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EDECMO 21- The Vienna Project: A Randomized-Controlled Trial of ECPR for Out-Of-Hospital Cardiac Arrest

Posted on May 20, 2015 // 2 Comments

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SchoberAndreas Schober is an Emergency Medicine physician and resuscitationist from the Medical University of Vienna. Dr. Schober is a world-expert in resuscitation, ECPR, and cardiac arrest. We met Schober in Chicago at the 2014 American Heart Association (AHA) Resuscitation Symposium (ReSS) where he presented their experience with a “Load & Go” model for out-of-hospital cardiac arrest (OHCA): Screen Shot 2015-05-01 at 10.08.03 PM

In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing “Load & Go” (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. “standard care” (staying on scene until the patient achieves either ROSC or is pronounced dead).  Zack and Andreas talk about the impact this could have on the future of ECPR for OHCA.

Announcements:

SMACC Chicago 2015: There is still time to register for SMACC – the biggest and baddest ED Critical Care conference in the World. Just check out the lineup of speakers! You won't want to miss this.

Reanimate San Diego 2016:  The EDECMO team has put together a crew of world-class educators to teach you how to set up an ED ECMO program, teach you how to initiate ECPR in arresting patients, and teach you how to manage patients after they are on “on-pump”. Please join us in “America's Finest City,” San Diego, California, for 2-day immersion in ECPR. We are limiting the conference size to maximize your learning experience, so registration will sell out quickly:

Register for Reanimate San Diego 2016

 

**Special thanks to Camille Hudon for providing the “International Introduction”, in French, to this episode!!!  That was recorded in a small restaurant in Montreal during Bring Me Back To Life 2014

 

 

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EDECMO 20 – The Golden Hour & the Rule of 3’s: Optimizing the Critical First Hour on Heart-Lung Bypass

Posted on April 11, 2015 // 2 Comments

Podcast: Play in new window | Download (Duration: 28:52 — 26.6MB)

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Announcements

Upcoming Conferences:

  1. SMACC 2015: June 23-26, 2015. The biggest and baddest critical care conference of the year is in Chicago this year.
  2. Essentials of Emergency Medicine 2015. October 13-15, 2015. The Big Show. In Vegas. At the Cosmopolitan.
  3. Reanimate San Diego. February 25-26, 2016. The essentials of ECMO in 2 glorious days. Here is a sneak peak at the Reanimate 2016 Promo Video.

Flipped Classroom SMACC ECMO Workshop 2015

For those taking the upcoming ECMO courses with us, download both of these 2 attachments. The first is a diagram of a traditional ECMO circuit – its nice to print this out and follow along. Not every circuit is the same and we have ours custom built by Maquet.  The second is a self-study course.  While it isn't necessary to review these before our workshop, it will really put you ahead of the game and we focus more on procedures.

Custom Maquet Circuit

Figure 1. The Custom Maquet ECMO Circuit

Study Guide

Screen Shot 2015-04-04 at 11.04.36 PM

Review of the 3 stages of ECPR

  1. STAGE 1: Placement of any commercially available vascular catheter in the femoral vein and femoral artery
  2. STAGE 2: Replacement of each catheter with ECMO cannulae. Checkout EDECMO 5: Cognitive Task Management for ED ECMO Stages 1 and 2. Also, we learned several cannulation pearls from Stephen Bernard in EDECMO 14 Part 1 and Part 2
  3. STAGE 3: Initiation of Total Heart Lung Bypass

ECMO Circuit Setup:

  1. Plug in the machine and power-on the heater-cooler and the Rotaflow console.
  2. Unpackage the circuit and hold it up to orient yourself.
  3. Mounting the Rotaflow Pump to the Pump Drive

    Mounting the Rotaflow Pump to the Pump Drive

    Attach the Oxygenator to the bracket and the pump to the pump-drive; hang the distal ends of the circuit (the tubes that will connect to the patient) from the IV pole.

  4. Apply ultrasonic contact cream to the flow probe contact site
  5. Remove and DISCARD the yellow de-airing exit port cap on the top of the oxygenator.
  6. Connect the water lines from the heater-cooler to the Quadrox Oxygenator & open the stopcocks.
  7. “Run the circuit”, making sure that the recirculation bridge is OPEN, arterial and venous tubing is CLAMPED, rapid-prime tubes are CLAMPED, both of the blood sampling “pig tail” stopcocks are CLOSED.
  8. PRIME the circuit:  Priming the Circuit: Filling the ECMO circuit (tubing, pump, oxygenator) with crystalloid priming solution (ie Isolyte), adding 2,500 units of heparin to each 1-liter bag of priming solution.  We discuss the finer details of this with Greg Griffin, the Chief Perfusionist at the University of North Carolina, Chapel Hill in EDECMO 8.
    1. squeeze all air out of prime bag INTO the circuit and then hang those bags from the IV pole.
    2. Open the ratchet clamps: the circuit will fill (prime) by gravity.
  9. Connect the Oxygen supply line (from Oxygen tank) to the Oxygen inlet port on the oxygenator
  10. De-air the circuit:
    1. Remove the patient-lines that are hanging from the IV pole and drop them below the fluid level of the IV bags to prime them. ratchet-clamp them closed. Now the entire circuit has been primed.
    2. Open the recirculation bridge and briefly increase the RPM on the Rotaflow Console until the pump is running at 4LPM for 15 seconds. This will de-air the circuit as air is release from the de-ar exit port on the Oxygenator.  ***Some air may still be trapped in the pump though. So…
    3. Turn the RPM on the Rotaflow console to zero. Allow any air in the pump head to flow into the PVC tubing between the pump head and the oxygenator and then return the RPM to 4LPM to complete the de-airing process.
  11. Calibrate the flow-probe: Reduce pump speed to zero RPM, clamp off the recirculation bridge and “ZERO” the flow probe by pushing the “ZERO” button for a few seconds. The console will beep.

