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

55 – Anticoagulation of the ECMO Patient with Troy Seelhammer

Do you give heparin to your ECMO patients?  Well, let's rethink this.  This episode is All Things Anticoagulation!  Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester.  He manages ECMO patients in his daily practice there.  He has become a master of the subject of anticoagulation.  He will talk about heparin, bilvalirudin, or maybe no anticoagulation.  We talk about how TEG can affect our management.  We talk about PCC and Protamine when bleeding just won't stop.  He talks about the when to be aggressive and when to cut back.  Below is a wonderful synopsis of Troy's thoughts on anticoagulation on pump.

 

Goal Heparin levels are far from perfect but some suggestions

APTT 1.5 to 2.5 times normal

ACT level – 180-220 seconds

Antithrombin Levels – next generation

 

Seelhammer doc on BivalirudinBivalirudin & TEG During ECMO

 

54: Confirmation of Wire Placement with Sacha Richardson

In this episode, Sacha Richardson talks with Zack about a problem common to all ECPR programs- how do we confirm the placement of the wires?  During chest compressions and even in patients with a pulse, confirmation of which vessel you have cannulated can be difficult.  Sacha shares some tricks and trips on how to get real time confirmation of the wires.  Sacha also gives us a preview of some of the exciting endeavors that he has undertaken in Melbourne with pre-hospital ECMO.

53b: Resuscitationist Inserted Distal Perfusion Catheter with Chris Couch

 

In this episode, we again explore the world of the distal perfusion catheter.  You heard from Joe Dubose the vascular surgeons point of view; now let's see how non-surgeon resuscitationists are dealing with this problem.  You will hear from Chris Couch, a critical care trained emergency physician from Dallas Texas and his colleague Omar Hernandez who have some novel thoughts and experiences related to when and how we insert these catheters.  You will hear about checking compartment pressures, poor man's way to “fluoro” your catheter, and much more.

 

Great summary of supporting literature – DPC Lit Search

 

51 – Proximal Balloon Occlusion for Cardiac Arrest

 #tbs19 The Big Sick—-  You've heard of ECMO for cardiac arrest- utilizing a mechanical pump to aid in perfusion of the coronaries.  What if you can't do ECMO?  What if your resources are such that simply can't lug a 10 kilogram machine out into the field?  Well, Jostein Brede may have something for you to consider.  He and several other places worldwide are on the forefront of using a REBOA catheter to occlude the proximal aorta during chest compressions in hopes that coronary perfusion pressure increases.  This would subsequently improve chance of return of spontaneous circulation and overall survivorship.  Maybe this is the band-aid that can be used in austere environments like rural Norway where the temperatures are extreme, the people are sparse, but the physicians are motivated.  12

1.
Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. T. 2017;35(5):731-736. doi:10.1016/j.ajem.2017.01.010
2.
Aslanger E, Golcuk E, Oflaz H, et al. Intraaortic balloon occlusion during refractory cardiac arrest. A case report. R. 2009;80(2):281-283. doi:10.1016/j.resuscitation.2008.10.017

50b Inter-Facility Transport of ECMO patients Part 2 of 2

This is part 2 of Transport of ECMO patients.  Mikael Broman is one of the world's leaders on ECMO transport.  He works at the Karolinska institute in Sweden and ha

s and continues to publish in the arena of ECMO transport.  As you will see, he offers a world of experience and certainly some critical information that we would all benefit from listening to.  I'm a smarter ECMO-tologist as a result of Micke!1234

 

 

 

 

ELSO transport guidelines -https://www. elso.org/Portals/0/Files/ELSO%20GUIDELINES%20 FOR%20ECMO%20TRANSPORT_May2015.pdf

 

1.
Bryner B, Cooley E, Copenhaver W, et al. Two Decades’ Experience With Interfacility Transport on Extracorporeal Membrane Oxygenation. T. 2014;98(4):1363-1370. doi:10.1016/j.athoracsur.2014.06.025
2.
Javidfar J, Brodie D, Takayama H, et al. Safe Transport of Critically Ill Adult Patients on Extracorporeal Membrane Oxygenation Support to a Regional Extracorporeal Membrane Oxygenation Center. A. 2011;57(5):421-425. doi:10.1097/mat.0b013e3182238b55
3.
Broman LM. Inter-hospital transports on extracorporeal membrane oxygenation in different health-care systems. J. 2017;9(9):3425-3429. doi:10.21037/jtd.2017.07.93
4.
Ericsson A, Frenckner B, Broman L. Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation. Prehosp Emerg Care. 2017;21(4):448-455. [PubMed]

EDECMO 48: When Should I Transport a Cardiac Arrest?

