EDECMO 24 – Weaning VA-ECMO, with Deirdre Murphy

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 Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

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

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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?

snag-0002-2

 

EDECMO 23 – ORNATO LIVES! – How ECMO Saved a Pillar of Resuscitation

Dept of Emergency Medicine_Joseph Ornato_MD

Dept of Emergency Medicine. Joseph Ornato MD

“They RSI'd me…they cannulated me…

Here I am today, two months later…”

Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015.  First: hats off!!! to the Emergency Department, the resuscitation team, the CT surgeons and entire staff at VCU. How it all unfolded is amazing! You MUST listen to this episode to hear the details…

Joseph P. Ornato, MD, FACP, FACC, FACEP

Dr. Joseph P. Ornato is professor and chairman of the Department of Emergency Medicine at Virginia Commonwealth University Medical Center in Richmond, Virginia. He is also medical director of the Richmond Ambulance Authority, the Prehospital Paramedic System serving Richmond, Va. Dr. Ornato is triple board certified (internal medicine, cardiology, emergency medicine) and is an active researcher in the field of cardiopulmonary resuscitation. Dr. Ornato is an editor of the journal Resuscitation. He is past Chairman of the American Heart Association's (AHA) National Emergency Cardiovascular Care Committee and its Advanced Cardiac Life Support Subcommittee. He chaired the National Steering Committee on the NIH Public Access Defibrillation Trial. He is currently consultant and cardiac co-chairman of the NIH Resuscitation Outcomes Consortium (ROC) and serves as principal investigator for VCU on the NIH-sponsored Neurological Emergency Treatment Trials (NETT) Network. Dr. Ornato is a member of the Institute of Medicine.

Ornato and EMS team

Dr. Ornato and the prehospital trauma team

joe-ornato-photo-4_10937792

 

We lose the equivalent of one medium sized American city to the problem of sudden, unexpected cardiac arrest each year. The best weapon we have against this killer is early defibrillation. We need to move quickly to saturate the chain of survival, particularly the early defibrillation  component, in every community.”

-Joe Ornato, MD, FACC, FACEP

REANIMATE SAN DIEGO 2016: February 25-26, 2016

REANIMATE SAN DIEGO 2016:       February 25-26, 2016 in beautiful San Diego, California, USA.

ABOUT THE CONFERENCE:

REANIMATE is a 2-day conference that will teach you everything about Resuscitative ECMO and Extracorporeal Cardiopulmonary Resuscitation (ECPR). Multidisciplinary teamwork and human factors will be stressed throughout. Sessions will have a heavy emphasis on acquiring hands-on skills associated with initiation of ECMO including:

  • Cannulation Technique
  • ECMO Physiology
  • Pump Troubleshooting
  • Cardiac Arrest & Peri-ECMO Resuscitation

ABOUT THE FACULTY:

The REANIMATE faculty will include some of the brightest minds in all of Resuscitation Medicine. The EDECMO team will be joined by some of the best teachers in the ECMO world. Check out the Faculty Page to see more about our incredible professors. Also check out the Schedule of Events.

ABOUT THE LOCATION

REANIMATE will be held at the UCSD Simulation Center in San Diego, California. The Sim Center offers gorgeous classrooms and state of the art simulation capabilities. The surrounding area is amazing. Torrey Pines golf course and recreation center are a short walk away. Beaches with surfing, volleyball and swimming are also within 3 miles of the Sim Center. The conference will make use of these areas with a beach trip and hiking of Torrey Pines on the agenda.UCSD Med Ed buildingvode_ucsd_telemed_01-resized-600

 

February is one of the most beautiful times of the year to visit San Diego.  Bring the family and make it a vacation!

REGISTER TODAY! space is limited

EDECMO 20 – The Golden Hour & the Rule of 3’s: Optimizing the Critical First Hour on Heart-Lung Bypass

Announcements

Upcoming Conferences:

  1. SMACC 2015: June 23-26, 2015. The biggest and baddest critical care conference of the year is in Chicago this year.
  2. Essentials of Emergency Medicine 2015. October 13-15, 2015. The Big Show. In Vegas. At the Cosmopolitan.
  3. Reanimate San Diego. February 25-26, 2016. The essentials of ECMO in 2 glorious days. Here is a sneak peak at the Reanimate 2016 Promo Video.

Flipped Classroom SMACC ECMO Workshop 2015

For those taking the upcoming ECMO courses with us, download both of these 2 attachments. The first is a diagram of a traditional ECMO circuit – its nice to print this out and follow along. Not every circuit is the same and we have ours custom built by Maquet.  The second is a self-study course.  While it isn't necessary to review these before our workshop, it will really put you ahead of the game and we focus more on procedures.

