The history of extracorporeal membrane oxygenation (ECMO) in neonates began in 1975 when Dr. Bartlett and colleagues at the University of Irvine, CA successfully treated a 1-day-old newborn with severe persistent pulmonary hypertension of the newborn (PPHN) utilizing ECMO after conventional therapies had failed [1].

Since then, the use of ECMO in neonates has evolved significantly due to improved understanding of neonatal cardiopulmonary pathophysiology and advanced ECMO technology. As documented by the Extracorporeal Life Support Organization (ELSO), from 1989 to 2020, the registry reported that 43,707 neonates had been supported with ECMO worldwide [2].

Indications for ECMO in Neonates

Respiratory Indications

Historically, meconium aspiration syndrome, PPHN, and neonatal respiratory distress syndrome were the most common ECMO indications in neonates. Over time, the incidence of these indications has declined due to improved perinatal care. Currently, about one-third of ECMO neonatal diagnosis is represented by congenital diaphragmatic hernia (CDH) [3].

Congenital Heart Disease

In neonates with congenital heart disease (e.g., transposition of the great arteries with pulmonary hypertension), ECMO has been used for pre-operative stabilization, failure to wean from cardiopulmonary bypass, and low cardiac output syndrome post-operatively. Following congenital heart surgery, ECMO has been utilized in 1.4–5% of operations [4-6].

Myocarditis / Cardiomyopathy

Although rare, neonatal myocarditis/cardiomyopathy may require ECMO to maintain end-organ perfusion. In these cases, ECMO may be used as a bridge to recovery, to heart transplantation or ventricular assist device, or to decision-making. 

Cardiac Failure / Arrhythmias

ECMO may be indicated in neonates with cardiac failure associated with septic shock or cardiac arrest and severe arrhythmias. Arrhythmias may occur in the perinatal period, postoperatively, or in myocarditis/cardiomyopathy. In these cases, ECMO support is generally used to maintain end-organ perfusion while optimizing pharmacological and/or surgical treatment.

Timing and Duration of ECMO in Neonates

Significant debate surrounds the timing for ECMO deployment in neonatal cardiac failure. Some studies show early initiation may reduce hypoxia of the myocardium and/or peripheral organs [8]. However, prolonged ECMO in neonates with cardiac disease carries a high mortality and reduces the chances of a successful heart transplant [9]. 

Survival drops from 45 % (overall survival of children with cardiac disease) to:

  • 23–25 % when ECMO duration is between 14 and 28 days 
  • 13% when ECMO is used more than 28 days [10]

Meanwhile, prolonged respiratory ECMO > 21 days has a reported survival rate of 23.5% [11].

Based on multiple considerations, when evaluating ECMO as a bridge to a ventricular assist device, its duration should not be longer than 5–7 days [12].

Overall Survival Rates for ECMO in Neonates

Hospital survival when using ECMO in neonates is around 40%. This figure has remained relatively constant despite cumulative ECMO clinical experience, improved equipment, and advanced understanding of neonatal cardiopulmonary pathophysiology. 

Rather than being a failure to improve, the unchanged survival rate may be due to a constant widening of indications and increasingly complex patient risk profiles [13]. 

Conclusion

ECMO has been utilized in the treatment of neonates with severe cardiopulmonary disease for nearly five decades. ECMO is now an essential care option for newborns with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation.

Click here to learn more about ECMO treatment for acute respiratory failure or acute cardiopulmonary failure. 

References:

