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

EDECMO 27 – A Real-World Case of a Crashing Multi-Drug OD Patient Saved with ED ECMO

mccollum2013

Dan McCollum MD

Dan McCollum MD
Assistant Program Residency Director at Georgia Regents University
Augusta, Georgia
Academic Medical center, Level 1 Trauma Center: census >90,000/yr

“If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad.”

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Case: 38 y/o female multi-drug OD on (possibly):

  1. Montelukast 10 mg (Singulair) – leukotriene receptor antagonist. mild tox profile (3698 pediatric ingestions from Texas Poison Control: 95% asymptomatic)
  2. Promethazine 25 mg (Phenergan) – Anticholinergic (56% tachycardia, 42% delirium, 2% mechanical ventilation, 1% hypotension)
  3. Cyproheptadine 4 mg  – Anticholinergic; mild tox profile (892% of OD in one case series had no or mild symptoms)
  4. Clonazepam 1 mg (Klonipin) – Common: respiratory depression and hypotension; Rare: heart block/dysrythmia
  5. Amitriptyline 25 mg – TCA – Hypotension.  QRS widening with R wave in AVR
    • Treatment:
      • antidote = sodium bicarbonate
      • crystalloid for hypotension
      • Pressors for refractory hypotension
  6. Amlodipine 5 mg – Calcium Channel Blocker – Common: Bradycardia, hypotension, heart block; Rare: apnea, pulmonary edema, ARDS, coma, Lactica acidosis, hypoerglycemia, bowel infarction
    • Treatment:
      1. IVF
      2. High Dose Calcium (inotrope)
      3. Pressors – Isoproterenol
      4. Glucagon
      5. Atropine
      6. High Dose Insulin – 1-10 unit/kg/hr infusion (consider simultaneous glucose infusion)

 

Timeline before ECMO:

  • 02:00-17:00     Estimated time of ingestion:  (2-15 hours PTA).
  • 19:00                 Presentation to ED
  • 19:30                 BP 55/33; sats 93% on 60% FiO2
  • 19:41                  PEA ARREST #1
    • Epinephrine, Atropine, Sodium Bicarbonate, Calcium Gluconate, D50
    • Narcan > No response
  • 19:54                  Bradycardia with pulse
  • 20:10                  Bicarbonate gtt
  • 20:15                  Epinephrine gtt
  • 20:18                  High Dose Insulin bolus, then gtt
  • 20:31                  TC pacing
  • 20:40                 Norepi gtt, Charcoal
  • 20:46                 CXR = pulmonary edema
  • 21:07                  Bivent initiation
  • 21:14                  Intralipid bolus
  • 21:16                  Glucagon
  • 21:21                  43/29 with sats 69% and pulse 70
  • 21:31                 pRBC transfusion initiated

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Total Meds used in resuscitation:

  • Calcium Gluconate:                21 Amps
  • Sodium Bicarbonate:             19 Ams
  • Epinephrine:                           9.5 mg + drips
  • Insulin:                                     ~150 units

Complications during hospitalization (but the patient is alive!):

  1. AF with RVR
  2. DVT
  3. ipsilateral limb ischemia > Necrotizing fasciitis > AKA
  4. Pleural Effusion > chest tube
  5. Bowel perforation (due to ischemia) > laparotomy
  6. Trach/PEG
  7. Abdominal Wall Abscess > I&D

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Learning Points:

  1. RUSH exam early for undifferentiated shock
  2. Restrictive lung strategy to avoid ARDS
  3. Multi-agent OD: contact Poison Control – they can actually help! 1-800-411-8080
  4. ECMO is a bridge to metabolism/recovery.

“If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad.” – Dan

*and special thanks to Dan McCollum for creating and sharing the Napoleon Dynomite memes.

EDECMO 26 – “ECPR is a Step Too Far” – Ho vs. Bellezzo: a SMACCback Chicago Cage Match

CHRIS HO VS JOE BELLEZZO – ECPR IS A STEP TOO FAR

***republished with permission from the SMACC team from: http://www.smacc.net.au/2016/02/chris-ho-vs-joe-bellezzo-ecpr-is-a-step-too-far/

Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago.

