EDECMO 42: Organ Transplantation On ECMO

In this episode, we tackle the subject of organ transplantation on ECMO.  2017 featured several articles showing the efficacy of ECMO for organ transplantation.  In Italy, 56% of total potential patients were successfully transplanted.  The success of these transplants have been comparable to patients not on ECMO.  Zack Shinar interviews Lionel Lamhaut, ECMO specialist from Paris, and Cyrus Olsen, ethicist from the University of Scranton, to dive into some of the deeper questions including financial implications, ethical angles, and research extrapolations.  Join Zack, Lionel and Cy at Big Sick 18 (bigsick18.org) in Zermatt Switzerland on February 7-9th,, 2018!!

 

1: Christopher DA, Woodside KJ. Expanding the Donor Pool: Organ Donation After
Brain Death for Extracorporeal Membrane Oxygenation Patients. Crit Care Med. 2017
Oct;45(10):1790-1791. doi: 10.1097/CCM.0000000000002633. PubMed PMID: 28915178.

2: Bronchard R, Durand L, Legeai C, Cohen J, Guerrini P, Bastien O. Brain-Dead
Donors on Extracorporeal Membrane Oxygenation. Crit Care Med. 2017
Oct;45(10):1734-1741. doi: 10.1097/CCM.0000000000002564. PubMed PMID: 28640022.

3: Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, Citerio G. Organ
donation in cardiac arrest patients treated with extracorporeal CPR: A single
centre observational study. Resuscitation. 2017 Sep;118:133-139. doi:
10.1016/j.resuscitation.2017.06.001. Epub 2017 Jun 12. PubMed PMID: 28596083.

4: Dalle Ave AL, Bernat JL. Donation after brain circulation determination of
death. BMC Med Ethics. 2017 Feb 23;18(1):15. doi: 10.1186/s12910-017-0173-1.
PubMed PMID: 28228145; PubMed Central PMCID: PMC5322624.

5: Larsson M, Forsman P, Hedenqvist P, Östlund A, Hultman J, Wikman A, Riddez L,
Frenckner B, Bottai M, Wahlgren CM. Extracorporeal membrane oxygenation improves
coagulopathy in an experimental traumatic hemorrhagic model. Eur J Trauma Emerg
Surg. 2017 Oct;43(5):701-709. doi: 10.1007/s00068-016-0730-1. Epub 2016 Nov 4.
PubMed PMID: 27815579; PubMed Central PMCID: PMC5629226.

6: Dalle Ave AL, Shaw DM, Gardiner D. Extracorporeal membrane oxygenation (ECMO)
assisted cardiopulmonary resuscitation or uncontrolled donation after the
circulatory determination of death following out-of-hospital refractory cardiac
arrest-An ethical analysis of an unresolved clinical dilemma. Resuscitation. 2016
Nov;108:87-94. doi: 10.1016/j.resuscitation.2016.07.003. Epub 2016 Jul 20.
Review. PubMed PMID: 27449821.

7: Fan X, Chen Z, Nasralla D, Zeng X, Yang J, Ye S, Zhang Y, Peng G, Wang Y, Ye
Q. The organ preservation and enhancement of donation success ratio effect of
extracorporeal membrane oxygenation in circulatory unstable brain death donor.
Clin Transplant. 2016 Oct;30(10):1306-1313. doi: 10.1111/ctr.12823. Epub 2016 Sep
5. PubMed PMID: 27460305.

8: Jasseron C, Lebreton G, Cantrelle C, Legeai C, Leprince P, Flecher E,
Sirinelli A, Bastien O, Dorent R. Impact of Heart Transplantation on Survival in
Patients on Venoarterial Extracorporeal Membrane Oxygenation at Listing in
France. Transplantation. 2016 Sep;100(9):1979-87. doi:
10.1097/TP.0000000000001265. PubMed PMID: 27306536.

9: Migliaccio ML, Zagli G, Cianchi G, Lazzeri C, Bonizzoli M, Cecchi A, Anichini
V, Gensini GF, Peris A. Extracorporeal membrane oxygenation in brain-death organ
and tissues donors: a single-centre experience. Br J Anaesth. 2013
Oct;111(4):673-4. doi: 10.1093/bja/aet323. PubMed PMID: 24027145.

