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Have you ever wondered about how initiating ECMO changes the cardiovascular physiology? Have you wondered what metrics you should be looking at when resuscitating a patient that has a beating heart and a ECMO flow? Dr. Sage Whitmore, an ED Intensivist from Nashville with ECMO training from UMichigan, leads us through the basic to the tough questions of ECMO physiology.
Podcast: Play in new window | Download (Duration: 33:44 — 27.5MB)
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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!Podcast: Play in new window | Download (Duration: 32:28 — 26.5MB)
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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
Podcast: Play in new window | Download (Duration: 27:26 — 22.0MB)
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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!
Podcast: Play in new window | Download (Duration: 36:22 — 29.2MB)
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Jason Bartos and his crew at the University
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
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.
Podcast: Play in new window | Download (Duration: 51:07 — 41.2MB)
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We've had some recent episodes on ECMO physiology. Today's episode focuses on the differences between ECMO physiology in the patient in cardiogenic shock versus the one in cardiac arrest. Scott Weingart talks with Zack about how the difference between these two patient populations is HUGE! Scott also mentions details about cannulation and some critical post ECMO initiation pearls.
The Patient
1. OOH Cardiac Arrest Patients are Different
Cannulation
2. Ultrasound-Guided Percutaneous Placement
3. Wire choices
4. Wire Location Verification
5. Small arterial cannulae
6. Simpler Circuits
Post-Pump Critical Care
7. Find the Injuries
8. Mandatory leg perfusion
9. Lower Anticoagulation Goals
10. Lower Flow Goals
11. Try to avoid venting – Truby et al. PMID:28422817, less is more
12. Understanding Cardiac Prognostication / Stunning
13. Understanding Neuro Prognostication
14. Protection/Ownership
15. In it for the Long Haul
Podcast: Play in new window | Download (Duration: 30:43 — 24.8MB)
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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
Podcast: Play in new window | Download (Duration: 36:34 — 29.7MB)
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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.
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
Podcast: Play in new window | Download (Duration: 23:18 — 19.6MB)
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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.
Podcast: Play in new window | Download (Duration: 23:07 — 19.0MB)
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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!
