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

 

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?