EDECMO Episode 41 is REPOSTED

The original post for EDECMO 41 had to be permanently removed from the internet (for reasons beyond our control!!!) but its back. Click this link to take you to the new and improved (and HIPAA-compliant!!) episode: EDECMO 41 – The 3 stages of ECMO – Diane’s Story

EDECMO 40: EROCA – The trial that asks “Should ER Docs Initiate ECPR?”

 

EROCA – University of Michigan – Gunnerson/Shinar

Should Emergency Physicians initiate ECMO on arresting patients?  That is the question that Kyle Gunnerson from the University of Michigan (UMich) is asking with their new trial – EROCA.  UMich has had a robust ECMO program for over 30 years and recently they have received a grant to fund an out of hospital cardiac arrest protocol for emergency physician initiated ECPR.  In this episode, Zack asks Kyle how this trial is being undertaken with key side points on how to start a program, how to train the personnel, and how to circumnavigate the many roadblocks we commonly face in the development of an ECMO program.  They talk about the limitations of running a trial with physicians with no prior experience in ECPR initiation as well as the novel resuscitation strategies that UMich is deploying in all of their cardiac arrest patients.

 

2016 ECMO CPT Codes, RVUs, and MediCare Reimbursement

Ok, so we just crashed an arrested patient onto ECMO and he is going to the cath lab. Now, how do I document the procedure again?  What was the CPT for percutanous cannulation for VA-ECMO?  Does my billing company even know?

Bookmark this page for future quick reference of the current CPT codes, RVU values and MediCare reimbursements.

EDECMO 39: Who Do We Put On ECMO? – New Data on Prognostics

In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?”  Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important.  Guillaume’s data shows importance of short low times, lower lactates and higher pH values.  The real question is what number for each of these should we consider a hard stop on initiation.  This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial.  He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions.  With many ECMO studies having average arrest to

initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide.  This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65.   We  conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival.  This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this.

 

Bibliography:

1: Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of
extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac
arrest-An ELSO registry study
. Resuscitation. 2017 Oct;119:56-62. doi:
10.1016/j.resuscitation.2017.08.003. Epub 2017 Aug 5. PubMed PMID: 1.

 

2: Reynolds JC, Grunau BE, Elmer J, Rittenberger JC, Sawyer KN, Kurz MC, Singer
B, Proudfoot A, Callaway CW. Prevalence, natural history, and time-dependent
outcomes of a multi-center North American cohort of out-of-hospital cardiac
arrest extracorporeal CPR candidates. Resuscitation. 2017 Aug;117:24-31. doi:
10.1016/j.resuscitation.2017.05.024. Epub 2017 May 25. PubMed PMID: 2.

 

3: Debaty G, Babaz V, Durand M, Gaide-Chevronnay L, Fournel E, Blancher M,
Bouvaist H, Chavanon O, Maignan M, Bouzat P, Albaladejo P, Labarère J. Prognostic
factors for extracorporeal cardiopulmonary resuscitation recipients following
out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.
Resuscitation. 2017 Mar;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011. Epub
2016 Dec 19. Review. PubMed PMID: 3.

References

1.
Haas N, Coute R, Hsu C, Cranford J, Neumar R. Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study
. Resuscitation. 2017;119:56-62. [PubMed]
2.
Reynolds J, Grunau B, Elmer J, et al. Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation. 2017;117:24-31. [PubMed]
3.
Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation. 2017;112:1-10. [PubMed]

REANIMATE 4 Mashup Video!

REANIMATE 4 was THE best conference event I’ve ever had the pleasure to be associated with!  Take a look at this short video mashup of the entire event (and thanks to Jeremy Haywood, our videographer, video editor, and video producer)

For those of you who attended, thank you for bringing your “A-Game”!  Ya’ll came prepared and motivated! Your energy and devotion has completely re-energized us!  It was a little bittersweet when we all had to part ways on Friday. But welcome to the REANIMATE family!

If you couldn’t make it to “R4”, now’s the time to register for REANIMATE 5, which will be March 8-9, 2018 in San Diego.

REANIMATE 4 Video Mashup from Joe Bellezzo on Vimeo.

Crash Episode: Iowa OHCA ECMO Save – with Andrew Karl Terry

Crash Episode – This is a great example of where a little persistence with your colleagues can help save someone’s life.  Dr. Andrew Karl Terry, having had only limited exposure to ECMO, was able to encourage his Cardiologists to put a witnessed VF patient on ECMO.  The rest is history!