Initiation of Total Heart Lung Bypass (STAGE 3)

Maquet-Circuit-mockup.001So you've cannulated your patient while your ECMO-nurse has primed the circuit with crystalloid.  Connect the venous and arterial PVC lines from the circuit to the ECMO cannulas in the patient. And since this is STAGE 3, we've established the EDECMO “Rule of 3's.”  There are 3 things you need remember before, during, and after you've initiated heart-lung bypass.

A.  3 Critical First Steps BEFORE initiating bypass:

  1. Heparinize the patient = 5,000 units IV bolus
    1. Heparin 2,500 units in each liter of priming solution
    2. Bioline coating
    3. ACT > 200 seconds
  2. Attach O2 source (@ 4-6 LPM) to the Oxygenator
  3. No open central lines (CVP, Swan-Ganz, etc).

CLOSE the Recirculation Bridge and OPEN the venous and arterial ratchet clamps. Turn up the RPM on the Rotaflow console. Your patient is on heart-lung bypass.

B.  3 Critical things to confirm JUST AFTER your patient is on bypass:

  1. The arterial line should have bright red (oxygenated) blood and the venous line should be dark-red.
    1. IF you see BRIGHT-BRIGHT, you've incorrectly placed both cannulas in the same vessel.
    2. If you see DARK-DARK, there is a problem with the oxygenator. Confirm your O2 supply to the oxygenator.
  2. Your cannulas are secured to the skin with suture and tape.
  3. The recirculation bridge is CLOSED.

C.  3 Critical Values to Optimize ECMO

1. Optimize Blood Flow:

  • Establish the MAXIMUM blood flow (LPM) at the lowest RPM. GOAL = 60 ml/kg
  • Increase the RPM on the Rotaflow console until:
    1. Any further increases in RPM does not result in increased blood flow (LPM).
    2. The circuit begins to “Chatter.”
    3. SvO2 > 70%

IF flow is too low: 1. Infuse more volume 2. reposition venous cannula 3. add a venous cannula

2. Arterial Blood Gas Analysis:

  • GOAL:  “normal” ABG (PaO2 80-100; PaCO2 35-45)

IF PaO2 < 80,   THEN you need more blood flow through the Oxygenator

IF PaO2 > 100, THEN its time to add a gas blender and turn down the FiO2 from the Oxygen source

IF PaCO2 < 35, THEN decrease your “Sweep Gas Rate” by lowering the LPM on the O2 supply

IF PaCO2 > 45, THEN increase your “Sweep Gas Rate” by increasing the LPM on the O2 supply

 

3. Optimize Systemic Vascular Resistance (SVR)

SVR = (MAP – CVP) x 80
C.O.

SVR = (MAP – 0)      x 80
Blood Flow

***GOAL = SVR > 800

IF, for a given blood flow, the MAP is unreasonably low, you need a pure VASOPRESSOR = Phenylephrine

IF, for a given blood flow, the MAP is unreasonably HIGH, you need a VASODILATOR = Nitroprusside

Or, Goal MAP > 65

 

 The Shinar 3000: Tall Paul ECMO Simulator

Zack built an ECMO simulator model in his garage. Here is the video:

Tall Paul Compilation 3 from Joe Bellezzo on Vimeo.

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EDECMO 19 – ECPR for Out-of-Hospital Cardiac Arrest Japanese-Style!

Posted on February 19, 2015 // Leave a Comment

Podcast: Play in new window | Download (Duration: 13:23 — 9.3MB)

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SakamotoTetsuya Sakamoto is the principal investigator of a multi-center prospective observational study comparing ECPR vs. traditional resuscitation for out of hospital cardiac arrest. His study was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Sakamoto during the 2014 AHA RESS conferences and talked all things ECPR.  After that, Shinar sat down with Dr. Sakamoto to get his take on how the Japanese EMS system is setup and how they are able to implement ECPR into their resuscitation protocols.

 

The Japanese Emergency Care System

  • Ambulance Crew = 1 EMT paramedic + 2 EMT's
    • EMT paramedic
      • Epi
      • Intubate
    • 2 Basic-trained EMT's
  • Hospital Systems:
    • General Hospital
    • Tertiary Hospital Receiving Centers (271 Centers)
      • Trauma
      • Resuscitation
      • Critical Care
  • Emergency Department at Japanese Tertiary Care Center
    • Emergency ICU
    • Trauma resuscitation, PCI, etc.
  • Pre-hospital protocols for Termination of Resuscitation protocols in Japan
    • In Japan, prehospitals providers are not empowered to pronounce
    • Average time on Scene = 10-20 min (scoop and run!)
    • They transport everyone!

