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Original article

Vol. 149 No. 1516 (2019)

Outcome of inter-hospital transfer of patients on extracorporeal membrane oxygenation in Switzerland

  • Markus J. Wilhelm
  • Devdas T. Inderbitzin
  • Diana Reser
  • Maximilian Halbe
  • Koen Van Tillburg
  • Roland Albrecht
  • Stefan M. Müller
  • Urs Wenger
  • Marco Maggiorini
  • Alain Rudiger
  • Dominique Bettex
  • Reto Schüpbach
  • Alberto Weber
  • Stefano Benussi
  • Ludwig K. Von Segesser
  • Andreas J. Flammer
  • Francesco Maisano
  • Frank Ruschitzka
DOI
https://doi.org/10.4414/smw.2019.20054
Cite this as:
Swiss Med Wkly. 2019;149:w20054
Published
17.04.2019

Summary

AIMS OF THE STUDY

An extracorporeal membrane oxygenation system (ECMO), as a bridge to either recovery, a ventricular assist device (VAD), or heart or lung transplantation, may be the only lifesaving option for critically ill patients suffering from refractory cardiac, respiratory or combined cardiopulmonary failure. As peripheral hospitals may not offer ECMO treatment, tertiary care centres provide specialised ECMO teams for on-site implantation and subsequent patient transfer on ECMO to the tertiary hospital. This study reports the results of the largest ECMO transportation programme in Switzerland and describes its feasibility and safety.

METHODS

Patients transported on ECMO by our mobile ECMO team to our tertiary centre between 1 September 2009 and 31 December, 2016 underwent retrospective analysis. Implantation was performed by our specialised ECMO team (primary transport) or by the medical staff of the referring hospital (secondary transport) with subsequent transfer to our institution. Type of ECMO, transport data, patient baseline characteristics, operative variables and postoperative outcomes including complications and mortality were collected from medical records.

RESULTS

Fifty-eight patients were included (three patients excluded: one repatriation, two with incomplete medical records). Thirty-five patients (60%) received veno-venous, 22 (38%) veno-arterial and one patient (2%) veno-venoarterial ECMO. Forty-nine (84%) patients underwent primary and nine (16%) secondary transport. Thirty-five (60%) patients were transferred by helicopter and 23 (40%) by ambulance, with median distances of 38.1 (13–225) km and 21 (3-71) km respectively. No clinical or technical complications occurred during transportation. During hospitalisation, three patients had ECMO-associated complications (two compartment syndrome of lower limb, one haemothorax after central ECMO upgrade). Median days on ECMO was 8 (<1–49) and median days in hospital was 17 (<1–122). ECMO weaning was successful in 41 patients (71%), on-transport survival was 100%, 40 patients survived to discharge (69%), and overall survival was 67% (39 patients) at a median follow-up of 58 days (<1–1441). Cumulative survival was significantly affected by cardiogenic shock vs. ARDS (p = 0.001), veno-arterial and veno-venoarterial vs. veno-venous ECMO (p = 0.001) and after secondary vs. primary transport (p <0.001). The ECMO weaning rate was significantly lower after secondary transfer (22%, two patients, both vaECMO) vs. primary transfer (80%, p = 0.002, 39 patients of which 35 (71%) had vvECMO).

CONCLUSIONS

The first results of our ECMO transportation programme show its feasibility, safety and efficacy without on-site implant or on-transport complications or mortality. The favourable early survival may justify the large effort with respect to logistics, costs and manpower. With rising awareness, referring centres may increasingly consider this lifesaving option at an early stage, which may further improve outcomes.

