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

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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]

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]

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.

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]

EDECMO 44: Bob Bartlett: Peristaltic Pumps, Hollow Fibers, and the History of ECMO

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In this episode, Zack Shinar interviews Dr. Bob Bartlett from the University of Michigan.  Dr. Bartlett has revolutionized the world with his leadership and innovation from the very beginnings of ECMO.  Zack and Bob discuss the history of ECMO and the prior use of roller pumps and bubble oxygenators.  They go on to describe the advantages of centrifugal pumps and hollow fiber oxygenators.  Additionally, they talk about PMP (polymethylpentene)-coated membranes inside oxygenators and their improved ability to safely oxygenate blood.  They discuss anticoagulation and how Bob believes that direct thrombin inhibitors are superior.  They wrap it up with a discussion on the future of ECMO and how peristaltic pumps have some significant advantages2.

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1.
Perchinsky M, Long W, Hill J, Parsons J, Bennett J. Extracorporeal cardiopulmonary life support with heparin-bonded circuitry in the resuscitation of massively injured trauma patients. Am J Surg. 1995;169(5):488-491. [PubMed]
2.
Bartlett RH. Esperanza. A. 2017;63(6):832-843. doi:10.1097/mat.0000000000000697
3.
Ali AA, Downey P, Singh G, et al. Rat model of veno-arterial extracorporeal membrane oxygenation. J. 2014;12(1):37. doi:10.1186/1479-5876-12-37
4.
Spurlock DJ, Raney DN, Fracz EM, Mazur DE, Bartlet RH, Haft JW. In Vitro Testing of a Novel Blood Pump Designed for Temporary Extracorporeal Support. A. February 2012:1. doi:10.1097/mat.0b013e318245d356

EDECMO 43: The Cutdown

The Cutdown Approach to ECMO Cannula Insertion with Alice Hutin, Lionel Lamhaut, and Zack Shinar

In this episode,  Alice Hutin of the Paris SAMU talks about the modified cutdown approach to cannula insertion.  She is an emergency physician who is one of four physicians who cannulates on the pre-hospital ECMO ambulance.  She describes the process of their modified cutdown.  We are holding off on written descriptions and pictures of the procedure pending Alice's publication so you will just have to listen!!!! We'll post the pictures soon!  Until then, here is a youtube segment showing a femoral cutdown -https://www.youtube.com/watch?v=zzu7cU3YoXo

 

Another recent publication by Alice:

Hutin A, Lamhaut L, Lidouren F, Kohlhauer M, Mongardon N, Carli P, Berdeaux A, Ghaleh B, Tissier R. Early Coronary Reperfusion Facilitates Return of Spontaneous Circulation and Improves Cardiovascular Outcomes After Ischemic Cardiac Arrest and Extracorporeal Resuscitation in Pigs. J Am Heart Assoc. 2016 Dec 22;5(12). pii: e004588. doi: 1. PubMed PMID: 28007740; PubMed Central PMCID: PMC5210433

1.
Hutin A, Lamhaut L, Lidouren F, et al. Early Coronary Reperfusion Facilitates Return of Spontaneous Circulation and Improves Cardiovascular Outcomes After Ischemic Cardiac Arrest and Extracorporeal Resuscitation in Pigs. J. 2016;5(12):e004588. doi:10.1161/jaha.116.004588