Percutaneous Cardiopulmonary Support (ECMO) and the Save-J team

Final Thoughts

  • ECPR has huge promise for saving the lives of patients who would otherwise not survive with standard ACLS. But the cost is not trivial. So,
    1. we need to drill down into the inclusion criterion to ensure we are using this therapy on patients who will gain the most benefit.
    2. ECPR requires a team-approach, much like a trauma team activation.  The successful ECPR team still demands good-quality chest compressions, appropriate use of ACLS protocols, etc.
    3. Training is important because cannulation during arrest is tough.
  •  The Save-J approach to cannulation:   much like we do it here in the US, ultrasound-guided percutaneous approach is usually the go-to approach, with cut-down used as a rescue intervention.
*The EDECMO authors would like to thank Tetsuya Sakamoto for joining us on this episode of the EDECMO podcast and allowing us to share his thoughts on ECPR.

 

…No sex, no drugs, no wine, no women, no fun, no sin, no you, no wonder its dark…

~The Vapors (1980)

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EDECMO 18 – Remote Ischemic Conditioning – with Graham Nichol

Posted on January 5, 2015 // 11 Comments

Podcast: Play in new window | Download (Duration: 20:49 — 19.2MB)

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Remote Ischemic Conditioning to Reduce Ischemia-Reperfusion Injury after Cardiac Arrest

In this episode Zack and Joe talk with a true pioneer in resuscitation and the science of cardiac arrest management. Graham Nichol, from the University of Washington,  joined us at Sharp Memorial Hospital for an amazing discussion about “Remote Ischemic Conditioning” and its role in prevention of ischemia-reperfusion injury resulting from cardiac arrest.  Is this VooDoo or a real phenomenon? Listen to this episode to find out…

Some Definitions:

  • “Ischemia-Reperfusion” injury:  prolonged ischemia to the brain and heart often occur after circulatory arrest. Immediate CPR minimizes this phenomenon but many of our patients who arrest in the pre-hospital setting don't receive immediate bystander CPR, resulting in prolonged ischemia. CPR reintroduces blood flow and oxygen to the previously ischemic tissues.  This hyperoxic ‘reperfusion' is known to be a main contributor to infarct size in  both the heart and brain causing poor neurologic outcomes after arrest. Minimizing this reperfusion injury is major focus of resuscitative science right now.
  • “Ischemic Conditioning”: purposeful application of ischemia and reperfusion, off and on, to the tissues.
    • “Pre-conditioning” = applying this therapy BEFORE circulatory arrest
    • “Peri-conditioning” = applying this therapy either DURING circulatory arrest
    • “Post-conditioning” = applying this therapy AFTER circulatory arrest
  • “Targeted” vs. “Remote” Ischemic Conditioning:
       “Targeted” ischemic conditioning: application of conditioning directly to the  specific target organ (ie the heart or the brain). This can be done in one of two ways:

    • systemic  ischemic conditioning.
      • In a pig model of cardiac arrest, Demetris Yannapoulos and Keith Lurie applied brief periods of ischemic post-conditioning via “Stutter CPR” (3-4 cycles of 20 seconds of CPR with 20 second pauses) after prolonged “no flow” arrest – upwards of 20 minutes without CPR – and found normal LV function and elimination of ischemic insult to the brain using this technique.   They discussed this controversial topic with Weingart on the emcrit podcast Episode 69.
    • Local conditioning: applying ischemic conditioning directly to the target organ
      • Many studies have shown effectiveness of local ischemic conditioning during PCI for acute MI.  After restoration of vessel patency, reperfusion was interrupted by cycles of 1 min of coronary balloon reocclusion. Here is a good summary:

 “Remote“ ischemic conditioning: application of ischemic conditioning to a REMOTE area of the body (ie the limb) to reduce the degree of injury to the heart and brain that results from cardiac arrest (ischemia) followed by reperfusion (chest compressions, ROSC, or ECMO) by applying the ‘remote' ischemia-reperfusion by using a blood pressure cuff on a limb.

How it Works:

*courtesy of the Lancet Vol 374; Oct 2009

*courtesy of the Lancet Vol 374; Oct 2009

Several theories exist to explain the benefit of ischemic conditioning. I'll break it down in two ways:

1.)  Simple explanation: “good humors” are released from the ischemic limb and protect against cell death/apoptosis in the heart and brain.

2.) Complex hypothesis:

1.) RIC induces a cascade of intracellular kinases and modifies mitochondrial function within the cell by opening ATP-sensitive potassium channels and closing the mitochondrial permeability transition pore. 2.) RIC causes release and transport of micro-RNA-144 from the ischemic limb.  Amongst other effects, miRNA-144 effevely down-regulates protein expression involved in apoptosis, autophagy, and survival signaling. Supernerds, if you really want more on this:

Przyklenk Basic Res Cardiol 2014 RIC microRNA

role of mitochondria in protection of the heart by preconditioning Halestrap 2007

How its Done:

  1. On any limb, inflate a simple blood pressure cuff to a pressure above the systolic blood pressure. 200 mmHg is a good starting point. If you are using a manual cuff, Graham recommends clamping a Kelly on the tubing to prevent deflation of the cuff too soon.
  2. Keep the cuff inflated for 5 min and then deflate for 5 min.
  3. Do 3-4 cycles of this, and you're done.

