EDECMO Episode 8 – “Prime Time!” – prepping the ECMO circuit for action!

Dr. Jim Manning

Dr. Jim Manning

The ED ECMO crew left the www.edecmo.org World Headquarters in May 2014 to meet with Dr. Jim Manning at the University of North Carolina Chapel Hill to do some animal experiments incorporating ECMO.  Dr. Manning is an Emergency Department attending physician at UNC-Chapel Hill and has a distinct interest in endovascular resusscitation. Specifically, Jim is working with a new catheter called the “Selective Aortic Arch Perfusion” (or SAAP) catheter in non-compressible abdominal and pelvic trauma. The SAAP catheter functions much like REBOA (resuscitative endovascular balloon occlusion of the Aorta) and we will compare and contrast those two technologies in the near future.

Dr. Manning’s expertise in animal models of resuscitation drew us to North Carolina. The experience was far beyond anything we could have expected and much much more will be posted over the coming months!

The Manning Lab

Dr. Manning, Zack Shinar, Shane McCurdy, and Joe Bellezzo

The Experiments

The Experiments

Manning in prep

Joe Bellezzo MD

Joe Bellezzo MD

 

“PRIME TIME!” ~Nuances of priming the ECMO circuit with Greg Griffin, the Chief Perfusionist at UNC-Chapel Hill

Greg Griffin, Chief Perfusionist - UNC Chapel Hill

Greg Griffin, Chief Perfusionist – UNC Chapel Hill

The folks at UNC-Chapel Hill have a very active inpatient ECMO program. While they aren’t yet doing ECPR in the ED (and we hope to help change that!), they do a lot of ECMO.  Greg Griffin has been the Chief Perfusionist at UNC-Chapel Hill for the past 3 years and has been a perfusionist at their facility for over 20 years. While in Dr. Manning’s lab, Zack had the opportunity to sit down with Greg and talk in depth about ECMO, the Maquet Cardiohelp ECMO machine, and some pearls and pitfalls of “priming the pump!”

Introduction

  • The ECMO circuit consists of:
      1. The machine: which is basically a centrifugal pump (a machine that generates forward blood flow via centrifugal force), an oxygen supply, and a water bath to control the temperature. Simple.
      2. The circuit: the circuit is a.) the tubing that the blood flows through, b.) a membrane oxygenator (a small plastic box that contains a membrane…blood flows across that membrane while oxygen is added to the blood and CO2 is removed), and c.) the pump head (a plastic chamber that transfers the centrifugal forces from the pump to generate forward blood flow).
        • The combination of the tubing, oxygenator and pump head are also referred to as the “disposables,” because they come into contact with the patient’s blood, and are later disposed of.
      3. The cart: which is the support structure that holds all the equipment.
  • Definitions:
    1. Priming the circuit = filling the entire circuit with fluid. Priming is done by hanging the fluid higher than the circuit and letting gravity fill the entire circuit.  At the present time, we prime with a crystalloid solution.
    2. De-Airing: removing all air bubbles from the circuit. The nuances of this are discussed in this episode.

The Formula One Racetrack Analogy

  • When the circuit is set up and the pump is flowing, a maze of tubes seems to spread haphazardly about the machine.   What appears complicated and confusing is really quite simple:  The circuit is nothing more than a big oval tube with blood flowing around the oval, not unlike an oval auto racetrack. When priming the pump you run the “cars” through the oval until you are ready to initiate bypass and add your patient to the circuit. Priming involves filling the circuit with fluid and de-airing the entire system.
  • When it comes time to put your patient on bypass, you divert the “cars” from the “racetrack” and have them take a detour into the “pit,” which is your patient. Oxygenated blood that has just left the oxygenator exits the oval “racetrack” via detour-tubing, enters the arterial cannula, and enters the patient’s arterial system.  Deoxygenated venous blood that is returning to the heart is captured by the venous cannula (who’s tip is at the right atrial inlet) and directed back onto the “racetrack”.  The circuit once again passes the blood through the centrifugal pump (generating forward blood flow) and then, again, through the oxygenator.
  • At any time you can elect to run your “race cars” through the circuit only (staying on the track), or through your patient. One or the other…but not both at the same time.

 

In keeping with the “North Carolina” theme, here is the Charlotte Motor Speedway in Charlotte, North Carolina:

Charlotte Motor Speedway

Racetrack mockup 2.001

Racetrack mockup 3.001

 

Now, lets take another look at a diagram of the whole circuit:

 

Maquet Circuit mockup.001

Enjoy the Interview:

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

EDECMO Episode 6 – On Life & Death with Peter Rosen

Today I sat down with Dr. Peter Rosen to talk about the topic of life and death.

Peter is a close friend and one my mentors throughout my training and career. I trained under Peter as a resident at UCSD and I whenever Peter is in town I try to meet up with him to talk about anything BUT emergency medicine!  He usually tries to goat me into a tennis match but I’ve been beat up too many times to take the thrashing anymore!

Today I convinced Peter to go on-the-record with me and talk a little bit on the topic of life and death, since the topic is so important to what we are doing with ECPR.  Peter has spent decades watching gadgets, toys, and technology come and go – and carries a very understandable skepticism toward any process that artificially prolongs life.  I’m not sure I convinced him during this session but my career goal will be to show him that ECPR works in the right patient population.

Hearing Peter talk is always fascinating and I hope to have him on regularly on the podcast.

Enjoy the Episode:

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.

