ECMO: Providing a Bridge

Patients are considered candidates for extra-corporeal membrane oxygenation (ECMO) when they have suffered catastrophic failure of either their cardiovascular or respiratory systems. Common scenarios are infants with congenital heart disease, children with acute myocarditis, or children with respiratory failure not responsive to standard ventilator support, according to Celeste Capers, MD, medical director of the St. Louis Children’s Hospital Transport Team.

Respiratory failure may be acute, such as in influenza, or chronic but progressive, such as in cystic fibrosis, Capers added. “ECMO provides a way to ‘bypass’ either the heart or the lungs and may provide a bridge to recovery, a bridge to an assist device such as the Berlin heart or artificial lung, or even a bridge to transplantation,” Capers noted.

In November of last year, a 6-day-old baby from Emporia, KS, was the first to be transported to St. Louis Children’s Hospital while receiving ECMO. Bentley Clark had difficulty breathing from birth. The delivering physicians discovered only one side of his body was receiving oxygenated blood from his heart. He was airlifted from the family’s home-town hospital to a pediatric hospital in Kansas City, where the medical team found and removed clot in his aortic valve, while he was just 2 days old. Bentley’s pulmonary function continued to decline. With no other option available, physicians decided to place him on ECMO as a temporary solution until his condition stabilized and improved. A heart transplant was Bentley’s only chance for long-term survival.

St. Louis Children’s Hospital, the most active heart transplant center in the region, had just launched its ECMO transport program a matter of days earlier. ECMO transport is only undertaken when the accepting hospital can provide a service the referring hospital cannot. That service is generally a bridge to an assist device or referral for transplantation. A physician, two nurses and a perfusionist accompanied the newborn on the fixed-wing flight from Kansas City to St. Louis.

Upon arrival, Bentley was placed on a Berlin heart, a ventricular assist device used to support the patient until a donor heart becomes available, while his medical team created a bridge plan. Unfortunately, he suffered a catastrophic stroke days after his arrival and passed away.

Death is the biggest danger in transporting a patient on ECMO, Capers told ADVANCE. “Children who are placed on ECMO for cardiovascular or respiratory support are sicker than any other patients,” she noted. Patients on ECMO also face inadvertent dislodgement of the cannula which would lead to infection, hemorrhage and death, stroke or uncontrolled bleeding due to the need for anticoagulant therapy while on ECMO.

While Bentley’s death was tragic, only a handful of centers across the country could have given him the chance that St. Louis Children’s Hospital afforded. As a leading transplant center, St. Louis Children’s Hospital’s respiratory and heart failure population has substantially increased, along with growing numbers of patients on ventricular assist devices and paracorporeal lung assist devices — patients who may require ECMO prior to definitive care, and depend on the hospital’s unique transport service.

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Since Bentley’s groundbreaking transport, the hospital has transported three more patients on ECMO, one from Kosair Children’s Hospital in Louisville, one from Omaha Children’s Hospital and another from Mercy Children’s, in Kansas City.

A Finely Tuned Team
ECMO transport requires a finely tuned and choreographed team of individuals to care for the patient,” Capers said. The team includes a critical care physician, perfusionist, two ECMO-trained nurses and an EMT. The St. Louis Children’s Hospital ECMO program has attained magnet status under the direction of Mary Mehegan, nurse manager.

Additionally, specialized — and costly — equipment from the ECMO circuit itself is required in the vehicles which transport the teams. “We are lucky at St. Louis Children’s Hospital to have generous private donors who have helped to fund our ECMO transport program and support our mission,” Capers reported. Few hospitals have such support and infrastructure.

“This program is going to save lives by providing a lifeline to patients at referring hospitals,” Capers stressed. “Many hospitals can put a patient on ECMO. Few can provide a bridge to recovery — whether that bridge be advanced cardiac care or cardiovascular surgery, an assist device such as the Berlin heart or transplantation.” Without the St. Louis Children’s Hospital transport program, many of these patients would have no chance at life without the access to such resources.

Kerri Hatt is on staff at
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