ECMO in COVID-19 related severe cardiopulmonary failure: visual summary of the recently published ELSO – Extracorporeal Life Support Organization Consensus guideline: unique considerations on when & how to provide ECLS in SARS-CoV-2 Coronavirus pandemic, with potential indications/contraindications. Download full document at https://bit.ly/ELSOCOVID19
Surviving Sepsis Campaign COVID-19 guidelines to support management of critically ill ICU patients with SARS-CoV-2 Coronavirus infection: here a graphic summary! infection control, diagnosis & testing hemodynamics support monitoring, fluids & vasoactives non-invasive ventilatory support: SpO2 targets, conventional oxygen therapy, High Flow Nasal Cannula & Non-Invasive Positive Pressure Ventilation invasive mechanical ventilation: MV settings, recruitment maneuver, prone posi tioning, fluids, NMBAs & inhaled vasodilators therapy: steroids antipyretics, antivirals, IVIg, convalescent plasma, rIFNs, chloroquine, tocilizumab & more! full open access at https://bit.ly/SSCCOVID19
Basic advices & informal decisional algorithm by a study Group on management of critically ills COVID-19 patients based at Niguarda Ca’ Granda Hospital (Director Prof. R. Fumagalli) & Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Director Prof. A. Pesenti) in Milan, Italy: hot to set mechanical ventilation (initial acute phase, stabilization, weaning), hot to do recruitment maneuver & notes on porne positioning… to do or (maybe) not? therapy: antivirals/adjuvants (be careful with lopinavir/ritonavir!) antibiotics, fluids/NE, analgesia & sedation, NMBA temperature management monitoring Aim to stardardize treatments, optimizing outcome & resources consumption, and support physicians, nurses, HCPs dealing with severe respiratory failure related to COVID19, waiting for the response of the immune system, the most effective strategy! By Thomas Langer & Nicola Bottino Graphics by @foamecmo available both in English & Italian
Request full document with management advices to the authors Thomas Langer email@example.com & Nicola Bottino firstname.lastname@example.org
PS Advices are based on preliminary informations collected during the first experience in China, and during the first week of the emergency in Lombardy, Northern of Italy; additional data ad evidence eventually arising will impose updating the recommendations.
COVID-19 network in Lombardy to early identify, triage & manage SARS-CoV-2 Coronavirus patients: JAMA livestream with Professor Maurizio Cecconi, Here a summary… Do not underestimate! high percentage of patients will require hospitalization, high percentage will require intensive care: get ready, prepare now, work on protocols and have plans: outbreak could comes near to you!also check related paper by Prof Cecconi, Giacomo Grasselli and Antonio Pesenti just released on JAMA.
COVID19 dedicated GiViTI video conference with intensivists from North of Italy sharing their initial experience with Coronavirus SARSCoV19 epidemics: lung ultrasound LUS, prone positioning, MV, ECMO… it’s like a tsunami, you can’t understand if you are not in. Recordings of the conference (for the ones speaking in Italian!) available link thanks to Istituto Mario Negri
How to manage critically ills with COVID19? be prepared! be familiar with case definition, ensure strict compliance with IPC, beware of diagnostic testing… ESICM webinar with Prof Yaseen Arabi moderated by Lennie Derde. Here a graphics, slideset & summary available.
Missed the ESICM COVID-19 webinar with Professor Bin Du from China? here some dedicated notes: data about #Coronavirus pandemic, disease evolution, clinical features, organ failure & need for mechanical ventilation; check ESICM blog at for more data! full open access webinar here. A summary in the graphics.