 

The Evidence:

  1.  Xu Crit Care Med 2015 Conditioning in Rat Model of Cardiac Arrest  – In rats, better myocardial and cerebral function with longer duration of survival occurred when RIC was applied prior to arrest (preconditioning), at the time of arrest, or after arrest (arrest) when compared to controls (no conditioning). This take-home from this study was that the conditioning did not have to occur before the arrest; benefit was seen if conditioning were applied intra-arrest or post-arrest.  Application: RIC appears to be beneficial even if done after ROSC.
  2. Sloth Eur Heart J 2013 Long Term RIC – In humans, RIC before PCI improved long term clinical outcomes in patients with STEMI.
  3. Rentoukas RIC JACC CV Intervention 2010 – Remote Ischemic PERI-conditioning (applying the RIC at the time of revascularization in the cath lab) was cardioprotective.
  4. Przyklenk Basic Res Cardiol 2014 RIC microRNA – An explanation of the proposed mechanism of RIC at the cellular level; Good Humors
  5. Lancet Botker Ischemic Conditioning Trial – This is a great review paper on remote ischemic preconditioning.

Graham Nichol MD, MPH, FACP

Graham Nichol MD, MPH

Graham Nichol MD, MPH

nichol@uw.edu

@grahamnichol

Current Positions:

  • Professor of Medicine, Division of General Internal Medicine at the University of Washington in Seattle
  • Director, UW Medical Center/Harborview Medical Center for Pre-hospital Emergency Care
  • Medical Director, University of Washington Clinical Trial Center
  • Leonard A Cobb Medic One Foundation Endowed Chair in Prehospital Emergency Care
  • Medical Director, Resuscitation Outcome Consortium Clinical Trial Center

Professional Endeavors:

  • American Heart Association’s Basic Life Support Subcommittee and Advanced Life Support Subcommittee
  • chair of the Basic Life Support Subcommittee and received the American Heart Association Award of Merit
  • chair of the Basic Life Support Subcommittee and received the American Heart Association Award of Merit
  • Co-founded and  co-directed the Resuscitation Science Symposium (ReSS) of the American Heart Association
  • National Institutes of Health (NIH) reviewer and a grantee
  • chair of the epidemiology panel for the National Heart Lung and Blood Institute-sponsored PULSE conference and PULSE leadership group
  • co-principal investigator of the Resuscitation Outcomes Consortium (ROC) Data Coordinating Center
  • co-investigator of the Australian Resuscitation Outcomes Consortium

 TrackBacks

LITFL Reviews Episode 164

LITFL Reviews Episode 164

 

More with Graham Nichol

Death Ride

Death Ride

Graham is an avid cyclist and attributes his ability to ride more than 100 miles and climb more than 10,000 feet in a day to his off-label use of remote ischemic conditioning!  Here, he and a friend are about to begin the long ride up Carson Pass to finish the Death Ride.

 Upcoming Events

CastleFest: April 14-16, 2015

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CCUS Montreal: May 1-3, 2015

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SMACC Chicago 2015: June 23-26, 2015

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Recording EDECMO 18 EDECMO World Headquarters San Diego, CA

Recording EDECMO 18
EDECMO World Headquarters
San Diego, CA

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EDECMO 17 – The Reanimateur: Lionel Lamhaut on Pre-Hospital ECPR

Posted on December 10, 2014 // Leave a Comment

Podcast: Play in new window | Download (Duration: 15:06 — 10.5MB)

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Lamhaut

Dr. Lionel Lamhaut

In this episode Zack sits down with Dr. Lionel Lamhaut, an anesthesiologist and “reanimateur” from Paris, France, about their pre-hospital ECMO program. Yes. You read that right. This group from France is  sending an ECMO team to the scene of the cardiac arrest and, in appropriate cases, initiating ECMO in the field.  Does this really work? What are the logistics of making this happen? Is this the future of pre-hospital resuscitation? Does this model translate to EMS models in other countries?  And most importantly, does this finally challenge the despicable “Termination of Resuscitation” (TOR) policies that have been metastasizing throughout our EMS communities?

The Plague of the TOR:

In the U.S. the “Termination of  Resuscitation” (TOR) policies are plaguing our pre-hospital colleagues. By TOR ideology, paramedics arrive to the scene of an arrested patient and work the patient until either ROSC or death.  This is the “stay and play” model at its extreme.  They simply don't transport patients to the hospital unless they achieve ROSC in the field.  No ROSC = No transport.  Dead.   We have become victims of our own success; Paramedics are now so good that they can do (almost) everything in the field that could be done at the hospital.  And, as the argument goes, transporting patients only results in: 1.) lesser-quality chest compressions, 2.) potential EMS/rescuer injury (by not being strapped into their safety harnesses during transport), 3.) inherent public dangers in transporting patients “Code 3” (lights and sirens), etc.  In other words, Emergency Departments traditionally couldn't offer anything that medics could not offer in the field and the quality and safety of the patient and the rescuers was worse because of the transport.

Well…that all changes with ECMO.  Here are the three current options:

  1. San Diego:  In our Emergency Department Emergency Physicians initiate ECMO.  We still suffer from the policies of TOR but try to encourage our EMS team to consider transport of certain patients.
  2. Australia (CHEER), rescuers initiate CPR with a mechanical chest compression device, begin intra-arrest cooling, and transport immediately to their ECMO/CPB center (The Alfred Hospital in Melbourne). For more on CHEER and the Alfred Hospital in Melbourne, Australia, check out Part 1 of our interview with Dr. Stephen Bernard on EDECMO Episode 14.  And Part 2 of our interview with Dr. Bernard was EDECMO Episode 15.
  3. France: Pre-Hospital ECMO.  Hell, the word “Reanimation” is painted right on the front of the ambulances in Paris!    This is what this episode of the EDECMO podcast is all about.

