Patients with refractory cardiopulmonary failure may benefit from extracorporeal membrane oxygenation, but extracorporeal membrane oxygenation is not available in all medical centers. We report our ...institution's nearly 20-yr experience with interhospital extracorporeal membrane oxygenation transport.
Retrospective review.
Quaternary care children's hospital.
All patients undergoing interhospital extracorporeal membrane oxygenation transport by the Arkansas Children's Hospital extracorporeal membrane oxygenation team.
Data (age, weight, diagnosis, extracorporeal membrane oxygenation course, hospital course, mode of transport, and outcome) were obtained and compared with the most recent Extracorporeal Life Support Organization Registry report.
Interhospital extracorporeal membrane oxygenation transport was provided to 112 patients from 1990 to 2008. Eight were transferred between outside facilities (TAXI group); 104 were transported to our hospital (RETURN group). Transport was by helicopter (75%), ground (12.5%), and fixed wing (12.5%). No patient died during transport. Indications for extracorporeal membrane oxygenation in RETURN patients were cardiac failure in 46% (48 of 104), neonatal respiratory failure in 34% (35 of 104), and other respiratory failure in 20% (21 of 104). Overall survival from extracorporeal membrane oxygenation for the RETURN group was 71% (74 of 104); overall survival to discharge was 58% (61 of 104). Patients with cardiac failure had a 46% (22 of 48) rate of survival to discharge. Neonates with respiratory failure had an 80% (28 of 35) rate of survival to discharge. Other patients with respiratory failure had a 62% (13 of 21) rate of survival to discharge. None of these survival rates were statistically different from survival rates for in-house extracorporeal membrane oxygenation patients or for survival rates reported in the international Extracorporeal Life Support Organization Registry (p > .1 for all comparisons).
Outcomes of patients transported by an experienced extracorporeal membrane oxygenation team to a busy extracorporeal membrane oxygenation center are very comparable to outcomes of nontransported extracorporeal membrane oxygenation patients as reported in the Extracorporeal Life Support Organization registry. As has been previously reported, interhospital extracorporeal membrane oxygenation transport is feasible and can be accomplished safely. Other experienced extracorporeal membrane oxygenation centers may want to consider developing interhospital extracorporeal membrane oxygenation transport capabilities to better serve patients in different geographic regions.
Since 1990, extracorporeal membrane oxygenation (ECMO) has been used as a bridge to cardiac transplantation in 47 patients.
A review of the ECMO database, approved by the Arkansas Children’s Hospital ...institutional review board, forms the basis of this report. We made statistical comparison using Fisher’s exact probability testing. The ECMO circuitry was a roller occlusion pump with computer-assisted perfusion system technology.
Thirty-two (68%) patients underwent transcatheter septostomy for cardiac decompression. Diagnosis at presentation was either congenital heart disease (CHD,
n = 15) or cardiomyopathy (
n = 32). Ages ranged from 1 day to 22 years old (median, 18 months old), and weight ranged from 2.9 to 100 kg (median, 10 kg). The average duration of support was 242 hours (range, 22–1,078 hours). Overall long-term survival was 47%, with 16 (34%) patients successfully bridged to cardiac transplantation (of which 9 56% survived) and 13 (28%) successfully weaned from ECMO. Patients undergoing ECMO after cardiotomy had 31% survival. Survival was improved significantly (
p < 0.02) in patients with cardiomyopathy (59%) vs those with CHD (20%). Patients with cardiomyopathy underwent 8 transplantations with 7 survivors (88%), whereas in the CHD group, there were 8 transplantations with only 2 survivors (25%),
p < 0.05. Sub-analysis of the cardiomyopathy group revealed that patients with acute cardiomyopathy in association with documented viral illness had a 75% chance of being weaned from ECMO without undergoing transplantation. Complications during ECMO occurred in 45% of survivors and were more frequent in non-survivors. Infectious complications were most frequent, followed by neurologic complications, technical ECMO problems, and renal insufficiency.
Patients with cardiomyopathy has a better prognosis than did those with CHD when using ECMO as a bridge to transplantation or survival. Complications are significant and increase with the duration of support. Extracorporeal membrane oxygenation for salvage and subsequent transplantation in this high-risk group of patients requires critical review. Alternative support options must be developed in the pediatric population that will allow improved outcomes, comparable with outcomes achieved in the adult population.
...nearly 50% of current clinical guideline recommendations are expert opinion, and even those with the highest level of evidence are primarily based on efficacy data (2). The ACC also supports ...cost-effectiveness analyses that are based on high-quality comparative clinical effectiveness research. Since cost-effectiveness analyses vary depending on the assumptions used, and since such assumptions vary depending on the payer, multiple analyses for any technology or procedure may, in fact, be carried out.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
When it comes to health system reform and ensuring quality care, the ACC's continuous review of new science, evidence-based guidelines and standards, data reporting, and collection tools are examples ...of a true professional society. Given the recent ruling by the U.S. District Court for the District of Columbia that the Department of Health and Human Services must release Medicare physician claims data for Illinois, Maryland, Virginia, Washington, and Washington, D.C., the ACC's continued efforts to disseminate principles and to develop tools that facilitate reporting of accurate patient encounter data could not be more necessary.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Undoubtedly, the economic burden of cardiac care will continue to rise because of the rising costs of cardiac technological advances (3) and the increasing prevalence of cardiac disease (4). ...we ...can expect that public and private payers will increase their focus on both improving the quality and efficiency of cardiac care. There are essentially no randomized controlled trials demonstrating the effectiveness of P4P programs and very few reports in the literature that analyze the existing programs (5,11-14). Because of the lack of health services research and solid supporting evidence regarding P4P programs, the ACC and other organizations (15-18) have developed principles to guide their members and payers through the transition to novel payment mechanisms.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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