EDECMO 16: The End-of-Life Matrix & The Ethics of Advanced Resuscitation with Dr. Cyrus P. Olsen III, D.Phil.

In this episode, Zack and Joe talk with Dr. Cyrus Olsen, Oxford graduate and expert in bioethics about how to decide when to “Stop the Train”.

 


WARNING: This is going to get waaaaay touchy-feely and waaaaay outside of Joe’s comfort zone (Zack, on the other hand, is feeling right at home here). With that in mind…

“How young is too young…” to withhold resuscitation?

The Dilemmas:

  1. How old is too old…or better yet…how young is too young?  aside from routine resuscitation: drugs, chest compressions, shocks, is there an age that is too old for ECMO? We currently use a soft cutoff of 75 yoa. Lets take all of the variables out of the equation and just assume a person has ZERO medical problems and is on ZERO medications. They ambulate on their own, live independently, and they believe they have a good quality of life.  In this scenario, is there any age that is too old for ECMO? This should be our starting point and then move down (in age) from there.  The 95 year old is easy.  The 40 year old is easy. All the rest are tough and that’s where we will get criticism for “doing too much.”
  2. Concrete resuscitation cutoff vs. a graded response?  Whatever we decide is the cutoff (age, quality of life, comorbidities), should we use the exact same set of criteria for even initiating CPR as we do for ECMO? Should they be the same? In other words, should we have the same set of criteria for both or should there be a graded response to the dying patient (over 75 I do CPR and intubate but don’t do ECMO but under 75 I go full-court-press and possible ECMO)?
  3. Only Reverse the Reversible. Somehow we need to identify inevitable death and allow that to happen. Greg Henry always says, “Despite all the advances of modern medicine, the death remains the same: one per person.”  But when we can’t be sure that death is inevitable, does everyone deserve a shot?  In other words, should we be making that decision on the front end (ED) when little information is known to us, or should that be sorted out on the back end…in the ICU?  Is there a way to tell a resuscitationist that its ok to err on the side of over-resuscitation, so long as your intent to is to reverse the reversable? Peter Safar’s quote, “Death is not the enemy, but occasionally need help with timing.” exemplifies this.
  4. Define “Quality of Life”. How do we determine “Quality of Life”? Who decides this in the heat of the moment? The doctor or the family?
  5. What is the real goal of resuscitation? Should we only resuscitate people who were previously healthy and have a chance of 100% recovery? It seems we’ve come to a place where the knee-jerk reaction by ED doctors is to do full CPR on everyone and then see what happens.  So how do we determine when and where to stop?
  6. MD paternalism vs. patient automony = “The Tyranny of Choice.”

 

The Episode Play-by-Play:

Dr. Olsen talks about the first concept: The “3 Senses of Dignity” from Daniel Sulmasy MD, PhD, a spokesman for the President’s Council on Biotheics

  1. Intrinsic Dignity = your value for just being human
  2. Attributed Dignity = your “market value” to society
  3. Inflorescent Dignity = your “flourishing”; or your quality of life

Utstein Variables for CPR

 The Life Matrix and the Functional Threshold:

Life Matrix

“We cannot predict the neurologic outcome of patients that are in cardiac arrest” – Zack Shinar MD

Bottom line: As a resuscitationist in the Emergency Department you MUST err on the side of aggressive curative care, unless there is compelling evidence to do otherwise.  You are on ethical solid-ground to approach resuscitation in this fashion. But…you will fuck this up. And that’s ok if your heart is in the right place. And once you realize that your patient does not belong in the AGGRESSIVE CURATIVE arm, you begin AGGRESSIVE PALLIATIVE care. In either case, you care is MAXIMALLY AGGRESSIVE.  

Joe & Zack recording

Joe & Zack recording

 

 


Dr. Cyrus P. Olsen III, D.Phil.

Dr. Cyrus P. Olsen III, D.Phil.

Dr. Cyrus P. Olsen, D.Phil.

Dr. Olsen is a graduate of the University of Oxford and is now an Associate Professor at The University of Scranton, in Pennsylvania where he specializes in Ethics and Theologic Studies. He has published extensively in the arena of medical ethics and sits on the IRB (Institutional Review Board) for both human and animal studies at his institution. A graduate of the Comparative History of Ideas Program at The University of Washington, and Systematic Theology from The University of Oxford, his research and teaching address many aspects of human studies and bioethics.

