ECMO: Our History, References

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, 12.

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 Trauma Acute Care Surg. 2013 Jun;74(6):1493-7. doi: 10.1097/TA.0b013e31828d636e.

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, Sperley BP, et. al.: Protocolized use of High Frequency Percussive Ventilation (HFPV) reduces time on ECMO for Adults with ARDS.  International Journal of Artificial Organs. 36(4):268, May 2013.

12) Michaels, AJ, Hill JG, Long WB, et al.: Reducing time on for extra-corporeal membrane oxygenation for adults with H1N1 pneumonia with the use of the Volume Diffusive Respirator. Am J Surg 205(5): 500-504 (2013)