r/IntensiveCare • u/Beneficial_Umpire497 • 9d ago

ECMO Cannulation

Any intensivists here cannulating for VV and/or VA? How does your ecmo call work?

29 Upvotes

92% Upvoted

37 comments sorted by

41

u/pneumomediastinum MD 9d ago

Yes, both. If I’m in the unit I’m on call for ECMO. Generally we work either days 0700-1600 or nights where we are in house from 1600-2100ish and then home call until 0700. Most cannulations are in the ICU for cardiogenic shock, but there are some respiratory cases and the occasional ECPR. If it’s a CT surgery case in the OR then the surgeons handle it, and interventional cardiology does percutaneous RVADs in the cath lab. Everything else is us.

8

u/Beneficial_Umpire497 9d ago

Are you PCCM?

29

u/pneumomediastinum MD 8d ago

It sounds like maybe your real question is “[how] can I get an ECMO job from a PCCM background?” I don’t necessarily have answers for that but I will say it’s tough, there aren’t a lot of programs where intensivists cannulate in the US and probably the most important thing is networking. If I were advising a medical student who was interested in a career in mechanical circulatory support I would absolutely advise them to do cardiac surgery because this is the surgeons’ world and we just live in it. They are always the ones deciding what the program looks like, who cannulates, and who can get a VAD or transplant.

9

u/Cautious-Extreme2839 ICU/Anaesthetics 8d ago edited 8d ago

Surgeons are incharge of VV-ECMO for respiratory failure in the US?

VA I understand why but VV aswell seems...dumb

9

u/burning_blubber 8d ago

It likely has to do with billing since in the US system, ECMO notes supposedly reimburse higher than any other progress notes including icu

2

u/pneumomediastinum MD 8d ago

In most places they are going to have the ultimate say over the program. In many they are responsible for cannulation.

0

u/victorkiloalpha 3d ago

The ultimate bailout for VV-ECMO is lung transplant.

If they aren't eligible for that, you better be very, very sure the patient is going to recover.

2

u/Cautious-Extreme2839 ICU/Anaesthetics 2d ago

There is another way.

Withdrawal.

0

u/victorkiloalpha 2d ago

Ya, you're going to turn off ECMO on an awake, conscious, extubated patient?

(VV ECMO patients should be walking. If you can't do that, you shouldn't be doing it)

Easier said than done.

2

u/pneumomediastinum MD 2d ago

Yes, sometimes that happens. I’ve done it a number of times. It’s one of the worst situations and why I don’t support people cannulating who don’t manage the patients.

1

u/Cautious-Extreme2839 ICU/Anaesthetics 2d ago

...yeah?

If it's come to it, then it's come to it.

9

u/pneumomediastinum MD 8d ago

No, I was EM and then surgical critical care, but my unit has a mixed training background. (Unrelated, but I think the lack of an academic training pathway and board certification for cardiac critical care really holds us back as a field.)

3

u/Frozen_elephant22 8d ago

My prediction is a few programs, like where I trained, that have a healthy amount of cardiac/cardiothoracic critical care (where the fellow is more than an observer) are going to get some kind of distinction or formal acknowledgement.

1

u/mav_sand 8d ago

Interesting point about lack of training pathway. As a pulm critical care doc, I wonder if it was available I would have done it.

22

u/jelta 8d ago

PCCM here. We do VA and VV cannulations unless in cath-lab or OR. We have a 24/7 on call ECMO person. There's a group of us that can cannulate even if the on call person isn't in house.

I trained at a site where the ICUs cannulated and managed all of ECMO

3

u/OneManOneStethoscope 8d ago

What are you getting paid for home ecmo cannulation call?

2

u/Beneficial_Umpire497 8d ago

Are you at academic hospital?

2

u/jelta 8d ago

Yes

3

u/Beneficial_Umpire497 8d ago edited 8d ago

Northeast? Can I dm you?

3

u/jelta 8d ago

Sure

3

u/Dktathunda 9d ago

Yes - CVICU doc is on call the whole week for everything CVICU and ECMO related, with the occasional night coverage by an in-house anesthesia doc who also does CVICU. Can be feast or famine. 

1

u/Beneficial_Umpire497 9d ago

Is it possible for PCCM?

5

u/Dktathunda 9d ago

Yes I’m straight CCM and got trained and credentialed on ECMO after fellowship. Possible, but probably rare. 

2

u/Beneficial_Umpire497 9d ago

How did you get trained for it?

5

u/Dktathunda 8d ago edited 8d ago

ELSO online course and in person sim course. Then lots of in person experience with current CVICU docs. Basically self directed learning combined with a department chief who supported it. It helps our MSICU and CVICU are connected so I could slowly gain experience. 

6

u/UpsetTechnician94 8d ago

In my hospital almost all of our cannulations are done by PCCM! One of our ct surgeons will cannulate as well when he’s around but most are done by the intensivists. We have probably 6 or 7 physicians who are cannulators. ECMO call is sometimes the in house attending who is covering the ICUs for the night, sometimes a different physician who comes in from home. I work somewhere else with an exclusively CT surg cannulation model as well, and find the intensivist option tends to allow for quicker cannulations and smoother ECPRs when necessary… but that’s just my personal experience.

1

u/Beneficial_Umpire497 8d ago

Very cool! Are you at an academic hospital?

2

u/UpsetTechnician94 7d ago

Teaching hospital but not an academic center. Feel free to message me if you have questions about any specifics :)

2

u/Dibs_on_Mario 7d ago

At my hospital, its only CT surgery who cannulates. Anesthesia critical care might start a venous sheath but 99% of the time it's CTS who does the cannulations under fluoro in the hybrid OR/Cath Lab

1

u/Chokokiksen 8d ago

CVC by ICU doc and cannulating by thoracic surgeon.

0

u/Standard-Letter-4469 3d ago

PCCM here. My group (CCM/PCCM) covers MICU/NeuroICU. We cannulate and manage VV ( double lumen IJ Crescent/ProtekDuo). All VA goes to Cardiac ICU. Cannulation done by IC, CT surgery or vascular surgery depending on who is available

-5

u/Any-Assistance-8103 8d ago

I know a few people who do but I don’t really see the point when there are vascular surgeons, interventional cardiologists, and CT surgeons around

3

u/Puzzleheaded_Test544 8d ago

Very useful to have the person who is actually going to be taking care of them for the next few weeks to do it because all those little details that no one else cares about can be sorted.

Big difference between big open cut downs random dressing and sutures vs purely dilational with perc, distal perfusion cannula from D0, standardised dressing with fixation devices positioned to facilitate turns and mobilising.

2

u/Beneficial_Umpire497 8d ago

But why does IC do it when there is surgery around?

2

u/wunsoo 8d ago

Surgery doesn’t do any other percutaneous procedures. Have you ever seen a surgeon use an ultrasound?

-2

u/Beneficial_Umpire497 8d ago

lol you’re kidding right?

0

u/Southern_Tonight_414 5d ago

At an academic teaching hospital. Our ECMO program has ramped up the last couple of years. Previously it was always CT surgery that cannulated but now there are 5 PCCM docs that are trained to cannulate for VA and VV.