 


Medical Journal Articles on the Ethics of Resuscitation Discussed in this Episode

Circulation- Ethics of CPR

Ethics of Resuscitation – Hayes

Freedom from the Tyranny of Choice

Br. J. Anaesth.-1997-Mohr-253-9

IMG_8217_2


 

Trackbacks:

1. Emcrit Podcast 25: End of Life and Palliative Care in the ED – Scott Weingart from the Emcrit Podcast

2. Emcrit Podcast 93: Critical Care Palliation with Ashley Shreves

EDECMO 15: The CHEER Trial & Part 2 of our Interview with Dr. Stephen Bernard

In this episode Zack and Joe discuss the CHEER Trial (mechanical CPR, Hypothermia, ECMO, and Early Revascularization) and follow up with Dr. Stephen Bernard with a few more questions about ECMO at the Alfred. Just days after we published our initial interview With Dr. Stephen Bernard from the Alfred Hospital in Melbourne, Australia, the CHEER Trial was published.

Background:   Recently, we reviewed two big papers in the ECPR (Extracorporeal Cardiopulmonary Resuscitation) World: 1.) The Chen Trial (Lancet 2008): a large prospective observational study of in-house arreest (IHCA), out of Taiwan, that showed 32.6% (ECPR) benefit vs. 17% (non-ECPR); and 2.) The Save-J Trial (Resuscitation 2014): a large prospective observational study of Out-of-Hospital cardiac arrest (OHCA) that showed a 11.2% (ECPR) benefit vs. 2.6% (non-ECPR). Indeed these numbers are impressive! We all know that we need a randomized, controlled trial (RCT) but until then the guys at the Alfred Hospital in Melbourne, Australia decided to up the ante and published the initial findings of this pilot study. That study was called CHEER.  This amounts to a hyper-aggressive, bundled protocol that begins on the street (EMS) and ends in the cath lab, whereafter world-class critical care has resulted in some remarkable initial numbers.

 

Screen Shot 2014-10-13 at 11.10.27 AMCHEER (mechanical CPR, Hypothermia, ECMO, & Early Revascularization)

This is a single-center, prospective, pilot study that was done over 32 months.  The primary outcome measure was short and long-term outcomes at CPC 1 or 2 (excellent neurologic outcome). The guys down-under generated inclusion criteria to capture the most salvageable patients who suffered out-of-hospital cardiac arrest (OHCA), combined those with in-hospital cardiac arrest (IHCA) patients and applied the CHEER algorithm:

  • CPR (using the Zoll Autopulse)
  • Hypothermia (initiated intra-arrest with iced saline)
  • ECMO (cannulation in the ED by intensivists)
  • Early Revascularization (aka a trip to the cath lab)
Autopulse

Zoll Autopulse (TM)

And all this was begun in the prehospital setting. Since the EMS system in their neighborhood is a single-provider system, they were able to get support from Zoll Pharmaceuticals to supply all of their rigs with their mechanical chest compression device – the Zoll Autopulse. Patients who met inclusion criteria were met by EMS, put on the Autopulse, and transported to the Alfred. EMS also began intra-arrest cooling by rapid infusion of iced saline at 30cc/kg. On arrival to their Emergency Department, intensivists met the patient and began the cannulation process. Once on ECMO the patients were immediately brought to the cath lab for revascularization. IHCA patients received the identical protocol, obviously minus the limo ride to the hospital.

In 2014 this amounts to a super-aggressive bundle therapy that just makes us salivate over here in the US.  Initiating intra-arrest cooling and mechanical chest compressions in the pre-hospital setting is formidable goal for us.

Their results: 26 patients were entered into the protocol (11 with OHCA, 15 with IHCA). The median age was 52 years. ECMO was established in 24 (2 patients in the OHCA arm were pushed through the protocol but didn’t actually go on pump; one was cannulated but achieved ROSC prior to going to cath lab and therefore was not put on bypass, and the other patient had a failed cannulation attempt but was taken to the cath lab anyway (presumably on Autopulse) and survived. Both OHCA patients and IHCA arrest patients were grouped together in their outcome data. ROSC (return of spontaneous circulation) was achieved in 25 (96%) patients. 13/24 (54%) were able to be weaned from ECMO support and survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%).  These are remarkable initial results that higher than what we’ve seen in larger studies.

