This article is reprinted from China News Weekly
By penny
At present, it is a time when many hospitals are eager to launch ECMO
The problem of personnel training and standardization is imminent
In the rescue of severe patients with new crown pneumonia, ECMO has been used for many times.
Late on the night of February 6, the news that Li Wenliang, an ophthalmologist in Wuhan Central Hospital, was in critical condition affected thousands of people. In the process of rescuing him, ECMO was used all the time.
ECMO (extracorporeal membrane oxygenation, also known as ye Ke membrane) is suitable for critical patients with cardiopulmonary function problems, such as respiratory failure, cardiac arrest, etc
Situation.
Because ECMO can assist breathing and blood circulation, it is also called life support technology and regarded as the "ultimate weapon" in intensive care unit (ICU).
As a result, the technology is also known as the "ultimate weapon" in the I intensive care unit (ICU)——
ECMO, the ultimate weapon in ICU
Our reporter / Peng Danni
Issued on June 3, 2019, issue 901 of China News Weekly
The boundary between life and death is gradually being redefined by medical technology, such as ECMO. In the past, some diseases, such as explosive viral myocarditis, were judged to be almost incurable. Now if an experienced ECMO team is encountered, it has a great chance of survival. In the past, when the heart stopped beating and cardiopulmonary resuscitation reached a certain period of time, it is declared dead. Now, this is the time for ECMO to fight for life. When the ECG has been in a straight line, it is able to turn the tide It happens from time to time.
In ICU, various organ support devices support one or more patients with organ failure. ECMO is known as the ultimate means of life support, the last warrior of critical care, with many honors, and is generally considered as the highest level of the ability of a hospital and a region to treat critical patients.
A lot of reports related to ECMO cases often have some exciting flavor, because the title is always accompanied by the word "come back from the dead". In a ted speech in 2013, Ke Wenzhe, mayor of Taipei and surgeon of Taida hospital, Li Tui's ECMO, mentioned that a 56 year old man had his heart trimmed again and again due to bacterial infection, and finally had no heart. ECMO provided circulation support for 16 days, and finally recovered after heart transplantation.
In less than 20 years since its introduction into China, the technology, known as artificial membrane lung, has developed rapidly and even become a technological highland for some hospitals to compete for. Liu Xiaojun, director of ICU of the Second Affiliated Hospital of Zhengzhou University, said, "in the past, when comparing hospitals with hospitals, I would ask you if you could carry out heart surgery?"? How many can be done in a year? Can there be more than 100 cases? Now the hospital to hospital ratio will ask you, can we carry out ECMO? How many can be done in a year? "
ECMO's past life and present life
ECMO (extracorporeal membrane oxygenation) is also transliterated as ye Ke membrane in Taiwan and other regions. It is suitable for critical patients with cardiopulmonary function problems, such as acute cardiogenic shock, respiratory failure, cardiac arrest and so on. Its working principle is not difficult to understand: lead the venous blood out of the body, let the blood combine with oxygen, and then pump it back into the body. According to different blood return routes, ECMO can be divided into two modes: vv (vein to vein) and VA (vein to artery): the former assists breathing, while the latter pumps blood back to the artery after oxygenation, bypassing the heart and lungs, which makes these two organs, especially when the heart cannot work normally, ECMO can assist breathing and blood circulation, so ECMO is also called life support technology Surgery.
For patients using ECMO, taking VA mode as an example, a catheter is usually inserted into the femoral vein at the thickest thigh root to draw out the venous blood, which is then pumped back to the femoral artery on the other side after the oxygenation and heating of silicone rubber membrane. Compared with traditional cardiopulmonary bypass, ECMO does not need thoracotomy and intubation on the aorta, and it is a closed loop. The dosage of anticoagulant is small, the damage of blood circulation cells is less, and the cost is lower, so it can be used for a long time.
This seemingly simple technical equipment has experienced more than 60 years of technological evolution before it is mature. The United States has invested heavily in ECMO since the 1970s, but the repeatability of the successful treatment is not high. Only in neonatal respiratory failure, the supporting effect is good, and ECMO was not good. With the continuous progress of technology and equipment, as well as the continuous efforts of industry associations in training and promotion, ECMO made a breakthrough and began to be widely promoted in the millennium.
In 2002, Li binfei, deputy director of anesthesiology department and director of ECMO Research Office of Zhongshan People's Hospital in Guangdong Province, successfully treated a patient with severe myocarditis by using ECMO technology, which is recognized as the first case of planned development of this technology in mainland China.
He specializes in heart transplantation, critical illness and first aid. He is a pioneer in introducing ECMO technology in Taiwan, and has great contributions to the introduction of ECMO in the mainland. When he ran for mayor of Taipei in 2014, he mentioned that he had been to the mainland 18 times to guide the application of ECMO. Li binfei told China News Weekly that at that time, Taiwan's ECMO technology was leading in Asia. He went to Taiwan to study, organized several ECMO national conferences and invited Ke Wenzhe to give lectures.
Hou Xiaotong, director of critical cardiac surgery of Beijing Anzhen Hospital Affiliated to Capital Medical University, was the first group of students to study in Zhongshan People's hospital. At that time, Ke Wenzhe held a one or two-day training course in the hospital. Around 2004, as ECMO began to be carried out in a few large hospitals with famous cardiology departments in China, such as Beijing Fuwai Hospital and Beijing Anzhen Hospital, the number of ECMO cases began to increase gradually. Hou Xiaotong said that at the beginning, ECMO treatment had to fight against various complications, with a high mortality rate. He had encountered 14 consecutive patients died of infection.
