53: Distal Perfusion Catheter with Joe Dubose

Episode 53 is all about the distal perfusion catheter12.  We are inserting a 15-19 Fr catheter into the femoral artery.  This limits the flow of blood to the affected extremity.  Many institutions have gone to mandatory distal perfusion catheters.  This episode is all about those catheters – when, how, which, and where.  Joe Dubose, the world reknown vascular and trauma surgeon, joins us to discuss the details of this important piece of post pump initiation.

Take Homes –

  • Common Femoral -> Superficial Femoral Artery or Posterior Tibial/Dorsalis Pedis
  • Check distal perfusion frequently
  • 5-7 Fr Catheters
  • Doppler/Temperature/Color of distal extremity
  • Remember side port of arterial ECMO catheter significantly limits the flow dynamics through the catheter

1.
Kaufeld T, Beckmann E, Ius F, et al. Risk factors for critical limb ischemia in patients undergoing femoral cannulation for venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory approach? Perfusion. February 2019:267659119827231. [PubMed]
2.
Lamb K, DiMuzio P, Johnson A, et al. Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation. J Vasc Surg. 2017;65(4):1074-1079. [PubMed]

52: Brain Freeze- Selective Retrograde Cerebral Perfusion for Intra-Arrest Neuroprotection

1,23456

We've all heard of therapeutic hypothermia.  Some of us have heard of deep hypothermia for traumatic arrest.  But what about deep regional hypothermia of brain for cardiac arrest!  Zack interviewed Rob Schultz, a CT surgeon resident from Calgary who is doing research on deep hypothermia of the brain using some of the tactics that are utilized in operating room.  His stuff is mind blowing!

1.
Milewski RK, Pacini D, Moser GW, et al. Retrograde and Antegrade Cerebral Perfusion: Results in Short Elective Arch Reconstructive Times. The Annals of Thoracic Surgery. 2010;89(5):1448-1457. doi:10.1016/j.athoracsur.2010.01.056
2.
Keeling WB, Leshnower BG, Hunting JC, Binongo J, Chen EP. Hypothermia and Selective Antegrade Cerebral Perfusion Is Safe for Arch Repair in Type A Dissection. The Annals of Thoracic Surgery. 2017;104(3):767-772. doi:10.1016/j.athoracsur.2017.02.066
3.
Papadopoulos N, Risteski P, Hack T, et al. Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe? Thorac cardiovasc Surg. 2017;66(03):215-221. doi:10.1055/s-0037-1604451
4.
Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis. The Annals of Thoracic Surgery. 2016;101(1):146-152. doi:10.1016/j.athoracsur.2015.06.029
5.
McCullough J, Zhang N, Reich D, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg. 1999;67(6):1895-1899; discussion 1919-21. [PubMed]
6.
Yan T, Bannon P, Bavaria J, et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg. 2013;2(2):163-168. [PubMed]

50a Inter-facility Transport of ECMO patients Part 1 of 2

This month we are looking at how to transport patients from one facility to another on ECMO.  This is a difficult task, full of potential catastrophes.  Zack interviews Leon Eydelman, an ER/Critical Care physician from Chicago, and Michael Broman out of Karolinska in Sweden.  Leon will be bringing us up to speed on what to do, potential fails, and how to start the process of setting up a transport process for ECMO patients.  Dr. Eydelman will be teaching a new section at Reanimate this January specifically geared toward the transport of patients.  So if you are a nurse, medic, perfusionist, or RT involved in the transport of ECMO patients you will not want to miss Leon's section  Sign up at Reanimateconference.com.  Part 2 of this podcast includes the interview with Dr. Broman which will blow your mind.  So much great stuff in both of these interviews.

NEW PAPER: Extracorporeal Life Support in the Emergency Department: A Narrative Review for the Emergency Physician

Pulmonary Critical Care guru Justyna Swol from Nuremberg, Germany invited Scott, Zack and me to co-author this paper along with several other ECLS experts.   Just published in the Journal Resuscitation, this is a great overview of Emergent ECLS(AKA ECPR) from the point of view of the Emergency and Critical Care specialist.1

https://doi.org/10.1016/j.resuscitation.2018.10.014

 

1.
Swol J, Belohlávek J, Brodie D, et al. Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation. 2018;133:108-117. [PubMed]

49 – You Can’t Spell REBOA without the ER – Endovascular Resuscitation of the Trauma Patient – Zaf Qasim

In this episode, Zack Shinar interviews Zaf Qasim about the recent controversies with ACEP and ACS about who can do REBOA.  Zaf is one of the world's experts on REBOA and he's an ER doc!  Zaf works at the University of Pennsylvania, trained in London

as well as Shock Trauma in Baltimore and teaches at Reanimate.  When you come to the essence of this episode, the question is what is the emergency physician's role in the trauma resuscitation?  Both Zaf and Zack agree; we need to be the resuscitationist in the trauma suite.  We need to manage the airway and then quickly take over the arterial and venous access, interpret the transduced pressures, manage the massive transfusion protocol and be ready to insert the REBOA catheter while the trauma surgeon is involved with the left chest, the source of bleeding and where the next destination for this patient will be.

Save These Dates!

EDECMO involved upcoming conferences:

April 10-11: Mayo Scottsdale.

April 25-28: The Society for Cardiovascular Angiography and Interventions.

May 18-23: American Thoracic Society.

AND SAVE THE DATE

Reanimate 6

January 30th-Feb 1st, 2019.

Sign ups will be opening up shortly

 

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.

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.

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.

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!