Optimal site for providing extracorporeal cardio-pulmonary resuscitation ECPR in out-of-hospital cardiac arrest? maybe in the hospital, in the cath-lab better! here notes from the talk given by Jan Belohlavek, EuroELSO president, at EuroELSO2019 meeting: not ECLS alone, but a comprehensive approach including ECMO, with high quality bystander CPR/high quality ACLS, may have an impact on logistics for OHCA patients; we have technology but we still need to define proper patients & optimize logistics: randomized studies are absolutely necessary. Everything else is just an emotional bias. Visual abstract by @foamecmo See you at EuroELSO2020 Congress, next May 6-8 2020 in London! register here
Perfect prime for ECMO circuit?? We take care for neonates, pediatrics, growing number of adult patients… there is no gold standard that defines ideal prime, as no prime is going to fit all these populations, and sometimes is a race against time! here some notes freely based on the talk by Christine Franciscovich at 2019 ELSO Conference: clear & blood priming, and factors to be considered when choosing dilutional hematocrit calculation additives options: calcium, albumin, heparin, NaHcO3… lab/ABG on prime graphics by Velia Marta Antonini @foamecmo
The first ELSO ECMOed ECMO education twitter chat has been held few hours ago, involving participants from all Continents: Lots of interesting comments, questions, idea and suggestions have been shared, focused on the target to standardize ECMO education making it globally available & properly train/certify providers. Here, nearly (as feasible) complete transcript of the chat… some hints: implement the ELSO ECMO education dedicated guidelines focus on (a partially) online education strategy to improve worldwide accessibility, to be integrated with high fidelity #simulation/practice increasing availability of free open access resources ie dedicated webinars, conference talks organize a social media based platform to discuss interesting ECMO cases (with a proper management of sensitive data)… Improving cost and sustainability of education & training, particularly in low income Countries and for low income HCPs, without negatively impact on quality seems an important issue! investing in ECMO team education/updating is an investment towards patients/program outcome improvements. mandatory certifications? using something like ACLS/ALS model or not?
to view original posts, reply & comment search for #ECMOedPP hashtag on twitter, enjoy!
About ELSO ECMOed
@EcmoDiaz The goal of this Taskforce is to take further what ELSO has done in education: standarization in curriculum, evaluation, simulations and education research with the best team work: international collaboration. @kshekar01 There is so much variation in ECMO practice and outcomes that high quality education can have a huge impact on all aspects of ECMO care – huge gains to be made with education as things stand. @HerxxAU The ECMOed framework is a great start and builds the framework for future structures. National and regional solutions are next. @bishoy_zakhary. We hope the global framework will help guide organization at the national levels. @EcmoDiaz Exactly! collaboration is the first step to get the framework @slthomps12 Need to standardize the expectations, medical knowledge, technical knowledge, and troubleshooting of ECMO. Having a standard to meet in order to care for ECMO patients is needed that is comparable across all centers. @JenelleBadulak Agree that this will also be essential for unifying ECMO practice better enabling meaningful clinical research: if we do it similarly in multiple institutions, we can study it across multiple institutions. @ecmocare I fully agree to fact that ECMO education should be standardised and supported. The ECMOedPP chat is a right initiative, but we need to further structure the initiative. @kshekar01 Agree – ongoing educational research will help optimise/calibrate educational content and delivery both and to measure impact over time. With representation from all ELSO chapters, ECMOed can enable every chapter to build capacity in terms of both endorsed courses and trainers; all the suggested options for affordability etc sound good. @KrKrramanathan That would ensure quality education for sure. Basic standards are needed not just for learners but also for trainers and on how training it is imparted. @g_alinier The collective experience & wiseness of ELSO ECMOed taskforce is impressive! Really honoured to have been invited to be part of this. All together we can really have an impact, and improve ECMO patient care through better education
How to provide highly accessible, high quality ECMO education?is online ECMO education the answer??
@EcmoNinja How do you ensure that everyone has equal access to education, not just those at big ECMO centers that have resources to send people to meetings? @JenelleBadulaK web-based didactic education will help extend the reach of standardized education and make in-person simulation sessions able to be shorter (and cheaper!) focusing on hands-on skills. @jkukutschka Online education is a great option for this and will definitely have a greater outreach at a lower cost in a blended training model or for CME. @FOAMecmo How to match free open spreading of ECMO education resources, to make these globally available, with high content quality and economical sustainability? Think the use of (partly) online strategy by ELSO ECMOed experts could be really effective to support spread of standardized high quality/highly accessible also meaning low cost ECMO education. @g_alinier So true that cost is often a barrier to education & training but that is often a false economy! ignorant unskilled uninformed unprepared workforce cost money (in hospital beds through extended patient stays, additional treatment/procedures) & in patients’ lives. Online education needs to be followed up by hands-on face to face activities as ECMO relies also so much on good technical & communication skills to provide optimal care. ELSO and ELSO ECMOed are the key coordinating channels for dissemination! @kshekar01 Agree – the non-technical skills are so important too – other big area is for providers to open up their minds to idea of shared decision making and team work that’s so critical for ECMO. @jkukutschka Absolutely! A blended (online + onsite) model for training ECMO practitioners. @bishoy_zakhary this is a very important challenge without easy solutions. Widespread ELSO endorsement can be a helpful step but ultimately Online Education may be a viable option. @KrKrramanathan Great question. The answer may not be straightforward. Basic ECMO knowledge can be streamlined online or via e-learning; we are striving towards that. However the skill component would be tricky- you can achieve that with experience or only with high fidelity simulation. @kshekar01 We need to change thinking; access to ECMO = access to ECMO for patients + access to ECMO education for providers. What are your thoughts to help to make this happen? @EcmoNinja It will have to be multi-modal. Heavy use of online content that is controlled. Using the hub center to train the spokes/referring centers has generally worked well in my practice. @kshekar01 Great question – the hub and spoke model for ecmo service delivery should also work for education, hope we can use qualitative research tools to study these models of education over time! @ecmocare More webinars. The ELSO courses to be available online, the conference proceedings to be available live as webcast: free up knowledge, involve more participants! @bishoy_zakhary Yes webinars have a great potential for reach and exposure!
