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)

NEW ED ECMO Article from the ERECT Collaborative is in Press:

download

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO)

Joseph E. Tonna,∗, Nicholas J. Johnson, John Greenwood, David F. Gaieskie, Zachary Shinar, Joseph M. Bellezzo, Lance Becker, Atman P. Shah, Scott T. Youngquist, Michael P. Mallin, James Franklin Fair III , Kyle J. Gunnerson, Cindy Weng, Stephen McKellar, for the Extracorporeal REsuscitation ConsorTium (ERECT) Research Group

 

The REANIMATE 3 Fellowship Contest – 2017

The #REANIMATE 3 Fellowship Contest

Calling all future resuscitationists: medical students, PGY3/4 residents and fellows-in-training desiring the ultimate experience in Endovascular Resuscitation training: we are officially offering one ***FREE*** ticket (currently a $3200 value) to the winner of the #REANIMATE3 essay contest.

#REANIMATE3 is March 2-3, 2017 in San Diego, California.

Here is what you need to do:

Write a short essay in 300 words or less, on:

  1. The future management of cardiac arrest. Better chest compressions? ECPR?  or something altogether new and different? Bonus point for thinking way outside the box here.
  2. Why you would be the best choice for the #REANIMATE fellowship.

Here is what you get:

  1. One ***FREE*** ticket to #REANIMATE3 (a $3200 value) in San Diego, California on March 2-3, 2017
  2. A bunch of cool #REANIMATE3 schwag
  3. An experience like no other:  this will give you one-on-one experience with world-leaders in resuscitation…and a behind-the-scenes look at how #REANIMATE is created.
  4. An 8×10 glossy autographed glossy photo of Zack Shinar (this would be worth the effort alone! shirtless or not is entirely at your discretion)

Why are we doing this? We want to find the most motivated, brightest, most innovative young minds in Emergency Medicine & Critical Care. Lets face it, #REANIMATE3 is not cheap! So we decided to support young brilliance and bring them under our wing.

But be forewarned, the #REANIMATE3 Fellowship is no easy job. But its an experience you will never forget.

 

Send all essays to: reanimatefellow@gmail.com

 

Note: This opportunity is limited to medical students, PGY3/4 residents, and fellows-in-training only. 

EDECMO 29 – ECMO in Hypothermic Cardiac Arrest – with Torvind Naesheim of Norway

Torvind Næsheim

 

 

University of North Norway, Tromso

University of North Norway, Tromso

University Hospital of North Norway:

  • located at 69 degrees North latitude – likely the northernmost ECMO center in the world.
  • The warmest month is July with a mean air temperature of 11.8C and mean sea temperature of 10.8 C.
  • The coldest month is January with a mean air temperature of -4.4 C and mean sea temperature of 5.1 C.
  • ECMO program since 1988
  • Yearly ECMO volume is approx 20 per year – including postcardiotomy support, ECPR, cardiogenic shock and respiratory failure
  • ECMO Retrieval Ambulance service: Since 12/2015: 5 ECMO transports
  • Cases are reported through the ELSO registry

Accidental Hypothermia – some definitions:
mild : 32-35 C – preserved capability to maintain core temperature through compensating thermoregulatory mechanisms
Moderate: 28-32 – loss of ability to sustain temperature via either voluntary or autonomic means
Severe: 20-28 – high risk of malignant arrhythmias
Profound: <20 Asystole

The Paper: Hilmo, J et al. Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas – A retrospective study from northern Norway. Resuscitation , Volume 85 , Issue 9 , 1204 – 1211

  • “Nobody is dead until warm and dead”
  • retrospective study looking at accidental hypothermia victims with cardiac arrest admitted to UNN between 1985-2013
  • no survivors prior to 1999
  • 1999-2013: 9/24 (37.5%) survival, defined as alive at 1 year – most with a ‘favorable' neurologic outcome
  • PRIOR studies suggested that asphyxiation, either via snow burial (avalance) or water submersion had a lower chance of survival, but this study suggests that hypothermic arrest during submersion injury may be very different. It is hypothesized that very cold temps create faster cooling rates and aspiration of cold water may induce rapid protective cerebral hypothermia. So drowning victims (asphyxia by submersion in cold water may have a higher survival)
  • Hyperkalemia is bad (>8 is bad; >12 is dead)
  • Bottom Line: “No patient is dead until they are warm and dead” – current neuroprognostication can't identify OHCA patients who may be salvageable.  So assume they are!

Key ECMO Points:

  1. Profoundly hypothermic patients cannot generate high flow rates – possibly due to increase blood viscosity.  Consider larger cannulae. Torvinde uses 29F venous and 21F arterial as a starting point.
  2. Rewarm with a veno-arterial temperature gradient of no more than 10 degrees C. Faster rewarming may result in bubble formation. Torvinde does this via the water bath heater/cooler.
  3. Therapeutic hypothermia is still in play. Torvinde holds the core temp at 36 for 24-28 hours.
  4. “You're not dead unless you're warm and dead” – consider transporting potentially salvageable patients with a reliable history.

Torvind and AnnaThe Story of Anna Bågenholm was told in this article in the Lancet:

Torvinde

 

 

 

EDECMO 28 – The University of Utah EDECMO Experience and the ERECT Collaborative

The University of Utah ECPR Program

Joe TonnaJoe Tonna MD – Emergency Physician with fellowship training in intensive care, Associate Director of ECMO Services

 

Scott YoungquistScott Youngquist – Emergency Physician, Prehospital Specialist

 

Stephen McKellarSteven McKellar – CT Surgeon

 

 

 

 

 

 

Screen Shot 2016-06-08 at 11.57.19 PM

Building REANIMATE 1: a video montage

While preparing for #REANIMATE16 there were no simulators for ECPR. There were no commercially available models for ECPR cannulation. There was nothing.

