EDECMO Archives

EDECMO 48: When Should I Transport a Cardiac Arrest?

Posted on August 10, 2018 // Leave a Comment

Podcast: Play in new window | Download (Duration: 35:13 — 28.3MB)

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This part two of August 2018. We are now tackling the difficult question of when to transport cardiac arrests if I have ECMO available? Brian Grunau is an expert in this question. Brian has become a giant in the world of ECMO. His research, leadership and experience have pushed the Canadian ECPR contingency to the forefront. Brian gives us some insight on what factors I should consider and when should I transport.¹

Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital? P. 2016;20(5):615-622. doi:10.3109/10903127.2016.1149652

Filed Under: podcasts // Tagged: brian grunau, cardiac arrest, EDECMO, Shinar, transport cardiac arrest, Zack Shinar

EDECMO 47: ECMO Donazione: Organ Transplantation with Velia Antonini

Posted on August 4, 2018 // Leave a Comment

Podcast: Play in new window | Download (Duration: 15:35 — 11.8MB)

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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

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Filed Under: podcasts // Tagged: ECMO, ecmo donation, EDECMO, featured, organ transplantation, velia marta antonini, Zack Shinar

EDECMO 46: Wire Assistant

Posted on July 5, 2018 // Leave a Comment

Podcast: Play in new window | Download (Duration: 25:25 — 20.5MB)

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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.

Filed Under: podcasts // Tagged: baldini, Bellezzo, ECMO, ECPR, EDECMO, featured, Shinar, Weingart, wire assistant, Zack Shinar

EDECMO 45: ECMO in Sepsis

Posted on May 10, 2018 // Leave a Comment

Podcast: Play in new window | Download (Duration: 31:02 — 25.1MB)

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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

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]

Datzmann T, Träger K. Extracorporeal membrane oxygenation and cytokine adsorption. J. 2018;10(S5):S653-S660. doi:10.21037/jtd.2017.10.128

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

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

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]

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]

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]

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]

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]

Filed Under: podcasts // Tagged: ECMO, EDECMO, emcrit, heididalton, joebellezzo, reanimate, scottweingart, Sepsis, zackshinar

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

Posted on March 21, 2018 // 1 Comment

Podcast: Play in new window | Download (Duration: 36:58 — 29.8MB)

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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.

^3,4

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]

Bartlett RH. Esperanza. A. 2017;63(6):832-843. doi:10.1097/mat.0000000000000697

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

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

Filed Under: podcasts // Tagged: Bob Bartlett, bubble oxygenators, ECMO, ECPR, EDECMO, featured, hollow fiber, peristaltic pumps, roller pump, Zack Shinar

EDECMO 42: Organ Transplantation On ECMO

Posted on January 16, 2018 // 2 Comments

Podcast: Play in new window | Download (Duration: 32:07 — 26.2MB)

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In this episode, we tackle the subject of organ transplantation on ECMO. 2017 featured several articles showing the efficacy of ECMO for organ transplantation. In Italy, 56% of total potential patients were successfully transplanted. The success of these transplants have been comparable to patients not on ECMO. Zack Shinar interviews Lionel Lamhaut, ECMO specialist from Paris, and Cyrus Olsen, ethicist from the University of Scranton, to dive into some of the deeper questions including financial implications, ethical angles, and research extrapolations. Join Zack, Lionel and Cy at Big Sick 18 (bigsick18.org) in Zermatt Switzerland on February 7-9th,, 2018!!

1: Christopher DA, Woodside KJ. Expanding the Donor Pool: Organ Donation After
Brain Death for Extracorporeal Membrane Oxygenation Patients. Crit Care Med. 2017
Oct;45(10):1790-1791. doi: 10.1097/CCM.0000000000002633. PubMed PMID: 28915178.

2: Bronchard R, Durand L, Legeai C, Cohen J, Guerrini P, Bastien O. Brain-Dead
Donors on Extracorporeal Membrane Oxygenation. Crit Care Med. 2017
Oct;45(10):1734-1741. doi: 10.1097/CCM.0000000000002564. PubMed PMID: 28640022.

3: Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, Citerio G. Organ
donation in cardiac arrest patients treated with extracorporeal CPR: A single
centre observational study. Resuscitation. 2017 Sep;118:133-139. doi:
10.1016/j.resuscitation.2017.06.001. Epub 2017 Jun 12. PubMed PMID: 28596083.