@HerxxAU As supposed to ALS – ECMO delivery has regional differences and something which works in Seattle is not practical in Japan @kshekar01 Agree: standardising what we can may provide a good starting point for local providers to work with – we are organising focus groups across all Chapters to understand the local expectations and challenges. @bishoy_zakhary This is true but at the sample time there is a minimal competency level that is across chapters and applicable to all ECMO practitioners. @EcmoNinja Agree: different indications, different patient populations, different technologies. All important factors to consider. What doesn’t work is other mandatory certifications (think ACLS or ATLS) – the training is mandatory for those that need it the least and often doesn’t reach the true target audience. @mamoon Accredited & well thought in situ simulation program development should be a priority, as you tend to miss latent threats in your own working environment. @JenelleBadulaK A certification from an organization like @ELSOOrg may help set a certain standard but content needs to evolve and change with the technology and integrate continued curricular evaluation & meet the needs of the learner. Otherwise risk content stagnation! @kshekar01 Certification is one area where we need a lot of feed back as there are so many models of ecmo care and multidisciplinary provider @bishoy_zakhary The challenge we are facing is the explosive growth in the number of ECMO centers that often outpaces the capability of courses to provide training!
@precordialthump Mastery learning should be a feature of a standardized approach to ECMO education (suggested reading: Cheng A et al. Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2018 open access link https://www.ahajournals.org/doi/10.1161/CIR.0000000000000583). Also, while a standardized ALS type entry course is important, so is ongoing spaced practice to guard against deskilling. Likely to need 6 monthly refreshers. In situ simulation for team training is likely even more important than courses though! Finally, I’d like to see “after action reviews” standardized after ECMO events (clinical debriefing) to maximize learning from real world events and contribute to a culture of learning. @foamecmo Important points! doing ECMO course once is not enough! certification matters but re-certification too… the less you practice/the lowest your ECLS volume, the most you need to run (simulation based/whole team) training & do no forget (online FOAMed?) updates in a moving so fast field. @succenyl impressive work by ELSO ECMOed: thanks for supporting ECMO community. I suggest adding another hashtag for weekly case presentation for open discussion from different aspects and controversies raised! @FOAMecmo Discussing interesting ECMO cases on Socia Media? could be effective to look for expert support/offer alternative viewpoints/diffuse ECMO centers results, providing every precaution is taken to protect patient’s privacy/confidentiality of personal information and image; what about consent? needed/feasible? @KrKrramanathan Difficult cases get discussed at the ELSO ECMOed blog!
