ELSO ECPR Textbook

Crew,

We are proud to announce the world's first ECPR textbook. We partnered with ELSO and 25 of the world's leaders in ECPR and resuscitative ECMO to create an awesome resource for both in depth learning and on shift quick reference.

Click the hyperlink for Ebook  or Hardcover

 

71: Should We Prioritize VV-ECMO over ECPR?

In this episode, we dive into the abyss of resource allocation.  Much of the world is saying that the limited number of ECMO circuits should be used for COVID induced lung injury.  This means that ECPR initiatives have been shut down or severely limited.  Is this the right thing to do?  What does the data say?  What strategy gives the most benefit to the most people? Make sure to get CPR Certification Cleveland so you can always be prepared in case of any emergency.

Zack invited Brian Grunau to discuss these topics as well as a recent ECPR paper out of Norway and study dealing with signs of life during CPR. Find more information about CPR Certification Wichita to keep saving lives and helping people in need.

 

Oslo Study

Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, Bendz B, Andersen GØ, Fiane A, Hagen OA, Kramer-Johansen J. Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol. Resuscitation. 2021 Feb 10;162:35-42. doi: 10.1016/j.resuscitation.2021.01.038. Epub ahead of print. PMID: 33581226.

Signs of Life Study

Debaty G, Lamhaut L, Aubert R, Nicol M, Sanchez C, Chavanon O, Bouzat P, Durand M, Vanzetto G, Hutin A, Jaeger D, Chouihed T, Labarère J. Prognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest. Resuscitation. 2021 Feb 17:S0300-9572(21)00077-0. doi: 10.1016/j.resuscitation.2021.02.022. Epub ahead of print. PMID: 33609608.

How To Get Started With CBD

What you can and cannot take with CBD? If you’re considering taking CBD in any form, there are two main categories to keep in mind: Do you smoke? If you’re worried that you will get too high on CBD, the short answer is: probably not. It’s not that the chemicals in it are particularly risky, but it's the way the CBD molecules interact with your body that poses risks. Have you ever wanted to try CBD but aren’t sure where to start? Do you have questions about what CBD is and how it can be beneficial to your health? Put simply, CBD works synergistically with the body’s endocannabinoid system, a complicated cell-activating system, to bring about relief from pain, nausea, and a host of other symptoms that stem from various diseases. Before you start to worry about what the best, exact dosing is, you should know that everyone’s body is different. Therefore, there is no right dose for any single person. In short, a dose that is effective for you might not be as effective for someone else. Make sure to check out this list by Ministry of Hemp first if you want t try CBD products, begin by taking a % dropper of a reputable 300mg CBD oil once per day. This should be the equivalent to about 5mg.. CBD also comes in different forms such as gummies, chocolates, capsules, vapes, and even creams, salves, and lotions. Some companies are even coming out with CBD-infused water, coffee, and seltzer.

The best way to know which type of CBD product to choose is to select the one that best suits your needs and your lifestyle. It’s important to remember that all CBD brands are not created equal. Sadly, the rise in popularity of CBD also created an influx of poorly crafted products. CBD oils and extracts come in a variety of different strengths and varieties. Some of the more common CBD oil strengths are 300mg, 600mg, 1200mg, and 2400mg. CBD tinctures also can come in a host of flavors such as berry, vanilla, mint, citrus, and natural. According to FDA’s product labeling guidelines, “do not take cannabis with tobacco, nicotine, alcohol, or diet drugs.” One study has even shown that CBD can do the opposite of smoking cigarettes, which means that it can actually help you quit smoking as a whole. However, most experts have dismissed the idea that CBD will bring you to a “hardcore” or “endless” addiction. In reality, CBD can be utilized for a variety of medical issues, just like most other compounds.

If you still have questions about taking CBD, it is important to know that the longer you sit on the sidelines, the more it will start to take the edge off your symptoms. After all, if you are able to manage your symptoms for a period of time, you are actually more likely to stick with it. Although there is no single prescription or medical approval to use CBD, there are plenty of self-help resources and specialty sites that provide detailed information about the benefits and therapeutic applications. Some sites even have a general knowledge board where people can ask and answer questions about this common compound. Even if you are not able to afford CBD medication, taking it as an added supplement is a smart way to make sure you can get enough CBD to be effective.

The good thing about supplementing CBD is that you don’t need to dedicate a large amount of money in order to achieve the results you want. Many supplements, both natural and in the form of tinctures and capsules, are available online at a fraction of the price of traditional pharmaceuticals. This could be an option for those who might not otherwise have access to a doctor, or for those who do have access, but would like to make sure they are not abusing CBD. This is why the best way to find out if CBD is right for you is to see a doctor. Many people have very successful results when they do so. The bottom line is that every patient is different and requires a different strategy. For example, if you have migraines, you might start taking CBD on an as needed basis. If you are a person that likes to exercise, then you may want to give CBD a try to start out. CBD does not work in all situations, but there are many benefits to its use that should be taken into consideration. For example, CBD seems to help people reduce their anxiety, but it might work best for people with anxiety related to pain or a full-blown panic.

56: Pressors, Fluid, or Flow – Optimizing ECMO Physiology

A post arrest patient just got initiated on ECMO.  Do you give fluids, add pressors, or increase flow?  Marc Dickstein, an anesthesiologist from Columbia University and an expert in the physiology of ECMO, talks with Zack about how to manage these patients, what diagnostics we need and how to optimize your use of the machine.  This talk is a must for everyone starting ECPR in their departments.

Photo: Marc Dickstein

Marc's ECMO physiology website Harvi

Marc's ASAIO article on ECMO physiology –

Dickstein ML. The Starling Relationship and Veno-Arterial ECMO: Ventricular Distension Explained. ASAIO J. 2018 Jul/Aug;64(4):497-501. doi: 10.1097/MAT.0000000000000660. PubMed PMID: 29076945.

Zack's recent Resus Editorial on Impella

Shinar Z. Is the "Unprotected Heart" a clinical myth? Use of IABP, Impella,
and ECMO in the acute cardiac patient. Resuscitation. 2019 May 21. pii:
S0300-9572(19)30173-X. doi: 10.1016/j.resuscitation.2019.05.005. [Epub ahead of
print] PubMed PMID: 31125528

Our Recent ED ECMO article in Journal of Emergency Medicine

 

Check out this link to the full article from our recent Emergency Physician initiated ECMO cohort

https://www.jem-journal.com/article/S0736-4679(19)30057-5/fulltext?fbclid=IwAR2yiup48NSVCKXQ9xv8ycJR6Ub2NnFB1Wuu4BagtR498O1dl9GlF0l3xAg

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.