise during ECMO. It helps in many ways during the ECMO run, as presented in Table 1.Table 1Indications for ECMO therapy.3 ECHO helps to identify or exclude new reversible pathology, which could be the ac Read More

Extracorporeal membrane oxygenation (ECMO) is used to support patients with hypoxemia due to severe respiratory failure. Hypoxemia can persist during ECMO as a result of reduction in mechanical ventilatory support as part of a lung protective strategy, following which gas exchange provided by the native lungs is reduced or absent. If tissue oxygen delivery is maintained, mild to moderate hypoxemia will be well tolerated, but if tissue Read More

The prone position has been used successfully for many years to improve oxygenation in patients who require mechanical ventilatory support for management of acute respiratory distress syndrome (ARDS). Proning improves oxygenation by optimizing lung recruitment and ventilation–perfusion matching. The following improved outcomes have been shown: when the prone position is used for moderate to severe ARDS; when used in Read More

Introduction: Extracorporeal circulation has been around for more than half a century, but many questions remain regarding how to best achieve anticoagulation in a patient on extracorporeal membrane oxygenation (ECMO). Although unfractionated heparin is the predominant agent used for cardiopulmonary bypass, the amount required and how best to monitor its effects are still unresolved. Extracorporeal circulation is associate Read More

Bleeding is a common complication in patients undergoing extracorporeal membrane oxygenation (ECMO) management.1 It requires immediate management to achieve hemostasis, replace blood, and compensate volume loss. Refractory hemorrhage can be lethal and can lead to massive transfusions with all their known complications. Refractory bleeding and massive transfusions in ECMO patients are associated with high mort Read More

The application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is becoming an increasingly frequent procedure in emergency medicine.1 Correct appraisal of clinical conditions and patient selection are critical not only in terms of expected outcome, but also in terms of adequate temporary support configuration, optimization of resources, and organization of daily hospital activities, since inappropriate implant may rem Read More

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly applied for the treatment of cardiogenic shock despite its high complication rate.1 The lack of left ventricular unloading is one of the serious problems associated with the poor outcome of VA-ECMO. Therefore, hemodynamic management during VA-ECMO should address the higher afterload caused by the retrograde blood flow and the consequent le Read More

The use of mechanical circulatory assistance remains controversial during refractory septic shock in adults.1 However, a profound myocardial dysfunction can occur during bacterial septic shock.2–4 In this context, extracorporeal membrane oxygenation (ECMO) is highly effective as salvage therapy for children with refractory septic shock.5,6 We reported the largest cohort of adults who received VA-ECMO for refractory cardiovas Read More

Background: Mortality of patients on extracorporeal membrane oxygenation (ECMO) remains high. Diagnosis of infection during extracorporeal life support (ECLS) is still challenging, and prevention strategies vary widely from center to center.1–3 These facts led us to analyze the occurrence rate, site, and organism in our ECLS patients in order to implement infection control measures to reduce the incidence of infections during ECLS.4 Read More

Veno-arterial extracorporeal membrane oxygenation (ECMO) has been used successfully for several years in refractory cardiogenic shock. Of note, the survival rate is markedly affected by the underlying patient condition, and especially their capacity to recover. Combes et al.1 demonstrated a short- and a long-term survival rate (11 months of median follow-up time) of, respectively, 42 and 36% in a large series of patients with cardiogenic sho Read More

Aim: Refractory cardiogenic shock (CS) complicates 5–7% of cases with ST-elevation myocardial infarction (STEMI), and is a leading cause of hospital death after myocardial infarction.1 CS complicating acute myocardial infarction (AMI) continues to have a high mortality of 40–50% despite early revascularization and adjunctive therapies.2 Extracorporeal membrane oxygenation (ECMO) technology has advanced significantly and is rea Read More

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is the rapid deployment of extracorporeal membrane oxygenation (ECMO) – or cardiopulmonary bypass – to provide immediate cardiovascular support for patients who have cardiac arrest unresponsive to conventional cardiopulmonary resuscitation (CPR) measures. There is improved survival with isolated cardiac lesions.1 Cardiac disease (adjusted for confo Read More

