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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 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
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?
Fantastic work guys – I have a feeling this may become mandatory listening for trainees at The Alfred ICU 😉
All the best,
Chris
Thanks Chris @precordialthump!
WOW, just what any CT- ICU doc wants to hear.
Top 10 podcast this year for me!
Thanks Thomas! So how can we climb to your 1!!??? 🙂
MORE of this. Bringing the whole package to all users for the good of the patients. For this new implemented technique all must be mastered to achive good outcome.
The cannulation, the run and weaning, and for a few the stopping of ECPR.
This involves a massive pool of knowlegde the you are putting out to us. Thanx a lot!
Much Appreciated Thomas. Will do!
Step three on above flow sheet – are you weaning the ecmo FiO2 (FdO2) on VA ECMO? VS Weaning the ECMO flows only. My perfusionists advise against weaning VA ecmo oxygenation.
Deirdre discussed weaning according to the Alfred ICU approach, which is not the same as the diagram shown in the post.
FiO2 is not adjusted during VA ECMO weaning (we stay at FiO2 1.0).
Cheers
Chris
PS. See here for a case-based Q&A on VA ECMO weaning: http://intensiveblog.com/weaning-va-ecmo/