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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!
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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.
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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
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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
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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
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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.
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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!
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
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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.
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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
Joe is an ED Invasivist who endorses any procedure looking for an indication.
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