oa Road transport on ECMO: The key elements

Aim: Extracorporeal membrane oxygenation (ECMO) may be lifesaving for patients with severe cardiac/respiratory failure. Typically, ECMO is provided by specialized or regional centers, and patients may have to be transported by road or air ambulance. Herein, we will review the essential requirements for road transport of adult ECMO patients, also known as “mobile ECMO”. Background: Interfacility transport on ECMO is defined as “primary” where the ECMO team cannulates the patient at the referring facility and subsequently transports the patient to the ECMO center. In “secondary” transport, the patient is already on ECMO support at the referring facility but a need to transfer to another center has arisen.¹ Patient safety is the overriding priority in any mode of transport; however, in primary transports there is also a need to expedite the arrival of the ECMO team.¹

Interhospital transfer of critically ill patients on multi-modal organ support can be hazardous and adherence to protocols is recommended.^2,3 ECMO patients represent the extreme condition of pathophysiology and therefore meticulous planning, competent personnel, checklists, and attention to details are necessary for ensuring patient safety. Mobile ECMO team: The team composition and specific roles vary considerably between centers. There is no consensus on the exact composition or number of the members. An ECMO nurse or physician can be trained to prime the circuit. Some centers do not include a respiratory therapist (RT) in the mobile ECMO team. ELSO team composition includes a cannulating physician and a surgical assistant (to perform cannulation), an ECMO physician, and specialist in addition to a RT.

Our model in Qatar is composed of two ECMO consultants, an ECMO nurse, a perfusionist, a RT, and a Critical Care Paramedic.

Whatever the configuration is, the mobile ECMO team should have the necessary skills and competency to safely initiate, maintain, and trouble-shoot any ECMO or clinical emergency. The team has to be able to manage the critically ill patient on ECMO, medications, ventilator, and invasive monitoring. Due to lack of back up, the mobile team must have all necessary skills for the mission.¹ECMO transport vehicle: It should provide adequate space to accommodate the patient, stretcher, and all attached equipment including ECMO console. Appropriate electric, oxygen, and gas supply, suction, climate control, and lighting are required.^4,5 Ground transport is recommended for distances up to 400 km,¹ generally using a custom-made mobile ECMO unit (Fig. 1).Figure 1.  HMC Mobile ECMO team (with permission). Note the 360° access, space, adequate lighting, and ancillary equipment within the ambulance.

Equipment: The use of checklists is recommended.¹ Mobile ECMO team should be self-sufficient and ensure adequate supply of all ECMO-specific equipment. Limited space during transportation mandates careful selection of transport equipment without exposing the patient or team to risk. The ECMO team must be familiar with equipment and items in sealed pre-packs help expedite the team dispatch.⁴Medications: The same medications used for in-house ECMO are typically used during transport. The team must ensure adequate supply of medication for the duration of the mission and anticipate possible delays. Equipment and medication redundancy, immediate availability of emergency medications, and use of a medication list further enhance patient safety.^1,4Conclusion: Adequately trained personnel, appropriate vehicle, equipment, and medication in addition to meticulous planning are key elements for safe ECMO transport.