  1. Bartlett RH (2017) Esperanza: the first neonatal ECMO patient. ASAIO J 63(6):832–843
  2. Extracorporeal Life Support Organization (2020) ECLS Registry Report. International summary – July 2020. Available on January 8, 2021; from https://www.elso.org
  3. Extracorporeal Life Support Organization (2020) ECLS Registry Report. International summary – July 2020. Available on January 8, 2021; from https://www.elso.org
  4. Mascio CE, Austin EH, Jacobs JP, Jacobs ML, Wallace AS, He X, et al. Perioperative mechanical circulatory support in children: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg. (2014) 147:658–64. doi: 10.1016/j.jtcvs.2013.09.075
  5. Salvin JW, Laussen PC, Thiagarajan RR. Extracorporeal membrane oxygenation for postcardiotomy mechanical cardiovascular support in children with congenital heart disease. Paediatr Anaesth. (2008) 18:1157–62. doi: 10.1111/j.1460-9592.2008.02795.x
  6. Sasaki T, Asou T, Takeda Y, Onakatomi Y, Tominaga T, Yamamoto Y. Extracorporeal life support after cardiac surgery in children: outcomes from a single institution. Artif Organs. (2014) 38:34–40. doi: 10.1111/aor.12191
  7. Amodeo, I., Di Nardo, M., Raffaeli, G. et al. Neonatal respiratory and cardiac ECMO in Europe. Eur J Pediatr 180, 1675–1692 (2021). https://doi.org/10.1007/s00431-020-03898-9 
  8. Ford MA, Gauvreau K, McMullan DM, Almodovar MC, Cooper DS, Rycus PT et al (2016) Factors associated with mortality in neonates requiring extracorporeal membrane oxygenation for cardiac indications. Pediatr Crit Care Med 17(9):860–870
  9. Merrill ED, Schoeneberg L, Sandesara P, Molitor-Kirsch E, O’Brien J, Dai H et al (2014) Outcomes after prolonged extracorporeal membrane oxygenation support in children with cardiac disease—Extracorporeal Life Support Organization registry study. J Thorac Cardiovasc Surg 148(2):582–588
  10. Roeleveld PP, Mendonca M (2019) Neonatal cardiac ECMO in 2019 and beyond. Front Pediatr 7(August):1–13
  11. Sharma J, Sherman A, Rimal A, Haney B, Weiner J, Pallotto E (2020) Neonatal respiratory extracorporeal membrane oxygenation and primary diagnosis: trends between two decades. J Perinatol 40(2):269–274
  12. Roeleveld PP, Mendonca M (2019) Neonatal cardiac ECMO in 2019 and beyond. Front Pediatr 7(August):1–13
  13. Barbaro RP, Paden ML, Guner YS, Raman L, Ryerson LM, Alexander P, et al., Pediatric extracorporeal life support organization registry international report 2016. ASAIO J. (2017) 63:456–63. doi: 10.1097/MAT.0000000000000603

In patients with acute respiratory distress syndrome (ARDS) due to COVID-19, indications for  Extracorporeal Membrane Oxygenation (ECMO) are similar to indications for its use in other clinical scenarios. ECMO may be considered when other advanced treatments fail, such as lung-protective ventilation, prone positioning, and high positive end-expiratory pressure (PEEP).1

For specific patient populations, there is solid clinical evidence to support the utility of ECMO. COVID-19 therapy protocols across the country are increasingly adopting this life-saving treatment. 

Case Study: ECMO Treatment for COVID-19

According to a Fresenius Medical Care report, 28-year-old Samantha Oravec suffered from COVID-19 infection during her third trimester of pregnancy. Following a successful C-section to save her baby, Samantha required continued mechanical ventilation. As her respiratory and clinical status declined, Dr. J.W. Awori Hayanga, Director of the ECMO Program at WVU Heart and Vascular Institute, approved Samantha as a candidate for Novalung® ECMO Therapy.2

Comparing ECMO vs. Ventilator for COVID-19

Novalung is an ECMO machine for COVID-19 treatment. Unlike a ventilator, ECMO provides extracorporeal circulation and physiologic gas exchange in cases of severe respiratory or cardiac failure. Novalung has been approved by the FDA for more than six hours of use. This indication makes Novalung an important therapy option for treating patients with severe COVID-19 disease.

How Does ECMO Work?

ECMO provides extended cardiac and respiratory support to patients whose heart and lungs cannot adequately function to sustain life. There are two types of ECMO:

  • Venovenous ECMO: Blood is removed from the venous system, passed through an artificial lung, and returned back to the venous system. The oxygenated blood then passes through the lungs.
  • Venoarterial ECMO: Blood is removed from the venous system, passed through an artificial lung, and returned to the arterial system. This method provides both cardiac and pulmonary support.

Recovery After ECMO COVID-19 Treatment

Initially, Samantha responded well to Novalung, and she was taken off ECMO for eight days. However, the infection returned, and she required a second round of ECMO. The treatment was successful in helping her to recover and return home. 

