Referring a patient to ECMO
Infants, children, teens and adults suffering from severe cardio-pulmonary failure and other life-threatening conditions may require the use of extracorporeal membrane oxygenation (ECMO). ECMO is a sophisticated procedure, similar to the heart-lung bypass machine used in cardiac surgery, which takes over the oxygenation and heart function in patients with serious lung disease, cardiac disease, or trauma.
- For consultation or referral, Legacy One Call Consult & Transfer: 1-800-500-9111
- Go here for our referral criteria for adults
- For non-emergent information on ECMO, call the ECMO coordinator at 503-413-4457; pager, 503-295-8937
Recognized for excellence
Legacy Emanuel Medical Center and Randall Children’s Hospital at Legacy Emanuel, a regional leader in ECMO for decades, has a focused program for each age group, from newborn to children and teens to adults. We have the most experience using the therapy of any medical center in the regions and the capability to treat and care for six patients on ECMO simultaneously. Our program, which began in 1986, was one of three centers internationally to first receive the ECMO Award of Excellence from the Extracorporeal Life Support Organization (ELSO).
Patients can read about our ECMO services here; for pediatric ECMO, patients and families can find more information is here.
We accept questions and referrals 24 hours a day, seven days a week. We are happy to receive consultations or to arrange transfer from centers in Oregon, Washington and the surrounding regions.
Expert consultation
If you are treating an infant, child or adult suffering from severe cardio-respiratory failure who is not responding to standard medical treatment, the experts at Legacy Emanuel and Randall Children’s Hospital provide collaborative, consultative advice. Our experience with hundreds of ECMO cases shows that early dialogue is crucial to optimal patient survival and outcomes. Survival of the potential ECMO patient is correlated to appropriate and safe transfer of the patient before the patient actually meets the clinical criteria for ECMO therapy –– we encourage you to call.
More patients with severe lung failure (ARDS) survive ECMO if it is started before they have been on the ventilator (breathing machine) for more than a few days. It is important to call us early. We are dedicated to be available to help these profoundly ill patients, their families and our community by providing this care at the highest possible standards.
Therapy for serious conditions
Our program helps patients with these conditions:
Neonates
• Meconium Aspiration Syndrome (MAS)
• Pneumonia
• Sepsis
• Respiratory failure
• Congenital diaphragmatic hernia
• Persistent pulmonary hypertension of the newborn (PPHN)
• Congenital heart disease
Infants/children/teens/adults
• Near drowning
• Pneumonia
• Sepsis
• Congenital heart disease
• Respiratory failure
• Shock
• Traumatic injury
• Acute Respiratory Distress Syndrome (ARDS)
• Hypothermia
• Acidosis
• Hypoxia
In addition to ECMO, we offer a full spectrum of related therapies. These include advanced ventilator management, kidney support therapy, plasmaphoresis, sophisticated monitoring, imaging and cardiac assist devices. All of these services are under the direction of specially trained, experienced and board-certified neonatal, pediatric and medical and surgical care specialists.
In addition, the PICU at Randall Children's Hospital uses volumeric diffusive respiration (VDR) systems to keep some patients with lung problems from needing ECMO.
Rooms in Randall Children's Hospital in the NICU and PICU are large enough to have room for the ECMO equipment.
Specialized, dedicated team –– around the clock
Our program features a range of specialists to provide minute-to-minute bedside support for the complex technology.
• ECMO-trained neonatologists and pediatric intensivists are available around the clock in the Neonatal Intensive Care Unit (NICU) and in the Pediatric Intensive Care Unit (PICU).
• Specially trained ECMO physicians work with pediatric surgeons, cardio-thoracic surgeons, trauma surgeons, cardiologists, and renal and pulmonary specialists to care for ECMO patients.
• The ECMO nurse specialist operates the ECMO machine, making adjustments. An additional nurse monitors vital signs and other aspects of patient care.
• We have a full team of specialists, perfusionists, therapists and more
ELSO database registry
ELSO maintains an international registry of information about ECMO patients. We submit information on each ECMO patient to this database, which provides us with invaluable information about ECMO therapy, underlying illnesses and patient outcomes. We use this data to evaluate and continually improve our care of the ECMO patient.
Our providers
Andy Michaels, M.D., medical director, adult ECMO
Martha Nelson, M.D., medical director, neonatal ECMO, Randall Children's Hospital
Peter Quint, M.D., medical director, pediatric ECMO, Randall Children's Hospital
Our history
We were the second ECMO center on the West Coast and one of the first three facilities in the nation to achieve a “Center of Excellence” designation. We are the only center in the Pacific Northwest to provide a formal, immediately available and experienced transport team; we are by far the busiest and most experienced center in the region.
Our first experience with multiple casualties needing cardio-pulmonary bypass (CPB) support was due to the Mt. Hood climbing disaster in 1986. Thirteen climbers on a high school outing became trapped at altitude (9,000 feet) in a blizzard and suffered severe hypothermia. Nine of these adolescents died. The four climbers found three days later were profoundly hypothermic. (<24 C), and the media generated an expectation that hypothermic patients are not dead until “they are warm and dead.” Because of the limitation of CPB teams and equipment at our hospital, we organized and coordinated with three other Portland hospitals to distribute the patients so that every patient had the opportunity to be revived by this technology1. There were several survivors, and our ECMO program was born.
