Yes We Can(nulate)* James D. Fortenberry, MD, MCCM, FAAP Critical Care Division Emory University School of Medicine Children’s Healthcare of Atlanta Atlanta, GA
E
xtracorporeal support has long provided potential benefit for neonates and children with respiratory and cardiac failure (1). However, the last decade has seen a remarkable increase in use of extracorporeal support, also termed “extracorporeal membrane oxygenation” (ECMO), for adults. A number of factors have led to the increased use of ECMO in adult respiratory failure. A randomized clinical trial in the United Kingdom (Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure) (2) demonstrated outcome benefit in adults transferred to a dedicated ECMO center and encouraged consideration of ECMO for adult respiratory failure. Favorable experience with adult ECMO during the 2009 H1N1 pandemic (3) further accelerated interest and experience. As a result, the use of venovenous ECMO for adult respiratory failure has more than doubled, based on data from the Extracorporeal Life Support Organization database registry (4). Use of ECMO for adult cardiac patients is similarly on the rise (5). An additional factor in the increasing popularity of venovenous extracorporeal support has been the introduction of larger double lumen catheters which can be placed percutaneously in the internal jugular vein and positioned with echocardiographic or fluoroscopic guidance. These catheters allow for single site ECMO delivery and potential improved mobility for patients (6). In most institutions, cannulation of patients for extracorporeal support has traditionally been performed by surgeons. Surgical expertise, as well as the ability to respond to complications that might ensue from cannula placement, has always been the reasoning behind use. However, with growing use, the availability and expertise of surgeons with ECMO experience may not be available at all institutions undertaking ECMO support. In addition, surgeons may not be immediately available at all programs due to daily surgical responsibilities. In this issue of Critical Care Medicine, Conrad et al (7) now share their institutional experience with the use of percutaneous ECMO cannulation. They report on 190 cannulations
*See also p. 1010. Key Words: extracorporeal membrane oxygenation; extracorporeal support; intensivist; percutaneous; venovenous Dr. Fortenberry served as a board member (on Steering Committee of Extracorporeal Life Support Organization). Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000912
1146
www.ccmjournal.org
in 100 pediatric and adult patients. Overall, success rate of placement was 98%. This included a wide variety of cannula locations and combinations. Impressive is the performance of cannulation in patients as small as 3 kg. A key component of placement was the use of ultrasound guidance in most patients. The authors performed both venous and arterial cannulation. They deferred to surgical colleagues for cervical venoarterial cannulation and for central cannulation for cardiac failure. This report provides insight into several novel approaches to ECMO cannula placement. Most noteworthy is the fact that cannulation could be successfully performed by nonsurgical intensive care specialists. Although other reported series have included performance of cannulation by intensivists under surgical guidance (8), this report is the first describing the use by intensivists in the primary role. Performance of cannulation by intensivists can offer several advantages. For instance, availability of surgeons could be limited at an institution. A surgeon could be involved in an operating room case and have difficulty breaking away from a case. The training background of the intensivists in the current series included adult, pediatric, or combined critical care fellowship. Three of the four study intensivists had specific cannulation training during their fellowship. The fourth physician was not formally trained but developed extensive experience in cannula placement. Hospital credentialing for the procedure included specific training in ECMO and proctoring of cannula placement prior to independent performance. Surgical backup was also available as needed but was not present for cannulation. The intensivists performing these procedures develop expertise over time, in part due to the small number of surgeons and ability to perform a relatively large number of procedures. Complications were minimal in the series, but not insignificant, with two cases of perforation. The common theme in these two cases was placement in emergent situations (including one with active cardiopulmonary resuscitation in progress) without ultrasound guidance. These two episodes of vessel perforation suggest that open cannulation might best be attempted during extracorporeal resuscitation efforts. Conrad et al (7) describe some additional unique approaches. They utilized ultrasound to measure approximate vessel diameter prior to cannula selection. This allowed approximation of the size of vessels to be cannulated and calculation of optimal cannula size in advance of placement for most patients. These estimates likely assisted in providing appropriate cannula choice from the onset of placement and may have allowed for selection to minimize complete occlusion. Femoral arterial cannulation can also be fraught with complications and risk of ischemia. Conrad et al (7) describe an approach in one patient with small arterial vessels identified by ultrasound, in which two smaller bilateral femoral arterial cannulae were instead placed. This approach likely avoided complete obstruction which might have occurred with cannulation of a single vessel. May 2015 • Volume 43 • Number 5
Editorials
Questions remain as to how this approach could be replicated at other institutions, including the nature of formal training and credentialing needed for nonsurgeons. Anecdotal and preliminary reports from other centers providing intensivist-driven cannulation, however, have also suggested efficacy, including a pediatric center (9). At the authors’ institution, Conrad et al (7) developed the approach and was able to train his colleagues. At institutions with no current intensivist performing the procedure, would surgeons be willing to provide oversight and proctoring? One could make an analogy to managing the transition in examining the evolution over time in performance of percutaneous coronary intervention (PCI) from direct performance/supervision of surgeons, to use with surgical backup, to common performance of PCI by cardiologists in the absence even of center surgical backup (10). The study has several limitations, including its retrospective nature. Although the study is a large case series, making definitive recommendations on safety cannot be achieved with only 100 patients. The study did not provide direct comparison to results from a center with performance of cannulation by surgeons. However, the authors provided reference to previous single-center studies in centers with surgical performance, and complications were similar in the range of 88–98% (8, 11) in adults and 92% in pediatric patients (12). The authors also emphasize the potential availability of surgical backup as needed. Publication of experience from other institutions would be beneficial to support the broader applicability of their approach. Nevertheless, Conrad et al (7) have provided unique experience to help define a broader pool of capable cannulators for the growing field of pediatric and adult ECMO. Yes we can.