How Long Can COVID-19 Patients Stay On ECMO?

Weaning patients from ECMO treatment for COVID-19 depends on improvements in lung compliance and arterial oxyhemoglobin saturation. Data indicates that longer durations of ECMO support for COVID-19 patients may be necessary compared to other causes of ARDS. In one study, a median duration of 29 days was required.3 Other studies support the use of ECMO for three to six weeks.4

ECMO for COVID-19 Patients Saves Lives

Samantha’s success story is but one among many cases where ECMO proved to be a valuable treatment for severe COVID-19 infection. According to the Fresenius report, Dr. Hayanga has successfully treated other pregnant women with ECMO. Several clinical studies have established ECMO as a valuable treatment option for COVID-19 patients with acute respiratory or cardiac failure.5

Indications For ECMO Use

ECMO systems, such as Novalung, are indicated for long-term (>6 hours) respiratory and cardiopulmonary support in adults with ARDS. 

ECMO is indicated when other treatment options have failed, and continued clinical decline is anticipated or the risk of death is imminent. These clinical indicators may include, but are not limited to:

  • Failure to wean from cardiopulmonary bypass following cardiac surgery in adults
  • ECMO-assisted cardiopulmonary resuscitation in adults

Click here to learn more about ECMO treatment for acute respiratory failure or acute cardiopulmonary failure. 

References: 

  1. Fitzsimons, M. G. (2022, April 27). COVID-19: Extracorporeal membrane oxygenation (ECMO). https://www.uptodate.com/contents/covid-19-extracorporeal-membrane-oxygenation-ecmo.
  2. ECMO in the time of COVID-19. (2022, January 12). Fresenius Medical Care. https://fmcna.com/insights/articles/ecmo-covid19/
  3. Mustafa, A. K. (2020, October 1). Extracorporeal Membrane Oxygenation for Patients With COVID-19 in Severe Respiratory Failure. https://pubmed.ncbi.nlm.nih.gov/32780089/.
  4. UpToDate. (n.d.). UpToDate – Evidence-based Clinical Decision Support | Wolters Kluwer. https://www.uptodate.com/contents/covid-19-extracorporeal-membrane-oxygenation-ecmo/abstract/3,5,20
  5. UpToDate. (n.d.). UpToDate – Evidence-based Clinical Decision Support | Wolters Kluwer. 

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How Perfusion School Has Changed: Past, Present & Future

The past 60 years have witnessed a major evolution in clinical cardiopulmonary perfusion education. Much of this progress can be attributed to the continued advancement of medical and surgical technologies. Additionally, a change in how the profession sees itself has impacted perfusion education. 

Let’s take a look at how perfusion school has changed and what we can anticipate for the future. 

Rapid Growth in Perfusionist Demand 

In the early days of perfusion practice, new clinicians were trained on the job or in a laboratory. However, with the rapid expansion in cardiac surgical procedures, formal perfusion educational programs became a necessity. 

As cardiac surgery became safer and more available, the number of procedures continued to grow. Upon adding in the development of heart and lung transplant surgery, the demand for qualified perfusionists increased even more. 

As an illustration, the chart below shows the explosion in the number of adult lung transplants worldwide:

Source: European Lung white book

Perfusionist Education & Certification

Initially, the American Society of Extracorporeal Technology was responsible for perfusionist credentialing and developing certification guidelines. Currently, the American Board of Cardiovascular Perfusion (ABCP) assumes these responsibilities. 

In 2015-2016, the ABCP surveyed 3,875 eligible Certified Clinical Perfusionists (CCPs) and 3,056 (78.9%) responded. The survey reported that 94 percent of perfusionists are graduates from accredited schools of perfusion. Even more encouraging is that 91 percent of the survey respondents consider their educational experience as being positive.

Perfusionist licensure has also been adopted by many states, and nearly 50% of all perfusionists are covered by some legislative act. 

How perfusion school has changed student evaluation methods  

One major challenge has been developing minimum standards for perfusionist clinical evaluations. Initially, standards included the use of checklists. This has since evolved to more complex monitoring and recording of significant events and parameters during procedures. Likewise, educational standards have been required to evolve to match new clinical realities.   

