On January 22nd, Zhongnan Hospital of Wuhan University used ECMO to successfully treat a severely ill patient with "new coronavirus pneumonia", the first case in the province.
On January 23rd, 81 sets of ECMO equipment and consumables were imported from Germany, and flew to the battlefield of Wuhan Jinyintan Hospital.
The fifth version of the diagnosis and treatment program announced by the Health Commission, proposed that the conditions of the critically ill patients should be used as soon as possible ECMO.
The fifth version of the National Health Commission diagnosis and treatment program (issued on February 8)
ECMO, the full name of the English Extracorporeal Membrane Oxygenation, Chinese name "Extracorporeal Membrane Oxygenation (ECMO), or "artificial membrane lung" for short, is the core part of the membrane lung and blood pump, which play the roles of an artificial lung and an artificial heart, respectively.
The first time we heard of ECMO was probably even earlier, when it was the February 18 web article "Middle-aged Beijingers under the Flu".
The author's father-in-law was bounced around from hospital to hospital with a small cold, diagnosed with pneumonia from an unknown viral infection, and was separated from the world 27 days later.
From this article, we see unknown viral infection, decreased oxygen saturation, large white lungs, respiratory failure, and ECMO, so similar to the keywords for patients with new crown pneumonia.
Even more prevalent, are the pneumonias that result from influenza A and B every winter and spring. They all fall into the same category as new crown pneumonia: viral pneumonia.
At the end of January 2018 in Guangzhou, 37-year-old Ms. Wang (a pseudonym), coughing and fever after getting cold, and taking medication without improvement. on February 5, Ms. Wang went to the First Hospital of Jinan University for shortness of breath and chest tightness. Chest X-ray showed inflammation in both lungs, with white coloration in the lower part of the lungs, and she was hospitalized on the same day. First of all, infusion and oxygen.
Why oxygen? Because the lung function becomes very weak, normal breathing can not provide enough oxygen. By inhaling pure oxygen, the damaged lungs can provide the body with a minimum amount of oxygen to keep the brain and vital organs alive.
Ms. Wang's condition was changing rapidly, and even with high-flow oxygen, her oxygen index was only 78% at its highest, well below the 95% safety value. That evening, Ms. Wang was transferred to the ICU ward.
The first step in the ICU was a non-invasive ventilator, which barely kept her oxygen at a "critical level" of 90%.
The disease continued to deteriorate, the ICU used the second trick "tracheal intubation", after using an invasive ventilator, it is still difficult to maintain Ms. Wang's "oxygen needs", her blood oxygen all the way down to 70% to 80%.
In the 48th hour of hospitalization, Ms. Wang's chest X-ray image has become a "big white lung". Normal lungs are black, but because of the severe inflammation, her lungs were white.
The lungs are basically non-functional, and if they don't improve quickly, her brain and organs may fail due to the "lack of oxygen" and even lead to death.
Ms. Wang's life is at stake. After communicating with her family, at 1 a.m. on February 8, Ms. Wang used a life-saving device called ECMO to replace her lungs. The medical staff inserted a tube into her femoral vein to drain venous blood outside her body, and then pumped the blood into her body after the oxygenation of the "artificial lungs.
Prof. Zhan Qingyuan of China-Japan International Hospital said in an interview on "Respiratory" that there are three principles of treatment for severe viral colds:
One is the treatment of the original disease, which mainly refers to antiviral treatment.
The second is supportive care, with respiratory support being the most important.
The third is the treatment of complications and comorbidities.
Ms. Wang's primary illness was influenza, with symptomatic antiviral drugs such as oseltamivir. Although there was a complication of kidney failure and infection with Acinetobacter baumannii, the doctors resolved it one by one with renal replacement therapy (CRRT) and antibiotics, and there was no risk.
From high-flow oxygen - non-invasive ventilator - invasive ventilator - ECMO artificial lungs, this top respiratory support miracle, to buy valuable time for treatment. 18 days later, Ms. Wang successfully withdrawn from the machine until the recovery of discharge.
If there is no symptomatic medication for the primary illness, as in the case of the unknown virus pneumonia in the case of New Crown Pneumonia and the Beijing flu, ECMO works to support the immune system in a direct fight against the virus, similar to a "scorched earth strategy.
Like locusts, C. neoformans invades the lungs, causing the immune system to attack the virus and cells indiscriminately, leaving the lungs as scorched earth and the virus dead.
The good ending is that ECMO sustains the patient's life instead of the lungs. After the virus dies and the lungs recuperate, oxygenation is restored.
The bad end is when the immune system over-attacks in a "scorched earth strategy", triggering an "inflammatory storm" that leads to multiple organ failure in the liver and kidneys, as in the case of Dr. Li Wenliang, or his father-in-law, a middle-aged man in Beijing, who had a severe co-infection with a drug-resistant bacterium; They lost their precious lives.
In the face of respiratory distress syndrome caused by viral pneumonia, ECMO as the top respiratory support, the treatment of viruses and complications determine the battlefield.
According to the world life support organization ELSO statistics, the ECMO resuscitation success rate is about 50%. Behind the percentage, there is a live life, a warm family, a city and a pool must also be captured.
