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52: Brain Freeze- Selective Retrograde Cerebral Perfusion for Intra-Arrest Neuroprotection

Posted on March 5, 2019 // Leave a Comment

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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!

1.
Milewski RK, Pacini D, Moser GW, et al. Retrograde and Antegrade Cerebral Perfusion: Results in Short Elective Arch Reconstructive Times. The Annals of Thoracic Surgery. 2010;89(5):1448-1457. doi:10.1016/j.athoracsur.2010.01.056
2.
Keeling WB, Leshnower BG, Hunting JC, Binongo J, Chen EP. Hypothermia and Selective Antegrade Cerebral Perfusion Is Safe for Arch Repair in Type A Dissection. The Annals of Thoracic Surgery. 2017;104(3):767-772. doi:10.1016/j.athoracsur.2017.02.066
3.
Papadopoulos N, Risteski P, Hack T, et al. Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe? Thorac cardiovasc Surg. 2017;66(03):215-221. doi:10.1055/s-0037-1604451
4.
Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis. The Annals of Thoracic Surgery. 2016;101(1):146-152. doi:10.1016/j.athoracsur.2015.06.029
5.
McCullough J, Zhang N, Reich D, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg. 1999;67(6):1895-1899; discussion 1919-21. [PubMed]
6.
Yan T, Bannon P, Bavaria J, et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg. 2013;2(2):163-168. [PubMed]
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NEW PAPER: Extracorporeal Life Support in the Emergency Department: A Narrative Review for the Emergency Physician

Posted on December 5, 2018 // Leave a Comment

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

 

1.
Swol J, Belohlávek J, Brodie D, et al. Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation. 2018;133:108-117. [PubMed]
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49 – You Can’t Spell REBOA without the ER – Endovascular Resuscitation of the Trauma Patient – Zaf Qasim

Posted on October 12, 2018 // Leave a Comment

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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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EDECMO 48: When Should I Transport a Cardiac Arrest?

Posted on August 10, 2018 // Leave a Comment

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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

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
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EDECMO 47: ECMO Donazione: Organ Transplantation with Velia Antonini

Posted on August 4, 2018 // Leave a Comment

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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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EDECMO 46: Wire Assistant

Posted on July 5, 2018 // Leave a Comment

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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.

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EDECMO 45: ECMO in Sepsis

Posted on May 10, 2018 // Leave a Comment

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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

1.
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]
2.
Datzmann T, Träger K. Extracorporeal membrane oxygenation and cytokine adsorption. J. 2018;10(S5):S653-S660. doi:10.21037/jtd.2017.10.128
3.
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
4.
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
5.
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]
6.
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]
7.
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]
8.
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]
9.
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]
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EDECMO 44: Bob Bartlett: Peristaltic Pumps, Hollow Fibers, and the History of ECMO

Posted on March 21, 2018 // 1 Comment

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1

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.

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1.
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]
2.
Bartlett RH. Esperanza. A. 2017;63(6):832-843. doi:10.1097/mat.0000000000000697
3.
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
4.
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
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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.

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

Posted on December 29, 2017 // Leave a Comment

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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:

  1. 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.
  2. 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
  3. 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

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