With the institution of formal schooling and curriculums, classroom testing and clinical rotation evaluation have become the norm. Also, many programs encourage clinical research as part of their core curriculum.

Modern Perfusion Simulation 

As a bridge between the classroom and the operation room, high-fidelity perfusion simulation is another component of modern perfusion education. 

Simulation labs may include:

  • Patient simulator
  • State-of-the-art perfusion equipment
  • Fully instrumented operating rooms
  • Digital patient data capture 
  • Audio-visual recording 

With simulation equipment, programs can develop a variety of patient scenarios to teach critical perfusion decision pathways and evaluate clinical skills without incurring any risk to actual patients.

The Future of Perfusion Education

As medical science advances, so will perfusion education. Some areas already seeing significant progress are real-time perfusion monitoring and electronic health records. As in nearly every industry, the capture and analysis of data open the door to new innovations and improved levels of performance. 

The ability to collect and analyze vast amounts of physiologic data promises to transform the practice of perfusion. Not only will monitoring become more diverse and accurate, but with machine learning (ML) and artificial intelligence (AI), the quality of care could improve significantly. 

AI/ML algorithms enable the creation of predictive models based on historical data sets. Therefore, we can foresee a future where the perfusionist could anticipate changes in patient status and make adjustments in a more proactive and preventative manner. 

In the future, perfusion education programs will more than likely incorporate these new technologies into their curriculums. 

Article references:

A 2015-2016 Survey of American Board of Cardiovascular Perfusion Certified Clinical Perfusionists: Perfusion Profile and Clinical Trends

https://pubmed.ncbi.nlm.nih.gov/28979037/

The evolution of perfusion education in America https://pubmed.ncbi.nlm.nih.gov/14575415/

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Perfusionist strategies for blood conservation

The use of allogeneic blood exposes patients to the risk of non-screenable transmittable diseases. Due to these risks, and since blood is a limited resource, perfusionist strategies for blood conservation continue to be developed.

Here we will review some of the methodology involved for effective blood conservation practice.

Blood Management Program

Effective blood resource management goes beyond a random collection of protocols and techniques. Rather, a cohesive multidisciplinary, multimodality strategy is more effective. Such an approach should include:

  • Documented policies and procedures
  • Rigid transfusion criteria 
  • Evidenced-based techniques
  • A blood management team that governs the program (physicians, blood bank directors, nursing supervisors, and perfusionists)

Now let’s look at some more specific perfusionist strategies for blood conservation.

Autologous Blood

Using the patient’s own (autologous) blood avoids many of the risks (transmissible disease and cross-matching errors) associated with allogeneic blood. Also, for personal or religious reasons, many patients might refuse allogeneic blood transfusions. Additionally, patients with multiple red blood cell (RBC) antibodies or unusual blood phenotypes find it difficult to obtain blood.

Drawbacks to pre-surgical auto-donation are the time and visits required to accumulate the blood as well as storage and phlebotomy costs. 

Blood Removal Prior to CBP

Another method of obtaining a patient’s blood is by removal just prior to cardiopulmonary bypass (CPB). After heparinization and cannulation, blood can be removed by a venous line and a Y connection to a collection bag. Later, the patient can be infused through an arterial cannula to maintain adequate arterial blood pressure. Some studies show blood saved in this manner decreases post-op bleeding by preserving coagulation factors and platelets.

One drawback of preoperative blood removal is that the patient’s hematocrit must be high enough to withstand the blood loss. Also, for patients with ischemic heart disease, some surgeons are reluctant to use this method of blood conservation.  

Autologous Priming

Another perfusionist strategy for blood conservation involves removing crystalloid in the CPB circuit and replacing it with the patient’s own blood just prior to bypass. This method minimizes hemodilution and, therefore, preserves the patient’s hematocrit.

Removal of crystalloid via autologous priming can be accomplished at nearly any point in the CPB circuit. Since the process must be completed gradually, perfusionists must coordinate with anesthesia to maintain adequate arterial blood pressure. The recirculation line on the oxygenator is a commonly used site for crystalloid removal.  

Autotransfusion (Cell Washing)

Autotransfusion involves aspirating blood from the surgical field with a special suction line into a holding cardiotomy. Also, remaining blood can be salvaged from the CPB oxygenator and circuit and drainage devices (chest tubes) at the end of the operation. 