We had to build it. From scratch.

This short video documents the building of #REANIMATE16: the first international endovascular resuscitation conference.

*special thanks to Jeremy Haywood for producing this video: jeremyhaywoodphotography.com

 

Thinking back on #REANIMATE16, I couldn't help but think of the iconic American movie ‘It's a Wonderful Life', featuring Jimmy Stewart. Although the audio soundbytes in this video may seem out of context, I hope the concept of ‘building' something from nothing was preserved:

~Joe

 

It's a Wonderful Life is a 1946 American Christmas fantasy drama film produced and directed by Frank Capra, based on the short story “The Greatest Gift”, which Philip Van Doren Stern wrote in 1939 and published privately in 1945. The film is now among the most popular in American cinema and because of numerous television showings in the 1980s has become traditional viewing during the Christmas season.

The film stars James Stewart as George Bailey, a man who has given up his dreams in order to help others, and whose imminent suicide on Christmas Eve brings about the intervention of his guardian angel, Clarence Odbody (Henry Travers). Clarence shows George all the lives he has touched and how different life in his community of Bedford Falls would be had he never been born.

Despite initially performing poorly financially because of high production costs and stiff competition at the time of its release, the film has come to be regarded as a classic. Theatrically, the film's break-even point was $6.3 million, approximately twice the production cost, a figure it never came close to achieving in its initial release. An appraisal in 2006 reported: “Although it was not the complete box office failure that today everyone believes … it was initially a major disappointment and confirmed, at least to the studios, that Capra was no longer capable of turning out the populist features that made his films the must-see, money-making events they once were.”[7]

It's a Wonderful Life is one of the most acclaimed films ever made, praised particularly for its writing. It was nominated for five Academy Awards including Best Picture and has been recognized by the American Film Institute as one of the 100 best American films ever made,placing number 11 on its initial 1998 greatest movie list, and number one on AFI's list of the most inspirational American films of all time. Capra revealed that the film was his personal favorite among those he directed, adding that he screened it for his family every Christmas season.

 

shinar bellezzo

#REANIMATE16 would not have been possible without ‘a little help from our friends’ from the Alfred ICU

Screen Shot 2016-02-29 at 1.28.52 PM

REANIMATE 2: September 12 & 13, 2016

REANIMATE 1 is now behind us. And it was a “yoooooooge” success (Reanimators from R1 will get that one!) On February 25 and 26, 2016 physicians, nurses and paramedics from around the globe met at the UCSD Simulation Center/Center for the Future of Surgery and immersed ourselves in the art and science of Endovascular Resuscitation: ECMO, ECPR, REBOA, bleeding-edge resuscitation, and more.    From  the entertaining (and for Bellezzo maybe a little humiliating!) didactic sessions to hands-on down-and-dirty sim sessions, participants were given the opportunity to train with the best educators in the world of resuscitative science. And now we are ready to make it even better!

REANIMATE 1 sold out one week after opening registration. Those who couldn't get into REANIMATE 1 made it onto a  waiting list for R2, which  is selling out fast. Register NOW and don't miss out!

Check out the video:

EDECMO 25.5 – (Part 2) an EDECMO short with Jim Manning – on location with the SAMU pre-hospital ECMO team in France

In followup to our discussion with Jim Manning MD (@JManning_UNC)  and Lionel Lamhaut (@LionelLamhaut) MD of the Service d’Aide Médicale Urgente (SAMU) for EDECMO Episode 25, the guys spent the last few days ‘just hanging out in Paris.”

The recent massacre in Paris certainly makes this topic..well…topical.

Manning spent several days with the prehospital ECMO team in France.  In this episode Zack interviewed Manning, who was on-location with the SAMU in France…and walks us through the experience of witnessing prehospital ECMO with the SAMU.

In the U.S., we aren't yet ready for pre-hospital endovascular resuscitation – indeed there are currently several barriers to overcome. But perhaps the Europeans are onto something here:

Femoral cutdown vs. percutaneous access? Discussed. Verdict?

Transporting a patient on ECMO:

You know, the thing is…that once you have a patient on ECMO, everything chills out…

-Jim Manning

Every patient gets:

  • Dobutamine: 5 ug/kg/min
  • Norepinephrine 3 mg/hr
  • pRBC 2 units
  • FFP 2 units

Flow goals: start 2.5-3 lpm…then slowly increase. Does this help quell reperfusion injury?

This is the exciting. This is fantastic. This is the future if you ask me. We are going to be doing this and its just a matter of time before the rest of us realize that…we are headed in the right direction

Jim Manning

Jim Manning

SAMU Ambulance

SAMU Ambulance

Lionel Lamhaut and the SAMU ambulance

Lionel Lamhaut and the SAMU ambulance

Manning & SAMU

Manning & SAMU

Torsades De Pointes with Rob Orman from ERCAST

This month Joe was honored to be a guest on Rob Orman's famed Podcast ERCast. Joe and Rob define Torsades de Pointes, talk about management, and explain why OVERDRIVE pacing isn't a real thing in the Emergency Department.

Check it out:

http://blog.ercast.org/torsades-de-pointes/