@ArpanCh21458537 The help from industry should be there. They have their own mannequins/ simulators. We can take support of that. Guidelines should include the industry participation also. @ECMONinja Industry is limited what they can do in the US because most products used for ECMO don’t carry that FDA designation- they are used off label. @kshekar01 A low cost sim can be locally developed; maybe we need to make this knowledge accessible and support centres with their basic sim program – a sim should hopefully be incorporated into any ECMO program along with wet drills etc. @ecmocare Need support and knowhow to develop a low cost sim. @MooreElizabethA Would there be interest in creating an ECMO simulation “know how” session to a future ELSO conference? @ecmocare There should be definitive guidelines for the trainers as well. The ELSO need to publish more clinical guidelines too. @jkukutschka ELSO provides Train the Trainers courses… Next one will be this march in Barcelona @FOAMecmo Considered to attend to the ELSO ECMOed Train the Trainers course to learn how to educate and train in the ECMO field… experts from all ELSO chapters will be involved! @kshekar01 Every ECMO centre ideally should have one or two trainers who have done the train the trainer course who can then champion local education- it is easy to set up basic simulation and organise basic in-house training @ecmocare Totally agree The train the trainers courses should be more frequent, should be more accessible and affordable. Can ELSO subsidize registration or offer travel grants or any other programme to encourage young minds?
@ecmocare The cost of the ELSO ECMOed courses in each Country or region to vary. Can’t keep same fee structure everywhere. Remember a huge number of participants are perfusionists and nurses. @KrKrramanathan Good suggestion. It is a daunting task as cost of resources vary from country to country @kshekar01 cost and sustainability are important issues – we will have to enable local providers to provide education tailored to local flavour while maintaining quality of education.
About ELSO ECMOed endorsement for ECMO educational initiatives
@ecmocare More centers should be endorsed to conduct the courses. At least one center in every country needs to be endorsed. Larger countries need to have multiple centers. @JenelleBadulak Completely agree! Creating a standardized curriculum that we can distribute and utilize train the trainer courses will enable us to make this standardized curriculum available worldwide. Also essential to this will be web-based didactics #ECMOedPP@kshekar01 I think the process for endorsement is in place and is an important area for ECMOed. @bishoy_zakhary Agree! There is a need for ELSO endorsement of ECMO courses across all the chapters so ECMO practitioners can have easy access to standardized material. @HajiJumana to standardise training, and streamline the ELSO endorsement process, would help if ELSO puts up some pre-endorsement guidelines and prerequisites for newer centres to model their training on the website. @HajiJumana It would help if ELSO puts up some pre endorsement guidelines and prerequisites for newer centres to model their training on the website. This would help to standardise training and streamline the endorsement process. @KrKrramanathan certainly some thing to ponder about! @FOAMecmo Seems ELSO ECMOed advices needed for “young” ECMO centers to adapt/organize ECLS education! meanwhile , consider checking the ELSO ECMO specialists education & training guidelines, open access and the the ELSO guidelines for ECMO centers, open access. @ECMOed For all centers/groups interested in or willing to ask for ELSO ECMOed endorsement, to ensure potential learners ELSO standard is met for your ECMO courses, simulation-based courses, workshops, check our dedicated post
Learning from other ECMO education experiences
@ArpanCh21458537 We have to think for the awareness educations to the General practitioners. They should be properly educated also regarding the timing of referral. They are the backbones of Indian Healthcare system. Short courses on ECMO can be designed for them also. @bishoy_zakhary This is an important suggestion that can have a significant impact on ECMO outcomes. ECMO Workshops targeting the Non-ECMO Practitioner is a great idea. Do you have this? @ArpanCh21458537 I am doing regular awareness campaigns to the various suburbs and districts. A gathering of local practitioners are interacting with us. Basic discussions on ECMO and its success stories are shared with them for early referrals. Sometimes We are engaging survivors. @bishoy_zakhary This is a good effort – especially with involvement from prior patients and families! @MooreElizabethA this could be an excellent idea to engage survivors. We have much to learn of their experiences post ECMO! @gracebichara My previous program in Brasil has a 1 day course for pediatric intensivist 2-3 times a year. We have amazing feedback! We focus on indications, #ECMO basics, outcomes, etc. @ecmocare At ECMO Kolkata we conduct awareness programmes for GPs, do basic training of residents, fellows and attendings at Med schools of the region. They participate more in case based discussion. Interested young minds come over to witness live cases. ECMO isn’t part of basic clinical curriculum in Med Schools yet. We can make basic #ECMO knowledge compulsory in undergrads and basic proficiency in ECMO in Residencies and fellowships (pediatrics, anesthesia, medicine, pulmonology, critical care, cardiac surgery). I fully agree to fact that ECMO education should be standardised and supported. The ECMOedPP is the right initiative. But we need to further structure the initiative. @bishoy_zakhary How would you envision structuring the initiative? @ecmocare The ESOI ECMO Society of India fellowship structure can be followed. There online webinars, log books, thesis, compulsary attendance of one comprehensive #ECMO workshop and a conference, 15 days training in an ECMO center, live case videos and discussions @kshekar01 This can be well embedded in a hub abs spoke model @ecmocare Can we have a definitine course like the ACLS/BLS model as well have the same literature circulated in every #ECMO workshop? @kshekar01 One possible model as it’s a lot of effort to design and run courses and it’s wasted energy , time and money for everyone to write their own content @bishoy_zakhary We are trying to implement something similar to the BLS/ACLS model by using ELSO Course Endorsement to increase the reach and impact of the ECMO curriculum worldwide. What are your thought on the effectiveness? @kshekar01 This is something we can test in the research domain. @KrKrramanathan interesting thought. We are trying streamlining this aspect at ELSO ECMOed. What should be the content of the course, duration of the course, how to assess participants and how to certify? We are getting there.