 

Mobile ICU = First responders

-physician on ambulance

-“Exactly like trauma room”

Prehospital ECMO Team

– 2 senior non-surgeon physicians with expertise in ECMO, 1 nurse, 1 paramedic

– Maquet™ Cardiohelp

– 2 units of packed RBCs and 2 units of FFP

– Sedation

– Therapeutic Hypothermia

Approach

– Seldinger technique with modified cutdown of proximal vessels. They FIRST do a cutdown to expose the femoral vessels. They then insert the needle DISTAL to the femoral cutdown and visualize direct vessel access within the open surgical field.  That way, the cannulas are actually placed percutaneous while vessel access can be directly visualized. Lionel says that this approach is actually faster and safer than just blindly stabbing around with the needle as is done with a blind percutaneous method. Hybrid seldinger

Inclusion Criteria

– Physician on scene makes assessment

– Positive bystander of CPR

– Younger people

– Shockable rhythm better

Ideology

– Out of hospital cardiac arrest survivorship should be the same as In-hospital cardiac arrest

– Need to decrease low flow state (shorten the time patients need chest compressions by getting them on the pump ASAP)

– 20 minutes to bypass in the field from arrival of prehospital ECMO team

– This gives you bypass of less than 60 minutes

– “Load and Go” is not fast enough

Results

– 10% survival from prehospital ECMO

– ECMO is a “Bridge to Neurologic Assessment”

– Organ Donation

Examples of Pre-hospital ECMO*

ECMO at the Louvre

ECMO at the Louvre

ECMO in the Supermarket

ECMO in the Supermarket

ECMO in the street

ECMO in the street

ECMO in the Subway

ECMO in the Subway

(*photos courtesy of Lionel Lamhaut)

Two Articles By Lamhaut:

Successful treatment of refractory cardiac arrest by emergency physicians using pre-hospital ECLS

Safety and feasibility of prehospital extra corporeal life support implementation by non-surgeons for out-of-hospital refractory cardiac arrest

Want More?

EDECMO 14: The CHEER Trial with Dr. Stephen Bernard

EDECMO 15: Part 2 of our interview with Dr. Stephen Bernard

INTENSIVE: The Alfred Hospital's amazing ECMO site

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EDECMO 16: The End-of-Life Matrix & The Ethics of Advanced Resuscitation with Dr. Cyrus P. Olsen III, D.Phil.

Posted on November 20, 2014 // 4 Comments

Podcast: Play in new window | Download (Duration: 22:59 — 18.5MB)

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In this episode, Zack and Joe talk with Dr. Cyrus Olsen, Oxford graduate and expert in bioethics about how to decide when to “Stop the Train”.

 


WARNING: This is going to get waaaaay touchy-feely and waaaaay outside of Joe's comfort zone (Zack, on the other hand, is feeling right at home here). With that in mind…

“How young is too young…” to withhold resuscitation?

The Dilemmas:

  1. How old is too old…or better yet…how young is too young?  aside from routine resuscitation: drugs, chest compressions, shocks, is there an age that is too old for ECMO? We currently use a soft cutoff of 75 yoa. Lets take all of the variables out of the equation and just assume a person has ZERO medical problems and is on ZERO medications. They ambulate on their own, live independently, and they believe they have a good quality of life.  In this scenario, is there any age that is too old for ECMO? This should be our starting point and then move down (in age) from there.  The 95 year old is easy.  The 40 year old is easy. All the rest are tough and that's where we will get criticism for “doing too much.”
  2. Concrete resuscitation cutoff vs. a graded response?  Whatever we decide is the cutoff (age, quality of life, comorbidities), should we use the exact same set of criteria for even initiating CPR as we do for ECMO? Should they be the same? In other words, should we have the same set of criteria for both or should there be a graded response to the dying patient (over 75 I do CPR and intubate but don't do ECMO but under 75 I go full-court-press and possible ECMO)?
  3. Only Reverse the Reversible. Somehow we need to identify inevitable death and allow that to happen. Greg Henry always says, “Despite all the advances of modern medicine, the death remains the same: one per person.”  But when we can't be sure that death is inevitable, does everyone deserve a shot?  In other words, should we be making that decision on the front end (ED) when little information is known to us, or should that be sorted out on the back end…in the ICU?  Is there a way to tell a resuscitationist that its ok to err on the side of over-resuscitation, so long as your intent to is to reverse the reversable? Peter Safar's quote, “Death is not the enemy, but occasionally need help with timing.” exemplifies this.
  4. Define “Quality of Life”. How do we determine “Quality of Life”? Who decides this in the heat of the moment? The doctor or the family?
  5. What is the real goal of resuscitation? Should we only resuscitate people who were previously healthy and have a chance of 100% recovery? It seems we've come to a place where the knee-jerk reaction by ED doctors is to do full CPR on everyone and then see what happens.  So how do we determine when and where to stop?
  6. MD paternalism vs. patient automony = “The Tyranny of Choice.”