REFERENCES
1. Brodie D, Bacchetta M: Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011; 365:1905–1914 2. Peek GJ, Mugford M, Tiruvoipati R, et al; CESAR trial collaboration: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet 2009; 374:1351–1363 3. Noah MA, Peek GJ, Finney SJ, et al: Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306:1659–1668 4. Paden ML, Conrad SA, Rycus PT, et al; ELSO Registry: Extracorporeal Life Support Organization Registry Report 2012. ASAIO J 2013; 59:202–210 5. Pellegrino V, Hockings LE, Davies A: Veno-arterial extracorporeal membrane oxygenation for adult cardiovascular failure. Curr Opin Crit Care 2014; 20:484–492 6. Turner DA, Cheifetz IM: Extracorporeal membrane oxygenation for adult respiratory failure. Respir Care 2013; 58:1038–1052 7. Conrad SA, Grier LR, Scott LK, et al: Percutaneous Cannulation for Extracorporeal Membrane Oxygenation by Intensivists: A Retrospective Single-Institution Case Series. Crit Care Med 2015; 43:1010–1015 8. Ganslmeier P, Philipp A, Rupprecht L, et al: Percutaneous cannulation for extracorporeal life support. Thorac Cardiovasc Surg 2011; 59:103–107 9. Gelvez J, Wolf RM, Olarte J, et al: Pediatric intensivist placed percutaneous Avalon catheters. Presented at 30th Annual Children’s National Health System Symposium: ECMO and the Advanced Therapies for Respiratory Failure, Keystone, CO, February 2014 10. Dehmer GJ, Blankenship JC, Cilingiroglu M, et al: SCAI/ACC/AHA Expert Consensus Document: 2014 update on percutaneous coronary intervention without on-site surgical backup. J Am Coll Cardiol 2014; 63:2624–2641 11. Pranikoff T, Hirschl RB, Remenapp R, et al: Venovenous extracorporeal life support via percutaneous cannulation in 94 patients. Chest 1999; 115:818–822 12. Foley DS, Swaniker F, Pranikoff T, et al: Percutaneous cannulation for pediatric venovenous extracorporeal life support. J Pediatr Surg 2000; 35:943–947
Quantifying the Value of Palliative Care and Advance Care Planning* Wendy G. Anderson, MD, MS Division of Hospital Medicine & Palliative Care Program University of California, San Francisco San Francisco, CA
*See also p. 1102. Key Words: advance care planning; critical care; end of life; intensive care unit utilization; palliative care Dr. Anderson’s institution received grant support from the National Institutes of Health (for research about communication in the ICU), the University of California Center for Health Quality and Innovation (for research about communication and palliative care), and the Gordon and Betty Moore Foundation (for research about communication in the ICU). Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000895
Critical Care Medicine
T
he use of ICUs near the end of life, along with the burden this use places on patients, families, and the healthcare system, is well documented. One in five Americans die after receiving ICU care, a similar number to those who die of cancer (1). Patients in ICUs and their families have a number of unmet needs for palliative care, including for management of physical symptoms, emotional support of families during and after ICU stays, and clear communication about prognosis and goals of care (2–5). Unclear communication about prognosis and goals of care results in many patients receiving very expensive care near the end-of-life that is not consistent with their wishes. ICU treatments are a significant burden to our healthcare system, where increasing costs are spent on critical care. For example, in the United States, critical care beds and occupancy rates increased between 2000 and 2005, whereas the total www.ccmjournal.org
1147
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
E
xtracorporeal support has long provided potential benefit for neonates and children with respiratory and cardiac failure (1). However, the last decade has seen a remarkable increase in use of extracorporeal support, also termed “extracorporeal membrane oxygenation” (ECMO), for adults. A number of factors have led to the increased use of ECMO in adult respiratory failure. A randomized clinical trial in the United Kingdom (Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure) (2) demonstrated outcome benefit in adults transferred to a dedicated ECMO center and encouraged consideration of ECMO for adult respiratory failure. Favorable experience with adult ECMO during the 2009 H1N1 pandemic (3) further accelerated interest and experience. As a result, the use of venovenous ECMO for adult respiratory failure has more than doubled, based on data from the Extracorporeal Life Support Organization database registry (4). Use of ECMO for adult cardiac patients is similarly on the rise (5). An additional factor in the increasing popularity of venovenous extracorporeal support has been the introduction of larger double lumen catheters which can be placed percutaneously in the internal jugular vein and positioned with echocardiographic or fluoroscopic guidance. These catheters allow for single site ECMO delivery and potential improved mobility for patients (6). In most institutions, cannulation of patients for extracorporeal support has traditionally been performed by surgeons. Surgical expertise, as well as the ability to respond to complications that might ensue from cannula placement, has always been the reasoning behind use. However, with growing use, the availability and expertise of surgeons with ECMO experience may not be available at all institutions undertaking ECMO support. In addition, surgeons may not be immediately available at all programs due to daily surgical responsibilities. In this issue of Critical Care Medicine, Conrad et al (7) now share their institutional experience with the use of percutaneous ECMO cannulation. They report on 190 cannulations