@HajiJumana I’m sharing the results of an ongoing survey I am conducting in India. Lack of training, lack of physician and patient awareness about ECMO as treatment option pretty in India, and lack of ELSO-registered centers, observed. @kshekar01 Great work: there is huge opportunity here for ELSO ECMOed, SWAAC ELSO, APELSO to collaborate with the ECMO community in India and work on many of these identified areas.
(Most) active participants & their twitter handles(alphabetical order)
Ahmed Rabie @succenyl Arpan Chakraborty @ArpanCh21458537 Bishoy Zakhary @bishoy_zakhary Chris Nickson @precordialthump Dipanjan Chatterjee @ecmocare Elizabeth A. Moore @mooreelizabetha Grace Bichara @Gracebichara Guillaume Alinier @g_alinier Hergen Buscher @HerxxAU Jeannie Kukutschka @jkukutschka Jenelle Badulak @JenelleBadulak Jumana Haji @HajiJumana Kiran Shekar @kshekar01 Mamoon @mamoon Ramanathan KR @KrKrramanathan Rodrigo Diaz @EcmoDiaz Shaun Thompson @slthomps12 Velia Antonini @FOAMecmo
Global ECMO education & agenda for the future: read the ELSO ECMOed Taskforce position paper on Critical Care Medicine at http://bit.ly/ECMOedpospaper & prepare your questions/comments! a dedicated twitter chat under the hashtag #ECMOedPP will be held on Jan 9 2020, with all the ECMOed Workgroups representatives and members! at 9.00 -10.00 pm CST 10.00 – 11.00 pm EST 7.00 – 8.00 pm PST 4.00 – 5.00 am CET/3.00 – 4.00 am UTC/GMT (Jan 10) 2.00 – 3.00 pm AEDT (Jan 10) etc…
Are you inexperienced with twitter & twitter chats?? in the picture some advices… do not forget to mention ELSO @ECMOed & add the official hashtag #ECMOedPP in all your replies, questions, comments!!
First authors Bishoy Zakhary @bishoy_zakhary & Kiran Shekar @kshekar01 Chat moderator Velia Antonini @foamecmo Critical Care Medicine twitter account @CritCareMed
Here twitter handles of ECMOed members (alphabetical order!) Ait Hssain: @AiHssain Assad Sassine: @Assad_sassine Bishoy Zakhary: @bishoy_zakhary Cara Agerstrand: @caraagerstrand Elizabeth A. Moore: @MooreElizabethA Grace Bichara: @gracebichara Guillaume Alinier: @g_alinier Ibrahim Fawzy Hassan: @IbrahimFawzyHa1 Jae-Seung JUNG: @JaeSeungJUNG1 Jayne Sheldrake: @jaynesheldrake Jenelle Badulak: @jenellebadulak Jeannie Kukutschka @jkukutschka Jose Alfonso Rubio: @joseAlfonsrubio Kiran Shekar: @kshekar01 KR Ramanathan: @KrKrramanathan Leen Vercaemst: @VercaemstLeen Leonardo Salazar: @demotucordis Lindsay Johnston: @lincjohnston Mark Davidson: @MarkGlasgowPICU Mark Ogino: @OginoMark Peter Roeleveld: @pproeleveld Simon Finney: @Simon_Finney Velia Antonini: @FOAMecmo Vitor Barzilai: @barzilaivs Wallace Ngai: @wallacengai