EDECMO # 13 – Does Pseudo-PEA Exist and What Should You Do About It

This is the first episode where all three of the EDECMO boys are together–yeah! Today we talk about a bunch of PEA stuff. Scott proposes 2 new terms to bring us into the modern era: PREM-pulseless with a rhythm and echocardiographic motion PRES-pulseless with a rhythm and echocardiographic standstill Joe asks why we shouldn't just treat the latter like asystole, and he's probably right. But what of the former? What should we do with that? Listen to the episode.  

Jim Manning's talk at GSA HEMS

On Youtube

Here's the Littmann Article on PEA

354195

A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity

Update

Our friend Gregor Posen performed this excellent Pseudo-PEA (PREM) Paper

 Bibliography

In this episode, Joe was “Orating via the Anus” while Zack and Scott took a more evidence-based approach:

 

Update

This new study seems to demonstrate that stratification by ecg width may not be evidence-based

 

TrackBacks

“PEA is just a bunch of BULLSHIT!”  Joe talks about the FALLACY OF PEA on the ER Cast podcast with Rob Orman…  

Evid-ECMO (Evidence for ECMO): Critical Analysis of the ECMO literature #1

Both of these articles are fantastic. We review these two articles and describe their impact on the ECMO World:

Article 1: Conventional CPR vs. ECPR for In-House Cardiac Arrest (CPS Chen Lancet Study)

Identification:

Title:  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

Authors: Chen, Lin, et al.

Location: National Taiwan University Hospital; Taipei, Taiwan

Source: Lancet 2008; 372: 554-61

ClinicalTrials.gov #: NCT00173615

Introduction:

Problem: Comparing ECPR to conventional CPR for in-hospital cardiac arrest. Prior studies that showed a  benefit of ECPR over conventional CPR may have had selection bias. Prior studies also included all causes of arrest whereas this study attempts to focus on arrest of cardiac origin.

Purpose:  Is ECPR superior to conventional CPR for in-hospital cardiac arrest of cardiac origin?

Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for in-house arrest.

Methods:

Study Type:  Prospective Observational with Propensity-Score analysis matching

        • Single-Center
        • 3 years
        • 975 total patients; 172 patients: conventional CPR = 113; ECPR = 59

Subjects:  18-75 YOA; witnessed cardiac arrest of cardiac origin who underwent CPR for longer than 10 min. Matching based on propensity-score;

      • CPR team: senior medical resident, junior residents, RT, several ICU RN's. *residents were cannulating!

Primary End-Point: Survival to hospital discharge, with sub-analysis of neurologic outcomes.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusion:
      • Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.
      • Survival to Hospital discharge:
        • Unmatched: 28.8% ECPR vs. 12.3% conventional CPR
        • Matched: 32.6% ECPR vs. 17.4% conventional CPR

****THE BOTTOM LINE:  EDECMO Critical Assessment:

    • Good study that showed a benefit of ECPR over conventional CPR for in-house arrest for short and long-term patient-oriented outcomes.
    • Propensity matching method reasonably mitigated selection bias
    • 3 patients in the ‘conventional CPR' arm were later put on ECMO because of persistent shock > Is there an implied benefit of ECMO for the post-cardiac arrest syndrome?
    • Criticisms/Confounders
      • Single-Center
      • Patients in the ECMO group had higher incidence of LVAD, intervention, and heart transplant.
      • first documented rhythm of VT/VF (49% ECPR vs. 32% CPR) was significantly higher in ECPR group; and asystole (22% ECPR vs. 27% CPR) was higher in the CPR group: ? selection bias?
      • Location of arrest/CPR may make a difference (Emergency Department vs. ICU/Operating room)
      • Failed conventional CPR was defined as CPR without ROSC at 30 minutes – is this timeframe too short.  What if conventional CPR were continued for 60 min?
      • No TTM or hypothermia in either group.

 

Article 2:  CPR vs. ECPR for Out-of-Hospital Cardiac Arrest (SAVE-J)

Identification:

Title:  Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study

Authors: Sakamoto, Morimura, Nagao, Asai, Yokota, Nara, Hase, Tahara, Atsumi, SAVE-J Study Group

Location: Yokohoma City University Graduate School of Medicine, Yokohama, Kanagawa, Japan

Source:  Resuscitation 2014 Jun;85(6):762-8

Introduction:

Problem: Does ECPR improve patient-oriented outcomes after OHCA? Prior to this study, the effects of ECPR on long-term neurologic outcomes were unknown.

Purpose:  To determine whether ECPR is better than conventional CPR for short and long term neurologic recovery for patients who suffer OHCA

Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for OHCA.