References

  1. Broman LM, Frenckner B. Transportation of Critically Ill Patients on Extracorporeal Membrane Oxygenation. Front Pediatr. 2016;4:63. doi:.https://doi.org/10.3389/fped.2016.00063
  2. Broman LM, Holzgraefe B, Palmér K, Frenckner B. The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation. Crit Care. 2015;19(1):278. doi:.https://doi.org/10.1186/s13054-015-0994-6
  3. Mendes PV, de Albuquerque Gallo C, Besen BAMP, Hirota AS, de Oliveira Nardi R, Dos Santos EV, et al. Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature. Ann Intensive Care. 2017;7(1):14. doi:.https://doi.org/10.1186/s13613-016-0232-7
  4. Bartlett RH, Gazzaniga AB, Fong SW, Jefferies MR, Roohk HV, Haiduc N. Extracorporeal membrane oxygenator support for cardiopulmonary failure. Experience in 28 cases. J Thorac Cardiovasc Surg. 1977;73(3):375–86.
  5. Abrams D, Combes A, Brodie D. Extracorporeal membrane oxygenation in cardiopulmonary disease in adults. J Am Coll Cardiol. 2014;63(25, 25 Pt A):2769–78. doi:.https://doi.org/10.1016/j.jacc.2014.03.046
  6. Boedy RF, Howell CG, Kanto WP, Jr. Hidden mortality rate associated with extracorporeal membrane oxygenation. J Pediatr. 1990;117(3):462–4. doi:.https://doi.org/10.1016/S0022-3476(05)81098-4
  7. Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011;365(20):1905–14. doi:.https://doi.org/10.1056/NEJMct1103720
  8. Fromm RE, Jr, Dellinger RP. Transport of critically ill patients. J Intensive Care Med. 1992;7(5):223–33. doi:.https://doi.org/10.1177/088506669200700503
  9. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al.; CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63. doi:.https://doi.org/10.1016/S0140-6736(09)61069-2
  10. Biscotti M, Agerstrand C, Abrams D, Ginsburg M, Sonett J, Mongero L, et al. One Hundred Transports on Extracorporeal Support to an Extracorporeal Membrane Oxygenation Center. Ann Thorac Surg. 2015;100(1):34–9, discussion 39–40. doi:.https://doi.org/10.1016/j.athoracsur.2015.02.037
  11. Bryner B, Cooley E, Copenhaver W, Brierley K, Teman N, Landis D, et al. Two decades’ experience with interfacility transport on extracorporeal membrane oxygenation. Ann Thorac Surg. 2014;98(4):1363–70. doi:.https://doi.org/10.1016/j.athoracsur.2014.06.025
  12. Carter JM, Gerstmann DR, Clark RH, Snyder G, Cornish JD, Null DM, Jr, et al. High-frequency oscillatory ventilation and extracorporeal membrane oxygenation for the treatment of acute neonatal respiratory failure. Pediatrics. 1990;85(2):159–64.
  13. Cornish JD, Carter JM, Gerstmann DR, Null DM, Jr. Extracorporeal membrane oxygenation as a means of stabilizing and transporting high risk neonates. ASAIO Trans. 1991;37(4):564–8.
  14. Bagdure D, Curtis DJ, Dobyns E, Glodé MP, Dominguez SR. Hospitalized children with 2009 pandemic influenza A (H1N1): comparison to seasonal influenza and risk factors for admission to the ICU. PLoS One. 2010;5(12):e15173. doi:.https://doi.org/10.1371/journal.pone.0015173
  15. Bai L, Gu L, Cao B, Zhai XL, Lu M, Lu Y, et al. Clinical features of pneumonia caused by 2009 influenza A(H1N1) virus in Beijing, China. Chest. 2011;139(5):1156–64. doi:.https://doi.org/10.1378/chest.10-1036
  16. Clement KC, Fiser RT, Fiser WP, Chipman CW, Taylor BJ, Heulitt MJ, et al. Single-institution experience with interhospital extracorporeal membrane oxygenation transport: A descriptive study. Pediatr Crit Care Med. 2010;11(4):509–13.
  17. Starck CT, Hasenclever P, Falk V, Wilhelm MJ. Interhospital transfer of seriously sick ARDS patients using veno-venous Extracorporeal Membrane Oxygenation (ECMO): Concept of an ECMO transport team. Int J Crit Illn Inj Sci. 2013;3(1):46–50. doi:.https://doi.org/10.4103/2229-5151.109420
  18. Combes A, Brodie D, Bartlett R, Brochard L, Brower R, Conrad S, et al.; 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;190(5):488–96. doi:.https://doi.org/10.1164/rccm.201404-0630CP
  19. Barbaro RP, Odetola FO, Kidwell KM, Paden ML, Bartlett RH, Davis MM, et al.; Analysis of the Extracorporeal Life Support Organization Registry. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry. Am J Respir Crit Care Med. 2015;191(8):894–901. doi:.https://doi.org/10.1164/rccm.201409-1634OC
  20. Ericsson A, Frenckner B, Broman LM. Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation. Prehosp Emerg Care. 2017;21(4):448–55. doi:.https://doi.org/10.1080/10903127.2017.1282561
  21. Raspé C, Rückert F, Metz D, Hofmann B, Neitzel T, Stiller M, et al. Inter-hospital transfer of ECMO-assisted patients with a portable miniaturized ECMO device: 4 years of experience. Perfusion. 2015;30(1):52–9. doi:.https://doi.org/10.1177/0267659114531611
  22. Javidfar J, Brodie D, Takayama H, Mongero L, Zwischenberger J, Sonett J, et al. Safe transport of critically ill adult patients on extracorporeal membrane oxygenation support to a regional extracorporeal membrane oxygenation center. ASAIO J. 2011;57(5):421–5. doi:.https://doi.org/10.1097/MAT.0b013e3182238b55
  23. Lucchini A, De Felippis C, Elli S, Gariboldi R, Vimercati S, Tundo P, et al. Mobile ECMO team for inter-hospital transportation of patients with ARDS: a retrospective case series. Heart Lung Vessel. 2014;6(4):262–73.
  24. Roncon-Albuquerque R, Jr, Basílio C, Figueiredo P, Silva S, Mergulhão P, Alves C, et al. Portable miniaturized extracorporeal membrane oxygenation systems for H1N1-related severe acute respiratory distress syndrome: a case series. J Crit Care. 2012;27(5):454–63. doi:.https://doi.org/10.1016/j.jcrc.2012.01.008