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

“Bring Me Back to Life” 2014 – Oct 21, 2014 in Montreal

 

 

All three of us (Bellezzo, Shinar, and Weingart) are guest speakers at this conference that is packed with some of the heaviest hitters in resuscitation medicine~

Date: October 21, 2014

Location: Montreal

Lineup:

Haney Mallemat     @CriticalCareNow
Scott Weingart     @emcrit
Vicki Noble     @nobleultrasound
Matt Dawson     @ultrasoundpod
Mike Mallin     @ultrasoundpod
Zack Shinar     @edecmo
Joe Bellezzo     @edecmo
Jean-Francois Lanctot     @EGLS_JFandMAX
Maxime Valois     @EGLS_JFandMAX
Pierre Pascual
Philippe Rola     @thinkingCC
Frederic LeMaire     @Frederic_MD

Website:  http://www.bringmebacktolife.ca/

Why attend?

#BMBTL14 is a conference  on resuscitation that focuses on the skills and knowledge needed to bring your critically ill patients…back to life !

With cutting edge topics and a world class faculty, the conferences will be packed with clinical pearls and only the stuff that matters !

Ventilation, sepsis, advanced trauma, volume assessment, medications, fluids, bedside ultrasound, ECMO  and much more…don’t miss this amazing event!

Brilliant Lecture!: Weingart’s “The New Intra-Arrest” from SMACCgold

This is one of the best lectures I've ever heard on State of the Art intra-arrest management. I recommend you carve out 20 minutes of your time and watch this!  This video was blatantly stolen (well, with permission from Scott of course!) from www.emcrit.org. There is so much stuff here that applies to ECPR that I had to post it here as well.

You should also check out Scott's shownotes from that post – chock-full of goodness!

~Joe

The New Intra-Arrest from SMACCgold from Scott from EMCrit on Vimeo.

 

 

Chain of Survival: Hands Only CPR works!

IMG_7041

Fire Medics Teach Hands-Only CPR

This is a little off the topic of “advanced resuscitation”, but equally as important.  Today I was walking into our local grocery store here in San Diego, California and found a team of firefighters teaching “Hands-only CPR” to anyone walking by who would listen.  Lots of folks stopped and practiced chest compressions on the mannequins.  I heard comments like, “wow, you really have to push harder than I imagined.”  Yep! Hard and fast baby!

Hands Only CPR

Hands Only CPR

Being at the receiving end of this very important part of the chain of survival, I really appreciate that we are taking strides at getting the word out.  In plain words, this is our chain of survival when ECMO is an option:

  • The only way we can get a patient, with a fixable coronary lesion and an intact brain, who is in refractory VF to the cath lab is on ECMO.
  • The only way to get them on ECMO, in time, is to run a good code. (see our discussion on the Tactical Approach to the Cardiac Arrest)
  • The only way to get to the point of running a code well is for medics to transport the patient with good quality CPR, and mechanical chest compression devices are the wave of the future.
  • The only way to get keep a patient's brain perfusing until medics arrive is “Hands Only CPR.”  The AHA has come a long way in now promoting this recommendation.

So lets all do our part in getting the good word out there:  If someone collapses in front of you:

  1. Call 9-1-1
  2. Push HARD & FAST in the center of their chest.

We are the very last link in the chain of survival. And since a chain is only as strong as its weakest link, lets get that first link as strong as possible. Remember that our inclusion/exclusion criteria for considering ECMO, the last bridge to a curative intervention, includes all components of this chain of survival, and the first (your chest compressions) are one of the most important.  If paramedics bring us an arresting patient in extremis and the history includes a delay until chest compressions are started, crappy CPR, or any other mitigating factor, we may decide that ECMO is not appropriate.

American Heart Association website

American Heart Association website

“The Story of Ralph”

Our First ECPR Case:

It was July 28, 2010. That morning Zack had just given our ER group a presentation on a “new” intervention: ECMO.

Zack and Joe were on shift that same night.  The radio call came in: 59 yr old male with chest pain, EKG shows ***Acute MI***.  Minutes later the medics came back on the radio with this message: “Sharp, be aware your patient just coded.” Here is the actual radio call (with subtitles):

Ralph radio call – “your patient just coded!” from Joe Bellezzo on Vimeo.