Talking points:

  • Why such good outcomes? The patient-oriented outcomes in this pilot study are remarkable. Why are their numbers so much higher than much larger studies we’ve seen in the past? Was it the small sample size? Was it because they grouped the OHCA and IHCA arrest patients into their outcome measures (with IHCA outcomes historically known to be much better)? Was it the bundle?
  • Which therapy really made the difference? Was this the result of aggressive pre-hospital cooling? Was it the result of a “load-and-go” EMS policy with proper use of the mechanical chest compression device? Was it rapid deployment of ECPR? Likely, its all of these. Like much in the resuscitation world, its likely the bundle (the CHEER) followed by excellent critical care at their ECMO facility. But we can’t say for sure.
  • Mechanical chest compression devices (ie the Zoll Autopulse or the LUCAS2 by Physio-Control). 3 studies so far have basically shown no benefit of these devices over good quality human CPR. But most resuscitationists who have used these devices believe in their utility. I believe in their utility. Many of the reasons are less tangible than the patient-oriented outcomes measured in those papers. One of those intangibles is highlighted in this study: patients can be safely and rapidly transported to the ED with excellent ongoing chest compressions, and rescue personal can be safely strapped into their harnesses during transport.
  • ECMO.
    stratos

    Red Bull Stratos

    Study after study has shown that the single biggest key to the success of ECPR is the time to initiation of bypass. So in this trial, the rapid transport with Autopulse and rapid activation of the ECMO team optimized this interval.  But we believe the success of this study would not have been possible without ECMO as the final bridge that could make all this happen.  To highlight this concept, on October 14, 2012 Austrian skydiver Felix Baumgartner jumped from the Red Bull Stratos capsule 24 miles above New Mexico, USA and broke  3 World Records: a.) Exit Altitude (24.2145 miles) b.) Maximum Vertical Speed (843.6 mph) and c.) Vertical Distance of Freefall (119,431 ft). And he broke the sound barrier.

    Baumgartner parachute

    Baumgartner parachute

    Advancements in technology, human transport, a willingness to push the envelope, and huge set of balls, made that happen. But that couldn’t have been done without a relatively simple device that has been around for decades that allowed Baumgartner to land on his feet: the parachute – a device that “bridges” the skydiver from potential free fall-death to soft landing with proper deployment.  ECMO can be thought of as one such device.

  • Update 10/25/2014 Hot off the press: Google Senior Vice-President Alan Eustace one-upped Baumgartner on October 24th when he jumped 135,890 ft from a helium balloon to become the World-record holder for highest parachute jump. Additionally, Eustace used no corporate funding and did not use a capsule, opting instead to be carried into the stratosphere in a space suit alone. Here are some photos of that:

    • Alan Eustace, a senior vice president at Google, broke the world record for high-altitude jumps.

      Alan Eustace, a senior vice president at Google, broke the world record for high-altitude jumps.

      Alan Eustace ascending to 135,890 feet on Friday. He later plummeted to earth at speeds reaching 822 miles per hour, setting off a small sonic boom heard by people on the ground.

      Alan Eustace ascending to 135,890 feet on Friday. He later plummeted to earth at speeds reaching 822 miles per hour, setting off a small sonic boom heard by people on the ground.

      Alan Eustace, Senior Vice President of Google

      Alan Eustace, Senior Vice President of Google

      Mr. Eustace landing. He wore a specially designed spacesuit with a life-support system.

      Mr. Eustace landing. He wore a specially designed spacesuit with a life-support system.


      MORE!

      1. Check out Part 1 of our interview with Dr. Bernard
      2. Check out INTENSIVE, The Alfred’s educational website and blog

      Announcements:

      1. Sign Up for the Mailing List

      Subscribe to our Mailing List:  (EDECMO will NEVER Spam)

      2. iTunes Reviews: Is the EDECMO podcast helpful to you? Please leave us a review on EDECMO page in iTunes

      3. EDECMO Voicemail: 1-470 – ED ECMO 1 (leave us a voicemail comment or question and we may use it as part of the show!)

      4. Upcoming Events:

      • “Bring Me Back to Life!” October 21, 2014 (That’s next week!). This is an All-Star Lineup of Resuscitationists:

      Screen Shot 2014-10-13 at 10.59.43 AM

 

 


