Support with Veno-venous and Veno-arterial Extracorporeal Membrane Oxygenation (ECMO) in the Medical Intensive Care Unit: Experience of a Department Located in a Hospital Lacking Cardiac Surgery

Abstract

Venovenous and veno-arterial extracorporeal membrane oxygenation (ECMO) offers an additional life-saving therapeutic intervention in patients presenting acute respiratory or cardiac failure refractory to the usual management including pharmacological and non-pharmacological optimized therapies. Despite the absence of cardiac surgery department in the hospital, the medical and toxicological intensive care unit (ICU) in Lariboisière Hospital has developed ECMO since 10 years to manage severe poisonings with cardiotoxicants. Our ICU physicians and care givers have been trained at femoral cannulation as well as ECMO-treated patient monitoring and weaning. This training required a tight collaboration with the departments of cardiac surgery of Caen University Hospital and Pitié-Salpêtrière University Hospital in Paris. Once available in our ICU, ECMO indications have been extended to treat patients with refractory cardiac arrest and non-toxic cardiogenic shock (using veno-arterial ECMO) and patients with acute respiratory distress syndrome, mainly resulting from viral and bacterial pneumonitis (using venovenous ECMO). Surgical as well as percutaneous femoral cannulation represents an invasive and complex intervention, with significant risks of life-threatening complications. In the absence of robust training and prolonged experience, as reached by the physicians in our team, femoral cannulation should be only performed by vascular surgeons, cardiac surgeons or trained intensivists, including within a mobile ECMO team at the patient’s bedside in the ICU. Decision to cannulate, for ECMO monitoring, and to wean ECMO require theoretical knowledge and prolonged experience. Practical procedures should be set-up by the ICU physicians and care-givers, in collaboration with a cardiac surgery department. However, several significant complications may occur, compromising ECMO-treated patient’s survival. A minimal number of ECMO-treated patients per year per center seem requested to maintain a motivated and trained ICU team. Thus, based on our large experience, we recommend that ECMO should only be performed by trained multidisciplinary specialized medicosurgical teams.