Methods:

Study Type:  Prospective Observational;

    • multi-center: 46 centers: 26 ECPR, 20 non-ECPR
    • 3 years
    • 454 patients: Conventional CPR = 194; ECPR = 260

Subjects: 20-75 YOA; VF/VT arrest; <45 total arrest time;

Primary End-Point: Rate of favorable outcomes (CPC 1 or 2) at 1 and 6 months after OHCA.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusion: In OHCA due to VF/VT, a treatment bundle of ECPR, TH (TTM?), and IABP was associated with improved neurologic outcomes at 1 and 6 months.
      • Intention-to-treat Analysis:
          • 1 month:
            • ECPR  = 12.3%
            • Non-ECPR = 1.5%
          • 6 months
            • ECPR = 11.2%
            • Non-ECPR = 2.6%
      • Per-protocol Analysis:
          • 1-month
            • ECPR = 13.7%
            • Non-ECPR = 1.9%
          • 6-month
            • ECPR = 12.4%
            • Non-ECPR = 3.1%

****THE BOTTOM LINE:  EDECMO Critical Assessment:

    • Excellent multi center study a benefit of ECPR over conventional CPR for OHCA for short and long-term patient-oriented outcomes.
    • Criticisms/Confounders:
      • Rate of use of TTM/TH and IABP were higher in ECPR group.
      • Choice of ECPR vs Non-ECPR was dependent on individual centers with each center doing one or the other but not both.  In other words, does the quality of care at an ECPR center trump the quality of care at a non-ECPR center and does that impose bias?

EDECMO Episode 12 – The Nurse-Based ECMO Program at Sharp Memorial Hospital with Suzanne Chillcott RN, BSN

In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a “nurse-run” ECLS program.  There is no lack of enthusiasm over the concept of doing ECPR in the Emergency Department.  As most of you already know, we think ECPR is the wave of the future for resuscitation.

Suzanne Chillcott BSN, RN Mechanical Circulatory Support Lead

Suzanne Chillcott BSN, RN
Mechanical Circulatory Support Lead

So you think  you want to set up the next ED/ICU ECPR program?  You think you want to do ECPR in your Emergency Department or ICU?  But where to begin? Hopefully this episode will hopefully answer many of those questions:

ECLS Program Models

Physician resuscitationists cannulate. But you need an “ECMO team” to prime the circuit, help initiate bypass, trouble-shoot the machine, and manage the patient after bypass is initiated.  But who is going to do that?  Who has jurisdiction over your ECMO program?  Well, if you are working at an institution with an active cardiothoracic surgery program, chances are you already have these roles established; and I  recommend you speak to the Chief of your CT surgery team.  But for the sake of argument lets pretend you are starting an ECMO/ECLS/ECPR program de novo. What are your options?

Well, whomever is going to do this MUST be “in-house.”  In the ED, Emergency Physicians should be cannulating because we are already right there. We are running the code. We should be the ones doing the cannulation. And the same goes for intensivists in the ICU.    There simply isn't time to call in a specialist to cannulate. The same goes for your ECMO team: they must be “in-house.” It would seem to make sense that perfusionists would be the first-responder ECMO team, however at many institutions (ours included) perfusionists aren't “in-house 24/7.”  So there are now 3 main ‘models' to address this:

  1. Perfusionist-based: Some facilities, usually teaching hospitals with very active ECMO programs, have in-house perfusionists.  In those cases the perfusionist is usually the “first-responder.”  In some cases the perfusionists handle all bedside activities from start to finish. In other cases the perfusionists help initiate ECMO and RN's or respiratory therapists (RT's) will ‘babysit” the machine when active adjustments aren't being made.
  2. RT-based: When Shinar and I were at the University of North Carolina Chapel Hill, we witnessed this type of program.  While the perfusionists there are doing all the heavy lifting, they have trained their RT's in supervising ECMO.
  3. Nurse-based: ICU nurses  are cross-trained in ECMO.  This is the model we use at Sharp Memorial Hospital in San Diego.  ICU nurses are trained in all aspects of ECMO and the ICU staffing is setup such that there is always at least 2 RN's in the SICU who are ECMO-ready.  If we have an ECPR case in the ED we call the SICU. Quickly those nurses temporarily hand-off their assignments and come to the ED.

Establishing an ECMO Program at Your Hospital

Key Players:

  1. CT Surgery
  2. Nursing
  3. Perfusionists
  4. Hospital Administration

    CardiacTransplantTeam_low

    The SMH Mechanical Circulatory Support Team

These are the key components. Of course, if you are doing ECPR in your ED then you also need an ED doctor champion.  If you are reading this, I assume that will be you. So welcome to your new role!

