This Concise Critical Appraisal explores an article published in Critical Care Medicine on a program at Cooper University Hospital in Camden, New Jersey, USA, that implemented a previously published successful ECMO model, in which ECMO cannulation primarily performed by cardiothoracic surgeons is transitioned to medical intensivist-led cannulation. This article is significant in advancing the role of the medical intensivist in the cannulation of patients who require ECMO.
Acute respiratory distress syndrome (ARDS) can occur in the setting of numerous medical conditions including bacterial pneumonia, pancreatitis, viral pneumonia, and postoperative respiratory failure. Most recently, the prevalence of ARDS has significantly increased due to viral pneumonia caused by COVID-19. The mortality rate of ARDS is 40% and often requires multiple forms of life support and ICU interventions.
1 Venovenous (VV) extracorporeal membrane oxygenation (ECMO) can be used to support patients with ARDS when other modalities are not enough. Because of the COVID-19 pandemic and the prevalence of critically ill patients with ARDS, the use of VV ECMO in established programs has become necessary and has been associated with improved outcomes in some ARDS patients.
Traditionally, both VV and venoarterial ECMO cannulation are performed by a cardiothoracic surgeon either at the bedside or in an operating room. Cooper University Hospital in Camden, New Jersey, USA, implemented a previously published successful ECMO model, in which ECMO cannulation primarily performed by cardiothoracic surgeons is transitioned to medical intensivist-led cannulation.
2 The transition was intended to occur over a 3-year period but it was greatly accelerated because of the increased number of patients and limited resources. Having medical intensivists perform bedside ECMO cannulation further advances their significance and role in management of this unique patient population.
3
A retrospective observational before-and-after chart review of 79 VV ECMO cannulations was performed in 40 adult patients. Eleven cannulations were performed by cardiothoracic surgeons and 57 by 8 different medical intensivists. All patients were diagnosed with ARDS. A majority of the intensivists’ patients were diagnosed with ARDS due to COVID-19. The primary outcome was major complications, defined as inability to complete cannular insertion, major vessel injury, major hemorrhage (2 units packed red blood cells needed within 24 hours), or death. The transitional model from cardiothoracic surgeon cannulation to medical intensivist cannulation occurred in stages, with de-escalating levels of bedside support. Each intensivist completed a 3-day immersive program and performed 10 separate successful cannulations under direct supervision by a cardiothoracic surgeon. Following completion of specified training requirements, the intensivists were able to independently perform ECMO cannulation at the bedside with a cardiothoracic surgeon in the hospital and available for backup in the event of a complication.
Both the cardiothoracic surgeon and intensivist groups were predominantly femoral-internal jugular configurations. There were no differences in ventilator days before cannulation, configuration, cannula size, or discharge condition. There were no differences between success rate (95.5 vs. 96.7,
P = 0.483) or complication rate per cannulation attempt (4.5% vs. 3.5%,
P = 1) or per patient (9.1% vs. 6.9%,
P = 1) between the 2 groups. All intensivist cannulations were performed using percutaneous Seldinger technique and ultrasound guidance. The high success rate and low complication rate of intensivist cannulation is attributed to the already established skill and expertise with both Seldinger technique and ultrasound use for vascular access. The conclusion of this study validates that bedside percutaneous ECMO cannulation is both safe and effective when performed by a trained medical intensivist.
This trial is significant in advancing the role of the medical intensivist in the cannulation of patients who require ECMO. Medical intensivists are already part of the multiprofessional team who manage these patients. The rapid deployment of the transition from cardiothoracic surgeon cannulation to intensivist cannulation was successful because of the already proficient procedural skill set and established ECMO program. Although the transition was intended to take place over a longer period of time, it was expedited because of the pandemic and was still successful. One limitation of the applicability of this trial is the requirement for a specially trained and dedicated intensivist group that can maintain clinical and procedural skills due to a diverse population of critically ill patients. The second limitation is selection bias, which is typical in a retrospective analysis of data. Regardless, the study demonstrates that, when the same intense training and attention to detail in ECMO cannulation procedures is applied to other institutions with established ECMO programs and a widely trained group of intensivists, the same success rate can be achieved.
References
- Tzotzos SJ, Fischer B, Fischer H, Zeitlinger M. Incidence of ARDS and outcomes in hospitalized patients with COVID-19: a global literature survey. Crit Care. 2020 Aug 21;24(1):516. https://pubmed.ncbi.nlm.nih.gov/32825837/
- Kouch M, Green A, Damuth E, et al. Rapid development and deployment of an intensivist-led venovenous extracorporeal membrane oxygenation cannulation program. Crit Care Med. Sep 2021. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/34637417/
- DellaVolpe J, Barbaro RP, Cannon JW, et al. Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force position paper on the role of the intensivist in the initiation and management of extracorporeal membrane oxygenation. Crit Care Med. 2020 Jun;48(6):838-846. https://pubmed.ncbi.nlm.nih.gov/32282350/
