79: Prolonged Arrests and the Denmark Experience

This month Zack gives a few pearls from the recent Reanimate courses and annual ELSO meeting in Boston before he interviews Gowry Mork from Aarhus University about her fantastic recent paper.

  • Pearl #1 is about hand placement in cannulation.  Hold the ultrasound in your left an
    d needle in right.  Once in the vessel, drop the US probe and take your left hand and gently hold the needle. With your right hand grab the wire far enough up to be to insert into the vessel in one push.
  • Gowry’s paper has many interesting points.  Probably the biggest is the reasonable survivorship for prolonger arrests.  This is tied to equality of care for patient who live far from the closest ECMO center.

 

 

Gowry’s paper – 

Mørk SR, Bøtker MT, Christensen S, Tang M, Terkelsen CJ. Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support. Resusc Plus. 2022 Apr 6;10:100230. doi: 10.1016/j.resplu.2022.100230. PMID: 35434669; PMCID: PMC9010695.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9010695/

Gowry’s Twitter

@MSivagowry –  https://mobile.twitter.com/msivagowry

78: ECMO in South Africa

This month we are honored to have Neville Vlok on the show.  Neville has been one of the key physicians pushing for ECPR in South Africa.  In this episode, we explore what medicine and resuscitation looks like in South Africa, how ECMO has been utilized, and whether ECMO even makes sense in developing countries.

 

Vlok N, Hedding KA, Van Dyk MA. Saved by the pump: Two successful resuscitations utilising emergency department-initiated extracorporeal cardiopulmonary resuscitation in South Africa. S Afr Med J. 2021 Mar 2;111(3):208-210. doi: 10.7196/SAMJ.2021.v111i3.15366. PMID: 33944740.

77: ECMO in Trauma with Justyna Swol

Using ECMO for traumatic patients has had some promising papers through the years, but the data overall is still poor.  Justyna Swol has teamed up with ELSO to improve this deficiency by making a trauma carve out of the ELSO registry.  In this episode, Zack discusses with Justyna the many facets of ECMO in trauma.  A few pearls and references are below:

  • Anticoagulation in ECMO is not mandatory.  A reasonable strategy is heparinized circuit with a titrating dose of systemic heparin as necessary in the trauma patient.  This includes everyone from isolated pulmonary contusions to intracranial hemorrhage.
  • VV-ECMO similar to ARDS in medical causes can be used and likely offers survival benefit to those patients with post traumatic lung injury.  Initiating early (maybe PaO2 of 80 on 100% FiO2) is likely best.
  • ECPR can be done in the traumatic arrest.  Best when done in parallel to the other resuscitative needs of the patient.  Data is promising in case series.  Need for bigger data sets is clear.

 