The cell saver collects the shed blood from the operative site and mixes it with heparinized saline, it then separates RBCs via centrifugation, washes the red cells, and diverts them to an infusion bag.

One risk to autotransfusion is that inadequate washing may leave heparin residue which may cause bleeding. Also, autotransfusion products are devoid of platelets and clotting factors.   

Plasmapheresis and Plateletpheresis

Plasmapheresis and plateletpheresis remove plasma or platelets from whole blood and then return the red blood cells back to the patient. This procedure harvests platelets and other clotting factors while preserving hematocrit during bypass. 

Uncontaminated blood is drawn into a centrifuge which separates the blood products. The collected RBCs can be transfused back immediately to the patient or held for use later.

Hemoconcentrators 

Hemoconcentrators remove fluid from the patient’s vascular system, which increases the hematocrit. The removed fluid consists of plasma water and solutes. Meanwhile, solutions can be added to the pump volume to control electrolyte concentrations if necessary.

The hemoconcentrator forces fluid and small solutes across a semipermeable membrane while larger formed blood elements cannot cross. Membrane pore sizes range from 15,000-55,000 daltons which enable electrolytes, creatinine, urea, and glucose to be removed. Likewise, heparin can also be removed in this process. Also, the level of circulating drugs may also be lowered by removing plasma.  

Finally, any residual blood left in the pump circuit can be salvaged and concentrated with the hemoconcentrator after CPB is completed. 

Conclusion

Blood is a valuable resource that also carries inherent risks. Some, or all, of these perfusionist strategies for blood conservation, should be implemented in any healthcare center’s approach to quality patient care.

Article reference:

Blood Conservation Summary

https://www.sciencedirect.com/science/article/abs/pii/S0003497510610077#:~:text=The%20conservation%20of%20blood%20can,after%20wound%20closure%2C%20and%20hemodilution

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Perfusion School: Expectations & Opportunity

Working as a perfusionist is a highly challenging and rewarding career path. The educational standards are high, and the profession appeals to those interested in working on surgical teams and in critical care scenarios.

Across the country, there has been an increased demand for perfusion services driven by several factors, such as:

  • Rising number of chronic disease cases such as cardiac disease, liver, and pulmonary diseases.
  • The emergence of new illnesses such as COVID-19.
  • An aging population is more susceptible to heart and lung failure and more likely to need heart surgery.
  • Improving medical treatment increases the number of lung transplants, heart/lung transplants, and heart assist devices.

Given these trends, the demand for qualified clinicians has grown and is expected to grow over the next several years. Here are some common questions about the educational requirements to become a clinical perfusionist. 

What are the qualifications for perfusionist program applicants? 

A Master of Science in Cardiovascular Perfusion (MSCVP) can be acquired at institutions of higher learning such as Lawrence Technological University

A preferred applicant will have a Bachelor of Science (B.S.) degree from an accredited college or university. Qualified candidates may also have experience as a Respiratory Therapist (RRT), Registered Nurse (RN), or in critical care. 

Persons with a B.S. who have completed courses in anatomy, algebra, calculus, physiology, physics, and chemistry are also eligible to apply for MSCVP programs.

How long does it take to get a perfusionist degree?

Most students studying to be a perfusionist already have solid health and/or science background. Many also have hands-on clinical experience working in surgical suites, ICUs, and on hospital floors. Building upon that valuable knowledge and experience, it usually takes two years to complete the requirements for an MSCVP degree. 

What courses are required to become a perfusionist?

The best perfusionist programs provide a comprehensive curriculum that encompasses the essential sciences as well as clinically relevant topics of study, such as:

  • Hematology
  • Patient Care & Professionalism
  • Physiological Science 
  • Perfusion Theory (Basic & Advanced)
  • Professional Practice
  • Applied Pharmacology
  • Pathophysiology
  • Research Methods
  • Critical Care

The demanding class subject matter reflects the exciting challenges included in the educational process and later as a professional perfusionist. 

Are research and hands-on experience part of perfusionist education?

