Crash Episode – MicroDissection of Yannopoulos’ ECMO Method

In ep. 36, Zack interviewed Demetris Yannopoulos on the amazing ECPR experience at University of Minnesota. In this crash episode, I reinterview Dr. Yannopoulos on the intricacies of how cannulates.

Some Highlights

  • Uses amplatz super-stiff with 1cm J-tip
  • arterial puncture first
  • dilates with 12 and 14 for artery and 16 and 18 for vein
  • places venous cannula first
  • 25 F venous cannula
  • places arterial 15 F in females and 17 F in males empirically (different than publication)
  • Dilates tracts with kelly
  • Starts flow at 2.5 50% fio2 and ramps up

 

 

 

EDECMO 30 – Post-Arrest ECMO Critical Care Management with Deirdre Murphy

In this episode, Scott talks with Deirdre Murphy, guru on all things Cardiothoracic Critical Care, on the topic of post-pump crit care.

The Alfred has put itself on the map in so many ways over the past decade. Home to Stephen Bernard (of the original Hypothermia after ROSC without RONF fame), Chris Nickson (@precordialthump, @ragepodcast, @intensiveblog, #SMACC, lifeinthefastlane.com), and good friends Jason McClure, Steve McGloughlin, Josh Ihle, Paul Nixon, and Deirdre Murphy, The Alfred is becoming a mecca for advanced resuscitation and ECMO/ECPR.  In this episode we sat down with Dr. Murphy to discuss the nuances of weaning a patient from ECMO.

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre Murphy

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre is Deputy Director ICU, Director of the Cardiothoracic ICU at The Alfred Hospital with particular interests in echocardiography and cardiac intensive care, especially mechanical circulatory supports including Ventricular Assist Devices and ECMO. Deirdre originally trained in Ireland with postgraduate training in general medicine and anaesthesia prior to undertaking intensive care training in Australia in 1999. She has been an Intensivist at The Alfred since 2003. Deirdre has been using echo in clinical practice since 2002 and heads the ICU echocardiography programme at the Alfred. She is convenor of the Alfred Critical Care Echocardiography Course and the Alfred TOE course and teaches on many of the other Alfred courses including the Ultrasound, ECMO and HeART courses.

 

Want More??

Check out Dr. Murphy’s talk from smaccGOLD on “ECMO: What could go wrong?”

Also, check out the incredible resources on ECMO on the INTENSIVE blog (the Alfred ICU Education blog)

EDECMO # 13 – Does Pseudo-PEA Exist and What Should You Do About It

This is the first episode where all three of the EDECMO boys are together–yeah! Today we talk about a bunch of PEA stuff. Scott proposes 2 new terms to bring us into the modern era: PREM-pulseless with a rhythm and echocardiographic motion PRES-pulseless with a rhythm and echocardiographic standstill Joe asks why we shouldn't just treat the latter like asystole, and he's probably right. But what of the former? What should we do with that? Listen to the episode.  

Jim Manning's talk at GSA HEMS

On Youtube

Here's the Littmann Article on PEA

354195

A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity

Update

Our friend Gregor Posen performed this excellent Pseudo-PEA (PREM) Paper

 Bibliography

In this episode, Joe was “Orating via the Anus” while Zack and Scott took a more evidence-based approach:

 

Update

This new study seems to demonstrate that stratification by ecg width may not be evidence-based

 

TrackBacks

“PEA is just a bunch of BULLSHIT!”  Joe talks about the FALLACY OF PEA on the ER Cast podcast with Rob Orman…  

EDECMO Episode 11 – The Paris ECMO Course

Paris ECMO Course

The excellent lecturer was Dr. Guillaume Lebreton,

Associate Professor and Cardiothoracic Surgeon
Director of the CPB and ECMO program,
Department of Cardio-Thoracic Surgery
Pitié Salpêtrière Hospital

How Not to Frack Up

  • DO NOT ADAPT TECHNIQUE TO YOUR CAPACITY
  • Fixed Point for Wire–meaning wire must be held stationary as you dilate, otherwise dilator will back wall through vessel with anything but the stiffest guidewire. We get a false sense of security from smaller line placement.
  • Discussed being fooled by echo
  • They do cutdowns for all ECPR

Inflow

  • Crap flow if too small
  • If you measure from the puncture site directly to the middle of the sternum, that should be your insertion. Too deep is better, with Maquet you want the tip in the RA
  • 24-29 F with 25 being the sweet spot
  • 55 cm Maquet for all adults
  • When the holes are through the vessel, PULL Back the Dilator

Outflow

  • Hemolysis if too small
  • 17-21 F for VA
  • 19-23 F for VV
  • IJ catheter length-15 cm on right, 23 cm on left
  • Don't pull back dilator for arterial placement

Placement

  • Pad behind buttocks to straighten vessels 4″ or so
  • Needle bevel facing up and wire's j facing up
  • Gentle Angle for  Needle Placement
  • Guidewire-go fast and it goes straight
  • Always use the 150 cm guidewire. Leave 1 meter out, 50 cm in pt
  • Scalpel-1 cm cut and plunge
  • Doesn't bother rotating the dilators
  • VV-do the femoral first as it is harder to knock out

