Questions on the ECLS Textbook

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Comments

  1. Dominic Larose says:

    what is the typical door-to ecmo stage 3 time? How many cases needed to be proficient?

    • Dominic, Good question. In successful cases (ECPR to full neuro recovery) our Door-to-pump times (completed stage 3) vary from 32 minutes to 69 minutes. Indeed we get better and faster with every case. I’m working on several things that will hopefully make cannulation easier and faster and I will keep you posted through the site. Many studies confirm the obvious: faster cannulation = faster on the pump >>> increased survival with neuro integrity.

  2. Dominic Larose says:

    what is the state of coronary perfusion during ecmo (compared to manual or mechanical compressions? (ecmo started, no chest compressions, no rosc). Do you keep shocking the heart every two minutes (if shockable rythm). Do you have patients waking up and needing sedation during the procedure^

    • Dominic – sorry for the late reply…this question sneaked by me! These are great questions and I will try to have more information on these exact topics uploaded to the site ASAP. Briefly, though, coronary perfusion during ECLS is just identical to a normal beating heart. Indeed patients could wake up during the procedure and in those cases sedation would be indicated; and we do see that during semi-elective cannulation (ie cardiogenic shock, pulmonary failure, etc). But during ECPR, our patients have failed traditional ACLS and all of them have prolonged resuscitations by definition. So you’d think of these patients just like your ROSC without RONF scenarios. TTM (we use 33 degrees still in these patients and we believe in intra-arrest cooling).

      As for you second question, we recommend continuing to shock shockable rythms, antidysrythmics, etc. Even though brain and coronary perfusion is supported fully by ECLS, a non-beating heart (VFIB) becomes a conduit – so retrograde flow of the ECLS circuit just throws a huge pressurized volume at the aorta >> LV >> pulmonary veins >> lungs. That causes pulmonary hemorrhage, which is devastating. So do everything possible to get the heart beating again!

  3. B. Victoria Jassman says:

    “ECPR is indicated when all other traditional resuscitative strategies have been exhausted and the only alternative is death.”

    This statement is on the page describing selection criteria for ECPR. Do you think that this is really the best strategy? For ECPR to be last resort and only to be tried after 30-60 of conventional CPR and ACLS? Out-of-hospital cardiac arrest survival rates continue to be less than 10%. Perhaps this is why our success rates with ECMO have not improved. The sooner ECMO is implemented after loss of spontaneous circulation, the sooner the restoration of adequate oxygenation and perfusion. I think the CHEER trial used by the Alfred Hospital in Australia has developed a good protocol for out-of-hospital cardiac arrest and ECPR.

    I have recently read a few case reports regarding portable ECMO, and its use in implementing ECPR out-of-hospital at the scene. Portable ECMO seems like an excellent idea for ECPR. What do you guys think about portable ECMO?

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