The extracorporeal membrane oxygenation (ECMO) program at Duke University Hospital (DUH) – one of the largest, oldest and most respected in the country – reached a major milestone in July when it treated its 1,000th patient.
Much has changed since the program began in 1990, when it saw just six patients, all newborns with lung problems or sepsis.
On hand back when the first baby at Duke was treated with ECMO was Ira M. Cheifetz, MD, FCCM, FAARC, ECMO medical director, professor of Pediatrics and Anesthesiology; chief medical officer, Children's Services; and associate chief medical officer, Duke University Hospital.
“The predictions were that 80-90 percent of these babies would not survive, but the inverse was seen as they started surviving at a rate of 80-90 percent. Furthermore, 90 percent of these infants were completely normal at 18 months of age and beyond. The risk of death was converted into a rate of survival. It was pretty miraculous,” Cheifetz said. “To he here for the 1000th patient is quite special.”
The program now supports neonates through adults across all specialties. Most other hospitals focus on one age group, or provide only limited services.
“We are one of the only centers that offer ECMO care for neonates through adults for cardiac and respiratory indications, and have the technology and experience to be innovative in the options we offer our patients for not only survival, but a high quality of life after hospital discharge,” said Desiree Bonadonna, MPS, CCP, LP, a perfusionist who manages the ECMO program.
Meanwhile, the program has been designated as a Center of Excellence by the Extracorporeal Life Support Organization (ELSO), whose benchmarks DUH’s ECMO program has exceeded. DUH’s overall survival-to-discharge rate is 71 percent for neonatal and pediatric ECMO patients (ELSO average is 66 percent) and 62 percent for adult patients (ELSO average is 48 percent).
Over 25 years, we have progressed a large distance from saving newborns with relatively simple disease processes to using ECMO for a large variety of complex conditions, and from keeping ECMO patients anesthetized to having them up and walking around the ICUs – all with impressive results.
“Our high number of patients means we have a lot of experience in ECMO therapy,” said Mani Daneshmand, MD, surgical director of adult ECMO. “That’s what sets us apart. Our experience means we are both an opinion leader and a guide to appropriate therapy.”
ECMO is essentially a portable version of a heart-lung machine and is used to treat patients who are in respiratory or cardiac failure. The device provides a number of advantages over ventilators or traditional medical management, which can harm the lungs and require a patient to remain in bed.
Rather than being bed-ridden and risking physical debilitation, many ECMO patients – including those with conditions severe enough to warrant a transplant – can be awake and active while the machine takes over the functions of the lungs or both the heart and lungs. At only 20 pounds, the machine can be placed on a cart to allow a patient to be mobile.
ECMO’s portability also allows patients to be safely transported to Duke from hospitals unable to offer this level of care. The Duke ECMO team can transport patients from essentially anywhere in the United States using ground or air medical transport.
Patients who do not recover their heart or lung function have options at Duke that most other institutions cannot offer, including a transplant or mechanical circulatory support, such as a ventricular assist device (VAD).
A highly trained team manages ECMO cases around the clock, seven days a week. In addition to Bonadonna, members include surgeons, operating room nurses, perfusionists, ECMO specialists, respiratory therapists, physical and occupational therapists, intensive care physicians and nurses,operating room technicians, advanced practice providers, pharmacists, patient resource managers, and dieticians.
The surgeons include Daneshmand; John Haney, MD; Matthew Hartwig, MD ; Carmelo Milano, MD; Jacob Schroder, MD; Robert Jaquiss MD, and surgical director of pediatric ECMO, Andrew Lodge. Craig Rackley, MD, serves as the medical director of adult ECMO.
“The ECMO team works tirelessly,” Daneshmand said. “They are an extremely dedicated and hard working group of people. Duke is one of very few institutions in the country that offer this procedure. It’s very labor intensive, and primarily used for patients who essentially are moments away from death with no other options. That’s why it’s an important therapy to have, and why our team plays such an important role.”
“Over 25 years, we have progressed a large distance from saving newborns with relatively simple disease processes to using ECMO for a large variety of complex conditions, and from keeping ECMO patients anesthetized to having them up and walking around the ICUs – all with impressive results,” Cheifetz said.
Looking toward the future of ECMO therapy, Daneshmand said the focus will be on inserting the ECMO cannula sooner to a wider range of patients.
“We have seen dramatic improvements in patient survival if they are placed on ECMO prior to medical deterioration or requiring CPR,” he said. “However, if patients require CPR and are placed on ECMO, their chance of survival increases threefold.”