*See also p. 1010. Key Words: extracorporeal membrane oxygenation; extracorporeal support; intensivist; percutaneous; venovenous Dr. Fortenberry served as a board member (on Steering Committee of Extracorporeal Life Support Organization). Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000912
1146
www.ccmjournal.org
in 100 pediatric and adult patients. Overall, success rate of placement was 98%. This included a wide variety of cannula locations and combinations. Impressive is the performance of cannulation in patients as small as 3 kg. A key component of placement was the use of ultrasound guidance in most patients. The authors performed both venous and arterial cannulation. They deferred to surgical colleagues for cervical venoarterial cannulation and for central cannulation for cardiac failure. This report provides insight into several novel approaches to ECMO cannula placement. Most noteworthy is the fact that cannulation could be successfully performed by nonsurgical intensive care specialists. Although other reported series have included performance of cannulation by intensivists under surgical guidance (8), this report is the first describing the use by intensivists in the primary role. Performance of cannulation by intensivists can offer several advantages. For instance, availability of surgeons could be limited at an institution. A surgeon could be involved in an operating room case and have difficulty breaking away from a case. The training background of the intensivists in the current series included adult, pediatric, or combined critical care fellowship. Three of the four study intensivists had specific cannulation training during their fellowship. The fourth physician was not formally trained but developed extensive experience in cannula placement. Hospital credentialing for the procedure included specific training in ECMO and proctoring of cannula placement prior to independent performance. Surgical backup was also available as needed but was not present for cannulation. The intensivists performing these procedures develop expertise over time, in part due to the small number of surgeons and ability to perform a relatively large number of procedures. Complications were minimal in the series, but not insignificant, with two cases of perforation. The common theme in these two cases was placement in emergent situations (including one with active cardiopulmonary resuscitation in progress) without ultrasound guidance. These two episodes of vessel perforation suggest that open cannulation might best be attempted during extracorporeal resuscitation efforts. Conrad et al (7) describe some additional unique approaches. They utilized ultrasound to measure approximate vessel diameter prior to cannula selection. This allowed approximation of the size of vessels to be cannulated and calculation of optimal cannula size in advance of placement for most patients. These estimates likely assisted in providing appropriate cannula choice from the onset of placement and may have allowed for selection to minimize complete occlusion. Femoral arterial cannulation can also be fraught with complications and risk of ischemia. Conrad et al (7) describe an approach in one patient with small arterial vessels identified by ultrasound, in which two smaller bilateral femoral arterial cannulae were instead placed. This approach likely avoided complete obstruction which might have occurred with cannulation of a single vessel. May 2015 • Volume 43 • Number 5
Editorials
Questions remain as to how this approach could be replicated at other institutions, including the nature of formal training and credentialing needed for nonsurgeons. Anecdotal and preliminary reports from other centers providing intensivist-driven cannulation, however, have also suggested efficacy, including a pediatric center (9). At the authors’ institution, Conrad et al (7) developed the approach and was able to train his colleagues. At institutions with no current intensivist performing the procedure, would surgeons be willing to provide oversight and proctoring? One could make an analogy to managing the transition in examining the evolution over time in performance of percutaneous coronary intervention (PCI) from direct performance/supervision of surgeons, to use with surgical backup, to common performance of PCI by cardiologists in the absence even of center surgical backup (10). The study has several limitations, including its retrospective nature. Although the study is a large case series, making definitive recommendations on safety cannot be achieved with only 100 patients. The study did not provide direct comparison to results from a center with performance of cannulation by surgeons. However, the authors provided reference to previous single-center studies in centers with surgical performance, and complications were similar in the range of 88–98% (8, 11) in adults and 92% in pediatric patients (12). The authors also emphasize the potential availability of surgical backup as needed. Publication of experience from other institutions would be beneficial to support the broader applicability of their approach. Nevertheless, Conrad et al (7) have provided unique experience to help define a broader pool of capable cannulators for the growing field of pediatric and adult ECMO. Yes we can.