Over the course of years, Jonathan Hill, M.D., and William Long, M.D., from the Legacy Emanuel trauma team, continued to use ECMO for a variety of indications, particularly patients suffering from “un-resuscitate-able” trauma. The extremes of hypothermia, acidosis, hypoxia and shock could be stabilized and corrected by acute ECMO. Cardiopulmonary bypass technology (and ECMO) can restore adequate blood flow, improve oxygenation, and re-warm the patient2.
It has been our experience that these profoundly compromised patients require a period of total support while their extreme physiologic derangements and injuries are corrected. Frequently they require extracorporeal support for a relatively short period of time before their native function begins to return3.
Some of these patients are too unstable for transport by normal means; therefore, in 1985 the Mobile Surgical Transport Team (MSTT) was formed to address the logistical problems of transporting patients in extremis from referring institutions. The program was designed to take a team to the patient and provide additional personnel, resources, capabilities and experience at the referring institution and en route back to the level I trauma center.
With the development of miniature, simple CPB or ECMO systems and heparin bonded circuits; this technology was added to the MSTT missions. Selected members of the operating room, critical care, trauma resuscitation, perfusion, and surgical teams were trained and credentialed to function on an MSTT4-6. A strong transport capability is essential for a regional ECMO referral center to be effective.
The neonatal and pediatric ECMO programs developed simultaneously, beginning in 1987 and 1998 respectively.
In 1998, with the addition of Andy Michaels, M.D., who was trained by Dr Bartlett in Michigan, we began using ECMO for isolated ARDS more frequently and added protocols to our approach to severe lung injury7,8. We have been early adopters of new technologies in critical care, perfusion science, vascular access and resuscitation and continue to have a state-of-the-art clinical program.
During the H1N1 “swine flu” pandemic of 2009–2010, we were among the busiest centers in the world and treated the second highest volume of patients in the nation9. Since then, our regional impact has grown and our volume of patients and outcomes have been excellent10,11.
In January 2013 we instituted a focused ECMO service integrating the neonatal, pediatric and adult programs with our critical care services to create the Randall/Emanuel Severe Cardio-pulmonary Failure and ECMO (RESCUE) Center. It is our goal to treat the most compromised patients in our region with standards of care and outcomes that are consistent with the best international practices.
Our current results reflect that goal. We have a 65 percent survival rate for adults with profound refractory hypoxemic ARDS. This compares favorably with international rates of 55 percent for severe ARDS patients treated with ECMO and 45 to 47 percent survival for similar patients treated with the best “non-ECMO” methods. In addition, the time that the survivors in our care required ECMO is significantly shorter than for the survivors reported to the international ELSO ECMO registry treated in other centers11.
References
1) Hauty, M G, Esrig, B C, Hill, J G and Long, W B Prognostic Factors in Severe Accidental Hypothermia: Experience from the Mt. Hood Tragedy. J Trauma 1987:27:1107-1112
2) Perchinsky MJ, Long WB, Hill JG, Parsons JA, Bennett JB.: Extracorporeal cardiopulmonary life support with life support with heparin bonded circuitry in the resuscitation of massively injured trauma patients. Am J Surg. 1995 May;169(5):488-91
3) Sasadeusz KJ, Long WB 3rd, Kemalyan N, Datena SJ, Hill JG. Successful treatment of a patient with multiple injuries using extracorporeal membrane oxygenation and inhaled nitric oxide. J Trauma. 2000 Dec;49(6):1126-8.
4) Bennett JB, Hilkl JG, Long WB 3rd et al; Interhospital transport of the patient on extracorporeal cardiopulmonary support. Annals of Thoracic surgery, 1994 Jan; 57(1): 107-11
5) Long WB, Michaels AJ, Hill J, et al: The Mobile Surgical Transport Team: level I outreach. J Trauma Jan 2003, presented at the 33rd annual meeting of the Western Trauma Association, Snowbird UT
6) Wick JM, Wade J, Datena SJ, Long WB: Mobile surgical transport team. AORN J. 1998 Feb;67(2):346-52, 354.
7) Michaels AJ, Schriener RJ, Kolla S, Awad SS, Rich PB, Reickert C, Younger J, Hirschl RB, Bartlett RH. : Extracorporeal life support in pulmonary failure after trauma. J Trauma. 1999 Apr;46(4):638-45.
8) Michaels AJ, Wanek SM, Dreifuss BA, Gish DM, Otero D, Payne R, Jensen DH, Webber CC, Long WB: A protocolized approach to pulmonary failure and the role of intermittent prone positioning. J Trauma. 2002 Jun;52(6):1037-47
9) Michaels AJ, Hill JG, Bliss DW, et. al.: Pandemic Flu and the Sudden Demand for ECMO Resources: A mature trauma program can provide surge capacity in acute critical care crises. J of Trauma, 2013. in review
10) Michaels AJ, Hill JG, Long WB, et. al.: Adult Refractory Hypoxemic ARDS Treated With ECMO: the role of a regional referral center. Am J Surg. May 2013
11) Michaels AJ, Hill JG, Long WB, et. al.: The Protocolized Use of Percussive Ventilation Reduces the Cost and Risk of ECMO for Refractory Hypoxemic ARDS in Adults, Pacific Coast Surgical Association, Kauai HI, Feb 2013