Category Archives: NEXT


ECMO Course

Session 1 – Antonio Pesenti, Refractory Hypoxaemia Therapuetic Strategies

Before deciding on support, first need to know what targets. One might be PaO2? If you climb up a mountain it’s low? Is this important – not according to Grocott in NEJM 2009 where low levels were compensated for by higher Hb.

Rx hypoxia broadly divided as follows

  1. Treat cause – antibiotics, thrombolysis, etc, etc
  2. Increase FiO2
  3. Reduced atelectasis – PEEP
  4. Increase pulmonary blood flow
  5. Reduce venous admixture – ECMO

Reabsorption atelectasis complicates high FiO2 administration.

PEEP prevents collapse = recruitment manoeuvres are needed to open collapsed lung. Indeed main difference between traditional IPPV & HFOV/APRV is high airway pressure – theory being more recruitment AND retention.

Don’t forget effects of heart + shunt upon O2 but iNO doesn’t work.

The benefits of proning extend beyond its effects on PaO2 – failure to improve this variable does not mean you should stop doing it.

Longer term, hypoxemia is a risk factor for long-term neuropsychological impairment but HYPEROXIA IS BAD.


Session 2 – Jan Bakker, Haemodynamic effects upon ECMO

Very variable! Limited prospective scores – ENCOURAGE might be useful for VA, or clearing fluid balance on day three but in essence little evidence.

When considering you need to ask:

  • What other support have you got?
  • What configuration are you using?

Peripheral VA-ECMO can significantly increase after load – first consider dilators, then increase forward flow whilst remember to treat acidodsis/anaemia. If that doesn’t work, add an IABP.

With VV-ECMO, RV afterload will fall with PVR effect because of beneficial effects upon CO2/PAO2.


Session 3 – Weaning from ECMO Giacomo Grasselli

No science to this – lack of definite criteria, indications from guidelines and local protocol and personal experience

Four scenarios

  1. wean ECMO, then vent
  2. Emergency discontinuation, e.g. bleed
  3. First wean vent, then ECMO
  4. Withdraw

Weaning from VV is weaning gas flow – you don/t need to reduce flow

Weaning GF increases muscle effort and needs vent support 

ELSO guidelines

You need haemodynamic stability as well as respiratory improvement. Measure oxygen delivery – the target is tissue oxygenation NOT PaO2.

How long do you keep the gas off? – Karolinska say 4 hours

Some authors propose leaving cannulae in place for put to 48 hours flushed with heparinised solution – practice VARIABLE

How to decannulate VV?

  • Stop/reduce heparin
  • Put purse string around insertion cannula
  • Clamp lines
  • Stop pump
  • Remove pipe allowing small amount of leakage to red air embolism
  • Manual compression 20 min for venous and 30 min for arterial.
  • Close monitoring distal perfusion for arterial and consider  vascular ultrasound in both as high incidence of clot or injury


Keynote – Michael QUINTEL, 50 years of ECMO

ECLS first developed by John Gibbon and Mali in 1936 in response to sudden death young patient with PE and first used in ORD for ASD repair May 1953

First trials negative – but badly done – so perhaps can be better interpreted as even if you do ECMO badly, you don’t kill everyone…

CESAR trial

First oxygenators bubble before developed hollow fibre oxygenator

The development of heparin-coated circuits allowing limiting APTT was one the major steps in reducing morbidity and mortality

Single centres such as Michigan have led the way – now more adult/paed, less neonates

Then H1N1 prompted exploration

H1N1 make worldwide excessive use of the technology but there is no new real data.

Reasonable data about risk/benefit ratio does not exist. Cerebral micro emboli are universal. 85% get DVT.

Is informed consent even possible?


Pro: Is ECMO always an Option? Steffen Weber-Carstens

UK evidence summarised by @CochraneUK in 2015

Similar International Consensus Position Paper by Coombes and colleagues on what defines an ECMO centre

Triage essentially as duration IPPV significant risk factor of deaths.

Con: Giacomo Bellani 

In one series, 87% of referrals had at least one relative contraindication

25% of patients in CESAR didn’t get it

EOLIA trial has not reported and is ongoing – we are in the infancy of what we know

16% rates of head bleed

20% nosocomial infection

Why use more resources when you can achieve the same thing with less? LungSafe shows we still don’t get optimium PEEP, NMBA, fluid balance and supportive care in ARDS.


EuAsia 2017 Day 1: ESICM Worldwide

ESICM Education Worldwide (P Gruber)

Education is a essential part of ESICM

An international survey of training in adult intensive care medicine.


ESICM Academy


The benefits of worldwide research network (A Pesenti)

Build a community of Critical Care phycisians and nurses

More people, more ideas

Quick enrolment

Specific for ICU

  • mainly syndromes rather than diseases
  • syndromes are common
  • underlying diseases are rare
  • non-homogeneous population in syndromes


Worldwide Intensive Care in the next 20 years (JLV)

JLV predicts (Intensive care medicine in 2050: the future of ICU treatments)

  • Less hospital days, shorter stays – moving pts out of hospital to the community to recover
  • Hospital rooms to become more comfortable and more like your living room
  • Entering room would be computer controlled after handwashed
  • Limits between hospitals and outside will be blurred – more telemedicine
  • Monitors to be miniaturised – biosensor
  • ICUs would make up a bigger proportion of the hospital
  • Death of stethoscope
  • Full extracorporeal support circuit – heart, lung, kidney, liver
  • Automation of numerous processes
  • Personalised medicine

The Future of Critical Care Medicine: Integration and Personalization.




The second day of the conference started in the NEXT lounge with a feisty debate between Mervyn Singer and Jean-Louis Vincent – entitled “Rewriting the rules time and time again – Why syndromes are not diseases” but quickly unravelled to a lively debate with the audience asking these giants of ICU what on earth they should do know treatments are debunked and definitions changing and guidelines expanding.  Lots of fun and a positive vibe in the end – I think the summary is as #merv says, do what makes sense!

I can’t seem to get Mervyn Singer on “the twitter” but I’ve given him the hashtag #merv! – Chris Nickson had some ideas…

End of life care on the ICU

There is precious little training in end of life care on the ICU

It needs to be a team approach and involve the multidisciplinary team

Increased expectation of patients, relatives and colleagues outside the ICU is pressurising

Be aware of cultural differences

Could/should intensivists write in the patient’s ICU diaries?

The ethics of end of life care

Review: Dying with dignity on the ICU

Clinical trial on having palliative care teams on the ICU