Higher quality perfusionist educational centers will typically encourage or include some kind of clinical research prior to graduation. This enables students to dive deeper into a particular area of interest. Perfusion research may even continue after graduation for professionals interested in a scientific investigation. 

The final phase to complete a perfusionist master’s degree consists of clinical experience. Here, students work alongside practicing perfusionists in real-world settings, such as operating rooms, ICUs, and lung / heart-lung transplant units. This hands-on experience ties together everything learned up to this point and puts it into practice. 

The ultimate goals of perfusionist education are:

  • To empower graduates with the skills and knowledge needed for practice.
  • To help graduates feel comfortable working in the clinical perfusionist setting.
  • To encourage continued study and research in the field of perfusion. 

How is performance evaluated when studying to be a perfusionist?

Each school has its own method of evaluation, however, most programs have high standards. This is important since perfusionists work with advanced life-saving technology where the utmost attention to patient care is required.

Perfusionist programs may require a certain grade point average to graduate. Also, in clinical rotations, instructors evaluate students based on their knowledge and technical skills. Clinical skills may be evaluated by a letter grade or competence level required for graduation. 

Perfusionists prepared to achieve and serve   

As the demand for perfusionists continues to grow, more people will be drawn to this exciting and rewarding career path. Although the education is rigorous, the effort is worth it for those who seek to make a positive impact in surgical and critical care scenarios. Quality education is stepping up to prepare future perfusionists to provide the highest quality of service and care.

Learn how CCS teams up with LTU to offer one of the country’s most advanced Master of Science in Cardiovascular Perfusion (MSCVP) programs.

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What are the expectations of a perfusionist career?

For those with a strong background or interest in healthcare and science, a career working as a perfusionist can be highly rewarding. Perfusionists work as key members of cardiovascular surgical teams by using specialized equipment and patient monitoring techniques. 

Let’s find out more about this exciting career path essential to the practice of modern medicine.

What is a perfusionist?

A perfusionist is a highly skilled, formally trained and accredited healthcare professional that works as a member of an open-heart, surgical team. The perfusionist is responsible for the operation of a cardiopulmonary bypass (CPB) device commonly known as the heart-lung machine. 

During open heart surgery, the patient’s heart is stopped to facilitate delicate surgical techniques. By taking over heart function, the CPB device diverts blood away from the heart and lungs, oxygenates the blood, and then returns the blood to the patient. In addition to operating the heart-lung machine, perfusionists monitor blood circulation parameters and administer blood products or medications to help ensure optimal surgical outcomes. 

In addition to CPB, the perfusionist may apply their skills and expertise to other clinical scenarios, such as:

  • Extracorporeal membrane oxygenation (ECMO) – Similar to CPB used in surgery, this methodology can be used in other scenarios such as acute respiratory failure, cardiac arrest, or as a bridge to heart / lung transplant.
  • Other types of extracorporeal circulation (ECC), such as the delivery of chemotherapeutic drugs to cancer patients’ organs and/or limbs (limb perfusion).

Key perfusionist skills

  • Scientific thought: Perfusion is a demanding medical science that requires skill in understanding and applying scientific data and techniques.
  • Communication: Perfusionists must keep surgeons updated during life saving procedures and critical situations.
  • Stamina: Since surgeries can last several hours, perfusionists require high levels of physical and mental stamina. 
  • Time management: Multiple surgeries, administrative tasks, and patient monitoring all require excellent time management skills.
  • Attention to detail: Perfusionists must pay attention to changes in a patient’s status and make detailed adjustments to care when needed.

What does it take to become a perfusionist?

Most people studying to be a perfusionist already have a solid health and/or science background, such as a Bachelor’s degree in biology or experience as a registered nurse or respiratory therapist. It typically takes two years at an accredited school to complete the requirements for a masters degree in perfusion. 

To begin perfusionist practice, candidates must pass the Perfusion Basic Science Examination (PBSE) and the Clinical Applications in Perfusion Examination (CAPE) to earn their Certified Clinical Perfusionist (CCP) credential. Candidates must complete at least 75 cases, with a minimum of 40 independent cases, before sitting for the exams.

Perfusionists must also satisfy continuing education requirements and maintain up to date knowledge in their field. To maintain credentials, perfusionists complete ongoing training/education and submit proof of education credits to the American Board of Cardiovascular Perfusion (ABCP).