Chris and Joe are the director and vice-director respectively, of Emergency Medicine at Sharp Memorial Hospital in San Diego, California. They are two of the leading experts in ECPR, with Joe being one of the key players behind EDECMO. On a day-to-day basis, they are friends and colleagues, working together in one of the very few centers around the world to deliver ECPR. However in this Cage Match, friends become foe and there are no limitations to how far each will go to prove their side of the debate.

On the AFFIRMATIVE side, Chris Ho delivers a convincing argument for why ECPR IS a step too far. From lack of evidence to the cost of “re-animating the dead” and everything in between, Chris Ho delivers a practical approach to the argument and demonstrates without a doubt why we are not ready for this to be the next step in resuscitation.

On the NEGATIVE side, Joe Bellezzo delivers an outstanding rebuttal to “Dr Ho’s Nutty Brown Bullshit”. In an inspiring argument filled with anecdotes and occasional facts, Joe Bellezzo makes it impossible to think the ECPR shouldn’t be the next step in our ALS algorithm,

Despite strong arguments from either side, as in all debates, there must be a winner. Do you agree with the outcome?

If you want to find out whether Chris and Joe were able to kiss and make up, check out the exclusive ICN interview with the two, where they discuss more on ECPR.

Also check out the ‘SMACCback' interview of Ho and Bellezzo by Sophie Connolly and Alice Young of the SMACC Chicago team:

Ho-bellezzo-SMACC-CHICAGO-THE-INTERVIEWS

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

EDECMO 25 – ‘Ze ECMO TEAM.’ Manning and Lamhaut: Updates on ECMO, the new 7F REBOA Catheter, and Pre-hospital ECMO in France

In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut of the famed French SAMU (Service d'Aide Médicale Urgente).

Highlights:

2015 Resuscitation Science Symposium updates:

“ECMO is at the forefront of resuscitation science” – Jim Manning

The New REBOA Catheter: Pryor Medical – just obtained FDA approval for endovascular proximal control of non-compressible hemorrhage below the diaphragm.

At Sharp Memorial Hospital we currently use the 12Fr Chek-Flo sheath, paired with 12F (external diameter) CODA balloon occlusion catheter for non-compressible hemorrhage below the diaphragm.  Pryor Medical has just gained FDA approval to market their REBOA catheter – a 7F version that doesn't seem to require surgical repair of the arteriotomy site.  For those of us doing REBOA, this is a BIG DEAL:

Website Image 10-26-15

Selective Aortic Arch Perfusion Catheter (SAAP) – which is like a REBOA catheter but has a lumen large enough to perfuse blood (or a blood substitute) through.  Manning talks about what's sexy with his device.

 

Lionel Lamhaut from the French SAMU (Service d'Aide Médicale Urgente) gives us an update on their prehospital ECMO program in France:

SAMU Inclusion Criteria:

  1. Medical Cardiac Arrest
  2. Age < 75
  3. No Flow < 5 min (bystander CPR must be started within 5 min)
  4. Hypothermia is always considered
  5. Intoxications (of any kind) are always considered
  6. ETCO2 > 10

For review, check out our original discussion with ‘reanimateur' Dr. Lamhaut about prehospital ECMO: edecmo.org/17

In keeping with all of the in-hospital and out-of-hospital ECPR data accumulating, it appears that Lamhaut's team is also seeing a success rate (survival with CPC 1 or 2) of around 30% (final data pending publication).

 

Consider this: the modified cut-down technique. The French prehospital team, quite obviously, don't have ultrasound access in the field.  So instead of using ultrasound visualization of the femoral vessels, they necessarily use direct visualization.  Listen to this episode to hear the details…

 

 

 

 

EDECMO 24 – Weaning VA-ECMO, with Deirdre Murphy

In this episode, Zack and Joe talk with Deirdre Murphy, the Deputy Director of the ICU, director of the cardiothoracic ICU at the Alfred Hospital in Melbourne, Australia. 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.

As ED Docs, Zack and I find ourselves at the heroic end of the resuscitation spectrum when the dying patient goes on pump…but what happens at the other end? What happens in the hours, days, and weeks that follow?  Listen to this episode to find out…

 

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

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

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.

A paper just published in Intensive Care Medicine followed this algorithm:

(Intensive Care Med (2015) 41:902-905)

How to wean a patient from veno-arterial extracorporeal membrane oxygenation

Screen Shot 2015-09-07 at 12.26.16 PM

Some Notes

Signs of improvement

  • Pulsatility indicates the patient is getting better
  • ETCO2 starts to rise
  • Weaning Vasopressors

 

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)

Update:

Can we use ETCO2 to assess weaning?

