Cross-Country ECMO Transport. Linda Mongero CCP Michael P. Brewer CCP

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1 Cross-Country ECMO Transport Linda Mongero CCP Michael P. Brewer CCP

2 I have no conflict of interest for this presentation DISCLOSURES

3 Overview Emergent air transport of an ECMO patient ECMO cannulae configuration and changes made Circuit access for CVVH and medications Military Logistical plan Air transport concerns Sentinel event Air pressure constraints Military Tradition

CVVH and medications Military Logistical plan Air transport

4 NYP-Columbia ECMO Program

5 Adult ECMO YTD Jan Feb Mar April May June July Aug Sept Oct Nov Dec

9 8 9 5 5 8 77 2012 8 5 10 9 5 15 7 11 13 7 11 9 110 2013 10 4 10 13 12 15 7 7 10 11 9 12 120

6 Pediatric ECMO YTD Jan Feb March April May June July Aug Sept Oct Nov Dec

3 1 2 2 2 4 1 2 2 6 2 28 2012 0 0 3 3 2 3 2 4 3 1 1 2 24 2013 3 3 3 2 3 0 4 2 1 3 3

7 Patient AK, 33 yo female Stay at home mother of 2, Wife of enlisted Army officer Cystic Fibrosis 12/28 admitted to San Antonio Military Medical Center (SAMMC) (cough/ chest tightness/ fever/ diarrhea) Assumed pseudomonal PNA levaquin Placed on ECMO and?transport to New York

Medical Center (SAMMC) (cough/ chest tightness/ fever/ diarrhea)

8 Events Bacchetta and Cannon, MDs, Lieutenant Colonels 430p notified transport is a go, 630p flight from LGA to Houston 11p arrival in Houston 1130 flight to San Antonio Arrive in SA 1230a Arrive at SAMMC 130a go bedside to evaluate patient Food and to hotel

arrival in Houston 1130 flight to San Antonio Arrive in SA 1230a

BAMC is the command element over all Army medical facilities in the San Antonio area, including SAMMC.

9 San Antonio Military Medical Center (SAMMC) situated at Fort Sam Houston, San Antonio, Texas, and is part of Brooke Army Medical Center (BAMC) and the U.S. Army Medical Command. BAMC is the command element over all Army medical facilities in the San Antonio area, including SAMMC. It is a University of Texas Health Science Center at San Antonio and USUHS teaching hospital and is home to the Army Burn Center.

10 Patient on SAMMC Patient was placed in the Burn Unit in a burn unit bed. Keep her to herself. V-V-V config. IJ, FV, FV

11 Mannifold with meds into the neg.pressure line, CVVH in Cardiohelp circuit.

12 ECMO Reconfiguring 11am - Decision made during morning rounds to change portions of the ECMO circuit to improve oxygen delivery to patient 1210pm - Patient converted back to Fem- Fem VV ECMO sats dropped to high 50 s (groin in and out) 1220pm - Out flow cannula (LIJ) upsized 21 Maquet 1230pm - Converted back to VVV Oxygenator pressures dropped substantially Able to increase flows 6.1 LPM Negative pressures increased proportionally 115pm 3ft of excess venous line removed BQ 6.3 LPM

1220pm - Out flow cannula (LIJ) upsized 21 Maquet 1230pm - Converted back to VVV Oxygenator pressures dropped

13 V-V-V to V-V to increase O 2 Baseline ECMO vitals Fem-Fem VV vitals

14 Flow Optimization After upsized outflow cannula Removal of excess venous line 5.6 LPM LPM

15 Transport from SAMMC to Joint Base San Antonio

16 Military Logistical Planning Full scale military mission All personnel given official orders (MB-Lieutenant Colonel) Civilian clearance had to be specially requested for the Perfusionist (Brewer) to take part in the military operation Enough supplies for 5 days was packed onto the C-17 Secondary backup present on the flight for all critical team members Full debriefing with duties and responsibilities assigned prior to transport from SAMMC to Joint Base San Antonio

Enough supplies for 5 days was packed onto the C-17 Secondary backup present on the flight for all critical team

17 The facility is under the jurisdiction of the United States Air Force 502d Air Wing, Air Education and Training Command (AETC) It is is an amalgamation of the United States Army Fort Sam Houston, the United States Air Force Randolph Air Force Base and Lackland Air Force Base Joint Base San Antonio

amalgamation of the United States Army Fort Sam Houston, the United States

18 C-17 Globemaster Strategic airlift missions Transporting troops Cargo Tactical airlift Medical evacuation Airdrop duties Taller than a 5 story building 174ft long with a 170ft wing span Max payload Tons Capacity troops Unrefueled range - 2,800 nautical miles Cruising speed 515 mph $218 Million - fly away cost (2007)

long with a 170ft wing span Max payload - 85.

