Lionel Lamhaut and the SAMU ambulance
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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:
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:
- Medical Cardiac Arrest
- Age < 75
- No Flow < 5 min (bystander CPR must be started within 5 min)
- Hypothermia is always considered
- Intoxications (of any kind) are always considered
- 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…
Great update! In Baltimore, we’ve started using the ER-REBOA catheter in the cadaver portion of the Basic Endovascular Skills for Trauma course since it gained FDA approval. Importantly, not yet being utilized in actual patients, but we want to see how it will function in cadavers initially. The catheter fits through a 7Fr sheath, which as you say has incredible implications for placement in the ED and expanding its role and accessibility for a variety of providers.
The catheter itself is stiff enough to not require a wire to be placed initially, and so cuts out some steps. We’ve found the balloon is a little thinner walled than the current Coda balloon we use, and this may have implications if the balloon is repeatedly inflated and deflated in specific scenarios. Additionally, the new catheter allows arterial pressure measurements proximal to the balloon which is pretty neat.
The future is indeed becoming very very interesting!
Zaf, Your comments are much appreciated! I have some pretty good experience using the Chek-Flo and CODA 12F in crashing sub-diaphragmatic hemorrhage. But I have no experience yet with the newer 7F Pryor REBOA cannula. Thanks for your thoughts and keep ’em coming!
So I have questions for you! In your opinion, Can you pull the wire or do would you leave the wire? We are pulling it so as not to create a point of thrombosis, but don’t know the answer yet. you using amplatz? super or extra stiff?
Joe
Joe thanks for the questions!
We are using the Amplatz Super Stiff 260cm 0.035 inch wire, with the proximal 7cm floppy tip. This has the benefit of reducing risk of aortic injury during insertion and allows great feedback if it enters a branch vessel.
We always leave the wire in place. This is for two reasons: the presence of the wire increases the overall stability of the device, and I think goes a long way to preventing balloon migration in zone 1 placement. Those reports where the balloon has migrated have had the wire removed and only the balloon in place in zone 1. The second reason is that should you choose to remove the balloon and/or sheath and the patient suddenly deteriorates, the wire is in place and ready to go for rapid reinsertion. So our practice is to leave the wire in place until the time of arteriotomy repair.
The thrombosis issue is a crucial one – despite these folk being sick as hell, and you thinking they will not clot, almost inevitably there is some clot present on or around the sheath at the time of removal. Our surgical colleagues who end up removing the sheath and repairing the artery regularly see this. We’ve debated this problem repeatedly, and there is no clear solution. What is a benefit I think of the larger current sheath is that it mandates open repair and hence direct visualization and/or intervention to ensure adequate distal perfusion and removal of clot if needed. I think this is one of the reasons we have not had any reported cases of limb ischemia or limb loss secondary to REBOA in the US. Those countries that have reported it (anecdotally and in the literature) are coincidentally all countries that are using smaller catheters in this setting, and so once use of the ER-REBOA or similar catheters becomes more common, we need to be that much more vigilant of limb perfusion issues.
Thanks again for the opportunity to discuss this fascinating topic! Let me know if I can answer anything else.
Great comments and thoughts. Thanks, Zaf. ~joe