WellSpan Team Takes Innovative Approach to Help New Mom Recover from Postpartum Complications

Wednesday, February 10, 2021

For the last 10 years, WellSpan Health has been utilizing extracorporeal membrane oxygenation (ECMO), a piece of technology that can help patients whose heart or lungs are not functioning properly. It has been of particular use during the COVID-19 pandemic. And in 2020, it was used in a way it had never been used before at a WellSpan hospital.

“This was the first postpartum patient we have seen who needed to go on ECMO,” says Dmitriy Zubkus, MD, pulmonologist with WellSpan Health. “Postpartum patients don’t normally have cardiac arrests. Ninety-nine out of 100 postpartum patients go home, they enjoy their lives, they do fine and fantastic. The key thing is to have this available in case something bad happens.”

That was the case for a new mom at WellSpan York Hospital in September. At 37 weeks pregnant, she went into labor. After welcoming her new baby to the world, it appeared both mom and baby were doing fine.

A few hours later, that mom went into cardiac arrest. She was quickly taken to the Intensive Care Unit, where she was put on ECMO.

ECMO is used for patients suffering from severe failure of the heart or lungs. ECMO is a short-term life-support system that replaces or supplements the natural function of the heart and/or lungs, allowing them to rest and potentially recover. ECMO provides valuable time to further assess and treat the underlying cause of the acute problem.

“ECMO works very well for patients whose heart isn’t working, or whose lungs aren’t working,” Dr. Zubkus explains. “We were able to get her on ECMO in about 15 minutes after we started, which is very good time. After we got her on ECMO, we no longer had to continue doing CPR. The ECMO circuit takes care of all of the heart’s functions.”

For patients who are put on ECMO, time is of the essence, since the heart and/or lungs are not functioning. At WellSpan York Hospital, Dr. Zubkus and his team were able to react quickly and use ECMO to help the new mother heal.

“The next day, she woke up. We took the breathing tube out. She was walking around the Intensive Care Unit with the ECMO cannulas in,” Dr. Zubkus says. “Her heart recovered. Her lungs recovered. We took the ECMO circuit out within 72 hours, and eventually she went home completely intact — which is an amazing story.”

After about two weeks, that patient was able to leave the hospital and go home with her newborn baby.

A Lifesaving Tool at WellSpan

ECMO may be a lifesaving measure for patients with severe injury to the heart or lungs when traditional treatments don’t work. Patients with severe congestive heart failure may also be candidates for ECMO as a bridge to more durable mechanical support, recovery or transplantation.

Throughout ECMO support, the patient is the center of a highly coordinated medical team effort and receives around-the-clock care.

For the last three years, WellSpan Health has been certified as a Gold ECMO Center by the International ELSO Organization. WellSpan is one of only three Gold ECMO Centers in Pennsylvania. It is recommended ECMO teams undergo 40 to 80 hours of training. At WellSpan, those teams undergo 250 hours of training.

“This has been revolutionary for both WellSpan and our patients,” says Dwayne Houpt, ECMO specialist. “Before, it was only the major medical institutions and major universities that offered this. Now, we can offer it to the local community here in South Central Pennsylvania. So instead of adding more time for travel, we can get them on ECMO fast and improve their recovery.”


For more information on the cardiovascular care services provided by WellSpan, visit WellSpan.org/Heart.

Criteria for Initiation of ECMO

Criteria at WellSpan York Hospital were amended and simplified during the pandemic and increased ECMO utilization to better select patients who will benefit from ECMO the most. After the pandemic is resolved and ECMO volume is down, criteria will be appropriately revised.


INDICATIONS

  • Age < 65
  • Asthma
  • Acute MI (w/cardiogenic shock)
  • Acute PE (w/ cardiogenic shock – tPA not given)
  • s/p cardiac surgery (unable to wean CPB)
  • ARDS
    • (inability to maintain O2 sats > 88%, pO2 > 55, pCO2 < 100, pH > 7.2)
    • < 7 days on mechanical ventilation
    • shunt > 30%
  • Chest syndrome
  • Pulmonary Vasculitis

ECPR

  • Witnessed VT VF arrest, resuscitation started within 5 min and total resuscitation time under 30 min with ETCO2 of 10+
  • No ECPR is performed on COVID + patients
  • In-hospital ECPR will be offered at all times, however out of hospital ECPR may be suspended depending on the active ECMO volume

VA ECMO

  • Cardiogenic shock refractory to pharmacologic therapy or mechanical support
  • Hypothermia (Pt temp < 28 C)

VV ECMO (non COVID) — ARDS/asthma

  • Severe hypoxemia (e.g., ratio of PaO2 to Fio2 < 100, despite the application of high levels of PEEP [typically 15–20 cm of water]) for at least 3 hours in patients with potentially reversible respiratory failure
  • Uncompensated hypercapnia (PaCO2 > 50) with acidemia (pH <7.2) despite the best accepted standard of care for management with a ventilator
  • Excessively high-end inspiratory plateau pressure (>30 cm of water) despite the best accepted standard of care for management with a ventilator
  • Pressure or volume induced lung injury not amenable to conventional treatment (i.e., pneumothorax, pneumomediastinum, etc.)
  • Under 10 days on ventilator

VV ECMO (COVID)

  • Criteria are the same as non-COVID with the following amendments:
    • Every case will be discussed among three ECMO physicians for appropriateness of cannulation
    • Proning and paralysis MUST be attempted unless clinically contraindicated
    • Under 7 days on ventilator

RELATIVE CONTRAINDICATIONS

  • Immunocompromised/immunosuppressed
  • End-stage kidney disease
  • Acute chronic heart failure w/VAD transplant plan
  • Contraindication to anticoagulation
  • Chronic pulmonary arterial hypertension
  • ARDS: 7-10 days of mechanical ventilation
  • Hemorrhagic shock
  • Total cardiac arrest time 30-60 min
  • Septic shock
  • BMI > 50

ABSOLUTE CONTRAINDICATIONS

  • Unwitnessed cardiac arrest.
  • Initial rhythm of ASYSTOLE or PEA
  • ETCO2 < 10 mmHG @ presentation
  • Compressions > 30 minutes
  • DNR/DNI
  • Pre-existing chronic disease w/oxygen requirements (includes any chronic interstitial lung disease)
  • Age > 65
  • End-stage liver disease
  • Septic shock (w/respiratory failure + 2 other organ system failures)
  • Severe, irreversible brain injury
  • Active malignancy
  • Any shock condition w/4+ organ system failures

If a patient meets these criteria for initiation of ECMO, make a referral immediately. If a patient does not yet meet these criteria but is deteriorating, please consider early referral for the potential need for mechanical support.

Physicians with patients who might be candidates for ECMO should contact WellSpan. Call (717) 851-BEDS (2337) and inform the logistics coordinator you have an ECMO patient.