EDECMO Episode #14: ECPR with Stephen Bernard 1/2

This is the first in a 2-part series on ECPR with Dr. Stephen Bernard.  In today’s episode, Joe and Zack interview Dr. Stephen Bernard about Extracorporeal Cardiopulmonary Resuscitation (ECPR) and how they do it The Alfred Hospital in Melbourne, Australia.   As most of you  know, Dr. Bernard has been a huge contributor to the critical care world.  While he is widely known for his work with therapeutic hypothermia (2002 NEJM ‘Treatment of Comatose Survivors of Out-of-Hospital Cardia Arrest with Induced Hypothermia), Dr. Bernard is now at the forefront of ECPR, reshaping pre-hospital dogma and intra-arrest management, including the use of ECMO during cardiac arrest.

Stephen Bernard MB BS, MD, FACEM, FCICM

Stephen Bernard MB BS, MD, FACEM, FCICM

Professor Stephen Bernard MB BS, MD, FACEM, FCICM

Senior Intensive Care Specialist
The Alfred Hospital
Melbourne, Australia

Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University
Medical Advisor, Ambulance Victoria
Member, Medical Advisory Committee, Ambulance Victoria
Member, Clinical Practice Guideline Review Committee, Ambulance Victoria
Member, Clinical Incident Review Committee, Ambulance Victoria
Co-Chair, Steering Committee, Victorian Ambulance Cardiac Arrest Register, Ambulance Victoria
Member, Clinical Committee, Council of Australasian Ambulance Authorities
Medical Officer, Australian Formula 1 Grand Prix
Medical Officer, Australian Motorcycle Grand Prix
Member, National Medical Advisory Committee, Confederation of Australian Motor Sport
Supervisor of PhD students x2
Director of Intensive Care, Knox Private Hospital
Chair, Medical Advisory Committee, Knox Private Hospital
Member, Patient Care Review Committee, Knox Private Hospital


 Today’s Episode:

  1. Development of the ECPR protocol at the Alfred in Australia
    • Reconstruction of the “Chain of Survival”
    • TOR (termination of resuscitation)
  2. The Alfred ECMO CPR Guideline 2014 version 13: This is the PDF version of their latest ECPR protocol.
  3. The CHEER (CPR, Hypothermia, ECMO and Early Reperfusion)
    • Check out a GREAT lecture on CHEER by Dr. Bernard that was presented on the Intensive Care Network run by Oli Flower and Matt MacPartlin
    • Registry: clinicaltrials.gov registry
    • Updated CHEER results:  You gotta listen to the podcast! This stuff is In Press and soon to be published

 


More!

Screen Shot 2014-10-01 at 10.47.45 AM

Evid-ECMO 2: Veno-Venous ECMO in ARDS – The CESAR Trial & ANZ-ECMO

Episode 2 of Evid-ECMO features  Dr. David Willms, who is the Director of Critical Care Medicine at Sharp Memorial Hospital. Dr. Willms has over 25 years of experience with VA and VV ECMO and is an amazing resource for us at our hospital. Dr. Willms has been a key player in the development of our highly successful ECMO program at Sharp. Zack and Dave discuss two of the “big” articles in VV-ECMO for ARDS:

 

CESAR TrialArticle 1: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

PDF: cesar-trial

Identification: 

Title:  Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

Authors:  Giles J Peek, Miranda Mugford, Ravindranath Tiruvoipati, Andrew Wilson, Elizabeth Allen, Mariamma M Thalanany, Clare L Hibbert, Ann Truesdale, Felicity Clemens, Nicola Cooper, Richard K Firmin, Diana Elbourne, for the CESAR trial collaboration

Location: UK-based multi-center trial

Source: Lancet. 2009 Oct 17;374(9698):1330

PMID: 19762075

Introduction:

Problem:  Does ECMO provide improved safety, efficacy and cost-effectiveness, when compared to traditional therapy, in patients with severe ARDS?

Significance: This is the first positive RCT that shows a statistically significant benefit of VV-ECMO for severe ARDS.

Methods:

Study Type: Randomized Controlled Trial

Subjects: 180 adults with severe ARDS were randomized to receive conventional management or referral to ECMO center.