 

The Episode Play-by-Play:

Dr. Olsen talks about the first concept: The “3 Senses of Dignity” from Daniel Sulmasy MD, PhD, a spokesman for the President's Council on Biotheics

  1. Intrinsic Dignity = your value for just being human
  2. Attributed Dignity = your “market value” to society
  3. Inflorescent Dignity = your “flourishing”; or your quality of life

Utstein Variables for CPR

 The Life Matrix and the Functional Threshold:

Life Matrix

“We cannot predict the neurologic outcome of patients that are in cardiac arrest” – Zack Shinar MD

Bottom line: As a resuscitationist in the Emergency Department you MUST err on the side of aggressive curative care, unless there is compelling evidence to do otherwise.  You are on ethical solid-ground to approach resuscitation in this fashion. But…you will fuck this up. And that's ok if your heart is in the right place. And once you realize that your patient does not belong in the AGGRESSIVE CURATIVE arm, you begin AGGRESSIVE PALLIATIVE care. In either case, you care is MAXIMALLY AGGRESSIVE.  

Joe & Zack recording

Joe & Zack recording

 

 

Dr. Cyrus P. Olsen III, D.Phil.

Dr. Cyrus P. Olsen III, D.Phil.

Dr. Cyrus P. Olsen, D.Phil.

Dr. Olsen is a graduate of the University of Oxford and is now an Associate Professor at The University of Scranton, in Pennsylvania where he specializes in Ethics and Theologic Studies. He has published extensively in the arena of medical ethics and sits on the IRB (Institutional Review Board) for both human and animal studies at his institution. A graduate of the Comparative History of Ideas Program at The University of Washington, and Systematic Theology from The University of Oxford, his research and teaching address many aspects of human studies and bioethics.

 

Medical Journal Articles on the Ethics of Resuscitation Discussed in this Episode

Circulation- Ethics of CPR

Ethics of Resuscitation – Hayes

Freedom from the Tyranny of Choice

Br. J. Anaesth.-1997-Mohr-253-9

IMG_8217_2

 

Trackbacks:

1. Emcrit Podcast 25: End of Life and Palliative Care in the ED – Scott Weingart from the Emcrit Podcast

2. Emcrit Podcast 93: Critical Care Palliation with Ashley Shreves

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EDECMO 15: The CHEER Trial & Part 2 of our Interview with Dr. Stephen Bernard

Posted on October 14, 2014 // 4 Comments

Podcast: Play in new window | Download (Duration: 31:42 — 21.9MB)

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In this episode Zack and Joe discuss the CHEER Trial (mechanical CPR, Hypothermia, ECMO, and Early Revascularization) and follow up with Dr. Stephen Bernard with a few more questions about ECMO at the Alfred. Just days after we published our initial interview With Dr. Stephen Bernard from the Alfred Hospital in Melbourne, Australia, the CHEER Trial was published.

Background:   Recently, we reviewed two big papers in the ECPR (Extracorporeal Cardiopulmonary Resuscitation) World: 1.) The Chen Trial (Lancet 2008): a large prospective observational study of in-house arreest (IHCA), out of Taiwan, that showed 32.6% (ECPR) benefit vs. 17% (non-ECPR); and 2.) The Save-J Trial (Resuscitation 2014): a large prospective observational study of Out-of-Hospital cardiac arrest (OHCA) that showed a 11.2% (ECPR) benefit vs. 2.6% (non-ECPR). Indeed these numbers are impressive! We all know that we need a randomized, controlled trial (RCT) but until then the guys at the Alfred Hospital in Melbourne, Australia decided to up the ante and published the initial findings of this pilot study. That study was called CHEER.  This amounts to a hyper-aggressive, bundled protocol that begins on the street (EMS) and ends in the cath lab, whereafter world-class critical care has resulted in some remarkable initial numbers.

 

Screen Shot 2014-10-13 at 11.10.27 AMCHEER (mechanical CPR, Hypothermia, ECMO, & Early Revascularization)

This is a single-center, prospective, pilot study that was done over 32 months.  The primary outcome measure was short and long-term outcomes at CPC 1 or 2 (excellent neurologic outcome). The guys down-under generated inclusion criteria to capture the most salvageable patients who suffered out-of-hospital cardiac arrest (OHCA), combined those with in-hospital cardiac arrest (IHCA) patients and applied the CHEER algorithm:

  • CPR (using the Zoll Autopulse)
  • Hypothermia (initiated intra-arrest with iced saline)
  • ECMO (cannulation in the ED by intensivists)
  • Early Revascularization (aka a trip to the cath lab)
Autopulse

Zoll Autopulse (TM)

And all this was begun in the prehospital setting. Since the EMS system in their neighborhood is a single-provider system, they were able to get support from Zoll Pharmaceuticals to supply all of their rigs with their mechanical chest compression device – the Zoll Autopulse. Patients who met inclusion criteria were met by EMS, put on the Autopulse, and transported to the Alfred. EMS also began intra-arrest cooling by rapid infusion of iced saline at 30cc/kg. On arrival to their Emergency Department, intensivists met the patient and began the cannulation process. Once on ECMO the patients were immediately brought to the cath lab for revascularization. IHCA patients received the identical protocol, obviously minus the limo ride to the hospital.

In 2014 this amounts to a super-aggressive bundle therapy that just makes us salivate over here in the US.  Initiating intra-arrest cooling and mechanical chest compressions in the pre-hospital setting is formidable goal for us.

