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81: In Hospital Cardiac Arrest ECMO Inclusion Criteria with Joe Tonna

Posted on November 14, 2022 // 1 Comment

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In this podcast, Joe Tonna tells us how to approach hypothermia with ECPR patients.  He also goes through his paper RESCUE-IHCA giving us an immediate way to prognosticate in patients to use of ECMO or not.

Hypothermia – Resuscitation

Nakashima T, Ogata S, Noguchi T, Nishimura K, Hsu CH, Sefa N, Haas NL, Bĕlohlávek J, Pellegrino V, Tonna JE, Haft J, Neumar RW. Association of intentional cooling, achieved temperature and hypothermia duration with in-hospital mortality in patients treated with extracorporeal cardiopulmonary resuscitation: An analysis of the ELSO registry. Resuscitation. 2022 Aug;177:43-51. doi: 10.1016/j.resuscitation.2022.06.022. Epub 2022 Jul 3. PMID: 35788020.

Hypothermia Meta-Analysis

Duan J, Ma Q, Zhu C, Shi Y, Duan B. eCPR Combined With Therapeutic Hypothermia Could Improve Survival and Neurologic Outcomes for Patients With Cardiac Arrest: A Meta-Analysis. Front Cardiovasc Med. 2021 Aug 13;8:703567. doi: 10.3389/fcvm.2021.703567. PMID: 34485403; PMCID: PMC8414549.

In Hospital Cardiac Arrest and ECPR Inclusion

Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, Zhang C, Rycus P, Keenan HT; American Heart Association Get With the Guidelines–Resuscitation Investigators. Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation. JACC Cardiovasc Interv. 2022 Feb 14;15(3):237-247. doi: 10.1016/j.jcin.2021.09.032. Epub 2022 Jan 12. PMID: 35033471; PMCID: PMC8837656.

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80: The Expert Approved ECPR Procedure with Florian Schmitzberger

Posted on October 7, 2022 // Leave a Comment

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In this episode,  Zack interviews Florian Schmitzberger who just published a fantastic study that incorporates fourteen leaders within the ECPR community to hash out the specific procedural steps associated with ECPR.

 

INCLUSION
• Age <75 years
• Witnessed arrest
• Initial rhythm is shockable rhythm (VF / VT)
• ECPR can be initiated within 60 minutes of the arrest, though a longer interval may be considered circumstantially (e.g. hypothermic arrest)
• Aggressive ICU care consistent with patient wishes
• No prolonged downtime without CPR
• End-tidal CO2 ≥ 10 mmHg (unless pulmonary embolism is suspected)
• Treating physician/surgeon agreement to proceed
EXCLUSION
• Contraindication to anticoagulation
• Cannot perform activities of daily living at baseline
• Advanced comorbidities / known irreversible organ failure
• Advanced COPD or other pulmonary comorbidities
• Metastatic malignancy
• Major stroke or neurologic impairment
• Do-not-resuscitate / Do-not-intubate status

 

The Paper

Schmitzberger FF, Haas NL, Coute RA, Bartos J, Hackmann A, Haft JW, Hsu CH, Hutin A, Lamhaut L, Marinaro J, Nagao K, Nakashima T, Neumar R, Pellegrino V, Shinar Z, Whitmore SP, Yannopoulos D, Peterson WJ. ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation. Resuscitation. 2022 Oct;179:214-220. doi: 10.1016/j.resuscitation.2022.07.003. Epub 2022 Jul 8. PMID: 35817270.

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79: Prolonged Arrests and the Denmark Experience

Posted on September 19, 2022 // 1 Comment

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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

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78: ECMO in South Africa

Posted on August 15, 2022 // Leave a Comment

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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.

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76: Netherlands Pre-Hospital ECPR Program

Posted on June 12, 2022 // 1 Comment

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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/

 

 

 

 

 

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73:The Hyperinvasive Trial with Jan Belohlavek

Posted on May 24, 2021 // Leave a Comment

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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

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72: Should We All Switch To Bivalirudin?