Episode 4 – The Tactical Approach to the Cardiac Arrest

In this episode we talk about how we prepare for, and run, our codes.  When we began incorporating ECPR into our resuscitation strategy we found ourselves saving patients who would have otherwise died.  The traditional nihilistic approach to the arresting patient was overturned with ECPR by providing hope that wasn’t previously there. Naturally,  we took a closer look at each element of the code, from the time the patient hit the door to the time we started the pump.  And we realized we were doing a lot of stuff wrong.  Here is how I do it:

1.  Medic gurney entry:    If you’re doing ECPR, then vascular access of the femoral vessels is a top priority. Most of us are right handed and prefer to access the femoral vasculature on the patient’s right.  But that’s EXACTLY where the medic gurney offloads the patient- big mistake. Time is wasted waiting for the medics to move the patient to your hospital gurney, remove monitor leads, pack up the monitor, avoid pulling out IV’s and then leave the room.  Only then could the “line doctor” push the ultrasound machine into the room, disrobe the patient, gown up, place a sterile US probe cover, prep the field and get to work.  That’s precious minutes wasted.  Stop doing that!  Bring the medic gurney in on the other side!  Your “line doctor” is already completely ready to go.

2. Protocolize EVERYTHING:  ACLS provides  a protocolized framework for running a code.  But what about all that stuff that happens from the ambulance bay until care is transferred to you?  And can we improve on the current ACLS algorithm?  Most of us appreciate that protocoling doesn’t restrict us; in fact, quite the opposite.  A protocol allows cognitive offloading of important, yet routine, steps in a process which frees us to focus on tasks specific to that patient.

If you are considering establishing an ED ECMO or ECPR program at your facility, I highly recommend that you take a close look at everything that is done from the time the patient hits your door to the time the ECLS pump is started. We aren’t saying this is the only way to do it, but this is how we do it:

Anticipating the Arrival of an Arresting Patient:

  • Staging the room: not unlike a theatrical play, each person and each piece of equipment has a specific role and a specific position in resuscitation suite.  Do it the same way every single time.Slide1

 

resusc room 2014

Accepting the CPR patient on the “RIGHT Side!”

Some roles that are unique to our resuscitation team:

  • “Line Doctor”: MD responsible for femoral vascular access
  • “Code Doctor”: MD responsible for running the code and decision-making
  • “Code Team Leader”: RN responsible for timing of important events (ie drug delivery, shocking, pulse checks, etc). This RN also does computer-based charting.
  • “Med/Electric Nurse”: RN responsible for pushing drugs and delivering shocks
  • “Resuscitation Cart”: lives just outside the room and has two shelves and house the following:

Resuscitation Cart

  • Quiet the room: as the medics enter the room, quickly remind everyone to limit unnecessary noise.

Patient Arrival:

  • The paramedic gurney (with ongoing CPR) enters the room on the right side of the room (if you are looking from outside to inside the room), not the left (which is how you are likely accepting your patients now.)

Slide2

 

  • After transfer of the patient from the medic gurney to the ED bed, chest compressions are immediately assumed by “Chest compressor #1”.  compressions then move back and forth between the two “Chest compressors” at pulse checks.
  • Since femoral vascular access is a huge focus, I would also recommend that you assign a free hand (RN or tech) to “groin access,” who is standing outside the room with trauma shears in one hand a bottle of betadine in the other.  Once the patient is moved from the medic gurney to the ED Bed, that individual is tasked with stripping the pants off (by cutting or pulling) and drenching the groins in betadine.  It becomes an efficient task for the “line doc” to drop a drape, place the US probe, and gain femoral vascular access.
  • Of course, the need for both of these human chest compressors (and valuable real estate in the resuscitation room) is eliminated if you have a mechanical chest compression device such as the LUCAS2:

LUCAS2

Resuscitative ECMO Interview from EMCrit.org

This is the interview that started all of the trouble. Scott got to interview Joe on the amazing resuscitative ECMO program at Sharp Memorial in San Diego on an episode of the EMCrit podcast.

Episode 3 – Who the HELL do we put on ECMO during Arrest?

Who Gets ECPR and Who Doesn’t?

Great question! This may be the hardest question we deal with when a patient arrives and ECPR is a consideration.

This episode is broken down into three parts:

  1. Who exactly do we consider an appropriate candidate for ECPR?
  2. TOR = Termination of Resuscitation in the pre-hospital arena and why we HATE it!
  3. Pre-hospital ECPR – REALLY?

 

Episode 2 – The Three Stages of ECPR

In this episode, Joe and Zack discuss the three stages of ECPR initiation.

For greater detail, videos, and simulations come to the ECPR Page in the tutorial section.

Episode 1 – An Introduction to ECMO Terminology

In this episode, Joe and Zack discuss some of the terminology and basics of ECMO and ECLS.

Terminology: (Synonyms)

  • ECMO = Extracorporeal Membrane Oxygenation
  • ECLS = Extracorporeal Life Support
  • CPS = Cardiopulmonary Support
  • ECPR (extracorporeal cardiopulmonary resuscitation)=ECLS initiation in the arresting patient

ECPR candidates:

  • STEMI with refractory VFIB
  • PE with shock or dysrythmia
  • Aortic Dissection
  • Massive OD
  • Pregnant with Amniotic fluid embolus
  • Hypothermia with temperature-dependent dysrythmia
  • Trauma

Future podcast episodes will drill down into the details of ECMO initiation, but in this episode Zack and Joe discuss Zack’s recent case where Zack did it all: managed the code…placed the cannulas…and initiated bypass, right there in the Emergency Department.

Episode 0 – About the EDECMO Project and the Hosts

In this episode you’ll hear why we started the EDECMO project and a little bit about what we hope to offer.