Their results: 26 patients were entered into the protocol (11 with OHCA, 15 with IHCA). The median age was 52 years. ECMO was established in 24 (2 patients in the OHCA arm were pushed through the protocol but didn't actually go on pump; one was cannulated but achieved ROSC prior to going to cath lab and therefore was not put on bypass, and the other patient had a failed cannulation attempt but was taken to the cath lab anyway (presumably on Autopulse) and survived. Both OHCA patients and IHCA arrest patients were grouped together in their outcome data. ROSC (return of spontaneous circulation) was achieved in 25 (96%) patients. 13/24 (54%) were able to be weaned from ECMO support and survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%).  These are remarkable initial results that higher than what we've seen in larger studies.

Talking points:

  • Why such good outcomes? The patient-oriented outcomes in this pilot study are remarkable. Why are their numbers so much higher than much larger studies we've seen in the past? Was it the small sample size? Was it because they grouped the OHCA and IHCA arrest patients into their outcome measures (with IHCA outcomes historically known to be much better)? Was it the bundle?
  • Which therapy really made the difference? Was this the result of aggressive pre-hospital cooling? Was it the result of a “load-and-go” EMS policy with proper use of the mechanical chest compression device? Was it rapid deployment of ECPR? Likely, its all of these. Like much in the resuscitation world, its likely the bundle (the CHEER) followed by excellent critical care at their ECMO facility. But we can't say for sure.
  • Mechanical chest compression devices (ie the Zoll Autopulse or the LUCAS2 by Physio-Control). 3 studies so far have basically shown no benefit of these devices over good quality human CPR. But most resuscitationists who have used these devices believe in their utility. I believe in their utility. Many of the reasons are less tangible than the patient-oriented outcomes measured in those papers. One of those intangibles is highlighted in this study: patients can be safely and rapidly transported to the ED with excellent ongoing chest compressions, and rescue personal can be safely strapped into their harnesses during transport.
  • ECMO.
    stratos

    Red Bull Stratos

    Study after study has shown that the single biggest key to the success of ECPR is the time to initiation of bypass. So in this trial, the rapid transport with Autopulse and rapid activation of the ECMO team optimized this interval.  But we believe the success of this study would not have been possible without ECMO as the final bridge that could make all this happen.  To highlight this concept, on October 14, 2012 Austrian skydiver Felix Baumgartner jumped from the Red Bull Stratos capsule 24 miles above New Mexico, USA and broke  3 World Records: a.) Exit Altitude (24.2145 miles) b.) Maximum Vertical Speed (843.6 mph) and c.) Vertical Distance of Freefall (119,431 ft). And he broke the sound barrier.

    Baumgartner parachute

    Baumgartner parachute

    Advancements in technology, human transport, a willingness to push the envelope, and huge set of balls, made that happen. But that couldn't have been done without a relatively simple device that has been around for decades that allowed Baumgartner to land on his feet: the parachute – a device that “bridges” the skydiver from potential free fall-death to soft landing with proper deployment.  ECMO can be thought of as one such device.

  • Update 10/25/2014 Hot off the press: Google Senior Vice-President Alan Eustace one-upped Baumgartner on October 24th when he jumped 135,890 ft from a helium balloon to become the World-record holder for highest parachute jump. Additionally, Eustace used no corporate funding and did not use a capsule, opting instead to be carried into the stratosphere in a space suit alone. Here are some photos of that:

    • Alan Eustace, a senior vice president at Google, broke the world record for high-altitude jumps.

      Alan Eustace, a senior vice president at Google, broke the world record for high-altitude jumps.

      Alan Eustace ascending to 135,890 feet on Friday. He later plummeted to earth at speeds reaching 822 miles per hour, setting off a small sonic boom heard by people on the ground.

      Alan Eustace ascending to 135,890 feet on Friday. He later plummeted to earth at speeds reaching 822 miles per hour, setting off a small sonic boom heard by people on the ground.

      Alan Eustace, Senior Vice President of Google

      Alan Eustace, Senior Vice President of Google

      Mr. Eustace landing. He wore a specially designed spacesuit with a life-support system.

      Mr. Eustace landing. He wore a specially designed spacesuit with a life-support system.

      MORE!

      1. Check out Part 1 of our interview with Dr. Bernard
      2. Check out INTENSIVE, The Alfred's educational website and blog

      Announcements:

      1. Sign Up for the Mailing List

      Subscribe to our Mailing List:  (EDECMO will NEVER Spam)

      2. iTunes Reviews: Is the EDECMO podcast helpful to you? Please leave us a review on EDECMO page in iTunes

      3. EDECMO Voicemail: 1-470 – ED ECMO 1 (leave us a voicemail comment or question and we may use it as part of the show!)

      4. Upcoming Events:

      • “Bring Me Back to Life!” October 21, 2014 (That's next week!). This is an All-Star Lineup of Resuscitationists:

      Screen Shot 2014-10-13 at 10.59.43 AM

 

 

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EDECMO Episode #14: ECPR with Stephen Bernard 1/2

Posted on September 30, 2014 // 4 Comments

Podcast: Play in new window | Download (Duration: 33:57 — 31.1MB)

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This is the first in a 2-part series on ECPR with Dr. Stephen Bernard.  In today's episode, Joe and Zack interview Dr. Stephen Bernard about Extracorporeal Cardiopulmonary Resuscitation (ECPR) and how they do it The Alfred Hospital in Melbourne, Australia.   As most of you  know, Dr. Bernard has been a huge contributor to the critical care world.  While he is widely known for his work with therapeutic hypothermia (2002 NEJM ‘Treatment of Comatose Survivors of Out-of-Hospital Cardia Arrest with Induced Hypothermia), Dr. Bernard is now at the forefront of ECPR, reshaping pre-hospital dogma and intra-arrest management, including the use of ECMO during cardiac arrest.
Stephen Bernard MB BS, MD, FACEM, FCICM