Reynolds HN, Cottingham C, McCunn M, Habashi NM, Scalea TM. Extracorporeal lung support in a patient with traumatic brain injury: the benefit of heparin-bonded circuitry. Perfusion. 1999 Nov;14(6):489-93. doi: 10.1177/026765919901400612. PMID: 10585157.
Bein T, Scherer MN, Philipp A, Weber F, Woertgen C. Pumpless extracorporeal lung assist (pECLA) in patients with acute respiratory distress syndrome and severe brain injury. J Trauma. 2005 Jun;58(6):1294-7. doi: 10.1097/01.ta.0000173275.06947.5c. PMID: 15995487.
Parker BM, Menaker J, Berry CD, Tesoreiero RB, O’Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg. 2021 Jun;87(6):949-953. doi: 10.1177/0003134820956360. Epub 2020 Dec 9. PMID: 33295187.
Bosarge PL, Raff LA, McGwin G Jr, Carroll SL, Bellot SC, Diaz-Guzman E, Kerby JD. Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg. 2016 Aug;81(2):236-43. doi: 10.1097/TA.0000000000001068. PMID: 27032012.
Mazzeffi M, Kon Z, Menaker J, Johnson DM, Parise O, Gelsomino S, Lorusso R, Herr D. Large Dual-Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage. ASAIO J. 2019 Sep/Oct;65(7):674-677. doi: 10.1097/MAT.0000000000000917. PMID: 30398981.
Lorusso R, Belliato M, Mazzeffi M, Di Mauro M, Taccone FS, Parise O, Albanawi A, Nandwani V, McCarthy P, Kon Z, Menaker J, Johnson DM, Gelsomino S, Herr D. Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database. Crit Care. 2021 Mar 17;25(1):107. doi: 10.1186/s13054-021-03533-5. PMID: 33731186; PMCID: PMC7968168.
Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, Matteucci M, Fina D, Heuts S, Bidar E, Natour E, Sels JW, Delnoij T, Lorusso R. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J. 2021 May 1;67(5):476-484. doi: 10.1097/MAT.0000000000001216. PMID: 32657828.
Trivedi JR, Alotaibi A, Sweeney JC, Fox MP, van Berkel V, Adkins K, Condley C, Alwair H, Slaughter MS. Use of Extracorporeal Membrane Oxygenation in Blunt Traumatic Injury Patients with Acute Respiratory Distress Syndrome. ASAIO J. 2022 Apr 1;68(4):e60-e61. doi: 10.1097/MAT.0000000000001544. PMID: 34352816.
Swol J, Brodie D, Napolitano L, Park PK, Thiagarajan R, Barbaro RP, Lorusso R, McMullan D, Cavarocchi N, Hssain AA, Rycus P, Zonies D; Extracorporeal Life Support Organization (ELSO). Indications and outcomes of extracorporeal life support in trauma patients. J Trauma Acute Care Surg. 2018 Jun;84(6):831-837. doi: 10.1097/TA.0000000000001895. PMID: 29538235.

76: Netherlands Pre-Hospital ECPR Program

The Netherlands has undertaken a monumental task: provide ECPR to 100% of their country.  Dinis Reis Miranda and his team have put in place an unbelievably organized and robust project to improve the survival from cardiac arrest for their entire country.  Listen to Dinis explain about the project, their struggles, and this world changing experiment going on right now in the Netherlands.

 

Here is their projects website and some of its content – https://onscenetrial.com/

 

 

 

 

 

74: Do 70 year old’s deserve ECPR? A Deep Dive into the Economics of ECPR

Have you ever pondered whether all the work over ECPR was worth it?  Even if you did save a few patients, does this really make sense from a societal standpoint?  Am I giving up my life on a project where my efforts could be better elsewhere?  Then this episode is for you (and me).  This month I talk with Melissa Barnes and Ryan Coute about the economics of cardiac arrest and specifically ECPR.  Ryan has just published a great paper in Resuscitation on the costs on OHCA.  We will talk with Ryan and Melissa Barnes, ECMO manager at Sharp Memorial Hospital about benefits and costs to society of OHCA and ECMO.  I learned several pearls from Ryan’s paper as well as a paper by Grosse that Ryan references.  Below are the links to both papers with a couple graphs to try to wrap your head around.

Coute

Image

 

Coute

Economic loss of productivity of OHCA

Grosse

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688510/

 

 

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

 

73b: Conclusions for Hyperinvasive Trial with Jan Belohlavek

Here is the conclusion for the interview of Jan Belohlavek and his Hyperinvasive Trial

73:The Hyperinvasive Trial with Jan Belohlavek

Wait…ECPR works?

To the believers, this has been a foregone conclusion.  To the rest of the world, the question of whether ECPR improves cardiac arrest survivorship has been in question. Jan Belohlavek and his Prague colleagues just presented their 8 year data showing better outcomes in cardiac arrest patients that got a grouped therapy of early transport, prehospital targeted temperature management, mechanical chest compressions, and ECMO over those who got a traditional resuscitation.  This study is key and contrasts to the Oslo study that we reviewed just a few months earlier.  Jan speaks with Zack about the details of the results and what were the keys to their success.

 

 

Hyperinvasive trial study proposal – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492121/

Jan’s slides on Hyperinvasive Results

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.

69: 2020 Synopsis

2020 was a crazy year.  This month Zack goes through the biggest ECMO lessons learned in 2020.  This is a short concise run through of ECPR, ECMO for COVID, Imaging, and Aortic Dissection.  It’s a reminder of how organization is so critical to the outcome of your ECMO program.  He also reminds us how improvement in these systems of care can lead to survival rates even the believers in ECMO thought were unattainable.