Acute myocardial infarction is a common cause of cardiogenic shock (approximately 75% of all patients) and out-of-hospital cardiac arrest (approximately 70% of survivors).1 Mechanical hemodynamic support is employed prior to coronary revascularization (pre-percutaneous coronary intervention (PCI)), during or after PCI.2 Revascularization procedure is characterized by a transient interruption of coronary blood flow (due t Read More

The rapid institution of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for patients with prolonged, recurrent cardiac arrest (CA) complicated by severe shock and cases of refractory arrhythmia without return of spontaneous circulation (ROSC) is now termed ECMO-CPR (E-CPR). The use of E-CPR is increasing and there are reported benefits for both out-of-hospital and in-hospital patient populations. Recently, this Read More

Cardiac arrest is a common problem, both in the in-hospital environment and in the out-of-hospital environment with an estimated incidence of over 300,000–400,000 cases of out-of-hospital cardiac arrests every year in the USA. Globally, the outcome of cardiac arrest remains poor, particularly with respect to neurological outcomes.1 It is estimated that approximately 10–11% of patients with cardiac arrest survive to hospital discharge. A Read More

Since its development in the early 1990s, extracorporeal membrane oxygenation (ECMO) has become a standard therapy for a wide variety of respiratory and cardiac problems in neonates. Traditionally, the preferred method of access and support has been using a venous inflow, with arterial outflow methodology (venoarterial or VA ECMO), bypassing the cardiac circulation.1 Ongoing improvements in catheter configuration have m Read More

Introduction: Strategy during extracorporeal membrane oxygenation (ECMO) support is guided by available outcome data. Boundaries limiting selection of cases are shifting with advances in ECMO technology, conventional support, and destination therapies. Evolution: Neonatal respiratory ECMO numbers continue to decline due to improved conventional therapies, whereas infants historically excluded from ECMO (for example, ex-premature inf Read More

For neonates, veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support is still commonly used for respiratory as well as for cardiac or combined failure. However, in the pediatric population, veno-venous (VV) ECMO is establishing itself as the standard mode of support for respiratory failure.1 The need for ECMO in neonatal respiratory support has declined over the past years following introduction of alternative options. Co Read More

VA support remains common in neonates and children placed on extracorporeal membrane oxygenation (ECMO) for respiratory, cardiac or combined dysfunction.1 Providing adequate ECMO flow to reverse tissue oxygen debt is imperative in the first few hours of ECMO. Several studies outline the poor outcome which results if lactic acidosis and pH do not improve after institution of ECMO. Following serial lactate, urine output, and other signs Read More

Extracorporeal membrane oxygenation (ECMO) is a commonly used form of mechanical circulatory support in children with congenital or acquired heart disease, and cardiac failure refractory to conventional medical treatments.1 The cardiac output is partially or completely provided by the ECMO machine. To assess how much support is needed at any given time, a constant balance of oxygen delivery and oxygen consumption is require Read More

Background: Extracorporeal membrane oxygenation (ECMO) is a rapidly expanding, life-supporting therapy for critically ill patients with severe respiratory and/or cardiovascular failure. Cerebrovascular impairment can result in hemorrhagic and ischemic complications commonly seen in the patients supported on ECMO. The healthy brain is protected by cerebral autoregulation, which maintains an adequate cerebral blood flow in f Read More

Survival of patients with malignancy over the last 30 years has continually improved due to advancements in aggressive chemotherapeutic regimens as well as supportive measures toward treatment and prevention of infection.1,2 Even though cancer remains a significant cause of mortality in children, 5-year survival for childhood cancers, including hematologic malignancies and solid tumors, is greater than 80%. In these children, critical illn Read More

Background: Harlequin syndrome is a rare autonomic disorder, characterized by unilateral diminished sweating and flushing of the face in response to heat or exercise.1 Harlequin syndrome is described in patients receiving peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), where differential oxygen saturation is observed between the upper and lower parts of the body. It is a phenomenon related to cannulation, Read More

Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support that can be lifesaving in people with potentially reversible heart or lung injuries. ECMO is nearly always used urgently, when all other treatment options for cardiopulmonary injury have failed and high mortality is otherwise expected. Standard ECMO treatment involves venous drainage from the femoral vein or left atrium with artificial extra-circulatory Read More

Background: Obesity, defined according to body mass index (BMI > 30 kg/m2), is an increasing problem in the world's population. The proportion of extremely obese patients (BMI > 40 kg/m2) in intensive care units varies between 2.8 and 6.8%.1 A BMI higher than 40 kg/m2 seems to be associated with an increased risk of developing acute respiratory distress syndrome (ARDS) along with greater morbidity, length of stay, and duration of Read More

Interstitial lung disease comprises a heterogeneous group of histologically distinct pathological entities characterized by a diffuse inflammatory process affecting the lung parenchyma. Classification of interstitial lung disease is complex and usually determined by a combination of clinical features, radiological, particularly computed tomography, appearance, and findings at lung biopsy. Interstitial lung disease presentations can range fro Read More

Extracorporeal membrane oxygenation (ECMO) is increasingly being used in adult patients with either cardiac or respiratory failure or both in many settings.1,2 This includes pregnant patients and those who are postpartum experiencing cardiac or respiratory failure, a particularly vulnerable population where both the mother and the fetus are at risk. There is scant literature addressing the use of ECMO for either cardiac or respira Read More

Pulmonary vasculitis is a rare disease that typically shows inflammation in pulmonary vessel walls and necrosis.1 The disease is usually immune mediated, common in young patients, triggered by many factors, and with wide clinical and radiologic presentations. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAVs) is the main focus in most literature and includes granulomatosis with polyangiitis (GPA), microsc Read More

Pulmonary infection and respiratory failure are the most common causes of admission to the intensive care unit (ICU) in human immunodeficiency virus (HIV)-positive patients.1,2 In our experience, in a developing nation (despite the advent of HAART), the commonest cause of admission to ICU and mechanical ventilation still remains Pneumocystis jiroveci pneumonia (PJP). Most of these patients presenting with PJP have not been on antir Read More

Congenital diaphragmatic hernia (CDH) remains a common defect in infants and occurs worldwide at a rate of 0.8–4.5 per 10,000 live births. It is associated with high mortality and morbidity. Veno-arterial (VA) support remains common in neonates with CDH, although venovenous support has also been used.1 Criteria for extracorporeal membrane oxygenation (ECMO) in CDH patients remain an inexact science. Studies have evaluated t Read More

Extracorporeal membrane oxygenation (ECMO) is an increasingly used life support modality in both respiratory and cardiac cases. The ECMO run may last from a few hours to several months and is usually associated with many major and minor events that can be overseen and may not always be documented. These ECMO complications are related to the circuit, the patient, or other factors such as procedures, drugs, environment, and Read More

With the introduction of veno-venous extracorporeal membrane oxygenation (VV-ECMO) to Qatar, the medical intensive care unit (MICU) team started to face new and challenging ethical dilemmas. These ethical questions have subjected the team of physicians, nurses, and other healthcare professionals to mental stress in addition to the physical stress already encountered running the ECMO service. In this article, we reviewed th Read More

Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) provides the respiratory support in acute severe respiratory failure until the underlying acute lung pathology improves.1,2 VV-ECMO support for >100 days is rare and in most situations requires a destination therapy of lung transplant.3,4 This may not be an option in some centers. We had our longest ECMO case of >300 days with severe residual fibrotic lung dise Read More

Aim: Extracorporeal membrane oxygenation (ECMO) may be lifesaving for patients with severe cardiac/respiratory failure. Typically, ECMO is provided by specialized or regional centers, and patients may have to be transported by road or air ambulance. Herein, we will review the essential requirements for road transport of adult ECMO patients, also known as “mobile ECMO”. Background: Interfacility transport on ECMO is defined as “primary Read More