Stephen Bernard MB BS, MD, FACEM, FCICM

Professor Stephen Bernard MB BS, MD, FACEM, FCICM

Senior Intensive Care Specialist
The Alfred Hospital
Melbourne, Australia

Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University
Medical Advisor, Ambulance Victoria
Member, Medical Advisory Committee, Ambulance Victoria
Member, Clinical Practice Guideline Review Committee, Ambulance Victoria
Member, Clinical Incident Review Committee, Ambulance Victoria
Co-Chair, Steering Committee, Victorian Ambulance Cardiac Arrest Register, Ambulance Victoria
Member, Clinical Committee, Council of Australasian Ambulance Authorities
Medical Officer, Australian Formula 1 Grand Prix
Medical Officer, Australian Motorcycle Grand Prix
Member, National Medical Advisory Committee, Confederation of Australian Motor Sport
Supervisor of PhD students x2
Director of Intensive Care, Knox Private Hospital
Chair, Medical Advisory Committee, Knox Private Hospital
Member, Patient Care Review Committee, Knox Private Hospital

 Today's Episode:

  1. Development of the ECPR protocol at the Alfred in Australia
    • Reconstruction of the “Chain of Survival”
    • TOR (termination of resuscitation)
  2. The Alfred ECMO CPR Guideline 2014 version 13: This is the PDF version of their latest ECPR protocol.
  3. The CHEER (CPR, Hypothermia, ECMO and Early Reperfusion)
    • Check out a GREAT lecture on CHEER by Dr. Bernard that was presented on the Intensive Care Network run by Oli Flower and Matt MacPartlin
    • Registry: clinicaltrials.gov registry
    • Updated CHEER results:  You gotta listen to the podcast! This stuff is In Press and soon to be published

 

More!

Screen Shot 2014-10-01 at 10.47.45 AM

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Evid-ECMO 2: Veno-Venous ECMO in ARDS – The CESAR Trial & ANZ-ECMO

Posted on September 26, 2014 // Leave a Comment

Podcast: Play in new window | Download (Duration: 21:00 — 19.3MB)

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Episode 2 of Evid-ECMO features  Dr. David Willms, who is the Director of Critical Care Medicine at Sharp Memorial Hospital. Dr. Willms has over 25 years of experience with VA and VV ECMO and is an amazing resource for us at our hospital. Dr. Willms has been a key player in the development of our highly successful ECMO program at Sharp. Zack and Dave discuss two of the “big” articles in VV-ECMO for ARDS:

 

CESAR TrialArticle 1: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

PDF: cesar-trial

Identification: 

Title:  Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

Authors:  Giles J Peek, Miranda Mugford, Ravindranath Tiruvoipati, Andrew Wilson, Elizabeth Allen, Mariamma M Thalanany, Clare L Hibbert, Ann Truesdale, Felicity Clemens, Nicola Cooper, Richard K Firmin, Diana Elbourne, for the CESAR trial collaboration

Location: UK-based multi-center trial

Source: Lancet. 2009 Oct 17;374(9698):1330

PMID: 19762075

Introduction:

Problem:  Does ECMO provide improved safety, efficacy and cost-effectiveness, when compared to traditional therapy, in patients with severe ARDS?

Significance: This is the first positive RCT that shows a statistically significant benefit of VV-ECMO for severe ARDS.

Methods:

Study Type: Randomized Controlled Trial

Subjects: 180 adults with severe ARDS were randomized to receive conventional management or referral to ECMO center.

Primary End-Point: Death or severe disability at 6 months.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusions: 
      • 6 month survival without disability: 63% ECMO group vs. 47% conventional group.
      • Quality-adjusted life years at 6 months: ECMO group showed a gain of 0.03 gain

****THE BOTTOM LINE:  EDECMO Critical Assessment:  If you need a paper to support your use of VV ECMO for severe ARDS, this is your ammunition.

 

 

Screen Shot 2014-09-25 at 10.11.17 PMArticle 2:  Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

PDF:  ANZ ECMO

Identification:

Title: Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

Authors: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators*

Location: Australia and New Zealand

Context:  The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO).

Source: JAMA, November 4, 2009—Vol 302, No. 17

Introduction:

Purpose: To describe the characteristics of all patients with 2009 influenza A(H1N1)– associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes.

Significance: 

Methods:

Study Type: Retrospective Observational Study

    • Subjects: All patients with 2009 influenza A (H1N1)- associated ARDS treated with ECMO

****THE BOTTOM LINE:  EDECMO Critical Assessment:  In 2009, VV ECMO was used with success to combat severe ARDS caused by Influenza A (H1N1).

David Willms MD Board Certified in Critical Care and Pulmonary Medicine

David Willms MD
Board Certified in Critical Care and Pulmonary Medicine

If you have a question for Dr. Willms you may post it in the comments section below or email him directly at david.willms@sharp.com

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

Posted on September 1, 2014 // 23 Comments

Podcast: Play in new window | Download (Duration: 35:07 — 32.2MB)

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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…  

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