Primary End-Point: Death or severe disability at 6 months.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusions: 
      • 6 month survival without disability: 63% ECMO group vs. 47% conventional group.
      • Quality-adjusted life years at 6 months: ECMO group showed a gain of 0.03 gain

****THE BOTTOM LINE:  EDECMO Critical Assessment:  If you need a paper to support your use of VV ECMO for severe ARDS, this is your ammunition.

 


 

Screen Shot 2014-09-25 at 10.11.17 PMArticle 2:  Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

PDF:  ANZ ECMO

Identification:

Title: Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

Authors: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators*

Location: Australia and New Zealand

Context:  The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO).

Source: JAMA, November 4, 2009—Vol 302, No. 17

Introduction:

Purpose: To describe the characteristics of all patients with 2009 influenza A(H1N1)– associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes.

Significance: 

Methods:

Study Type: Retrospective Observational Study

    • Subjects: All patients with 2009 influenza A (H1N1)- associated ARDS treated with ECMO

****THE BOTTOM LINE:  EDECMO Critical Assessment:  In 2009, VV ECMO was used with success to combat severe ARDS caused by Influenza A (H1N1).

David Willms MD Board Certified in Critical Care and Pulmonary Medicine

David Willms MD
Board Certified in Critical Care and Pulmonary Medicine

If you have a question for Dr. Willms you may post it in the comments section below or email him directly at david.willms@sharp.com

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…  

Evid-ECMO (Evidence for ECMO): Critical Analysis of the ECMO literature #1

Both of these articles are fantastic. We review these two articles and describe their impact on the ECMO World:

Article 1: Conventional CPR vs. ECPR for In-House Cardiac Arrest (CPS Chen Lancet Study)

Identification:

Title:  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

Authors: Chen, Lin, et al.

Location: National Taiwan University Hospital; Taipei, Taiwan

Source: Lancet 2008; 372: 554-61

ClinicalTrials.gov #: NCT00173615

Introduction:

Problem: Comparing ECPR to conventional CPR for in-hospital cardiac arrest. Prior studies that showed a  benefit of ECPR over conventional CPR may have had selection bias. Prior studies also included all causes of arrest whereas this study attempts to focus on arrest of cardiac origin.

Purpose:  Is ECPR superior to conventional CPR for in-hospital cardiac arrest of cardiac origin?

Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for in-house arrest.

Methods:

Study Type:  Prospective Observational with Propensity-Score analysis matching

        • Single-Center
        • 3 years
        • 975 total patients; 172 patients: conventional CPR = 113; ECPR = 59

Subjects:  18-75 YOA; witnessed cardiac arrest of cardiac origin who underwent CPR for longer than 10 min. Matching based on propensity-score;

      • CPR team: senior medical resident, junior residents, RT, several ICU RN’s. *residents were cannulating!

Primary End-Point: Survival to hospital discharge, with sub-analysis of neurologic outcomes.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusion:
      • Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.
      • Survival to Hospital discharge:
        • Unmatched: 28.8% ECPR vs. 12.3% conventional CPR
        • Matched: 32.6% ECPR vs. 17.4% conventional CPR

****THE BOTTOM LINE:  EDECMO Critical Assessment:

    • Good study that showed a benefit of ECPR over conventional CPR for in-house arrest for short and long-term patient-oriented outcomes.
    • Propensity matching method reasonably mitigated selection bias
    • 3 patients in the ‘conventional CPR’ arm were later put on ECMO because of persistent shock > Is there an implied benefit of ECMO for the post-cardiac arrest syndrome?
    • Criticisms/Confounders
      • Single-Center
      • Patients in the ECMO group had higher incidence of LVAD, intervention, and heart transplant.
      • first documented rhythm of VT/VF (49% ECPR vs. 32% CPR) was significantly higher in ECPR group; and asystole (22% ECPR vs. 27% CPR) was higher in the CPR group: ? selection bias?
      • Location of arrest/CPR may make a difference (Emergency Department vs. ICU/Operating room)
      • Failed conventional CPR was defined as CPR without ROSC at 30 minutes – is this timeframe too short.  What if conventional CPR were continued for 60 min?
      • No TTM or hypothermia in either group.

 

Article 2:  CPR vs. ECPR for Out-of-Hospital Cardiac Arrest (SAVE-J)

Identification:

Title:  Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study

Authors: Sakamoto, Morimura, Nagao, Asai, Yokota, Nara, Hase, Tahara, Atsumi, SAVE-J Study Group

Location: Yokohoma City University Graduate School of Medicine, Yokohama, Kanagawa, Japan

Source:  Resuscitation 2014 Jun;85(6):762-8

Introduction:

Problem: Does ECPR improve patient-oriented outcomes after OHCA? Prior to this study, the effects of ECPR on long-term neurologic outcomes were unknown.

