66: Crash VV ECMO

Have you ever wondered how you would crash someone onto VV ECMO?  Have you ever wondered where is the best place to put the cannulas?  Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO?  Then this is the episode for you!!  After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject.  Zack gets critical care physician and ECMO director Dr. David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO.

 

 

 

 

 

 

 

 

Great images from Penn – Femoral Jugular approach

Femoral Femoral Approach

 

 

 

 

 

 

 

Aortic Dissection recent paper and Editorial

https://www.resuscitationjournal.com/article/S0300-9572(20)30309-9/fulltext

https://www.resuscitationjournal.com/article/S0300-9572(20)30435-4/pdf

 

65: ECPR Journal Club: Dual Sequential Defibrillation, CT after ECMO, and much, much more

This month we tackle a number of topics.  Garrett Sterling is back again with Zack to talk about cutting edge resuscitation, ECMO, and the interplay between the two.  Dual sequential defibrillation, CT after ECMO initiation, should you perform bystander CPR in the era of Covid, some US ECMO data, and an awesome 3D modeling for ECPR training models.  All in one 30 minute podcast!
Reverse CPR – better systolic BPs
Brown J., Rogers J., Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001;50:233–238. [PubMed] [Google Scholar]
Mazer S.P., Weisfeldt M., Bai D. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279–285. [PubMed] [Google Scholar] DOI:  10.1016/s0300-9572(03)00037-6
Wei J., Tung D., Sue S.H., Wu S., van Chuang Y.C., Chang C.Y. Cardiopulmonary resuscitation in prone position: A simplified method for outpatients. Journal of the Chinese Medical Association. 2006;69:202–206. [PubMed] [Google Scholar]
SLides on Prone CPR
Risk to providers of CPR in Covid
 
Fear of Covid in CPR
Witnesses still providing CPR in Covid era – 53 vs. 49% in Paris
Witnesses didn't provide in Sydney
Dual Sequential Defibrillation (DSD)
Columbus Ohio Paramedics – http://dx.doi.org/10.1016/j.resuscitation.2016.08.002
San Antonio Texas – no benefit of DSD – http://dx.doi.org/10.1016/j.resuscitation.2016.06.011
Damaged Defibrillator from DSD – DOI: 10.1016/j.annemergmed.2017.04.005
Toronto – Cheskes RCT -DSD and vector change better than standard defibrillation –  https://doi.org/10.1016/j.resuscitation.2020.02.010
National Data on ECMO use in US
J. Hadaya, et al., National trends in utilization and outcomes of extracorporeal support for in- and
out-of-hospital cardiac arrest, Resuscitation (2020), https://doi.org/10.1016/j.resuscitation.2020.02.034
Early CT after ECMO
https://doi.org/10.1016/j.resuscitation.2019.11.024
3d printed  ECPR modeling
https://doi.org/10.1016/j.resuscitation.2020.01.032

64: Contraindicated??? – Long Live the Aortic Dissection with Garrett Sterling

Aortic Dissection is a contraindication for ECMO….or is it?  In this episode, Zack Shinar and Garrett Sterling discuss the sticky topic of ECMO for aortic dissection.  They discuss a recent case where Joe Bellezzo, Karl Limmer, Craig Larsen, and the entire Sharp team save a Type A aortic dissection with cardiac arrest.

Zack and Garrett traverse the details around ECMO in aortic dissection ranging from VA ECMO in ECPR to VVECMO for pulmonary edema.  They go through the literature on the subject and make some conclusions based on this data. The ultimate question – “Is Aortic Dissection a Contraindication for ECMO?”

Joe's interview of Michael – Great to hear his memory of the event.

Michael's podcast on his experience – The Heart of the Matter

 

 

Hou XT, Sun YQ, Zhang HJ, Zheng SH, Liu YY, Wang JG. Femoral artery

cannulation in Stanford type A aortic dissection operations. Asian Cardiovasc

Thorac Ann. 2006 Feb;14(1):35-7. PubMed PMID: 16432116.

 

Kelly C, Ockerse P, Glotzbach JP, Jedick R, Carlberg M, Skaggs J, Morgan DE.

Transesophageal echocardiography identification of aortic dissection during

cardiac arrest and cessation of ECMO initiation. Am J Emerg Med. 2019

Jun;37(6):1214.e5-1214.e6. doi: 10.1016/j.ajem.2019.02.039. Epub 2019 Feb 27.

PubMed PMID: 30862393.

 

Yukawa T, Sugiyama K, Miyazaki K, Tanabe T, Ishikawa S, Hamabe Y. Treatment of

a patient with acute aortic dissection using extracorporeal cardiopulmonary

resuscitation after an out-of-hospital cardiac arrest: a case report. Acute Med

Surg. 2017 Dec 19;5(2):189-193. doi: 10.1002/ams2.324. eCollection 2018 Apr.

PubMed PMID: 29657734; PubMed Central PMCID: PMC5891112

63: Covid and ECMO – Who do we cannulate? with Jenelle Badulak

“Normal life is changing.  It is now a covid 19 life” – Bin Cao

I write this with some trepidation as well as pride in the role we all get to play in Covid 19.  The sure in the US and many other places worldwide is just beginning.  It is on us to seek guidance from those who have gone through this already.  Today we will address the use of ECMO in Covid with an expert in ECMO who is in the throws of the worst outbreak of the United States – Seattle, Washington.  Jenelle Badulak and I give you a short yet powerful discussion about what Covid patients should receive ECMO.

