This document discusses the "Hub and Spoke" model for transporting neonatal patients on extracorporeal membrane oxygenation (ECMO) from peripheral hospitals to a specialized center. The model involves a specialized multidisciplinary team that can rapidly activate and travel to implant ECMO in a newborn at a spoke hospital and then transport the patient to the hub center for continued care. The team from Padua, Italy has used this model since 2009, completing 11 neonatal transports to date with a 100% survival rate for cases of severe meconium aspiration syndrome. While complications can occur during transport, the mortality risk is very low according to their experience and analyses of other ECMO transport programs. The specialized team and cooperation between spoke

1. Il trasporto dei pazienti ECMO assisititi
(Hub and Spoke)
Dario Fichera

2. Perché?

3. Perché?

4. Cosa sappiamo
• Almeno 20 casi ECMO/anno servono per mantenere le competenze
• Almeno 12-15 ECMO respiratori/anno = miglior outcome
• Almeno 20-22 casi pediatrici/anno sono correlati a minore mortalità

5. HFOV non responders (a/A ratio 0.08 or lower) after 6 hrs
Mortality without ECMO may vary
from 26 to 40 %
Louis D et al Predictors of mortality in neonates with meconium
aspiration syndrome. Indian Pediatr. 2014 Aug;51(8):637-40.
ECMO for severe MAS
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

6. ELSO database
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

7. ELSO database
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

8. Need for transfer to a higher level of care
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

9. HandS ECMO model
Hub and Spoke
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

10. HandS ECMO model
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

11. HandS ECMO model
Padua ECMO experience
 Almost 1000 ECMO cases (since 1986)
 5 ECMO programs: Card Ped – Resp Ped / Card Ad – Resp Ad / DCD
 Structured database from January 2001
 Jan 2001-Aug 2017: 202 Pediatric ECMOs
 26 Pediatric Respiratory (13%)
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

12. HandS ECMO model
 70 ECMO retrieval from peripheral hospitals (since 1995)
 Hub and Spoke Program since 2009
 11 Neonatal / Pediatrics
 First neonatal Hub and Spoke ECMO in 2014
 Longest run: Patras, Greece (2015)
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
1 1 3 1
4
5
12
13 13
2 3 3 3
2009 2010 2011 2012 2013 2014 2015 2016 2017
(partial)
Hub and Spoke
ECMO trend
RUNS ALERTS

13. The traveling team
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
Neonatal Hub and Spoke ECMO Team
Neonatologist 1
Pediatric Cardiac Surgeon 1
Perfusionist 1
Pediatric/Neonatal ICU Nurse 1
*
Surgical Assistant on demand 1*
Total 4 / 5*

14. Step 1 – The consulting line
 Indications
 TeamActivationTime
calculation
Spoke Center: Ref physician
Hub Center: Neonatologist
ACTIVATION HandS ECMO TEAM
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

15. Step 2 – Ready? Go!
 Dedicated Ambulance
 Military van
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

16. Step 3 – Spoke Center Checklist
The spoke Center is required to:
 maintain stable hemodynamic
 adequate maximal MV
 iNO if required
 provide adequate surgical
setting for the emergent ECMO
implantation
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

17. Step 4 – ECMO implantation-Stabilization
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

18. Step 5 – Transfer and care at Hub Center
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

19. Step 5 – Transfer and care at Hub Center
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

20. Step 5 – Transfer and care at Hub Center
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

21. Step 5 – Transfer and care at Hub Center
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

22. Step 5 – Transfer and care at Hub Center
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

23. Results – Padua’s experience
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
100% SURVIVAL

24. Results – Padua’s experience
6 neonates with
severe MAS
referred
4
appropriate
• 1 improved with telephone advice
• 1 excluded (unfavourable vasc anatomy)
indications
4 commenced on VA ECMO
4 survived
Cardiac ICU
discharge
4 survived
NICU discharge
4 alive and well at
recent follow-up
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
May 2014 – Dec 2016
100% SURVIVAL

25. Results – Padua’s experience
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
Update 2020

26. Results – Padua’s experience
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
Update 2020
90% SURVIVAL

27. Results and conclusions – Padua’s experience
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

28. Results – Padua’s experience
2 HandS ECMO runs
in the same day
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

29. Results and conclusions – Others’ experience
Fichera D
HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
62% by air
700 trasporti  1 morto

30. Results and conclusions – Others’ experience
Fichera D
HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
Analisi retrospettiva
3 anni (2010-2013)
n %
Transports with incidents
82 27.3
Transports witn > 1 incident 14 4.7
Total no of incidents 94
Patient related 66 22.0
Loss of tidal vol 38 12.7
flooding of lung 3 1.0
Bleedings 8 2.7
cannulation site 4 1.3
lung 3 1.0
nose 1 0.3
Hypoglycemia 1 0.3
Hyperkalemia 1 0.3
Bradycardia 1 0.3
Hypothermia 1 0.3
Thrombocytosis 1 0.3
Arousal 1 0.3
Cardiac stun 5 1.7
Leg ischemia 1 0.3
Vagal reflex/secretions 1 0.3
Hypovolemia 3 1.0
Circulatory instability 1 0.3
Pericardiac cannulation 1 0.3
Recirculation (VV ECMO) 1 0.3
Loss of arterial line 1 0.3
Equipment/technical 16 5.3
Clotting of ECMO-system 2 0.7
Canulla clot 1 0.3
Oxygenator clot 1 0.3
Broken lab device 4 1.3
Syringe pump failure 2 0.7
Broken heater/hose 3 1.0
Broken oxygen hose 1 0.3
Broken ventilator hose 1 0.3
Loss of power supply to pump 1 0.3
Staff flaw 2 0.7
ECMO-system forgotten 1 0.3
Pump head forgotten 1 0.3
Vehicle/transportation 7 2.3
Wrong ambulance 2 0.7
Ambulance traffic accident 2 0.7
colliding w wildlife 2 0.7
Ambulance; no electricity 1 0.3
Change in destination 1 0.3
No transport aft. delivery 1 0.3
Environment 3 1.0
Reload in low amb. temp. 1 0.3
Freezing of iv lines 2 0.7

31. Results and conclusions – Others’ experience
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.

32. Conclusions
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HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
Take home message:
• A specialized multidisciplinary HandS ECMO team is crucial for
the successful management of these severely ill newborns in
peripheral hospitals.
• Experience impact positively on success rate
• Spoke center cooperation is essential for a successful outcome.
• Many complications can occur, but mortality risk is very low

33. Trasporto in aereo

34. Trasporto in elicottero

35. Trasporto INTRA ospedaliero

37. Tools utili

41. Tools utili

42. Tools utili

43. Fichera D
HandS ECMO: The «Hub and Spoke» model for neonates with M.A.S. in peripheral hospitals.
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