How much does a perfusionist make?

A perfusionist’s work is highly demanding, and one can expect high levels of compensation depending on where you practice, a perfusionist may surpass $95 per hour and starting around $50 per hour.

Conclusion

For those interested in a fast-paced, demanding career in healthcare, perfusion is an attractive option. The standards are rigorous, and the on the job experience can be highly rewarding as you make a difference in life saving patient care.

Article References:

What You Need To Know About Being a Perfusionist

https://www.indeed.com/career-advice/finding-a-job/perfusionist

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Awake ECMO As A Treatment Option for Severe COVID-19

The use of extracorporeal membrane oxygenation (ECMO) in awake, spontaneously breathing patients (sometimes called “awake ECMO”) has been used for over a decade as a bridge for patients awaiting lung transplants. Cases have also been described where the therapy was used as an alternative to mechanical ventilation in COPD exacerbation.

In 2012, the first report of using venovenous ECMO support for the treatment of acute respiratory distress syndrome (ARDS) came out of Hannover Medical School, and research is ongoing in this area.

Today, as the world continues to confront the COVID-19 pandemic, the use of awake ECMO in the treatment of severe COVID-19 has produced promising results in early stage investigations.

Complications of Invasive Ventilation in COVID-19 Patients

Patients with severe COVID-19 infection can deteriorate rapidly thus requiring intubation and invasive ventilation. However, invasive respiratory support is not without complications which may include:

  • Ventilator disconnection
  • Ventilator associated pneumonia (VAP)
  • Barotrauma due to excessive airway pressures
  • Volutrauma damage due to excessive lung volumes
  • Atelectasis
  • Oxygen toxicity due to persistent high oxygen concentrations

Given these ventilator associated risks, some clinicians have been exploring the use of awake ECMO as an alternative treatment for severe COVID-19.

Awake ECMO for Severe COVID-19

Awake ECMO prior to intubation for severe COVID-19 is being tested by Jeffrey DellaVolpe, MD, medical director of the adult ECMO program at Methodist Hospital in San Antonio.

Before attempting ECMO, COVID-19 patients typically receive mechanical ventilation following the standard of care for severe ARDS using lung protective ventilator settings, prone positioning, and other strategies.

There have already been case reports of successful treatment of severe COVID-19 with awake extracorporeal membrane oxygenation. Della Volpe and his team at San Antonio now seek to confirm whether this is a viable treatment option. The goals of the study are to reveal whether awake ECMO reduces the need for ventilation and measure the impact on outcomes in critical COVID-19 cases.

Determining Early/Awake ECMO Efficacy 

According to Dr. DellaVolpe, “The later you put ECMO on, the more time you expose them to harmful effects of the ventilator.” 

Research at his center shows that when the application of ECMO is delayed for ventilated patients, there is an associated 56% increased risk of death after adjusting for covariates, including age, sex, and comorbidities.

One important obstacle to ECMO treatment is the lack of availability of equipment and qualified staff to administer the intervention. Meanwhile, DellaVolpe estimates that up to 80% of severe COVID-19 patients might fit criteria that show a benefit to early or awake ECMO.

For severe COVID-19 and other acute respiratory diseases, the use of ECMO is a valuable treatment to consider early during treatment. In the future, awake ECMO may even become the treatment of choice in selected cases.

Article references:

Artificial lung as an alternative to mechanical ventilation in COPD exacerbation

https://erj.ersjournals.com/content/39/1/212?ijkey=b94c50ff19b0b18907638539cc6244ed05ddf1b8&keytype2=tf_ipsecsha

Extracorporeal membrane oxygenation in a nonintubated patient with acute respiratory distress syndrome

https://erj.ersjournals.com/content/40/5/1296#ref-5

COVID-19 disease: invasive ventilation

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261657/#:~:text=Breathing%20complications%20include%20ventilator%20disconnection,to%20persistent%20high%20oxygen%20concentrations.

Successfully treatment of application awake extracorporeal membrane oxygenation in critical COVID-19 patient: a case report

https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-020-01376-9

Should ECMO Come Before Intubation for COVID-19?

https://www.medpagetoday.com/infectiousdisease/covid19/89562