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EDECMO 23 – ORNATO LIVES! – How ECMO Saved a Pillar of Resuscitation

Dept of Emergency Medicine_Joseph Ornato_MD

Dept of Emergency Medicine. Joseph Ornato MD

“They RSI'd me…they cannulated me…

Here I am today, two months later…”

Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015.  First: hats off!!! to the Emergency Department, the resuscitation team, the CT surgeons and entire staff at VCU. How it all unfolded is amazing! You MUST listen to this episode to hear the details…

Joseph P. Ornato, MD, FACP, FACC, FACEP

Dr. Joseph P. Ornato is professor and chairman of the Department of Emergency Medicine at Virginia Commonwealth University Medical Center in Richmond, Virginia. He is also medical director of the Richmond Ambulance Authority, the Prehospital Paramedic System serving Richmond, Va. Dr. Ornato is triple board certified (internal medicine, cardiology, emergency medicine) and is an active researcher in the field of cardiopulmonary resuscitation. Dr. Ornato is an editor of the journal Resuscitation. He is past Chairman of the American Heart Association's (AHA) National Emergency Cardiovascular Care Committee and its Advanced Cardiac Life Support Subcommittee. He chaired the National Steering Committee on the NIH Public Access Defibrillation Trial. He is currently consultant and cardiac co-chairman of the NIH Resuscitation Outcomes Consortium (ROC) and serves as principal investigator for VCU on the NIH-sponsored Neurological Emergency Treatment Trials (NETT) Network. Dr. Ornato is a member of the Institute of Medicine.

Ornato and EMS team

Dr. Ornato and the prehospital trauma team

joe-ornato-photo-4_10937792

 

We lose the equivalent of one medium sized American city to the problem of sudden, unexpected cardiac arrest each year. The best weapon we have against this killer is early defibrillation. We need to move quickly to saturate the chain of survival, particularly the early defibrillation  component, in every community.”

-Joe Ornato, MD, FACC, FACEP

EDECMO 22 – Managing the Crashing Tox Patient with ECMO – with Leon Gussow & Steve Aks from The Poison Review

 

…the key thing is to put them on ECMO when they need it, but not a minute sooner!

-Leon Gussow

In this episode Scott, Zack and Joe were all in the same room…in a conference room at the University of North Carolina, Chapel Hill – where we were doing ECPR studies in an animal model of cardiac arrest with Jim Manning. We spoke with legendary toxicologists Leon Gussow and Steve Aks about the role of ECMO and ECPR in the overdosed tox patient.

This is a fascinating discussion about the nuances of ECMO in the crashing intoxicated patient.

Check out THE POISON REVIEW and Subscribe to them in iTunes

GussowLeon Gussow MD,

University of Illinois Medical Center, Chicago
John H. Stroger Jr. Hospital of Cook County
Emergency Medicine News “Toxicology Rounds”
Medical Editor of ‘The Poison Review”

aks-1-186x250

Steve Aks DO, FACMT, FACOEP, FACEP

Director, Toxicology Fellowship Program, Department of Emergency Medicine, Cook County Health and Hospitals System


 

Some Unique Situations:

ECMO and intralipid?

  • What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient. Clin Toxicol (Phila). 2015 Mar;53(3):145-50. doi: 10.3109/15563650.2015.1004582. Epub 2015 Jan 29.
  • Bolus dose intralipid before ECMO is reasonable and should not result in significant pump complications with our current oxygenators.  However, starting intra-lipid after the patient is on bypass won't likely provide much more benefit and could shorten the life of your oxygenator.

ECMO and Dialysis?

  • Hemodialysis can be done in-line with the ECMO circuit, but its preferred to use a separate dialysis catheter placed at a remote site (ie the IJ).  A dialysis circuit CAN be spliced into the ECMO circuit, but is a little more complicated.

Mitochondrial and Cellular Respiration Poisons (dinitrophenol & Cyanid) and Carbon Monoxide?

  • ECMO is of NO USE in these intoxications.