Another widely reported use of ECMO is the treatment of fulminant myocarditis.
Outbreak myocarditis is a very aggressive disease that is highly prevalent in children and young adults under 40 years of age. The incidence is low, but the mortality rate is as high as 70%. The initial symptoms are very much like the common cold, but the disease progresses quite rapidly, producing severe heart damage in a short time and making sudden death very easy.
In 2009, an 11-year-old boy with fulminant myocarditis was brought to Hangzhou First People's Hospital. The boy had no heartbeat when he arrived at the hospital. After several rounds of CPR, doctors thought of ECMO.
After the child was put on ECMO, his ECG monitor was still a straight line, but his consciousness was actually clear.
Director of the ICU Hu Wei clearly remembers that day, the child was lying on the bed, his body was full of large and small tubes.
Suddenly, the child opened his eyes and said, "Mom, I want to drink Coke!" The parents were in tears. Soon, the child's condition improved, and withdrew from the plane and was discharged from the hospital.
ECMO commonly used V-V mode and V-A mode.
V-V mode is an artificial lung, used in acute respiratory distress syndrome, such as Ms. Wang, who had viral pneumonia.
The V-A mode is a combined heart-lung and is used in patients with heart (cardiopulmonary) failure, such as the boy who had fulminant myocarditis. It can also be used in heart repair surgery, ECPR (extracorporeal cardiopulmonary resuscitation), and so on.
The earliest ECMO was used in heart surgery.
Its prototype came from an extracorporeal circulator invented by American heart surgeon John Gibbon.
In 1980, Dr. Bale of the University of Michigan established the first ECMO center, and from then on, the life-saving device came out of the operating room.
The current mayor of Taipei, Wen-zhe Ko, was the first person to promote ECMO in Greater China. He used the "Yek Membrane" (a Taiwanese term) at the National Taiwan University School of Medicine to sustain the life of a "heartless" patient who had lost his heart function for 16 days, and then did a heart transplant to save his life. The first time I've seen a heart transplant, I've seen a heart transplant, and I've seen it.
At the beginning of this century, Prof. Koh came to mainland China to teach ECMO technology to many top cardiothoracic surgeons, including Beijing Fuwai, Anzhen, Shanghai Chest Hospital, etc. During the SARS outbreak in '03, ECMO began to be used in China for patients with respiratory failure.
ECMO, as a top life-saving device, is not available in every public tertiary hospital even. Driven by curiosity, I researched the situation in Mordor hospitals.
According to a relevant report from the Shanghai Extracorporeal Circulation Specialized Committee, 21 hospitals in Shanghai carried out ECMO technology in 2018, of which 18 were public tertiary hospitals, while the number of tertiary hospitals in Shanghai was 38 in 18 years.
Five hospitals in Shanghai carried out this technology earlier and had the most cases of ECMO treatment. They are: Shanghai Chest, Renji, Zhongshan, Children's Medical Center, and Changhai.
Since it is a life-saving technology to rescue critical illnesses, why is it not widely carried out? In addition to the high technical threshold, it is also because ECMO is expensive.
The same-day start-up cost of ECMO is about 60,000 dollars.
Among them, the machine and supplies 50,000, puncture tubing and membrane lungs are imported from abroad. There are also puncture operation fees, lab fees, and drug fees, totaling less than 10K.
The daily maintenance cost of ECMO is 2 thousand. The cost of running the artificial lungs is 1k, and the cost of labs and medications is less than 1k.
And critically ill patients are usually in the ICU, which also costs 10-20k per day.
The cost of ECMO plus the cost of the ICU, the Internet said, ECMO start 60,000, 20,000 per day. ECMO basically does not enter the medical insurance, need to pay out of pocket.
A pregnant woman in Huanggang who was suspected of having a new crown pneumonia stayed in the ICU for more than a week and was resuscitated using ECMO, and spent nearly 200,000 yuan on treatment. The borrowed money was spent and her husband decided to give up the treatment.
When she died, her husband and doctors cried because she was potentially curable. The day after giving up, the state announced free treatment for new crown patients.
This sad predicament could have been broken with a few hundred dollars in premiums. Most of the few best-selling general multimillion-dollar medical and mid-range medical insurance policies on the market reimburse ECMO costs.
In medical documentaries, the helplessness and tears of doctors are often seen, sometimes because of the limitations of medical technology, but more often because of the high cost of tortured hearts.
In order to protect your family, you need to make arrangements in advance.
References:
(1) Sohu "CSTCVS": 2018 Shanghai's first ECMO special technology quality control supervision style 2018-12-05
(2) Baidu Academic: 2018 Shanghai Extracorporeal Membrane Oxygenation special technical quality control supervision report
(3) Caixin.com critical care doctors in their own words: how we rescue critically ill patients 2020-02-05
(4) Sohu "Dingxiangyuan": doctors to save people, just to let people (5) Respiratory: Professor Zhan Qingyuan uses classic cases to tell you the exclusive recipe for treating severe influenza 2018-01-14
(7) Nanfang+: A cold for 6 days has turned into a "big white lung"! 02-28
(8) CCTV News: pregnant woman with severe pneumonia died: gave up treatment after spending all the borrowed 200,000 yuan 2020-01-29