Ralph was in refractory VFIB. Zack threw everything at him: every drug in the code box and an uncountable number of shocks – all unsuccessful. Joe and Zack put Ralph on ECMO. His case was initially thought to be unsurvivable and he was taken to the ICU, where he began moving and checking his watch! So he was taken to the cath lab and his 100% LAD lesion was stented.  9 days later Ralph walked out of the hospital (refusing to take a wheelchair).  Ralph is alive and well.  We do a yearly 5k event at Thanksgiving every year. In return, we've forced Ralph into a state of persistent guilt and retribution…and make him to come with us to various speaking events!!!!

In late 2010, we presented Ralph's case at Grand Rounds at USC…and as always we guilted Ralph into coming along.  Mel Herbert recorded that event and put together a little video about his story.  Here is Mel's video (note that the credits at the end should say “Sharp” hospital, not “Scripps”):

“The Story of Ralph” – 2010 – By Mel Herbert MD from Joe Bellezzo on Vimeo.

***Many thanks to Mel Herbert and EM:RAP for allowing us to share his video on our site!

 

Around the same time our hospital produced a video on Ralph's story as well. Here is that video:

July 2010: ECPR saves a patient in refractory V-Fib from Joe Bellezzo on Vimeo.

 

July 28. 2014:

…and today, July 28, 2014, Ralph and his wife Suzette stopped by our ED to say thanks. Today is the four-year anniversary of Ralph's remarkable resuscitation after VF arrest.

Screen Shot 2014-08-02 at 12.22.33 PM

 

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

 

Chatter causes IVC Trauma!

As we mentioned in our recent podcast Episode 8: “Prime Time!”, and as Weingart mentioned in his recent episode of the EMCRIT podcast:  Podcast 123 – Selective Aortic Arch Perfusion (SAAP) with Jim Manning, Zack and I were at UNC Chapel Hill in Jim Manning's lab doing several experiments in a pig animal model.

During one of the experiments we did a thoracotomy and what we saw was really impressive.  We all know that the ECMO lines will “chatter” when the RPM's were cranked up too high…caused by turbulence in the venous intake line when the negative pressure of the pump requests more volume than the IVC can deliver.  But I don't think any of us appreciated exactly what was happening at the IVC.

Bottom line: Chatter beats up the IVC and should really be avoided!  This video will raise your eyebrows!:

 

 

Chatter IVC from Joe Bellezzo on Vimeo.

WHERE in the World is Zack Shinar??!!

Cameroon, Africa

Cameroon, Africa

Zack is in Cameroon, Africa for 3 weeks visiting his amazing brother, who is a missionary over there.  He has very little access to the outside World and is overwhelmed with the dichotomy of our “world” of medicine and what he is experiencing over there.  Here is yesterday's email:

“Seriously rough day today.  I helped take a post-op c-section with sepsis back to or.  She died later today.  Under resuscitated.  I think I could have done better.  Open skull fx mca is looking awful.  I can see about 30 percent of his r brain missing from plain exam.  We washed him out today.  Plan to use Dr. xxxxx's fat transplant idea when cleaner.  Still not sure exactly best plan for him.  I put a pin in a kid with a mangled foot.  Tendon repair is not really an option.  Infant died of pneumonia.  Malaria everywhere.  Coartem for all!  Certainly humbles me to pray, makes me question the massive discrepancies in the world, and yet makes me value their simplicity of life so lacking from my current state.” ~Zack

 

 

 

 

Today, Zack sent a photo of their “Difficult Airway Cart”. This stuff really makes you appreciate what we have!

Airway

The “Airway Cart”

 

 

 

 

 

Here are some more shots Shinar just sent:

Cameroon OR

Cameroon OR

Shinar on Cameroon Radio Show

Shinar on Cameroon Radio Show

Cameroon EMS!

Cameroon EMS!

 

Resuscitation table

Resuscitation table

photo 3

Patients

Patients

photo 2

 

 

 

 

 

 

 

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