ECMO - jikeimasuika.jp

1 ECMO ICU 2017/11/7 International Journal of Surgery2016 33, 213-217 First successful ECLS patient. The first successful extracorporeal life support patient, treated by J. Donald Hill using the Bramsonoxygenator (foreground), Santa Barbara, 1971. The ECLS indication was shock lung due to polytraumasucceeding a motorcycle crash. The 24-year-old man was supported for 75 h. tSurvivedELSO Registry 2012-20172012 AdultTotalPatientsSurvivedECLS%Survived DC Transfer%Respiratory2892182363%157254%Ca rdiac1896100353%73339%ECPR64824338%18328 %2017 AdultTotalPatientsSurvivedECLS%Survived DC Transfer%Respiratory13712917466%804058%C ardiac12566718157%522241%ECPR3995157239% 114428%ECLS Registry Report 2012-2017 2042 65 2083 65 50 25 75% ECLS Intensive Care Med (2017) 43:1510 1511 ECMO Intensive Care Med. 2016 May;42(5):889-96.

2 ECMO VA-ECMO Am J RespirCritCare Med 190:488 496 ECMO QOL ECMO Do we want to continue ECMO if recovery with any quality of life is unlikely or perhaps impossible? Intensive Care Med (2017) 43:1510 1511A Survey of Physicians' Attitudes toward Decision-Making Authority for Initiating and Withdrawing VA-ECMO: Results and Ethical Implications for Shared Decision Withdrawing J Clin Winter;27(4):281-289 DESIGN A survey of resident/fellow physicians and internal medicine attendings SETTING academic medical center,May to August 2013. 24 VA-ECMO 179 internal medicine attendings 52%, resident/fellow 48% 32% VE-ECMO 56% VA-ECMO ECMO VA-ECMO , p= VA-ECMO 50%, p= ECMO VA-ECMO ECMO Intensive Care Med (2017) 43:1510 1511 ECMO Who decides?

3 When ECMO no longer seems to provide hope of recovery, should the decision to discontinue ECMO be a shared decision, or should clinicians alone decide when to stop? The burden of the decision, in the setting of great medical complexity, may overwhelm the very people we are trying to help; their experience of the decision-making process may be laced with feelings of profound guilt, anger or fear. Intensive Care Med (2017) 43:1510 1511 What Paradigm Might Be Best? An ethically preferable strategy involves keeping patients and families always meaningfully informed. futile The very word futile may have negative connotations for family members. It is intended to convey boundaries and the rationale for these boundaries, but it may assault what family members hope and feel.

4 Its use may seem high-handed to families. Perhaps in clinical care, regardless of the law, it should be jettisoned. Close guidance of the relatives VA-ECMO Intensive Care Med (2017) 43:1510 1511 Intensive Care Med (2017) 43:1510 1511 Preventive ethics interdisciplinary care mandatory ethics consultation policy Intensive Care Med (2017) 43.

5 1510 1511 Preventive ethics ECMO ECMO -Daily interdisciplinary rounds-Intensive Care Med (2017) 43:1510 1511 Preventive ethics ECMO ECMO ACP -Advance Care Planning (ACP)-Intensive Care Med (2017) 43:1510 1511 SilveiraMJ, NEJM 2011 ACP Preventive ethics -A mandatory ethics consultation policy -ECMO ECMO Intensive Care Med (2017) 43:1510 1511 JOURNAL OF PALLIATIVE MEDICINE Volume 16, Number 5, 2013 SCH ECLS The Pediatric Advanced Care Team (PACT) Design: Retrospective Setting: SCH, May 2009 ~December 2010 Patients: ECLS Methods: PAC T Results.

6 59 ECMO Low PAC T Medium High The Pediatric Advanced Care Team (PACT) PAC T PAC T Care planning meetings Decision-making tool Patient and family support during treatmentSeattle Children s Hospital Low High ECMO JOURNAL OF PALLIATIVE MEDICINE Volume 16, Number 5, 2013 Support by spiritual and palliative care providers Intensive Care Med (2017) 43:1510 1511 Design:Single-center prospective cohort studySetting:Tertiary care medical center, surgical ICU, 2014 3 2015 5 Patients:18 6 25 Methods: VAS Results: VAS 64 44 Ann Am ThoracSoc.

7 2016 Aug;13(8):1333-42 Need systematic research to better understand the demands of patients, relatives, and medical staff, and to propose solutions for potentially complex ethical dilemmas. ECMO ECMO Recommendations for Ethical ECMO Practices J CardiothoracVascAnesth29:229 233 ECMO ECMO Informed-consent J CardiothoracVascAnesth29:229 233 ECMO ECMO ECMO J CardiothoracVascAnesth29:229 233 VA-ECMO VV-ECMO - ECMO ECMO end-of-life J CardiothoracVascAnesth29:229 233 Managing impasse.

8 ECMO J CardiothoracVascAnesth29:229 233 ECMO ( ) ECLS ECLS Extracorporeal Life Support Organization (ELSO)General Guidelines for all ECLS Cases Version November 2013 / ECMO ECMO ECMO ACP ECMO ECMO ECMO ECMO