EDECMO 21- The Vienna Project: A Randomized-Controlled Trial of ECPR for Out-Of-Hospital Cardiac Arrest


SchoberAndreas Schober is an Emergency Medicine physician and resuscitationist from the Medical University of Vienna. Dr. Schober is a world-expert in resuscitation, ECPR, and cardiac arrest. We met Schober in Chicago at the 2014 American Heart Association (AHA) Resuscitation Symposium (ReSS) where he presented their experience with a “Load & Go” model for out-of-hospital cardiac arrest (OHCA): Screen Shot 2015-05-01 at 10.08.03 PM


In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing “Load & Go” (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. “standard care” (staying on scene until the patient achieves either ROSC or is pronounced dead).  Zack and Andreas talk about the impact this could have on the future of ECPR for OHCA.

Announcements:

SMACC Chicago 2015: There is still time to register for SMACC – the biggest and baddest ED Critical Care conference in the World. Just check out the lineup of speakers! You won't want to miss this.

Reanimate San Diego 2016:  The EDECMO team has put together a crew of world-class educators to teach you how to set up an ED ECMO program, teach you how to initiate ECPR in arresting patients, and teach you how to manage patients after they are on “on-pump”. Please join us in “America's Finest City,” San Diego, California, for 2-day immersion in ECPR. We are limiting the conference size to maximize your learning experience, so registration will sell out quickly:

Register for Reanimate San Diego 2016

 

**Special thanks to Camille Hudon for providing the “International Introduction”, in French, to this episode!!!  That was recorded in a small restaurant in Montreal during Bring Me Back To Life 2014

 

 

EDECMO 20 – The Golden Hour & the Rule of 3’s: Optimizing the Critical First Hour on Heart-Lung Bypass

Announcements

Upcoming Conferences:

  1. SMACC 2015: June 23-26, 2015. The biggest and baddest critical care conference of the year is in Chicago this year.
  2. Essentials of Emergency Medicine 2015. October 13-15, 2015. The Big Show. In Vegas. At the Cosmopolitan.
  3. Reanimate San Diego. February 25-26, 2016. The essentials of ECMO in 2 glorious days. Here is a sneak peak at the Reanimate 2016 Promo Video.

Flipped Classroom SMACC ECMO Workshop 2015

For those taking the upcoming ECMO courses with us, download both of these 2 attachments. The first is a diagram of a traditional ECMO circuit – its nice to print this out and follow along. Not every circuit is the same and we have ours custom built by Maquet.  The second is a self-study course.  While it isn't necessary to review these before our workshop, it will really put you ahead of the game and we focus more on procedures.

Custom Maquet Circuit

Figure 1. The Custom Maquet ECMO Circuit

Study Guide

Screen Shot 2015-04-04 at 11.04.36 PM

Review of the 3 stages of ECPR

  1. STAGE 1: Placement of any commercially available vascular catheter in the femoral vein and femoral artery
  2. STAGE 2: Replacement of each catheter with ECMO cannulae. Checkout EDECMO 5: Cognitive Task Management for ED ECMO Stages 1 and 2. Also, we learned several cannulation pearls from Stephen Bernard in EDECMO 14 Part 1 and Part 2
  3. STAGE 3: Initiation of Total Heart Lung Bypass

ECMO Circuit Setup:

  1. Plug in the machine and power-on the heater-cooler and the Rotaflow console.
  2. Unpackage the circuit and hold it up to orient yourself.
  3. Mounting the Rotaflow Pump to the Pump Drive

    Mounting the Rotaflow Pump to the Pump Drive

    Attach the Oxygenator to the bracket and the pump to the pump-drive; hang the distal ends of the circuit (the tubes that will connect to the patient) from the IV pole.

