ECMO quantity difficulties

“When ECMO rings, gold is worth two million.” This is the first perception of ECMO by many people.

The new crown pneumonia epidemic struck, and ECMO repeatedly appeared in the emergency scene and entered the public eye.

Dr. Li Wenliang died unfortunately, and ECMO became the last expectation when he died; the ridiculous Huanggang pregnant woman had to give up treatment because of the high cost of ECMO treatment; before January 22, Hubei Province successfully used ECMO for the first time and was treated. A patient with new coronary pneumonia.

Not medicine, but buying time from death, has become an important reason for ECMO’s attention in the epidemic. ECMO and ventilator are of great value for the treatment of new coronary pneumonia. Therefore, experts often call for the support of medical teams to bring ECMO and ventilator to Hubei to exert the effect of high-precision equipment.

It’s life-saving, amazing, and extremely expensive, which is a common label for ECMO. In many clinical stories, ECMO has also distressed the family members of patients, emotionally giving hope, and economically disintegrating. What is more binding is that the national stock of emergency ECMOs is only about 400 (excluding Hong Kong, Macao and Taiwan) ), Support for Hubei depends on the coordinated support of the whole country.

Life-saving artifact
The full name of ECMO is Extracorporeal Membrane Oxygenation. Extracorporeal membrane oxygenation, commonly known as artificial heart-lung machine, “Yeke membrane”, is the king of the existing extracorporeal circulation technology. It is often applicable to open chest surgery. A system that can form a life cycle outside the body, instead of performing cardiopulmonary bypass.

What equipment does an ECMO system include?

Ji Bingyang, director of the Department of Extracorporeal Circulation Center, Fuwai Hospital, Chinese Academy of Medical Sciences, told the reporter of “21CBR” that the system mainly includes blood-driven pumps (usually centrifugal pumps) and matching disposable supplies. Consumables include blood lines (packages), Membrane oxygenator, pump head, cannula (for blood drainage and return) and various connectors.

In addition, the auxiliary equipment includes a temperature changing water tank for regulating body temperature, an air-oxygen mixing instrument for regulating oxygen concentration, and monitoring equipment such as blood oxygen saturation, pressure, and temperature sensors.

The operating logic of ECMO is to replace the heart with a blood pump and the lungs to replace the lungs, and continuously transport blood to the human body to maintain the operation of various organs and maintain life. Compared with other cardiopulmonary bypass products, it can provide long-term cardiopulmonary support to patients with cardiopulmonary failure and provide longer time for treatment and recovery.

During the treatment of new coronary pneumonia, ECMO had a high appearance rate. Sun Kai, who is responsible for the marketing of a certain brand of ECMO, explained to 21CBR reporters that early domestic awareness of ECMO was limited, and the application focused on cardiogenic diseases. Now it has expanded to the critical and respiratory fields.

Especially in 2009, H1N1 bird flu swept the world and ECMO performed amazingly: The results of a document in the Journal of the American Medical Association (JAMA) showed that a high proportion (71%, 48) of 68 patients with ECMO recovered, Out of ICU; prior to ECMO, these patients suffered partial lung damage during traditional mechanical ventilation.

Since then, ECMO has grown in scenes such as myocarditis treatment, rescue of poisoned patients, and transfer of critically ill patients. Ji Bingyang introduced that as a short-to-medium-term support method, the general cycle support time is about one week in the clinic, and the respiratory support time is longer, more than two weeks or even longer. There are also successful cases in China that last more than 100 days.

However, ECMO is not a complete life-saving artifact.

Ji Bingyang emphasized to “21CBR” reporter that it provides time for the recovery of patients’ cardiopulmonary function. During the use, related accidents and complications may occur, including bleeding, thrombosis, infection, limb ischemia, and multiple organ failure. Wait, the severe ones even endanger life.

Depending on the recovery of organ function after healing, after successful withdrawal, it may also require further treatment due to infection, liver and kidney failure, etc. This requires the ECMO team to establish a series of standardized processes, strengthen observation and care, and minimize complications.

Expensive defense
ECMO is very expensive, both in the product and the scene.

As a first-line clinical expert, Ji Bingyang admits that considering the criticality of the patient’s condition and the complexity of the ECMO system, ELSO recommends that the ECMO center should be built in an ICU (Intensive Care Unit, Intensive care ward), “In clinical use, it is generally purchased by hospitals of level 3 or higher. They usually have intensive care, emergency and emergency treatment of cardiopulmonary critically ill patients, and a few units in the economically developed regions.

ECMO often shows up in intensive care and ICU, and is regarded as the ultimate means currently available, and is the last line of defense with death. “At this point, we are using money in exchange for survival opportunities.” Sun Kai bluntly said.

As for the product itself, the ECMO used by traditional bedsides has a purchase price of about 1 million yuan, and the price of mobile equipment is higher. It is not an expensive medical device, but special consumables are expensive.

For traditional extracorporeal circulation membrane lungs, the unit price of imported products is about 5,000 yuan, and most of the consumables are basically localized. The membrane lungs and other consumables used by ECMO require biocompatible coating technology to prevent blood from leaving the body for a long time. The operation produces thrombus, does not produce plasma leakage, the material will be much more expensive, and all rely on imports.

There are three main suppliers of ECMO products, namely Medtronic in the United States, Solin in Germany and Meike in Germany.

The good news is that there are already domestic companies that produce extracorporeal circulation membrane lungs. In the next few years, it is expected that some key products will be localized. “Don’t look at the commercial volume of only about 200 million yuan. The ECMO market has maintained a growth of more than 20% for many years. The future is expected, and the domestic companies with the courage to break the ice are very promising in the future.” Sun Kai said.

Since domestic ECMO is basically used by extremely critical patients, it is not possible to leave the ICU in a short time after entering ECMO, and the cost is naturally high.

“We often say that the start-up cost is 40,000-60,000 yuan. The start-up cost refers mainly to the cost of a kit, which includes the centrifugal pump head, pipes and membrane lungs. The kit can be used continuously, 10,000 to 20,000 per day. The cost is mainly the cost of ICU, medication, and monitoring equipment. ”

Sun Kai revealed that in actual clinical situations, the specific situation is very different. The most ideal thing is to be able to withdraw more than 100,000 people, and the actual average cost is much higher.

For example, the use of expensive kits varies in number of days. Once a thrombus or plasma leak occurs, the entire kit may need to be replaced again. In some clinical days, thrombosis will occur and the kit must be replaced. Sun Kai explained that patients often speculate that replacement is the hospital’s wish to charge more. In fact, the hospital does not want problems, but the existing technology cannot avoid it.

Going to ECMO requires full support from all staff. This is another expense. For example, ECMO requires anticoagulation of blood, which may increase the risk of bleeding, but also because of poor perfusion of limbs and risk of amputation. If brain protection is not enough, patients will have brain damage. The medical team must be closely monitored 24 hours. Decide on a treatment plan.