20 Patient enters plane

22 Sentinel Event Bubble detector triggered just prior to take off Air presumed from IV line Military personnel not fully familiar with Cardiohelp software Unable to reset or override pump stop protection (10-20 seconds) Columbia perfusionist present was able to reset bubble detector under multiple layers of alarms Flow reinstituted

23 1st US Cardiohelp Transport

24 Air medical services using ECMO pose special challenges. Air Transport Concerns Cabin pressure air supplied by bleed air from engines, cooled and sent to the cabin. Cabin air is also pressurized to ensure partial pressure is high enough. Pressurized to under 8000ft in the cabin (.74 atm) 50% fresh air/ 50% recirculated air Air entrainment from delivery ports on the manifold Cannula dislodgement

25 Positioning the Patient in the Aircraft The patient should be positioned with the head pointing to the tail of the plane Take-off and landing creates a temporary Trendelenburg position Changes to BQ and saturations caused from blood pooling in the upper half of the body G-force during take-off and landing may cause temporary decrease in blood flow

26 Aircraft Considerations Grounding of the Cardiohelp Electromagnetic interference RPM mode What type of outlets are on the aircraft Different voltage in different countries Cardiohelp 110 V V

27 Commercial Aircraft are Pressurized, But Not to Sea Level Aircraft cabin are pressurized to an altitude of 8000 ft (2438 m) while the aircraft is flying at ft (11582 m). Avoid air turbulence Maintain fuel efficiency

28 Altitude Affects Oxygen Delivery to Tissues At altitude of 8000 ft, partial pressure of oxygen falls 15% (equivalent PaO 2 X.85) In healthy individual without lung pathology PaO 2 may fall from 145 mmhg to 110 mmhg without significant changes to SaO 2 (100% - 98% saturation).

29 Altitude Affects Oxygen Delivery to Tissues

30 Clinical Implications of SaO 2 and High Altitude Try to maintain Patient s PaO2 > 60 mmhg Maintain SaO 2 > 90% When PaO 2 falls below 60 mmhg there is also a rapid decrease in SaO 2 At 8000 ft, PaO 2 of 60 mmhg will drop to PaO 2 50 mmhg (90%- 81%)

31 Plan Ahead: Anticipate for Problems to avoid delays Zulu time is used to avoid confusion (Greenwich Mean Time) A time in which all other world times were based Every military mission uses ZULU time Maximize patient before transport Drug requirements and oxygen requirement Ambulance to the Airport Passport and Visa requirements

32 Maximize the Patient Before Air Transport Diuretics To prevent water buildup in the lungs Improves A-a gradient Maximize O 2 carrying capacity Give exogenous PRBC? Decrease oxygen consumption Drift cool Allow for room to go up on the ventilator if needed FiO 2, Tidal Volume, Respiratory rate Allow for room to go up on ECMO circuit if needed Blood Flow, Fio 2

33 Do you have enough drugs and oxygen for the transport? Calculate for drugs needed for transport (Drip rates) X (transport time) Allow for time to spare Calculate for oxygen needed for transport Dependent on oxygen tank size and gas flow rate (PSI X Tank factor) / gas flow rate = time in Minutes Tank Factors: E =.28, M = 1.56, H = 3.14 Don t forget about the oxygen for the ventilator Allow for time to spare

34 Inflight cannula adjustment Suspected recirculation Outflow cannula recession

36 JFK

38 CUMC

39 Take Home Points 1. Be familiar with the equipment before you use it. 2. Try to do a local transport before attempting AIR 3. Adult Trauma Life Support (ATLD) FIX FIRST!!!

40 Military Tradition of Gratitude Patch given by the flight team off their jump suit sleeve Military tradition General s Medal Given to both members of the Columbia team present who assisted and supported the military personnel.

Traveling With Portable Oxygen

T R AV E L I N G W I T H P O R TA B L E O X Y G E N Traveling With Portable Oxygen PAT I E N T E D U C AT I O N G U I D E Introduction Each year, millions of travelers fly on commercial airlines in the