Purpose:  To determine whether ECPR is better than conventional CPR for short and long term neurologic recovery for patients who suffer OHCA

Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for OHCA.

Methods:

Study Type:  Prospective Observational;

    • multi-center: 46 centers: 26 ECPR, 20 non-ECPR
    • 3 years
    • 454 patients: Conventional CPR = 194; ECPR = 260

Subjects: 20-75 YOA; VF/VT arrest; <45 total arrest time;

Primary End-Point: Rate of favorable outcomes (CPC 1 or 2) at 1 and 6 months after OHCA.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusion: In OHCA due to VF/VT, a treatment bundle of ECPR, TH (TTM?), and IABP was associated with improved neurologic outcomes at 1 and 6 months.
      • Intention-to-treat Analysis:
          • 1 month:
            • ECPR  = 12.3%
            • Non-ECPR = 1.5%
          • 6 months
            • ECPR = 11.2%
            • Non-ECPR = 2.6%
      • Per-protocol Analysis:
          • 1-month
            • ECPR = 13.7%
            • Non-ECPR = 1.9%
          • 6-month
            • ECPR = 12.4%
            • Non-ECPR = 3.1%

****THE BOTTOM LINE:  EDECMO Critical Assessment:

    • Excellent multi center study a benefit of ECPR over conventional CPR for OHCA for short and long-term patient-oriented outcomes.
    • Criticisms/Confounders:
      • Rate of use of TTM/TH and IABP were higher in ECPR group.
      • Choice of ECPR vs Non-ECPR was dependent on individual centers with each center doing one or the other but not both.  In other words, does the quality of care at an ECPR center trump the quality of care at a non-ECPR center and does that impose bias?

EDECMO Episode 12 – The Nurse-Based ECMO Program at Sharp Memorial Hospital with Suzanne Chillcott RN, BSN

In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a “nurse-run” ECLS program.  There is no lack of enthusiasm over the concept of doing ECPR in the Emergency Department.  As most of you already know, we think ECPR is the wave of the future for resuscitation.

Suzanne Chillcott BSN, RN Mechanical Circulatory Support Lead

Suzanne Chillcott BSN, RN
Mechanical Circulatory Support Lead

So you think  you want to set up the next ED/ICU ECPR program?  You think you want to do ECPR in your Emergency Department or ICU?  But where to begin? Hopefully this episode will hopefully answer many of those questions:

ECLS Program Models

Physician resuscitationists cannulate. But you need an “ECMO team” to prime the circuit, help initiate bypass, trouble-shoot the machine, and manage the patient after bypass is initiated.  But who is going to do that?  Who has jurisdiction over your ECMO program?  Well, if you are working at an institution with an active cardiothoracic surgery program, chances are you already have these roles established; and I  recommend you speak to the Chief of your CT surgery team.  But for the sake of argument lets pretend you are starting an ECMO/ECLS/ECPR program de novo. What are your options?

Well, whomever is going to do this MUST be “in-house.”  In the ED, Emergency Physicians should be cannulating because we are already right there. We are running the code. We should be the ones doing the cannulation. And the same goes for intensivists in the ICU.    There simply isn’t time to call in a specialist to cannulate. The same goes for your ECMO team: they must be “in-house.” It would seem to make sense that perfusionists would be the first-responder ECMO team, however at many institutions (ours included) perfusionists aren’t “in-house 24/7.”  So there are now 3 main ‘models’ to address this:

  1. Perfusionist-based: Some facilities, usually teaching hospitals with very active ECMO programs, have in-house perfusionists.  In those cases the perfusionist is usually the “first-responder.”  In some cases the perfusionists handle all bedside activities from start to finish. In other cases the perfusionists help initiate ECMO and RN’s or respiratory therapists (RT’s) will ‘babysit” the machine when active adjustments aren’t being made.
  2. RT-based: When Shinar and I were at the University of North Carolina Chapel Hill, we witnessed this type of program.  While the perfusionists there are doing all the heavy lifting, they have trained their RT’s in supervising ECMO.
  3. Nurse-based: ICU nurses  are cross-trained in ECMO.  This is the model we use at Sharp Memorial Hospital in San Diego.  ICU nurses are trained in all aspects of ECMO and the ICU staffing is setup such that there is always at least 2 RN’s in the SICU who are ECMO-ready.  If we have an ECPR case in the ED we call the SICU. Quickly those nurses temporarily hand-off their assignments and come to the ED.

