(DIVISION OF EXTRA CORPOREAL LIFE SUPPORT, DEPARTMENT OF CRITICAL CARE MEDICINE, FMRI GURGAON):
Since the program took off in December 2014 when we successfully treated a patient of resistant septic shock with ECMO, we have used the modality in 25 patients with varying diagnosis.
Veno Arterial (VA) ECMO
This form of ECMO has been instituted in 3 cases of Aluminium Phosphide poisoning, a cardiotoxic poison with successful result in 2 of them. One of the survivor was put on ECMO during ongoing CPR (E-CPR).
VA ECMO has also been used in cases of Myocardial infarction, Septic shock with myocardial dysfunction, with results comparable to international centers.
In India, the need for rapid and effective management of poisonings is an essential requirement at all levels. Toxicology has always been handicapped by the absence of effective antidotes leading to high mortality in some poisons like Aluminium Phosphide (Celphos) which is cheap and easily available as rat poison but has a mortality approaching 99%. This modality has generated interest in these cases as now we feel that this mortality can be reduced greatly.
E-CPR was done in two young patient including the one mentioned above.
This form of Extra Corporeal Life Support (ECLS) is becoming essentially important in the current medical scenario but India is seriously lagging behind. This has even become part of the new Advanced Cardiac Life Support (ACLS) Guidelines 2015 by American Heart Association (AHA). This area will be our major area of interest over time to try and save young lives.
Veno Venous (VV) ECMO
This form of ECMO has been instituted in a much wider array of cases.
Primary Acute Respiratory Distress Syndrome (ARDS) like in Viral Pneumonia (eg H1N1) , Acute Interstitial Pneumonia (AIP), Alveolar Hemorrhage, MRSA Pneumonia, , Transfusion Related Acute Lung Injury (TRALI) and Secondary ARDS like Severe Acute Pancreatitis, Acute Liver failure and auto immune disorders; with encouraging results, comparable to international standards.
ARDS is a formidable adversary for intensivists worldwide. With protocolisation of ventilator and ICU care, mortality due to this syndrome declined worldwide but still remains a major cause of death due to respiratory causes. The modality of ECMO gives us hope of further bringing down the mortality rate especially in resistant cases when earlier giving up hope was the only way ahead.
We will regularly update this segment about the fresh cases and challenges we face.
Salient Features Of The ECMO programme at Fortis Memorial Research Institute
Experience of both VA / VV ECMO.
The team associated with the Extra Corporeal Membrane Oxygenation (ECMO) program has the experience of carrying out both forms of ECMO, be it Veno Arterial (VA) or Veno Arterial (VV). Till now, the team has done almost equal number of both modalities and is well versed with the intricacies of both.
Documented successful usage and outcomes.
We are in the process of sharing our data with Extracorporeal Life Support Organization (ELSO), the umbrella organization for ECMO worldwide. The data sharing will be both ways between both ELSO and us, we being members of ELSO.
Survival rates comparable with international standards.
The team success rates have been comparable to international centers, both for VA and VV ECMO. With continued improvement in skills and training at international centers, the team aspires to further improve upon its successes. It will be helped on its way by the guidance of ELSO and international experts who are part of our Annual Conference also.
One of the largest VA ECMO center in the North India.
VA ECMO in medical ICUs is uncommon and technically difficult. The team has the experience of carrying out VA ECMO in a great number and a wide variety of cases, one of the largest numbers in North India at least.
The team has also handled equal number of VV and some VVV ECMO also , wherever the situation demands.
Dedicated doctors / nursing team.
The team has a dedicated mix of doctors trained in ECMO both in India and University Hospital, Regensburg, Germany; a center with a large and high quality ECMO programme. It also has ECMO trained nurses and perfusionists with a robust cardiothoracic backup to manage any contingency at any time. All of them are on call 24X7. The ICU also has beds dedicated to ECMO.
The ECMO team is backed up by an experienced team of multispecialty Critical Care Doctors and Nurses because managing an ECMO patient is not just about initiating ECMO but also taking care of his critical needs right upto the point he is discharged from the unit.
All of the above is aimed to initiate ECMO within the shortest possible time, at anytime of the day or night; and to work towards a favorable outcome with minimum adverse events.
ECMO usage in conditions varying from oncology to septic shock.
Till this point of time, the team has handled a wide array of cases requiring VA or VV ECMO. The first case was a septic shock with ARDS which was handled successfully. Since then the team has handled cases varying in nature and challenges. From cardiac dysfunction due to toxins, Myocardial Infarction and Viral Myocarditis to that in sepsis. And from ARDS due to Community acquired pneumonias to that due to autoimmune diseases and Acute Interstitial Pneumonias. The team has also handled cases in oncology. E-CPR has also been one twice.
ECMO retrievals and “Doorstep” ECMO in Delhi NCR
This provision is for patients in those centers where ECMO is not available. Depending upon the condition of the patient, they can either be placed on ECMO there itself and then “retrieved” back to our center or managed there only if too unstable “at the doorstep”.
Our multidisciplinary team of critical care experts offers protocolised care of international standards with promptness and compassion. These physicians are acknowledged nationally and internationally for their clinical acumen and research. They have successfully incorporated IT tools of Electronic Medical Records (EMR) which auto-charts all the vital patient parameters onto an online database. This data is accessible to all physicians making it standardised and transparent, also cutting down on the response time. It has greatly reduced the paperwork for the nurses so they can be at the patient side at all times.
The team has achieved expertise in Extra Corporeal Membrane Oxygenation (ECMO), an amalgamation of technology and medicine, which takes life support to the next level. This modality, available in very limited centres in India, has helped the team save lives on several occasions when everything else has failed.
Thus our latest technological advancements helps us choose the best possible care for our patients and makes us the most sought after centre for Critical Care Medicine and ECMO in the region.
- Multispecialty Critical Care Unit (CCU)
- High Frequency Oscillatory Ventilator (HFOV)
- Nitric Oxide delivery system
- Haemodialysis/CRRT and MARS machines
- Extra Corporeal Membrane Oxygenation (ECMO) machines
- Centralised Electronic Medical Records (EMR)
- Advanced Hemodynamic Monitoring Systems (EV1000 and Volume View)