Femoral-Femoral VV

  • Return close to tricuspid, not multi-stage
  • Drainage as central as possible, but in IVC, not RA
  • Put in both guidewires first
  • Put the longer cannula (return) in first
  • Inflow-21-23 short insertion, but same length cannula (Maquet)
  • Outflow-17-19, single stage (Medtronic)

TroubleShooting

  • If at the same speed, decreased flow–think thrombosis

Starting VVECMO

  1. Clamp on tubing
  2. Start slow, 2000 rpm then slowly declamp
  3. Start sweep at 6 lpm (or 1:1 with flow)
  4. Go up to the max flow you can get at first to see your max
  5. You want to provoke reflow
  6. You should be able to get big flows (6-7 lpm)
  7. Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture)
  8. You should be able to get to 100% sat quickly
  9. If you are seeing recirc, pull back inflow slightly (max 1-3 cm)
  • Treat the pt not the xray when it comes to cannula positioning

Factors that increase Recirc

  • Proximate venous tips
  • Low CO
  • Hypovolemia
  • Increased pump flow rates

Avalon

Turn Head all the way to the left to align IVC and SVC

VA

FEM/FEM
do venous 1st if doing cutdown

Image by Cedric Lange

EDECMO Episode 7 – Dan Herr on Choosing VV Candidates and Weaning

Hey there Pump Heads,

Today, I got to talk with Dr. Dan Herr, director of the CSICU at the Shock Trauma Center.

Dan Herr

We discuss two topics: who is a candidate for VV ECMO and when you should think about weaning the ECMO.

Please leave your comments and questions below

How to Set-up a Pressure Transducer

Joe asked me to cross-post this video here from the EMCrit Site. Every doc and nurse should be able to set one of these up in <2 minutes for rapid arterial and central venous pressure monitoring.

 

Episode 5 – Cognitive Task Analysis of Stages I and II of Extracorporeal CPR

Joe and I discuss ECPR cannulae placement from a cognitive task analysis (sort of) perspective. Beware: agonizing detail follows.

I believe this episode may help you even if you never do ECMO, as it is directly applicable to large central line placement as well.

Steven Bernard on the CHEER Trial from Intensive Care Network

The amazing blog and podcast: Intensive Care Network run by Oli Flower and Matt Mac Partlin recorded this lecture by Steven Bernard talking about the CHEER Trial of ECPR.

Dr. Bernard's Slides

Now on to the Lecture…

ECMO Powerpoints from Velia Marta Antonini

Velia Marta Antonini is an ICU Nurse and ECMO Specialist in Parma Italy (Follow her on Twitter). She has some amazing slide presentations on ECMO. Hopefully, we'll interview her for the podcast in the coming months.

Part I – Indications and Configurations


 

Part II – The ECMO Circuit


 

Part III – ECMO Complications


 

Part IV – Monitoring and Nursing

 

First Prehospital-ECMO Initiation Abstract Just Published

My friend Bri Burns sent me this abstract this morning:

Thorac cardiovasc Surg 2013; 61 – P45 (DOI: 10.1055/s-0032-1332685)

Pre-hospital cardiopulmonary resuscitation supported by ECMO – a case series of 6 patients

M Hilker, A Philip, M Arlt, M Amann, D Lunz, T Müller, M Zimmermann, B Graf , C Schmid

  • Universitätsklinikum Regensburg, Regensburg, Germany

Objectives: Manual cardiopulmonary resuscitation (CPR) or automated CPR with chest compression systems are currently the standard treatments for cardiac arrest patients out of the hospital. There is a strong clinical evidence that rapid onset of ECMO in patients with cardiocirculatory failure can improve survival during in-hospital resuscitation. In contrast to these findings out-of-hospital cardiac arrest patients cannulated in the emergency room show a poor outcome.

Our aim is to shorten the „time-to-pump“ by initiation of the ECMO system on scene with safe transportation under stable hemodynamics. Therefore this case series of 6 patients demonstrate our first “real life” experience with this approach.

Methods: In the last two years (from September 2010 to 2012), ECMO was installed in 6 patients on scene by an interdisciplinary team. All patients who met the following citeria were included. 1. witnessed cardiac arrest; 2. refractory cardiac arrest; 3. a mobile ECMO team was available; 5. a lack of known, severe comorbidities; 6. age < 70 years.

Results: The results are subsumed in the following table.

Table 1: Patient data and Outcome
case years, gender location of ECMO implantation time to pump (min) diagnosis subsequet intervention outcome
1 11, f swimming lake 50 drowning CT dead, global brain ischemia
2 44, f apartment 90 PE CT dead, global brain ischemia
3 50, m doctor's office 55 AMI PCI, CT dead, global brain ischemia
4 53, m apartment 53 PE none dead on scene
5 52, m apartment 67 AMI DCI, CT persistent neurological deficit
6 57, m place of work 50 AMI PCI, CT alive without deficit

Conclusion: To the best of our knowledge, this is the first case series that shows not only the feasibility of implantation of ECMO on scene for refractory cardiac arrest but also the successful application of this approach. The holy grail is now to identify patients in advance who will suffer irreversible cerebral anoxia.