Custom Maquet Circuit

Figure 1. The Custom Maquet ECMO Circuit

Study Guide

Screen Shot 2015-04-04 at 11.04.36 PM

Review of the 3 stages of ECPR

  1. STAGE 1: Placement of any commercially available vascular catheter in the femoral vein and femoral artery
  2. STAGE 2: Replacement of each catheter with ECMO cannulae. Checkout EDECMO 5: Cognitive Task Management for ED ECMO Stages 1 and 2. Also, we learned several cannulation pearls from Stephen Bernard in EDECMO 14 Part 1 and Part 2
  3. STAGE 3: Initiation of Total Heart Lung Bypass

ECMO Circuit Setup:

  1. Plug in the machine and power-on the heater-cooler and the Rotaflow console.
  2. Unpackage the circuit and hold it up to orient yourself.
  3. Mounting the Rotaflow Pump to the Pump Drive

    Mounting the Rotaflow Pump to the Pump Drive

    Attach the Oxygenator to the bracket and the pump to the pump-drive; hang the distal ends of the circuit (the tubes that will connect to the patient) from the IV pole.

  4. Apply ultrasonic contact cream to the flow probe contact site
  5. Remove and DISCARD the yellow de-airing exit port cap on the top of the oxygenator.
  6. Connect the water lines from the heater-cooler to the Quadrox Oxygenator & open the stopcocks.
  7. “Run the circuit”, making sure that the recirculation bridge is OPEN, arterial and venous tubing is CLAMPED, rapid-prime tubes are CLAMPED, both of the blood sampling “pig tail” stopcocks are CLOSED.
  8. PRIME the circuit:  Priming the Circuit: Filling the ECMO circuit (tubing, pump, oxygenator) with crystalloid priming solution (ie Isolyte), adding 2,500 units of heparin to each 1-liter bag of priming solution.  We discuss the finer details of this with Greg Griffin, the Chief Perfusionist at the University of North Carolina, Chapel Hill in EDECMO 8.
    1. squeeze all air out of prime bag INTO the circuit and then hang those bags from the IV pole.
    2. Open the ratchet clamps: the circuit will fill (prime) by gravity.
  9. Connect the Oxygen supply line (from Oxygen tank) to the Oxygen inlet port on the oxygenator
  10. De-air the circuit:
    1. Remove the patient-lines that are hanging from the IV pole and drop them below the fluid level of the IV bags to prime them. ratchet-clamp them closed. Now the entire circuit has been primed.
    2. Open the recirculation bridge and briefly increase the RPM on the Rotaflow Console until the pump is running at 4LPM for 15 seconds. This will de-air the circuit as air is release from the de-ar exit port on the Oxygenator.  ***Some air may still be trapped in the pump though. So…
    3. Turn the RPM on the Rotaflow console to zero. Allow any air in the pump head to flow into the PVC tubing between the pump head and the oxygenator and then return the RPM to 4LPM to complete the de-airing process.
  11. Calibrate the flow-probe: Reduce pump speed to zero RPM, clamp off the recirculation bridge and “ZERO” the flow probe by pushing the “ZERO” button for a few seconds. The console will beep.

Initiation of Total Heart Lung Bypass (STAGE 3)

Maquet-Circuit-mockup.001So you've cannulated your patient while your ECMO-nurse has primed the circuit with crystalloid.  Connect the venous and arterial PVC lines from the circuit to the ECMO cannulas in the patient. And since this is STAGE 3, we've established the EDECMO “Rule of 3's.”  There are 3 things you need remember before, during, and after you've initiated heart-lung bypass.

A.  3 Critical First Steps BEFORE initiating bypass:

  1. Heparinize the patient = 5,000 units IV bolus
    1. Heparin 2,500 units in each liter of priming solution
    2. Bioline coating
    3. ACT > 200 seconds
  2. Attach O2 source (@ 4-6 LPM) to the Oxygenator
  3. No open central lines (CVP, Swan-Ganz, etc).

CLOSE the Recirculation Bridge and OPEN the venous and arterial ratchet clamps. Turn up the RPM on the Rotaflow console. Your patient is on heart-lung bypass.

B.  3 Critical things to confirm JUST AFTER your patient is on bypass:

  1. The arterial line should have bright red (oxygenated) blood and the venous line should be dark-red.
    1. IF you see BRIGHT-BRIGHT, you've incorrectly placed both cannulas in the same vessel.
    2. If you see DARK-DARK, there is a problem with the oxygenator. Confirm your O2 supply to the oxygenator.
  2. Your cannulas are secured to the skin with suture and tape.
  3. The recirculation bridge is CLOSED.