4: Dalle Ave AL, Bernat JL. Donation after brain circulation determination of
death. BMC Med Ethics. 2017 Feb 23;18(1):15. doi: 10.1186/s12910-017-0173-1.
PubMed PMID: 28228145; PubMed Central PMCID: PMC5322624.

5: Larsson M, Forsman P, Hedenqvist P, Östlund A, Hultman J, Wikman A, Riddez L,
Frenckner B, Bottai M, Wahlgren CM. Extracorporeal membrane oxygenation improves
coagulopathy in an experimental traumatic hemorrhagic model. Eur J Trauma Emerg
Surg. 2017 Oct;43(5):701-709. doi: 10.1007/s00068-016-0730-1. Epub 2016 Nov 4.
PubMed PMID: 27815579; PubMed Central PMCID: PMC5629226.

6: Dalle Ave AL, Shaw DM, Gardiner D. Extracorporeal membrane oxygenation (ECMO)
assisted cardiopulmonary resuscitation or uncontrolled donation after the
circulatory determination of death following out-of-hospital refractory cardiac
arrest-An ethical analysis of an unresolved clinical dilemma. Resuscitation. 2016
Nov;108:87-94. doi: 10.1016/j.resuscitation.2016.07.003. Epub 2016 Jul 20.
Review. PubMed PMID: 27449821.

7: Fan X, Chen Z, Nasralla D, Zeng X, Yang J, Ye S, Zhang Y, Peng G, Wang Y, Ye
Q. The organ preservation and enhancement of donation success ratio effect of
extracorporeal membrane oxygenation in circulatory unstable brain death donor.
Clin Transplant. 2016 Oct;30(10):1306-1313. doi: 10.1111/ctr.12823. Epub 2016 Sep
5. PubMed PMID: 27460305.

8: Jasseron C, Lebreton G, Cantrelle C, Legeai C, Leprince P, Flecher E,
Sirinelli A, Bastien O, Dorent R. Impact of Heart Transplantation on Survival in
Patients on Venoarterial Extracorporeal Membrane Oxygenation at Listing in
France. Transplantation. 2016 Sep;100(9):1979-87. doi:
10.1097/TP.0000000000001265. PubMed PMID: 27306536.

9: Migliaccio ML, Zagli G, Cianchi G, Lazzeri C, Bonizzoli M, Cecchi A, Anichini
V, Gensini GF, Peris A. Extracorporeal membrane oxygenation in brain-death organ
and tissues donors: a single-centre experience. Br J Anaesth. 2013
Oct;111(4):673-4. doi: 10.1093/bja/aet323. PubMed PMID: 24027145.

Filed Under: blogpost // Tagged: bronchard, casadio, cy olsen, Cyrus Olsen, ECMO, EDECMO, featured, lamhaut, Lionel Lamhaut, organ, Shinar, transplantation, Zack Shinar

EDECMO 41 – The 3 Stages of ECPR – Diane’s Story

Posted on December 29, 2017 // Leave a Comment

Podcast: Play in new window | Download (Duration: 30:32 — 42.2MB)

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[The original EDECMO 41 post had to be taken down…for reasons beyond our control! But here is the new and improved Episode 41]

In this episode Zack and Joe discuss the 3-stages of Extracorporeal Membrane Oxygenation (ECMO) – or put another way, this is how to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Emergency Department (ED). It's been 4 years since we talked about these basic premises of ECPR. But this time, its highlighted in a very special story.

The Three Stages of ECPR:

Placement of any commercially available catheters into the femoral artery and femoral vein.
- Ultrasound-guided percutaneous access is our preference, but cutdown is also considered. This is done in every patient, every time, and is done in parallel to ongoing ACLS. Transduce the arterial line to guide resuscitation and use the venous line for resuscitation purposes.
Transition to ECMO cannulas
- Using guidewires (we prefer the Amplatz Super Stiff 145 cm .038″ teflon coated floppy tip wires), remove the catheters placed in Stage 1, perform serial dilation, and place ECMO cannulas
Initiate the ECMO pump
- Perform ‘underwater seal' using crystalloid, which closes the circuit. The circuit is de-aired and the pump is started. Increase the RPM to 1500 and remove the clamps. Inspect the circuit and troubleshoot any issues.

