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Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting.
Air Med J. 2020 Mar - Apr; 39(2):124-132.AM

Abstract

Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment. Coagulopathy and bleeding are the most common complications occurring in up to 50% of ECMO patients. Loss of flow and hypotension from loss of volume or profound vasodilation after ECMO initiation need to be managed accordingly. Oxygenator malfunction can occur, and clinicians must be able to recognize the indicators of this complication promptly. Loss of pulsatility, low end-tidal carbon dioxide (ETCO2), and differential hypoxia are common complications in venoarterial ECMO. In addition, an air embolism is life-threatening on venoarterial ECMO but may be better tolerated in the setting of venovenous ECMO. Recirculation in venovenous ECMO leads to circulation of poorly oxygenated blood and must be recognized and addressed. Lastly, pump failure, circuit rupture, and decannulation are devastating complications. Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has accelerated rapidly,1-3 providing support for patients in severe respiratory or cardiac failure. With ongoing clinical experience and improvements in technology, the indications for ECMO are increasing.4 Many areas are developing centralized ECMO centers to serve their surrounding communities.5-7 To use a centralized ECMO referral model, patients need access to effective, safe critical care transport, but transporting a patient on ECMO carries a significant risk of adverse events.8-13 The purpose of this review is to highlight some of the most common adverse events in ECMO transports and provide management suggestions. Note that these recommendations are not a substitution for close collaboration with medical control, and all adverse events should be promptly reported per organizational protocols.

Authors+Show Affiliations

Boston MedFlight, Bedford, MA.Boston MedFlight, Bedford, MA.Boston MedFlight, Bedford, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA.Boston MedFlight, Bedford, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. Electronic address: swilcox1@partners.org.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

32197690

Citation

Vieira, Jennifer, et al. "Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting." Air Medical Journal, vol. 39, no. 2, 2020, pp. 124-132.
Vieira J, Frakes M, Cohen J, et al. Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting. Air Med J. 2020;39(2):124-132.
Vieira, J., Frakes, M., Cohen, J., & Wilcox, S. (2020). Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting. Air Medical Journal, 39(2), 124-132. https://doi.org/10.1016/j.amj.2019.09.009
Vieira J, et al. Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting. Air Med J. 2020 Mar - Apr;39(2):124-132. PubMed PMID: 32197690.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting. AU - Vieira,Jennifer, AU - Frakes,Michael, AU - Cohen,Jason, AU - Wilcox,Susan, Y1 - 2019/10/19/ PY - 2019/08/01/received PY - 2019/09/03/accepted PY - 2020/3/22/entrez PY - 2020/3/22/pubmed PY - 2020/3/22/medline SP - 124 EP - 132 JF - Air medical journal JO - Air Med. J. VL - 39 IS - 2 N2 - Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment. Coagulopathy and bleeding are the most common complications occurring in up to 50% of ECMO patients. Loss of flow and hypotension from loss of volume or profound vasodilation after ECMO initiation need to be managed accordingly. Oxygenator malfunction can occur, and clinicians must be able to recognize the indicators of this complication promptly. Loss of pulsatility, low end-tidal carbon dioxide (ETCO2), and differential hypoxia are common complications in venoarterial ECMO. In addition, an air embolism is life-threatening on venoarterial ECMO but may be better tolerated in the setting of venovenous ECMO. Recirculation in venovenous ECMO leads to circulation of poorly oxygenated blood and must be recognized and addressed. Lastly, pump failure, circuit rupture, and decannulation are devastating complications. Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has accelerated rapidly,1-3 providing support for patients in severe respiratory or cardiac failure. With ongoing clinical experience and improvements in technology, the indications for ECMO are increasing.4 Many areas are developing centralized ECMO centers to serve their surrounding communities.5-7 To use a centralized ECMO referral model, patients need access to effective, safe critical care transport, but transporting a patient on ECMO carries a significant risk of adverse events.8-13 The purpose of this review is to highlight some of the most common adverse events in ECMO transports and provide management suggestions. Note that these recommendations are not a substitution for close collaboration with medical control, and all adverse events should be promptly reported per organizational protocols. SN - 1532-6497 UR - https://www.unboundmedicine.com/medline/citation/32197690/Extracorporeal_Membrane_Oxygenation_in_Transport_Part_2:_Complications_and_Troubleshooting L2 - https://linkinghub.elsevier.com/retrieve/pii/S1067-991X(19)30200-7 DB - PRIME DP - Unbound Medicine ER -
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