  4. Apply ultrasonic contact cream to the flow probe contact site
  5. Remove and DISCARD the yellow de-airing exit port cap on the top of the oxygenator.
  6. Connect the water lines from the heater-cooler to the Quadrox Oxygenator & open the stopcocks.
  7. “Run the circuit”, making sure that the recirculation bridge is OPEN, arterial and venous tubing is CLAMPED, rapid-prime tubes are CLAMPED, both of the blood sampling “pig tail” stopcocks are CLOSED.
  8. PRIME the circuit:  Priming the Circuit: Filling the ECMO circuit (tubing, pump, oxygenator) with crystalloid priming solution (ie Isolyte), adding 2,500 units of heparin to each 1-liter bag of priming solution.  We discuss the finer details of this with Greg Griffin, the Chief Perfusionist at the University of North Carolina, Chapel Hill in EDECMO 8.
    1. squeeze all air out of prime bag INTO the circuit and then hang those bags from the IV pole.
    2. Open the ratchet clamps: the circuit will fill (prime) by gravity.
  9. Connect the Oxygen supply line (from Oxygen tank) to the Oxygen inlet port on the oxygenator
  10. De-air the circuit:
    1. Remove the patient-lines that are hanging from the IV pole and drop them below the fluid level of the IV bags to prime them. ratchet-clamp them closed. Now the entire circuit has been primed.
    2. Open the recirculation bridge and briefly increase the RPM on the Rotaflow Console until the pump is running at 4LPM for 15 seconds. This will de-air the circuit as air is release from the de-ar exit port on the Oxygenator.  ***Some air may still be trapped in the pump though. So…
    3. Turn the RPM on the Rotaflow console to zero. Allow any air in the pump head to flow into the PVC tubing between the pump head and the oxygenator and then return the RPM to 4LPM to complete the de-airing process.
  11. Calibrate the flow-probe: Reduce pump speed to zero RPM, clamp off the recirculation bridge and “ZERO” the flow probe by pushing the “ZERO” button for a few seconds. The console will beep.

Initiation of Total Heart Lung Bypass (STAGE 3)

Maquet-Circuit-mockup.001So you've cannulated your patient while your ECMO-nurse has primed the circuit with crystalloid.  Connect the venous and arterial PVC lines from the circuit to the ECMO cannulas in the patient. And since this is STAGE 3, we've established the EDECMO “Rule of 3's.”  There are 3 things you need remember before, during, and after you've initiated heart-lung bypass.

A.  3 Critical First Steps BEFORE initiating bypass:

  1. Heparinize the patient = 5,000 units IV bolus
    1. Heparin 2,500 units in each liter of priming solution
    2. Bioline coating
    3. ACT > 200 seconds
  2. Attach O2 source (@ 4-6 LPM) to the Oxygenator
  3. No open central lines (CVP, Swan-Ganz, etc).

CLOSE the Recirculation Bridge and OPEN the venous and arterial ratchet clamps. Turn up the RPM on the Rotaflow console. Your patient is on heart-lung bypass.

B.  3 Critical things to confirm JUST AFTER your patient is on bypass:

  1. The arterial line should have bright red (oxygenated) blood and the venous line should be dark-red.
    1. IF you see BRIGHT-BRIGHT, you've incorrectly placed both cannulas in the same vessel.
    2. If you see DARK-DARK, there is a problem with the oxygenator. Confirm your O2 supply to the oxygenator.
  2. Your cannulas are secured to the skin with suture and tape.
  3. The recirculation bridge is CLOSED.

C.  3 Critical Values to Optimize ECMO

1. Optimize Blood Flow:

  • Establish the MAXIMUM blood flow (LPM) at the lowest RPM. GOAL = 60 ml/kg
  • Increase the RPM on the Rotaflow console until:
    1. Any further increases in RPM does not result in increased blood flow (LPM).
    2. The circuit begins to “Chatter.”
    3. SvO2 > 70%

IF flow is too low: 1. Infuse more volume 2. reposition venous cannula 3. add a venous cannula

2. Arterial Blood Gas Analysis:

  • GOAL:  “normal” ABG (PaO2 80-100; PaCO2 35-45)

IF PaO2 < 80,   THEN you need more blood flow through the Oxygenator

IF PaO2 > 100, THEN its time to add a gas blender and turn down the FiO2 from the Oxygen source

IF PaCO2 < 35, THEN decrease your “Sweep Gas Rate” by lowering the LPM on the O2 supply

IF PaCO2 > 45, THEN increase your “Sweep Gas Rate” by increasing the LPM on the O2 supply

 

3. Optimize Systemic Vascular Resistance (SVR)

SVR = (MAP – CVP) x 80
C.O.

SVR = (MAP – 0)      x 80
Blood Flow

***GOAL = SVR > 800

IF, for a given blood flow, the MAP is unreasonably low, you need a pure VASOPRESSOR = Phenylephrine

IF, for a given blood flow, the MAP is unreasonably HIGH, you need a VASODILATOR = Nitroprusside

Or, Goal MAP > 65

 

 The Shinar 3000: Tall Paul ECMO Simulator

Zack built an ECMO simulator model in his garage. Here is the video:

Tall Paul Compilation 3 from Joe Bellezzo on Vimeo.