ECLS Fellowship 2019

Introduction

The rapid proliferation and adoption of extracorporeal therapies is driving a concomitant demand for professionals with greater experience with these technologies than they normally receive during a subspecialty fellowship in pediatrics or pediatric surgery. In the spring of 2019, Texas Children’s inaugurated its ECLS fellowship program. The objective of the program is to train pediatric subspecialists (intensivists, neonatologists, pediatric surgeons) in the principles and practice of different extracorporeal support modalities, including ECMO (VV or VA), ventricular assist and ECCO2R for cardiac and respiratory disease. When they finish the training graduates of the fellowship will possess the competencies to immediately join a high-functioning ECMO team at any leading children’s hospital or start a new ECMO program from scratch at an institution wanting to establish one.

Although called a “fellowship,” the 1-year training program is not ACGME-sanctioned. Approved trainees are appointed as Instructors in the Department of Pediatrics or Pediatric Surgery at Baylor College of Medicine, and provide attending-level coverage within their respective disciplines (pediatric critical care, neonatology, or pediatric surgery) during 6-10 weeks of their year.

The fellowship is designed to be tailored to the particular needs of our trainees. Our inaugural fellow is a pediatric intensivist who will be joining a combined pediatric and adult ECMO program with a sophisticated ECMO transport program, as well. She is currently receiving a broad-based training that includes rotations on adult ECMO services at collaborating institutions, ECMO transport (ground and air), priming, maintenance and troubleshooting of extracorporeal circuits, training in renal and liver replacement therapies, transfusion medicine, imaging and supervised cannulations.


Example Curriculum

As noted above, the curriculum is designed to flex to the need of each fellow. An example curriculum with objectives is included below.

Objectives to master and functions to execute

  1. Be familiar with the indications for, as well as, benefits and risks of ECMO for various physiologic indications
    1. Respiratory ECMO
    2. Post-cardiotomy ECMO
    3. ECMO for refractory shock
    4. E-CPR
  2. Perform consultations in the ICU to help determine the appropriate candidacy of patients for ECMO therapy
    1. VV ECMO candidates
    2. VA ECMO candidates
  3. Round on cannulated ECMO and VAD patients in all critical care units.
  4. Be capable of constructing and priming an ECMO circuit
    1. Understand tubing size selection
    2. Be familiar with the different types of oxygenators available
    3. Be able to choose an appropriate cannula size for a given patient
      1. Dual-lumen cannula
      2. Single-lumen cannula
        1. Venous
        2. Arterial
    4. Be familiar with both the standard ECMO circuit and the transport ECMO circuit
  5. Understand the anticoagulation strategies for patients requiring ECMO
    1. Be able to initiate and manage anticoagulation for patients on ECMO
    2. Understand coagulation assays used for patients on ECMO
    3. Become familiar with special situations that may require changes in anticoagulation management (e.g., surgery, bleeding, thrombosis, DIC, elevations in plasma-free Hgb, etc.)
    4. Have the opportunity to work closely with the transfusion medicine team
  6. Acquire the ability to cannulate patients onto VV ECMO with a dual-lumen cannula using ultrasound and fluoroscopy guidance
    1. To be done in conjunction with pediatric surgery
  7. Understand and be able to construct, prime and initiate ultrafiltration and/or dialysis via the ECMO circuit
    1. Basic ultrafiltration
    2. Dialysis using the ECMO circuit
    3. CRRT in tandem with ECMO
  8. Become familiar with ECMO transport
    1. Manage patients during transport
    2. Be capable of cannulating a patient at an outside institution
  9. Create practice guidelines to assist with management of ECMO patients at TCH
    1. Sedation
    2. Ventilation
    3. Coagulation
  10. Complete project/manuscript related to ECMO by the end of instructor year
  11.  Become involved in simulation
    1. Help run ECMO simulation scenarios for Fellows and Advanced Practice Providers
    2. Attend Lectures for ECMO orientation sessions
    3. Help create additional scenarios for senior fellows and junior faculty
    4. Will help give lectures for ECMO RN group
  12. Take ownership of the consult log, keep it updated and follow up on curbside consults
  13. Be a member of the ECMO journal club and present at least one article every 6 months.
  14. Lead Thursday ECMO/VAD meetings
    1. Running the list of current patients on mechanical devices
    2. Help maintain didactic schedule and speakers each week
    3. Present 5-6 topics during the year (1 per month)
  15. Attend high-impact national ECMO meetings to gain insight into current trends and future directions of mechanical support (e.g., ELSO international or regional (Euro oro LATAM) meeting, Keystone or SCCM)

Expected rotations and time allotment

  1. PICU Service Attending (8 weeks)
  2. ECMO Call (24 weeks)
    1. Will be on-call with the ECMO attending 24/7 during 2 month critical care blocks except for designated vacation time
    2. Will be on all ECMO transport
    3. Will attend ECMO rounds in all units as able (PICU, CICU, NICU)
  3. CVOR Perfusionist (1 week)
    1. Will spend 1 week in the CV OR shadowing perfusion teams/ sit pump with the perfusionists and log hours/patients
  4. Transfusion Medicine (1 week)
    1. Will spend 1 weeks with blood bank team performing consults, rounding on patients and listening to didactic lectures given
  5. Interventional Cardiology (1 week)
  6. Echocardiography (1 week)
  7. Renal-CRRT/TPE/MARS (4 weeks)
  8. Round with adult ECMO program(s) in Texas Medical Center (up to 8 weeks):
    1. Collaborating Hospitals: Houston Methodist Hospital, St. Luke’s Texas Heart Institute
  9. Round with Ethics Team (1-2 weeks)
  10. Vacation (4 weeks)

Total Weeks: 52 weeks