C.  3 Critical Values to Optimize ECMO

1. Optimize Blood Flow:

  • Establish the MAXIMUM blood flow (LPM) at the lowest RPM. GOAL = 60 ml/kg
  • Increase the RPM on the Rotaflow console until:
    1. Any further increases in RPM does not result in increased blood flow (LPM).
    2. The circuit begins to “Chatter.”
    3. SvO2 > 70%

IF flow is too low: 1. Infuse more volume 2. reposition venous cannula 3. add a venous cannula

2. Arterial Blood Gas Analysis:

  • GOAL:  “normal” ABG (PaO2 80-100; PaCO2 35-45)

IF PaO2 < 80,   THEN you need more blood flow through the Oxygenator

IF PaO2 > 100, THEN its time to add a gas blender and turn down the FiO2 from the Oxygen source

IF PaCO2 < 35, THEN decrease your “Sweep Gas Rate” by lowering the LPM on the O2 supply

IF PaCO2 > 45, THEN increase your “Sweep Gas Rate” by increasing the LPM on the O2 supply

 

3. Optimize Systemic Vascular Resistance (SVR)

SVR = (MAP – CVP) x 80
C.O.

SVR = (MAP – 0)      x 80
Blood Flow

***GOAL = SVR > 800

IF, for a given blood flow, the MAP is unreasonably low, you need a pure VASOPRESSOR = Phenylephrine

IF, for a given blood flow, the MAP is unreasonably HIGH, you need a VASODILATOR = Nitroprusside

Or, Goal MAP > 65

 

 The Shinar 3000: Tall Paul ECMO Simulator

Zack built an ECMO simulator model in his garage. Here is the video:

Tall Paul Compilation 3 from Joe Bellezzo on Vimeo.

EDECMO Episode #14: ECPR with Stephen Bernard 1/2

This is the first in a 2-part series on ECPR with Dr. Stephen Bernard.  In today's episode, Joe and Zack interview Dr. Stephen Bernard about Extracorporeal Cardiopulmonary Resuscitation (ECPR) and how they do it The Alfred Hospital in Melbourne, Australia.   As most of you  know, Dr. Bernard has been a huge contributor to the critical care world.  While he is widely known for his work with therapeutic hypothermia (2002 NEJM ‘Treatment of Comatose Survivors of Out-of-Hospital Cardia Arrest with Induced Hypothermia), Dr. Bernard is now at the forefront of ECPR, reshaping pre-hospital dogma and intra-arrest management, including the use of ECMO during cardiac arrest.

Stephen Bernard MB BS, MD, FACEM, FCICM

Stephen Bernard MB BS, MD, FACEM, FCICM

Professor Stephen Bernard MB BS, MD, FACEM, FCICM

Senior Intensive Care Specialist
The Alfred Hospital
Melbourne, Australia

Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University
Medical Advisor, Ambulance Victoria
Member, Medical Advisory Committee, Ambulance Victoria
Member, Clinical Practice Guideline Review Committee, Ambulance Victoria
Member, Clinical Incident Review Committee, Ambulance Victoria
Co-Chair, Steering Committee, Victorian Ambulance Cardiac Arrest Register, Ambulance Victoria
Member, Clinical Committee, Council of Australasian Ambulance Authorities
Medical Officer, Australian Formula 1 Grand Prix
Medical Officer, Australian Motorcycle Grand Prix
Member, National Medical Advisory Committee, Confederation of Australian Motor Sport
Supervisor of PhD students x2
Director of Intensive Care, Knox Private Hospital
Chair, Medical Advisory Committee, Knox Private Hospital
Member, Patient Care Review Committee, Knox Private Hospital


 Today's Episode:

  1. Development of the ECPR protocol at the Alfred in Australia
    • Reconstruction of the “Chain of Survival”
    • TOR (termination of resuscitation)
  2. The Alfred ECMO CPR Guideline 2014 version 13: This is the PDF version of their latest ECPR protocol.
  3. The CHEER (CPR, Hypothermia, ECMO and Early Reperfusion)
    • Check out a GREAT lecture on CHEER by Dr. Bernard that was presented on the Intensive Care Network run by Oli Flower and Matt MacPartlin
    • Registry: clinicaltrials.gov registry
    • Updated CHEER results:  You gotta listen to the podcast! This stuff is In Press and soon to be published

 


More!

Screen Shot 2014-10-01 at 10.47.45 AM

NEW ARTICLE: Emergency department initiation of percutaneous cardiopulmonary support for traumatic cardiac tamponade with coagulated pericardial effusion

2014 case report just published out of Japan. Interesting. Our 2012 ECPR study was cited here.

Why not simultaneously try the pericardiocentesis during the cannulation procedure?

 

But this is good proof of concept for another rare application of ECLS in a trauma scenario.

This article is open access, thanks to Elsevier, so here it is:

2014 coagulated cardiac tamponade with ECPR