Establishing an ECMO Program at Your Hospital

Key Players:

  1. CT Surgery
  2. Nursing
  3. Perfusionists
  4. Hospital Administration

    CardiacTransplantTeam_low

    The SMH Mechanical Circulatory Support Team

These are the key components. Of course, if you are doing ECPR in your ED then you also need an ED doctor champion.  If you are reading this, I assume that will be you. So welcome to your new role!

Who Cannulates?

  1. CT surgeons
  2. Interventional Cardiologists
  3. Intensivists/Pulmonologists
  4. Interventional Radiologists
  5. Emergency Physicians

The Sharp Memorial Hospital ECMO Nursing Training Program

  • Staffing:
    • SICU nurses must apply to be on the ECMO team
    • Coveted position
    • + financial differential (the RN’s get paid to cross-cover ECMO)
    • RN works a regular SICU assignment but must also respond to ECPR
  • Training:
    • Training Manual
    • One-on-one class: 10-12 hours of training per RN
    • RN must be able to establish circuit within 10 min
    • Ongoing Competency Evaluation every other month to maintain skills:
      1. MAD (mechanical assist device) Lab Day = wet-loop training
      2. Direct wet-loop training in the SICU
      3. Manage a real live patient
  • Costs:
    • Capital = Hardware (pump head, heater/cooler, blender, SVO2 monitor) is reusable
      • These are hard costs that are not billable to a patient. Roughly $100,000 per unit. We house 2 unit  = $200,000
    • Disposables (The Circuit and the Cannulae): Used on each patient and billable to the patient.
    • Nursing:
      • Shift coverage (12 hours shifts, 2 RN’s always on-shift) = 25 fully trained nurses
      • Training: 25 nurses @ 10 hours of training @ $50/hr =  $12,500
      • Continuing Competency Evalution training =  2 hrs ever other month @ $50/hr = $600 x 25 nurses = $15,000/yr for ongoing training
      • Premium differential paid to SICU nurses to be on the ECMO team
      • Perfusionist coverage: This is often a contracted rate with a local perfusionist team

A Day in the Life of an RN ECMO Team Member:ECMO RN

  • 2 ICU RN’s are always staffed in the SICU
    • staffed so the RN’s are working at opposite sides of the unit so an ECPR case won’t debilitate any arm of the ICU by calling RN’s away.
  • ER doctor calls the SICU when a potential ECPR case arrives to the ED
  • ECMO RN’s bring, from the SICU (located on the 2nd floor at our facility) to the ED:
    1. The ECMO cart – mobile ECMO hardware = pump head, heater/cooler, blender, SVO2 monitor
    2. The ECMO supply cart – carries all the disposables (circuits, cannulae, various supplies
  • Suzanne describes the logistics of priming the pump, connecting the patient to the circuit, and starting the pump
    • ***PEARL: the goal at initiation of bypass is maximize flow while minimizing RPMs, so the nurse will dial up the RPM until flow is maximized, but no further.
    • SVO2 goal = 70
  • ECMO RN calls OR to summon the perfusionist. In our system the perfusionist is on-call and has an established response time
  • ECMO RN hands off the pump duties to the Perfusionist and then goes back to their SICU assignment

Policies and Procedures

Please contact any of us if you want to take a look at our policies and procedures  – we are more than happy to share this stuff.

The Late Great Tony Gwynn Could Teach us Something About Success:

Suzanne says it best:  ” The way you gotta look at it…the patients we put on pump are all 100% dead when you start with them. You can’t make them more dead. You can’t make it worse. All you can do is possibly make it better…”

Established success rates, for long-term survival neuro-intact is 27-30% for in-hospital cardiac arrest.  That is significantly better than historical established success of non-ECPR ACLS of 17%.  So even though we almost double the survival of these patients, fully 70% still don’t survive or have neurologic recovery. To take that even further, for out-of-hospital cardiac the survival is dismal…and at this time we don’t even initiate ED ECMO until ACLS has failed – the point at which you would pronounce the patient dead.  So by definition, our starting point 0% survival. So any success is meaningful.

