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Out-of-hospital cardiac arrest is a leading cause of mortality with survival rates of less than 10%. In selected patients, survival may be improved via timely application of extracorporeal cardiopulmonary resuscitation (ECPR). However, ECPR is a complex and resource intensive intervention with a high risk of complications that impair widespread clinical adoption. This study employed a mixed approach of qualitative interview analysis embedded with quantitative data collection to uncover the major hurdles faced by clinicians during ECPR initiation. We conducted semi-structured interviews with eight ECPR intensive care specialists with 2-10 years of experience working at a large, tertiary ECPR center in Australia. Clinicians identified dilation as the most time-consuming step, followed by draping, and decision-making during extracorporeal membrane oxygenation patient selection. The most challenging step was the decision-making for patient selection, followed by dilation and imaging. These findings uncovered key barriers to ECPR, and identified priority areas for further research and clinical training. Major logistical hindrances will require well-defined protocols and improved clinical training. Engineering innovations in the identified areas may improve the delivery of ECPR, making it simpler and faster to deliver.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment. METHODS: This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov, NCT03793257. FINDINGS: Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] -32% [95% CI -49 to -15]; p

The apnea test (AT) during clinical brain death (BD) testing does not account for different arterial gas tensions on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). We aimed to develop a protocol and now report our experience with three patients. The protocol was developed and implemented in 2015 at a quaternary center in Australia, measures both right radial and postoxygenator carbon dioxide (CO2) and oxygen (O2) gas tensions during the AT, incorporates regular gas sampling and a gradual reduction in fresh gas flow to ensure patient oxygenation. Patient 1 remained apneic despite both right radial and postoxygenator CO2 gas tensions60 mmHg. Patient 2, despite having CO2 levels in a right radial arterial sample high enough to diagnose BD, postoxygenator CO2 remained60 mmHg. Patient 2 did not breathe but radiological tests confirmed BD. Patient 3 showed respiratory effort but only once CO2 levels rose high enough in both right radial and postoxygenator samples. No patient was hypoxic during the AT. Performance of a reliable AT on V-A ECMO requires measurement of both right radial and postoxygenator blood gases. A protocol, which measures both blood gas values, is feasible to implement, while being both safe and easy to perform.

The optimal staffing model during the inter-hospital transfer of patients on extracorporeal membrane oxygenation (ECMO) is not known. We report the complications and outcomes of patients who were commenced on ECMO at a referring hospital by intensive care physicians and compare these findings with patients who had ECMO established at an ECMO center in Australia. This was a single center, retrospective observational study based on a prospectively collected ECMO database from Melbourne, Australia. Patients with severe cardiac and/or respiratory failure failing conventional supportive treatment between 2007-2013 were placed on ECMO via a physician-led model of ECMO retrieval, including two intensivists in a four person team, using percutaneous ECMO cannulation. Patients (198) underwent ECMO over the study period, of which 31% were retrieved. Veno-venous (VV)-ECMO and veno-arterial (VA)-ECMO accounted for 27 and 73% respectively. The VA-ECMO patients had more intra-transport interventions compared with VV-ECMO transported patients, but none resulting in serious morbidity or death. There was no overall difference in survival at 6 months between retrieved and ECMO center patients: VV-ECMO (75 vs. 70%, P = 0.690) versus VA-ECMO (70 vs. 68%, P = 1.000). An intensive care physician-led team was able to safely place all critically ill patients on ECMO and retrieve them to an ECMO center. This may be an appropriate staffing model for ECMO retrieval.

Patients receiving extracorporeal membrane oxygenation (ECMO) are some of the most critically ill in the intensive care unit. In such patients, malnutrition is associated with increased morbidity and mortality.To describe the use, methods and adequacy of nutritional support in a consecutive group of patients receiving ECMO; to determine differences between the periods during and after ECMO support; and to determine differences in nutritional adequacy between ECMO survivors and ECMO non-survivors.We conducted a retrospective study of patients who received ECMO at the Alfred Hospital between January 2005 and December 2007. Patients who received venoarterial (VA) or venovenous (VV) ECMO had their case notes reviewed for clinical and nutritional outcomes. Nutritional adequacy was defined as the ratio of delivered nutrition to target nutrition, expressed as a percentage.Of 48 patients included in our analysis, 35 had VA ECMO and 13 had VV ECMO. Overall, the mean nutritional adequacy achieved for all patients over the periods during and after ECMO support was 62% (SD, 19%). Nutritional adequacy was lower during ECMO support (55%) than after ECMO removal (71%) (P = 0.003). Survivors did not achieve better nutritional adequacy than non-survivors (52% v 61%; P = 0.345).Patients receiving ECMO received inadequate nutritional support, with only 55% of their nutritional targets being achieved while receiving ECMO. Optimal nutritional support should be a major goal in the care of these patients, and measures to improve nutritional delivery require careful consideration.

To gauge use of extracorporeal membrane oxygenation (ECMO) in Australian and New Zealand intensive care units, to investigate attitudes to and experience with ECMO, and to assess interest in contributing to a national database of ECMO use.The survey was conducted by email in July 2004. A targeted cohort of ICUs across the two countries was chosen, comprising JFICM (Joint Faculty of Intensive Care Medicine) Approved Training Centres, and large regional and private institutions. Directors of the ICUs were invited to participate in the survey of department demographics, ECMO practice rates and experience, and attitudes to ECMO. The survey was registered (http://clinicaltrials.gov registration number NCT00157144), and local ethics approval was obtained.Response rate was 56% (39/70), with 49% of responses (19/39) from JFICM Approved Training Centres. ECMO practice in responding centres was low, with 69% (27/39) having managed no ECMO patients in the past year, and 62% (24/39) having managed none in the past 3 years. Only one centre had managed more than eight patients in the past year. Individual respondents had limited ECMO experience, with 56% (22/39) having ever managed two or fewer patients. The most common reasons given for not providing ECMO were lack of staff skill/training and lack of access to support services. Cost, high mortality and lack of evidence for ECMO efficacy were not regarded as significant factors preventing its use. Seventy-two per cent (28/39) of respondents supported ECMO use outside a randomised controlled trial, and 49% (19/39) would conduct ECMO at their own institution, while 74% (29/39) felt it a useful tool to facilitate transport to specialist centres.ECMO use in Australian and New Zealand ICUs is limited, but there is support for its use among survey respondents. Lack of training and experience with ECMO may be restricting its use.