Posted on March 24, 2021 // 1 Comment

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Heparin has been the mainstay of anticoagulation for ECMO patients for years.  In recent years, this has been challenged.  Bivalirudin has become a potential better anticoagulant.  Troy Seelhammer in EDECMO episode 55 gave us some insight into this.  This month Ryan Rivosecchi and his crew at UPitt have released their findings in Critical Care Medicine.  This retrospective study suggests great improvement in major bleeding in patients who received Bivalirudin compare to Heparin (40.7% vs 11.7%, p < 0.001).  Listen to Ryan and Zack discuss anticoagulant use in ECMO patients in this month’s episode.

Rivosecchi RM, Arakelians AR, Ryan J, Murray H, Padmanabhan R, Gomez H, Phillips D, Sciortino C, Arlia P, Freeman D, Sappington PL, Sanchez PG. Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin. Crit Care Med. 2021 Mar 15. doi: 10.1097/CCM.0000000000004944. Epub ahead of print. PMID: 33711003.

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68: ARREST – The First Randomized ECPR Trial Ever

Posted on November 22, 2020 // 2 Comments

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The ARREST Trial is published!  Demetris Yannopoulos, Jason Bartos and their army of rockstars have done it!  This is the first randomized ECPR trial and it showed tremendous benefit of ECPR compared to traditional therapies.  Zack explores this paper and their concurrent publication of process with Demetris.   Their two Lancet papers are below

  • https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32338-2/fulltext
  • https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30376-X/fulltext

In the news, Jenelle Badulak and her crew at UW saved a hypothermic mountaineer in Seattle.  Story here.

  • https://www.bbc.com/news/world-us-canada-54959874

Demetri Yannopoulos     Photo of Jason A Bartos

Demetris Yannopoulos and Jason Bartos

 

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67: Da DO2: Fundamental ECMO Physiology with Sage Whitmore

Posted on October 14, 2020 // Leave a Comment

Podcast: Play in new window | Download (Duration: 33:46 — 24.3MB)

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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.online pharmacy

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65: ECPR Journal Club: Dual Sequential Defibrillation, CT after ECMO, and much, much more

Posted on May 23, 2020 // 1 Comment

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!
Reverse CPR – better systolic BPs
Brown J., Rogers J., Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001;50:233–238. [PubMed] [Google Scholar]
Mazer S.P., Weisfeldt M., Bai D. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279–285. [PubMed] [Google Scholar] DOI:  10.1016/s0300-9572(03)00037-6
Wei J., Tung D., Sue S.H., Wu S., van Chuang Y.C., Chang C.Y. Cardiopulmonary resuscitation in prone position: A simplified method for outpatients. Journal of the Chinese Medical Association. 2006;69:202–206. [PubMed] [Google Scholar]
SLides on Prone CPR
Risk to providers of CPR in Covid
 
Fear of Covid in CPR
Witnesses still providing CPR in Covid era – 53 vs. 49% in Paris
Witnesses didn’t provide in Sydney
Dual Sequential Defibrillation (DSD)
Columbus Ohio Paramedics – http://dx.doi.org/10.1016/j.resuscitation.2016.08.002
San Antonio Texas – no benefit of DSD – http://dx.doi.org/10.1016/j.resuscitation.2016.06.011
Damaged Defibrillator from DSD – DOI: 10.1016/j.annemergmed.2017.04.005
Toronto – Cheskes RCT -DSD and vector change better than standard defibrillation –  https://doi.org/10.1016/j.resuscitation.2020.02.010
National Data on ECMO use in US
J. Hadaya, et al., National trends in utilization and outcomes of extracorporeal support for in- and
out-of-hospital cardiac arrest, Resuscitation (2020), https://doi.org/10.1016/j.resuscitation.2020.02.034
Early CT after ECMO
https://doi.org/10.1016/j.resuscitation.2019.11.024
3d printed  ECPR modeling
https://doi.org/10.1016/j.resuscitation.2020.01.032
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