This part two of August 2018.  We are now tackling the difficult question of when to transport cardiac arrests if I have ECMO available?  Brian Grunau is an expert in this question.  Brian has become a giant in the world of ECMO.  His research, leadership and experience have pushed the Canadian ECPR contingency to the forefront.   Brian gives us some insight on what factors I should consider and when should I transport.1

1.
Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital? P. 2016;20(5):615-622. doi:10.3109/10903127.2016.1149652

EDECMO 47: ECMO Donazione: Organ Transplantation with Velia Antonini

Over this last year we have had episodes on organ donation and decision to transport.  This month we are revisiting two topics with two amazing people in two separate episodes.  Here, I interviewed Velia Marta Antonini.   Velia works in Italy where several of the great ECMO donation papers have originated.  She explains why this research is coming from Italy, what the process looks like, and the implications of this for other countries.  Check out her slides below.

 

 

 

Here are Velia's slides on the subject

eisor ED ecmo (1)

 

 

 

EDECMO 46: Wire Assistant

Well, it only took us seven years to figure this one out.  The wire assistant has been the key advancement of 2018 for placement of ECMO cannulas.  In this episode, Zack and Joe talk through this process after an  interview with Alyssa Baldini.  Alyssa was one of our first true wire assistants and has been instrumental in getting cannulas in faster and safer.  We discuss how the wire assistant aids in sterility and getting the artery on the first stick.  Bottom line – train someone at your shop to be an expert wire assistant.

EDECMO 45: ECMO in Sepsis

In this episode, Zack talks with Heidi Dalton about ECMO use in Sepsis.  This is another controversial area with pediatric literature showing strong results while the adult results have been less impressive.  Heidi has been a key figure in both adult and pediatric ECMO.  She is the former chair of the yearly ELSO conference.  She is a professor at both George Washington University and Virginia Commonwealth University.  Her background is in pediatric critical care. She currently works at INOVA in Virginia where she is the director of adult and pediatric ECMO.

Sepsis has been thought to be a contraindication to ECMO use secondary to the pro-inflammatory nature of ECMO and potential to harbor infection.  Recent research is certainly controversial with adult studies showing low survival in septic shock and sepsis as a cause of arrest.  As with much of ECMO literature, the problem is with the denominator – What is the expected survival of these patients?  The follow up question becomes what effort is prudent for these low survival rates?  The sepsis cohort tend to be younger and potential for long term survival is high.  The question remains should we be utilizing ECMO for sepsis?1–9

1.
Maclaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution’s experience. Pediatr Crit Care Med. 2007;8(5):447-451. [PubMed]
2.
Datzmann T, Träger K. Extracorporeal membrane oxygenation and cytokine adsorption. J. 2018;10(S5):S653-S660. doi:10.21037/jtd.2017.10.128
3.
Perdue SM, Poore BJ, Babu AN, Stribling WK. Successful use of extracorporeal membrane oxygenation support in severe septic shock with associated acute cardiomyopathy. J. 2018;33(1):50-52. doi:10.1111/jocs.13508
4.
von Bahr V, Hultman J, Eksborg S, Frenckner B, Kalzén H. Long-Term Survival in Adults Treated With Extracorporeal Membrane Oxygenation for Respiratory Failure and Sepsis*. C. 2017;45(2):164-170. doi:10.1097/ccm.0000000000002078
5.
Millar J, Fanning J, McDonald C, McAuley D, Fraser J. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387. [PubMed]
6.
Choi M, Ha S, Kim H, Park S, Han S, Lee S. The Simplified Acute Physiology Score II as a Predictor of Mortality in Patients Who Underwent Extracorporeal Membrane Oxygenation for Septic Shock. Ann Thorac Surg. 2017;103(4):1246-1253. [PubMed]
7.
Tramm R, Ilic D, Davies A, Pellegrino V, Romero L, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev. 2015;1:CD010381. [PubMed]
8.
Park T, Yang J, Jeon K, et al. Extracorporeal membrane oxygenation for refractory septic shock in adults. Eur J Cardiothorac Surg. 2015;47(2):e68-74. [PubMed]
9.
Sharma A, Weerwind P, Maessen J. Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock. J Thorac Cardiovasc Surg. 2014;147(4):1441-1442. [PubMed]