Enclosed in this month’s edition of ASAIO Journal, the University of Michigan reports their utilization of extracorporeal membrane oxygenation (ECMO) in more than 2,000 patients over nearly 4 decades.1 Many will think this is just further documentation of Bob Bartlett’s extensive experience with the development of ECMO. However, I see this article as a single-institution chronicle of the evolution of ECMO. To put into perspective, these data report the largest series of ECMO utilization at one institution in the world to date. Of the 2,000 patients, most with life-threatening respiratory failure, overall 74% were weaned from ECMO and 64% survived to hospital discharge. Survival to hospital discharge was 84% in neonates, 76% in children, and 50% in adults, all in patients who were either judged by the attending physician to have exhausted maximum medical management or met criteria designed to identify approximately an 80% mortality. These data parallel the experiences chronicled in the Extracorporeal Life Support Organization Registry, which began in 1989, and that now include more than 63,000 patients worldwide as of November 1, 2014.
Some would say Bob Bartlett invented ECMO. In fact, many investigators were attempting to expand the utilization of cardiopulmonary bypass from the operating room to the intensive care unit as a support technique for patients dying from cardiopulmonary failure. Several early reports chronicle these efforts in adults, but the true genius of Bob Bartlett was the bold application of ECMO as a bridge-to-recovery for severe respiratory failure in neonates. Application in this patient subpopulation provided a remarkable improvement in survival (an estimated 80% mortality became an 80% survival) that persists to this day. Such an undeniable turnaround allowed adaptation of this technique initially by a few enthusiasts, then over the last few decades, acceptance worldwide. Once the original success was realized in neonates, expansion of the technique to children with 76% survival to discharge and 50% survival in adults to discharge was accomplished. Further expansion to congenital heart surgery patients has yielded a 45% survival in children. Extracorporeal membrane oxygenation during cardiac arrest, called extracorporeal cardiopulmonary resuscitation, was performed with a 41% survival to discharge.
Ironically, because of this vast expansion from neonates to more critically care adult populations, overall survival decreased from 74% to 55% between the first and second thousand patients. Bleeding continues to be the most common complication due to the prolonged use of anticoagulation to prevent thrombosis of circuit components. Intracranial bleeding, or infarction, likewise decreases survival. Trends seen over these 4 decades include improved circuit components with decreased complications, use of venovenous technique including ambulatory ECMO as a bridge to lung transplant or recovery, and multiple applications as rescue techniques when other efforts have failed.
I consider this landmark article to be a tribute to the career of Robert H. (Bob) Bartlett as chronicled in the third edition of the Red Book, for 2 decades, the comprehensive text of ECMO application and patient management.2 “Such a tribute is true to his humble style; however, those who know Bob realize he exudes much more than an encyclopedic knowledge of medicine and biotechnology. Rather, he embraces a philosophy of innovation, honesty, introspection, and critical analysis that has cut across all disciplines of critical care for the past 4 decades. We salute the man who has evolved from a pioneer in the day of gooseneck lamps in back treatment rooms to a proponent of prospective, randomized multicenter trials, and outcomes analysis. For the hundreds of physicians and students he has mentored, thousands of physicians he has impacted, the tens of thousands of patients who are alive today due to ECMO, and the millions who have benefited from his critical care teachings, Bob Bartlett is THE critical care physician.”
This article is a must-read for anyone practicing critical care in neonates, children, or adults. I am most impressed at how long it took the medical community to adopt a treatment that yielded such a remarkable improvement in outcomes. Imagine a new cancer therapy that converted 80% mortality to 84% survival in neonates, 76% in children, or 50% in adults! Over 4 decades, the University of Michigan has led the development of ECMO to a mature technology to be used for temporary life support with the potential for recovery from a high risk of dying from a variety of desperate circumstances.
1. Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett R. Extracorporeal life support: Experience with 2000 patients. ASAIO J. 2015;61:2–7
2. Van Meurs K, Lally KP, Peek G, Zwischenberger JB. Dedication. ECMO Extracorporeal Cardiopulmonary Support in Critical Care. 20053rd ed. Ann Arbor, MI Extracorporeal Life Support Organization (ELSO) page v.