The global outbreak of H1N1 H1N1 in 2009 and the avian influenza h7n9 epidemic in 2013 are two time nodes for ECMO to receive attention in China. During H1N1, an article published in the Journal of the American Medical Association showed that the mortality of critically ill patients could be reduced by 50% if they were transferred to a center with ECMO support as soon as possible. In that year, Hou Xiaotong's ECMO team went to Beijing Union Medical College Hospital, Beijing Chaoyang Hospital and other institutions for treatment, of which 9 critically ill patients were rescued back 5. In 2013, the national health and Family Planning Commission issued the diagnosis and treatment plan for human infection with h7n9 avian influenza (version 1, 2013), which included ECMO in the treatment of respiratory support. When the traditional ventilator is unable to do anything, ECMO is recommended.
In the past 10 years, ECMO has made rapid progress in China, with the number of cases jumping from 23 in 2004 to 1234 in 2016. In 2017, the professional committee of extracorporeal life support of Chinese medical doctor association was established, with Hou Xiaotong as the chairman. According to articles published in the Chinese medical journal in 2018 by him and several scholars, in 2017, 233 hospitals in China (except Taiwan) carried out 2826 ECMO cases, an increase of 129% year-on-year, and the number of medical institutions also increased by 64%. In the same year, the total number of ECMO cases registered in international elso (in vitro life support organization) was 9330.
Behind the great leap forward
ECMO is a highly demanding technology for operators. In the way of simulating the heart and lung, if the blood of four or five liters is drawn out and then beaten back, any mistake or mistake in the process may cause the patient to die directly.
The number of cases of EKM in the Second Affiliated Hospital of Zhengzhou University was 91 in 2018, ranking the top 10 in China. Liu Xiaojun, director of the Department, told China News Weekly that ECMO can be comparable to the nuclear weapons in the war, with great lethality. For example, how to avoid the related infection caused by catheter in the body, how to use anticoagulant reasonably to ensure that there is no thrombosis and bleeding in the blood circulation, how to control the daily blood flow and so on, all test the ability and experience of medical personnel.
Li binfei pointed out that,
The characteristics of ECMO are not the advanced nature of the equipment, but the people who use it.
"It's like the same gun. Everyone can aim at different positions. For patients, it's very different which team to meet. " Therefore, like the ICU, the cultivation and standardization of talents has become the top priority of ECMO technology promoters.
At present, the training of ECMO is mainly the spontaneous behavior in this field, for example, ECMO carries out the most famous hospitals to receive training personnel on a regular basis, the association promotes the exchange of practitioners in the form of holding meetings, writes standard guidelines such as the consensus of experts on the assistance of adult extracorporeal membrane oxygenation circulation, and members of the society provide personnel training in the form of lectures all over the country. Training at the national level is still blank.
In terms of economic benefits, ECMO is not a good business. In fact, it is a loss business for most hospitals. In Guangdong Province, for example, the starting cost of ECMO is about 50000 yuan, 130 yuan per hour when it is used, and nearly 100000 yuan a week. It seems very expensive, but at the same time, the cost is relatively high. Because patients using ECMO need close monitoring by multiple medical staff, the hospital needs to pay a lot of labor cost. The price of one ECMO is more than 1 million yuan, and the depreciation cost is also high Quite high. In contrast, a small gastroenteroscope operation costs only a few hundred yuan, but it can be done one or two hundred a day. The economic benefits are far better than the seemingly expensive ECMO. Hospitals using ECMO in Beijing are "even worse" - they don't charge for transportation and transfer, only charge for the first start-up, as well as 500 yuan per day for consumables.
Although it is not cost-effective economically, ECMO is considered to be the pyramid of modern medical technology system. In order to improve the academic status of hospitals, hospital brand and other factors, many domestic hospitals are eager to carry out ECMO.
"A lot of hospitals want to occupy this technological highland, otherwise it will appear to be inferior."
Said Hou Xiaotong.
A 16-year-old sudden death boy was rescued by ECMO in a hospital in Guangzhou. Picture / visual China
Hou Xiaotong found that even some county hospitals have such "ambitions". But the problem is that ECMO has high requirements for supporting facilities. For example, it should have a strong enough ICU to provide patients with close monitoring and necessary support for other organ failure, and other supporting departments that can timely treat the primary disease, such as cardiac surgery, cardiology, etc. Therefore,
What kind of hospital can carry out ECMO should be limited.
It has been pointed out in some literatures that the survival rate of 20-25 cases with annual number of auxiliary cases in ECMO center is significantly higher than that in centers with less than 10 auxiliary cases. According to China's statistics in 2017, the number of ECMO centers with less than 5 auxiliary cases per year accounts for 47% of the total number of ECMO centers in China. According to Xi Xiuming, director of intensive care unit of Renaissance Hospital Affiliated to Capital Medical University, there are only a few ECMO centers in Europe, while those in China are blooming everywhere, which is not conducive to experience accumulation and technology maturity. In his opinion, ECMO is a niche technology after all. For the ICU, if the ventilator is widely used, it is not well mastered, let alone ECMO.
There are also ECMO competitions not only among hospitals, but also in hospitals, including emergency department, respiratory department, comprehensive ICU, cardiology department and even cardiology department. However, Hou Xiaotong pointed out that ECMO is a rare treatment measure after all. At present, there are only more than 10 hospitals with more than 50 cases in one year. If we do this, each team will have fewer cases and the learning curve will be longer. He thinks that the model like the First Affiliated Hospital of Zhengzhou University can be used for reference: to release ECMO