Thank you for joining us. This short video is part of our Master Teacher Series and features
Dr. David Wessel. In the following video, he will discuss clinical insights related
to the use of ECMO in the setting of cardiopulmonary resuscitation, also known as ECPR.
David, could we turn now to the use of ECMO in a cardiac intensive care unit environment
in particular. As you well know, you were one of the pioneers of this kind of concept
of ECPR, or having ECMO available for urgent and emergent cannulation in situations where
the patient wasn't responding with return of spontaneous circulation after cardiac arrest.
Now that kind of concept has spread to many programs around the world. How should we be
thinking about the use of ECMO in this environment and in this context?
Well, I think it's true, Jeff, that ECMO has become part and parcel of therapies in the
cardiac intensive care unit. It's part of our standard description of a patient's well-being
in our morning reports, along with the vital sign description that's published for the
care team, the patient's name, and then his status with respect to whether or not he is
an ECMO candidate is published every day. And it just goes to the point that we've had
the discussion with the parents, and the family, and if there's any reason not to utilize ECMO,
then that's clearly stated. But the default position otherwise is that if the patient
has an unexpected cardiac arrest, that ECMO was part of the routine, the A, B, C, D's
and E's of resuscitation.
Having said that, I think that one point I'd like to make is that we too easily reserve
ECMO as rescue and perhaps don't, these days, bring it in as an intervention early enough.
When we see the patient deteriorating, I would prefer to cannulate for ECMO during the deterioration,
rather than thinking well, let's just see if we can get out of this because we know
if we have a cardiac arrest, then we can put him on ECMO.
We're going to have much better outcomes if we can intervene prior to a cardiac arrest
with ECMO, rather than waiting for a full cardiac resuscitation and then urgently trying
to cannulate for ECMO. And I see us go back and forth. As we learn and our results get
better, we then incorporate even more and more of a patient population that might benefit
from ECMO, so we do more and more complicated patients for ECMO. But I also see us relying
too much as a rescue therapy if the patient has a cardiac arrest.
So I think we need to focus more on what the predictors of arrest are, and to use a lot
of the work that's going on now to help us understand who is most likely to have a cardiac
arrest today. There's been some great work in Philadelphia and other places on cardiopulmonary
resuscitation in the intensive care units, how to improve the outcomes, improve the quality
of resuscitation.
I think identifying the patient's risk factors, sensitizing the staff at the bedside that
this is an at-risk patient, and then trying to mitigate all of the forces that come to
bear that will depress the cardiac output, lower the cardiac output are really important.
However, if ECMO is the right therapy, then let's intervene before the child has a cardiac
arrest, not after.
So failure to rescue is a hot topic, I know, these days. But I'm seeing ECMO as part of
that conversation. That if we introduce ECMO more and more for resuscitation, it's interesting
to see that the outcomes over the last 15 years in terms of survival using ECMO for
resuscitation, have been about 50%. And it really hasn't changed very much in the last
15 years. And there are a variety of reasons for that.
But I really hope that we can focus more on when to intervene earlier to support the myocardium.
Thank you for viewing this case reflection on ECPR, or the use of ECMO in cardiopulmonary
resuscitation. If you would like to view additional case explanations in this series, please see
them on the OPENPediatrics website.