3 stages. 3 steps.

You can find a whole lot more on our ECPR 3 stages page.

EVEN BETTER! If you are interested in learning all about ED ECMO, with hands-on simulators, Wold-renowned ECMO educators, REBOA, ECPR, computer simulation, check out the REANIMATE conference site or go directly to the REANIMATE registration page!!

Diane's Story:

November 30, 2017: Diane suffered ventricular fibrillation (VF) cardiac arrest and collapsed…just outside the ED doors. CPR was started immediately by an ED nurse. After 32 minutes of failed Advanced Cardiac Life Support (ACLS), with human and mechanical chest compressions, she remained in refractory VF.

Our Emergency Physician-initiated ECMO (ED-ECMO) protocol was initiated using the ‘3 stages of ECMO.' Diane was ‘on pump' in 32 minutes, taken to the cath lab, and had her 95% LAD lesion stented by Interventional Cardiologist Arvin Narula.

Diane went home with her family and friends on December 13, 2017. Listen to the episode to hear the details…

Diane's Widowmaker

Dr. Narula, Interventional Cardiology

Joe and Diane

Diane with Casey Gwynn and sister Joanne

Dr. Eads and Diane

Zack Shinar, Diane, and Jessica

Bellezzo And Diane

Filed Under: podcasts // Tagged: 2017, Bellezzo, cardiac arrest, CPR, Diane, ECPR, EDECMO, featured, reanimate, REANIMATE 5, resuscitation

EDECMO 39: Who Do We Put On ECMO? – New Data on Prognostics

Posted on October 6, 2017 // 2 Comments

Podcast: Play in new window | Download (Duration: 36:15 — 31.0MB)

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In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?” Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important. Guillaume's data shows importance of short low times, lower lactates and higher pH values. The real question is what number for each of these should we consider a hard stop on initiation. This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial. He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions. With many ECMO studies having average arrest to

initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide. This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65. We conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival. This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this.

Bibliography:

1: Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of
extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac
arrest-An ELSO registry study . Resuscitation. 2017 Oct;119:56-62. doi:
10.1016/j.resuscitation.2017.08.003. Epub 2017 Aug 5. PubMed PMID: ¹.

2: Reynolds JC, Grunau BE, Elmer J, Rittenberger JC, Sawyer KN, Kurz MC, Singer
B, Proudfoot A, Callaway CW. Prevalence, natural history, and time-dependent
outcomes of a multi-center North American cohort of out-of-hospital cardiac
arrest extracorporeal CPR candidates. Resuscitation. 2017 Aug;117:24-31. doi:
10.1016/j.resuscitation.2017.05.024. Epub 2017 May 25. PubMed PMID: ².

3: Debaty G, Babaz V, Durand M, Gaide-Chevronnay L, Fournel E, Blancher M,
Bouvaist H, Chavanon O, Maignan M, Bouzat P, Albaladejo P, Labarère J. Prognostic
factors for extracorporeal cardiopulmonary resuscitation recipients following
out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.
Resuscitation. 2017 Mar;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011. Epub
2016 Dec 19. Review. PubMed PMID: ³.

References

Haas N, Coute R, Hsu C, Cranford J, Neumar R. Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study . Resuscitation. 2017;119:56-62. [PubMed]

Reynolds J, Grunau B, Elmer J, et al. Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation. 2017;117:24-31. [PubMed]

Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation. 2017;112:1-10. [PubMed]

Filed Under: podcasts // Tagged: ECMO, ECPR, EDECMO, featured, guillaume debaty, indications, josh reynolds, kevin haas, prognostics

EDECMO 33a – “Bringing Down the House” by Zack Shinar (from RESUSfest 2016)

Posted on January 26, 2017 // 2 Comments

Podcast: Play in new window | Download (Duration: 19:12 — 26.4MB)

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In this episode of the EDECMO podcast, Zack describes how to use the concept of ‘TEAM PLAY”, much like the gang from the classic novel “Bringing Down the House” by Ben Mezrich, to optimize outcomes after cardiac arrest….with, or without, ECPR.

Zack's tips for running a code:

Proper, high-quality CPR
The choreography of running a code
Let your nurses run the code
CPR Alfresco (transitioning the patient from EMS gurney to hospital gurney IN THE AMBULANCE BAY)