EDECMO 38 – ECMO and Trauma – with Pal Ager-Wick and Magnus Larsson

ECMO in trauma

This episode is all about ECMO in trauma – not the usual ARDS, TRALI VV-ECMO – we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now.

Photo used with permission of SAMU of Paris


Bullet Points:

  • VV ECMO –
    • Marginal data suggests ECMO beneficial in ARDS (CESAR, ANZECMO trials)
    • ARDS and TRALI in trauma is a reasonable extension of this
  • Damage Control Surgery –
    • focus on coagulation
    • stop major bleeders and then take to ICU
    • lethal triad of coagulation includes hypothermia, dilution of coagulation factors and acidosis
  • Coagulation of trauma: ECMO can improve all three components of lethal triad
  • Heparin has been successfully withheld in bleeding trauma patients
  • ECMO in Severe Chest Trauma – 10 patients, 8 ruptured cardiac chambers1
  • Blunt cardiac arrest – a case report2
  • Bleeding less than 15% mortality after 1995, Intracranial hemorrhage patients can survive. In fact none of the ICH patients on ECMO who died died of brain bleeding (60-93% survived). Survival was 42-63% for VA ECMO. Lower ACT (<180 sec)3
  • ELSO – VA ECMO in trauma – 45% survival4
  • ECMO reduces venous pressure which may be beneficial in hemorrhaging patients5
  • Tisherman – Suspended Animation: Emergency Preservation and Resuscitation678

Magnus Larsson

References

1.
Huh U, Song S, Chung S, et al. Is Extracorporeal Cardiopulmonary Resuscitation Practical in Severe Chest Trauma? : A Systematic Review in Single Center of Developing Country. J Trauma Acute Care Surg. August 2017. [PubMed]
2.
Kudo S, Tanaka K, Okada K, Takemura T. Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report. Am J Emerg Med. August 2017. [PubMed]
3.
Bedeir K, Seethala R, Kelly E. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg. 2017;82(2):400-406. [PubMed]
4.
ELSO Registry. Extracoporeal Life Support Organization. http://www.elso.org/Registry/Statistics/InternationalSummary.aspx.
5.
Larsson M, Talving P, Palmér K, Frenckner B, Riddez L, Broomé M. Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage? Perfusion. 2010;25(4):217-223. [PubMed]
6.
Tisherman S, Safar P, Radovsky A, Peitzman A, Sterz F, Kuboyama K. Therapeutic deep hypothermic circulatory arrest in dogs: a resuscitation modality for hemorrhagic shock with “irreparable” injury. J Trauma. 1990;30(7):836-847. [PubMed]
7.
Tisherman S. Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia. Curr Opin Crit Care. 2013;19(6):594-598. [PubMed]
8.
Kutcher M, Forsythe R, Tisherman S. Emergency preservation and resuscitation for cardiac arrest from trauma. Int J Surg. 2016;33(Pt B):209-212. [PubMed]

REANIMATE 5: March 8-9, 2018

REANIMATE 5 will be on March 8-9, 2018 in San Diego, California.

Registration will open on September 21, 2017. Announcements will precede!  But if you want to guarantee a spot at R5, put yourself on the Reanimate 5 Pre-Reg list.  REANIMATE sells out quickly. People are always asking how to guarantee their spot. This is the ‘ticket’!!!

ECMO, ECPR, REBOA, TEE, & Bleeding-Edge Resuscitation

Special Guest Faculty Member: Resuscitationist and interventional cardiologist Demetris Yannopoulos from the University of Minnesota. For more on Demetris’ recent contributions to ECPR:

EDECMO 36 – Crushing the Nihilism of Cardiac Arrest – with Demetris Yannopoulos

Crash Episode – MicroDissection of Yannopoulos’ ECMO Method

For more information on the Conference: reanimateconference.com

 

Don’t forget to get your name on the Pre-Registration List for REANIMATE 5 NOW!

 

 

 

 

 

EDECMO 37 – Nate’s Story

Jake is an Emergency Physician from Santa Cruz California whose interest in resuscitation was put to the fullest test when his own son had a cardiac arrest. This is the amazing retelling of that day in November when what Jake learned in an EDECMO workshop was utilized in a dramatic fashion. This is a story of two heros: Jake and his son Nate.