REFERENCES
1. Brodie D, Bacchetta M: Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011; 365:1905–1914 2. Peek GJ, Mugford M, Tiruvoipati R, et al; CESAR trial collaboration: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet 2009; 374:1351–1363 3. Noah MA, Peek GJ, Finney SJ, et al: Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306:1659–1668 4. Paden ML, Conrad SA, Rycus PT, et al; ELSO Registry: Extracorporeal Life Support Organization Registry Report 2012. ASAIO J 2013; 59:202–210 5. Pellegrino V, Hockings LE, Davies A: Veno-arterial extracorporeal membrane oxygenation for adult cardiovascular failure. Curr Opin Crit Care 2014; 20:484–492 6. Turner DA, Cheifetz IM: Extracorporeal membrane oxygenation for adult respiratory failure. Respir Care 2013; 58:1038–1052 7. Conrad SA, Grier LR, Scott LK, et al: Percutaneous Cannulation for Extracorporeal Membrane Oxygenation by Intensivists: A Retrospective Single-Institution Case Series. Crit Care Med 2015; 43:1010–1015 8. Ganslmeier P, Philipp A, Rupprecht L, et al: Percutaneous cannulation for extracorporeal life support. Thorac Cardiovasc Surg 2011; 59:103–107 9. Gelvez J, Wolf RM, Olarte J, et al: Pediatric intensivist placed percutaneous Avalon catheters. Presented at 30th Annual Children’s National Health System Symposium: ECMO and the Advanced Therapies for Respiratory Failure, Keystone, CO, February 2014 10. Dehmer GJ, Blankenship JC, Cilingiroglu M, et al: SCAI/ACC/AHA Expert Consensus Document: 2014 update on percutaneous coronary intervention without on-site surgical backup. J Am Coll Cardiol 2014; 63:2624–2641 11. Pranikoff T, Hirschl RB, Remenapp R, et al: Venovenous extracorporeal life support via percutaneous cannulation in 94 patients. Chest 1999; 115:818–822 12. Foley DS, Swaniker F, Pranikoff T, et al: Percutaneous cannulation for pediatric venovenous extracorporeal life support. J Pediatr Surg 2000; 35:943–947
Quantifying the Value of Palliative Care and Advance Care Planning* Wendy G. Anderson, MD, MS Division of Hospital Medicine & Palliative Care Program University of California, San Francisco San Francisco, CA
*See also p. 1102. Key Words: advance care planning; critical care; end of life; intensive care unit utilization; palliative care Dr. Anderson’s institution received grant support from the National Institutes of Health (for research about communication in the ICU), the University of California Center for Health Quality and Innovation (for research about communication and palliative care), and the Gordon and Betty Moore Foundation (for research about communication in the ICU). Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000895
Critical Care Medicine
T
he use of ICUs near the end of life, along with the burden this use places on patients, families, and the healthcare system, is well documented. One in five Americans die after receiving ICU care, a similar number to those who die of cancer (1). Patients in ICUs and their families have a number of unmet needs for palliative care, including for management of physical symptoms, emotional support of families during and after ICU stays, and clear communication about prognosis and goals of care (2–5). Unclear communication about prognosis and goals of care results in many patients receiving very expensive care near the end-of-life that is not consistent with their wishes. ICU treatments are a significant burden to our healthcare system, where increasing costs are spent on critical care. For example, in the United States, critical care beds and occupancy rates increased between 2000 and 2005, whereas the total www.ccmjournal.org
1147
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