Take homes for decision to initiate- comorbidities (HTN, DM especially), single organ dysfunction, young age, trajectory of course

Hosts – Jenelle Badulak, Zack Shinar

 

ECMO guidance for Coronavirus

  • MERS ECMO Data
    • Alshahrani MS, Sindi A, Alshamsi F, Al-Omari A, El Tahan M, Alahmadi B, Zein A, Khatani N, Al-Hameed F, Alamri S, Abdelzaher M, Alghamdi A, Alfousan F, Tash A, Tashkandi W, Alraddadi R, Lewis K, Badawee M, Arabi YM, Fan E, Alhazzani W. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care. 2018 Jan 10;8(1):3. doi: 10.1186/s13613-017-0350-x. PubMed PMID: 29330690; PubMed Central PMCID: PMC5768582
  • Chinese Society of Extracorporeal Life Support. [Recommendations on extracorporeal life support for critically ill patients with novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 9;43(0):E009. doi: 10.3760/cma.j.issn.1001-0939.2020.0009. [Epub ahead of print] Chinese. PubMed PMID: 32035430.
    • http://rs.yiigle.com/yufabiao/1180132.htm
    • Inclusion criteria under this paper are–>
    • Under optimal ventilation conditions (FiO 2 ≥ 0.8, tidal volume 6 ml / kg, PEEP ≥ 10 cmH 2 O), ECMO can be started if there are no contraindications and one of the following conditions is met 7 , 8 , 14 , 16 , 17 , 18 ] : (1) PaO 2 / FiO 2 <50 mmHg for more than 3 h; (2) PaO 2 / FiO 2 <80 mmHg for more than 6 h; (3) FiO 2 = 1.0, PaO 2 / FiO 2 <100 mmHg; (4) Arterial blood pH <7.25 and PaCO 2 > 60 mmHg for more than 6 hours, and respiratory rate> 35 times / min; (5) When respiratory rate> 35 times / min, blood pH <7.2 The plateau pressure was> 30 cmH 2 O; (6) severe air leak syndrome; (7) combined with cardiogenic shock or cardiac arrest.

 

 

 

62: Jason Bartos Take 2: The Future of ECPR Now

Last month you heard Jason talk about the ECPR program at the University of Minnesota.  This month Zack and Jason talk about post initiation care and the crazy ECPR realities that Demetris, Jason and U of M have created.  The sky is the limit for their team!

61: Jason Bartos – ECPR Redefined

Jason Bartos and his crew at the University

Image result for university of minnesota cardiology"

of Minnesota have revolutionized the concept of ECPR for out of hospital cardiac arrests.  His crew are interventional cardiologists who take OHCA straight to the cardiac cath lab.  They have initiate times of around 6-8 minutes and have neurologically intact survival rates higher than 30%.  Below are two of Jason’s recent papers which every person who considers themselves an ECPR fan should pour over with a fine-toothed comb.  There is so much in these papers.  We split this interview into two pieces because there is so many pearls in it.

 

Outcomes

Resuscitation paper – 48% survival in 100 patients

Circulation paper 2020– 33% vs. 23% ALPS

  • Cohort who had VF/VT and one shock vs. a cohort who had VF/VT and failed to ROSC at the scene, in the ambulance, and then all the way to the hospital.
  • OHCA – > Straight to the Cath lab –> Get on ECMO –> Go to CCU under Cards care.
  • Inclusion criteria – Vf/vt, lactate <18, paO2 >50,ETCO2>10

 

References:

Bartos JA, Grunau B, Carlson C, Duval S, Ripeckyj A, Kalra R, Raveendran G,
John R, Conterato M, Frascone RJ, Trembley A, Aufderheide TP, Yannopoulos D.
Improved Survival with Extracorporeal Cardiopulmonary Resuscitation Despite
Progressive Metabolic Derangement Associated with Prolonged Resuscitation.
Circulation. 2020 Jan 3. doi: 10.1161/CIRCULATIONAHA.119.042173. [Epub ahead of
print] PubMed PMID: 31896278.

Bartos JA, Carlson K, Carlson C, Raveendran G, John R, Aufderheide TP,
Yannopoulos D. Surviving refractory out-of-hospital ventricular fibrillation
cardiac arrest: Critical care and extracorporeal membrane oxygenation management.
Resuscitation. 2018 Nov;132:47-55. doi: 10.1016/j.resuscitation.2018.08.030. Epub
2018 Aug 29. PubMed PMID: 30171974.

59: Partial REBOA and US PreHospital ECPR Revisited

This month we discuss two different topics we've recently had on the podcast.  Albuquerque had started the first US prehospital ECPR program…. and now they have the first patient as well.  Jon and Darren will share with us the exciting news.  Second, we recently had Matt Martin on the podcast talking about partial REBOA.  We got tons of email about this.  This month Zaf Qasim and Austin Johnson come on to talk about some of the controversial aspects of partial REBOA.  Zaf also gives us a great update on the state of REBOA in the world.

 

58: First U.S. Pre-Hospital ECPR Program

The U.S. has seen pre-hospital programs spring up in Paris, UK, and Australia.  It was thought that due to billing issues this could never happen in America….but it has.  Jon Marinaro and Darren Braude have accomplished this against all odds.  Zack interviews the two of them on how they were able to accomplish this task amidst the many financial, logistic, and medical problems surrounding this monumental task.

 

 

 

 

The Albuquerque Bean Dip!!  Love this organization from cleanse to cannulation

 

Update:

News story

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