Boston MedFlight, Bedford, MA.
Boston MedFlight, Bedford, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA.
Air Med J. 2020 Mar-Apr;39(2):124-132. doi: 10.1016/j.amj.2019.09.009. Epub 2019 Oct 19.
Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment. Coagulopathy and bleeding are the most common complications occurring in up to 50% of ECMO patients. Loss of flow and hypotension from loss of volume or profound vasodilation after ECMO initiation need to be managed accordingly. Oxygenator malfunction can occur, and clinicians must be able to recognize the indicators of this complication promptly. Loss of pulsatility, low end-tidal carbon dioxide (ETCO), and differential hypoxia are common complications in venoarterial ECMO. In addition, an air embolism is life-threatening on venoarterial ECMO but may be better tolerated in the setting of venovenous ECMO. Recirculation in venovenous ECMO leads to circulation of poorly oxygenated blood and must be recognized and addressed. Lastly, pump failure, circuit rupture, and decannulation are devastating complications. Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has accelerated rapidly, providing support for patients in severe respiratory or cardiac failure. With ongoing clinical experience and improvements in technology, the indications for ECMO are increasing. Many areas are developing centralized ECMO centers to serve their surrounding communities. To use a centralized ECMO referral model, patients need access to effective, safe critical care transport, but transporting a patient on ECMO carries a significant risk of adverse events. The purpose of this review is to highlight some of the most common adverse events in ECMO transports and provide management suggestions. Note that these recommendations are not a substitution for close collaboration with medical control, and all adverse events should be promptly reported per organizational protocols.
在医院环境中维持体外膜氧合（ECMO）患者时，一些被视为理所当然的因素在计划转运时可能会变得至关重要。这些问题包括但不限于将患者放置在小型转运担架上的位置、插管和设备的位置、确保充足的电源和供应、低效的温度控制以及更高的脱管风险。在相对简陋的环境中，使用有限的资源处理 ECMO 常见并发症所需的管理策略，这一点至关重要。凝血功能障碍和出血是 ECMO 患者中最常见的并发症，发生率高达 50%。在 ECMO 启动后，由于容量丢失或深度血管扩张导致血流丢失和低血压，需要相应地进行处理。氧合器故障可能会发生，临床医生必须能够迅速识别出这种并发症的迹象。在静脉-动脉 ECMO 中，搏动性丧失、低终末二氧化碳（ETCO）和差异缺氧是常见的并发症。此外，在静脉-动脉 ECMO 中发生空气栓塞是危及生命的，但在静脉-静脉 ECMO 中可能更容易耐受。静脉-静脉 ECMO 中的再循环导致含氧不良的血液循环，必须识别并处理。最后，泵故障、回路破裂和脱管是毁灭性的并发症。在过去的十年中，体外膜肺氧合（ECMO）的使用迅速加速，为严重呼吸或心脏衰竭的患者提供支持。随着临床经验的不断积累和技术的不断改进，ECMO 的适应证也在不断增加。许多地区正在建立集中的 ECMO 中心，为周边社区提供服务。要使用集中式 ECMO 转诊模式，患者需要获得有效的、安全的重症监护转运，但转运 ECMO 患者会带来严重不良事件的风险。本文的目的是强调 ECMO 转运中一些最常见的不良事件，并提供管理建议。需要注意的是，这些建议不能替代与医疗控制的密切合作，所有不良事件都应按照组织协议及时报告。
