American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

When should surgeons consider ECMO?

OCTOBER 24, 2018
Clinical Congress Daily Highlights, Wednesday Second Edition


Determining when to call in the mechanical cavalry and put a patient on the life-support machine known as ECMO (extracorporeal membrane oxygenation) can be tricky. As ECMO use has increased in recent years, so has surgeons’ understanding of its potential benefits and pitfalls. A panel discussion on Wednesday explored its diverse applications and covered tips and tricks for ECMO use.

Mauer Biscotti, MD, San Antonio Military Medical Center, Texas, kicked off the panel with a discussion of ECMO use with both civilian trauma patients and service members injured in military operations. “ECMO’s not a magic bullet; it’s another tool in your toolkit,” Biscotti said.

Better body armor means more soldiers are surviving blasts that previously would have killed them, and many of these patients have severe lung injuries. Determining who is a good candidate for ECMO means asking if it is a bridge to somewhere, Dr. Biscotti said. For example, someone with irreversible brain injury will not be well-served by the device.

In terms of making the call to put a patient on ECMO, the earlier the better, Dr. Biscotti said. With selective and careful use, it is possible to operate on a patient on ECMO, and even temporarily withdraw blood thinners. Because of changes in pressure, humidity, gravitational forces, and other factors, airlifting patients on ECMO warrants extra caution, he said, but it can be done and many patients have been successfully transported from war zones either on ECMO or to ECMO centers.

Zachary N. Kon, MD, NYU Langone Health, New York, said early cases of ECMO use were with pediatric patients who had problems like congenital heart disease, but ECMO is increasingly used with adults. Dr. Kon emphasized the need to pay special attention to bleeding risks, which can differ depending on which vein or artery is used for the exit and entry tubes. Surgeons should also be wary of venous air embolisms.

Jonathan Haft, MD, FACS, Ann Arbor, MI, rounded out the panel with a discussion of using ECMO as temporary support during cardiac procedures. Dr. Haft reiterated that a decision to use ECMO should be made quickly and early on to prevent complications. He also discussed the best circulatory sites for inserting the exit and entry tubes. “You ask 10 different surgeons and you get 10 different opinions,” Dr. Haft said. “And that’s because they all work the same,” citing a soon-to-be-published study.

Dr. Haft closed his talk with news that the CMS codes and reimbursements for ECMO changed in October, and that surgeons within many professional societies are working on officially objecting to the changes.

Additional information

The Panel Session, Extracorporeal Membrane Oxygenation (ECMO) in the Care of the Critically Ill Surgical Patient, was held October 24 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast and audio information is available online at facs.org/clincon2018.

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