Who Cannulates?

  1. CT surgeons
  2. Interventional Cardiologists
  3. Intensivists/Pulmonologists
  4. Interventional Radiologists
  5. Emergency Physicians

The Sharp Memorial Hospital ECMO Nursing Training Program

  • Staffing:
    • SICU nurses must apply to be on the ECMO team
    • Coveted position
    • + financial differential (the RN's get paid to cross-cover ECMO)
    • RN works a regular SICU assignment but must also respond to ECPR
  • Training:
    • Training Manual
    • One-on-one class: 10-12 hours of training per RN
    • RN must be able to establish circuit within 10 min
    • Ongoing Competency Evaluation every other month to maintain skills:
      1. MAD (mechanical assist device) Lab Day = wet-loop training
      2. Direct wet-loop training in the SICU
      3. Manage a real live patient
  • Costs:
    • Capital = Hardware (pump head, heater/cooler, blender, SVO2 monitor) is reusable
      • These are hard costs that are not billable to a patient. Roughly $100,000 per unit. We house 2 unit  = $200,000
    • Disposables (The Circuit and the Cannulae): Used on each patient and billable to the patient.
    • Nursing:
      • Shift coverage (12 hours shifts, 2 RN's always on-shift) = 25 fully trained nurses
      • Training: 25 nurses @ 10 hours of training @ $50/hr =  $12,500
      • Continuing Competency Evalution training =  2 hrs ever other month @ $50/hr = $600 x 25 nurses = $15,000/yr for ongoing training
      • Premium differential paid to SICU nurses to be on the ECMO team
      • Perfusionist coverage: This is often a contracted rate with a local perfusionist team

A Day in the Life of an RN ECMO Team Member:ECMO RN

  • 2 ICU RN's are always staffed in the SICU
    • staffed so the RN's are working at opposite sides of the unit so an ECPR case won't debilitate any arm of the ICU by calling RN's away.
  • ER doctor calls the SICU when a potential ECPR case arrives to the ED
  • ECMO RN's bring, from the SICU (located on the 2nd floor at our facility) to the ED:
    1. The ECMO cart – mobile ECMO hardware = pump head, heater/cooler, blender, SVO2 monitor
    2. The ECMO supply cart – carries all the disposables (circuits, cannulae, various supplies
  • Suzanne describes the logistics of priming the pump, connecting the patient to the circuit, and starting the pump
    • ***PEARL: the goal at initiation of bypass is maximize flow while minimizing RPMs, so the nurse will dial up the RPM until flow is maximized, but no further.
    • SVO2 goal = 70
  • ECMO RN calls OR to summon the perfusionist. In our system the perfusionist is on-call and has an established response time
  • ECMO RN hands off the pump duties to the Perfusionist and then goes back to their SICU assignment

Policies and Procedures

Please contact any of us if you want to take a look at our policies and procedures  – we are more than happy to share this stuff.

The Late Great Tony Gwynn Could Teach us Something About Success:

Suzanne says it best:  ” The way you gotta look at it…the patients we put on pump are all 100% dead when you start with them. You can't make them more dead. You can't make it worse. All you can do is possibly make it better…”

Established success rates, for long-term survival neuro-intact is 27-30% for in-hospital cardiac arrest.  That is significantly better than historical established success of non-ECPR ACLS of 17%.  So even though we almost double the survival of these patients, fully 70% still don't survive or have neurologic recovery. To take that even further, for out-of-hospital cardiac the survival is dismal…and at this time we don't even initiate ED ECMO until ACLS has failed – the point at which you would pronounce the patient dead.  So by definition, our starting point 0% survival. So any success is meaningful.

Tony GwynnWe really need to remind everyone that ECPR success is much like batting averages – a batting average over .300 will get you into the Baseball Hall of Fame!!  One of the greatest baseball hitters of all-time, San Diego favorite Tony Gwynn, FAILED 70% of the time and was one of the greatest hitters of all time; and elected to the Baseball Hall of Fame in Cooperstown.

So lets setup appropriate expectations from the beginning!  And remember, even the great Tony Gwynn occasionally went several ‘at-bats' without a hit.

 

 

Do you have Questions for Suzanne?  You may email her directly at suzanne.chillcott@sharp.com

 Announcements:

Aug 18-21: Emergency Medicine Update.  Bellezzo is speaking on “Resuscitation: State of the Art”

October 21: Bring Me Back to Life conference in Montreal, Canada

 

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.