Tony GwynnWe really need to remind everyone that ECPR success is much like batting averages – a batting average over .300 will get you into the Baseball Hall of Fame!!  One of the greatest baseball hitters of all-time, San Diego favorite Tony Gwynn, FAILED 70% of the time and was one of the greatest hitters of all time; and elected to the Baseball Hall of Fame in Cooperstown.

So lets setup appropriate expectations from the beginning!  And remember, even the great Tony Gwynn occasionally went several ‘at-bats’ without a hit.

 

 

Do you have Questions for Suzanne?  You may email her directly at suzanne.chillcott@sharp.com

 Announcements:

Aug 18-21: Emergency Medicine Update.  Bellezzo is speaking on “Resuscitation: State of the Art”

October 21: Bring Me Back to Life conference in Montreal, Canada

 

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 10 – “Sequencing” – Ultrasound Priorities During ECPR

Based on a voicemail message we received from Justin Cook, an Emergency Physician out of Portland, Oregon, this episode focuses on the cognitive task analysis of using ultrasound during ECPR.

When your patient hits the door with CPR in progress, what is your ultrasound priority? Diagnostics? Ultrasound-guided line placement?  This episode of the EDECMO podcast attempts to answer that question.

pericardial tamponade due to aortic transection > ECMO save.

pericardial tamponade due to aortic transection > ECMO save.

This is a snapshot of a patient we discussed who presented with tearing chest pain and arrested with HR 180 narrow-complex. pericardial tamponade relieved with drain placed by Bellezzo.  Still no pulses. We put him on ECMO and he was taken to the OR: he had back-dissected into his AV.  After ECMO the patient was taken to the OR where his AV was resuspended and the ascending aorta grafted.  He left the hospital neuro-intact.  In this case, diagnostic US took precedence over line placement. But this is a caveat to the usual rule that US-guided line placement is most urgent.

And here is a video clip of the tamponade:

dissection video from Joe Bellezzo on Vimeo.

 

Thanks for listening!

Hey! wait!  while you’re here give us a call on the listener voicemail line! Comments, Criticisms, or Questions may be incorporated into future episodes:  1-470-ED ECMO 1 (470-333-2661).

Or leave your comments below.

 

EDECMO Episode 9 – The Antithesis of ECPR: African Ingenuity!

FCO 303 - Bangladesh Travel Advice [WEB]This is an exciting and unique experience! – In April 2014 Zack went to visit his brother Joshua, who is working on information technology systems in Cameroon, Africa. While there Zack had the opportunity to teach, interact with their medical community, be a guest speaker on a local radio show, and interview one of their resuscitation specialists. We’ve tried to include a little of each of these experiences in this episode of the EDECMO podcast.  Yes, this is a little off-topic from our usual content; but we hope you’ll enjoy it.  Maybe medicine in the Third World is archaic and barbaric. Or maybe our First World medicine is just completely over the top?JoshuaShinar

Medicine and Resuscitation in the Third World

In this episode Zack spoke with Christian  Ngem, who is a Nurse Anesthetist/Anesthesiologist/intensivist in Cameroon, Africa.

Christian

Christian Ngem

Christian Ngemt, Nurse Anesthetist (Cameroon, Africa)

Nurse Training – BVH 2002-2004

Baptist Hospital, Banso – Scrub nurse 2004-2007

Nurse Anesthetist School  – 2007 – present

“End of Life” care is much different in other cultures.

“African Engineered” = African Ingenuity

Having to utilize limited resources to take care of really sick patients, they have been creatively using drugs we all know and love. For example, the concept of sub-dissociative-dose Ketamine has been going on for a long time!

Drugs:

Ketamine = “The Magic Drug”

Thiopental

Morphine

Halothane

succinylcholine

Physical Exam = I forgot what that was until I heard Christian’s talk here.

ECPR is a “WASTE OF TIME!” –

While they truly believe in resuscitation, they also believe in letting go when the time is right.  Cultural perspectives play a huge role here and there is a definite emphasis on allowing death with dignity. Are we wasting time, resources, money, and effort with our Western extravaganza? Maybe we are.  Let’s open the discussion!

 

Chest Tube Placement

Chest Tube Placement