EDECMO 45: ECMO in Sepsis

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]

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

[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

#REANIMATE4 Tickets Go On-Sale March 2, 2017!

REANIMATE 4, the World's only Endovascular Resuscitation Conference, is happening again on September 21-22, 2017!  Guest Faculty will include Scott Weingart, Zack Shinar, Joe Bellezzo, Chris Ho, Chris Nickson and STEVEN BERNARD (Yes! STEVE Friggin' BERNARD! — 2002 Bernard Hypothermia trials, CHEER, The Alfred).

To REGISTER, go to: www.reanimateconference.com/register

This Conference sells out within weeks of promotion so don't wait.

Want a taste of REANIMATE Goodness:

Reanimate 2 Highlight Video from Joe Bellezzo on Vimeo.

EDECMO 34 – The Day After REANIMATE – with Dr. Sean Deitch

In this episode, Joe talks with Dr. Sean Deitch, a non-academic Emergency Physician practicing in San Diego, California.  Dr. Deitch attended REANIMATE 3 – which just finished 2 weeks ago…and has an amazing story to tell.  You'll have to listen to the episode…

REANIMATE 4 is September 21-22, 2017 and features guest faculty member Stephen Bernard – coming all the way from Melbourne, Australia – and best know from the original therapeutic hypothermia trials and CHEER.  R3 was amazing and R4 will be even better!!

To register for REANIMATE 4: www.reanimateconference.com/register

 

REANIMATE 4 Tickets on Sale NOW!

REANIMATE 4: the World's premier endovascular resuscitation conference, held in San Diego California, is September 21-22, 2017. Join us for the most engaging immersion into the world of Extracoporeal Life Support, Extracorporeal CPR, REBOA, and hyper-invasive endovascular resuscitation teaching.

  • Registration: www.reanimateconference.com/register

Who:

The REANIMATE Core: Weingart, Shinar, Bellezzo, Ho

R4 Guest Faculty:

Steve Bernard (from The Alfred Hospital in Melbourne Australia, the ‘Bernard' Hypothermia trials, CHEER, ECPR), Zaf Qassim (REBOA specialist), Chris Muhr (TEE + ECHO specialist from Sweden), Jim Manning (endovascular resuscitation specialist & creator of the Selective Aortic Arch Perfusion Catheter – SAAP)

WHAT:

VA-ECMO, ECPR, Code Choreography, TEE/ECHO, endovascular resuscitation, VV-ECMO, mechanical CPR, vascular cutdown, REBOA.

  • tons of hands-on, practical, training and the opportunity to join the REANIMATE resuscitationist alumni team

WHERE:

San Diego, California.  The event is held at the UCSD Medical Education and Telemedicine building on the beautiful UCSD Medical School campus.  Didactic sessions are held in a beautiful state-of-the-art auditorium and practical hands-on simulation is done in the Center for the Future of Surgery: https://goo.gl/maps/jXUNBLcTih32

WHEN:  Sept 21-22, 2017

REGISTER:  www.reanimateconference.com/register

How to Build a REBOA Cannulation Model in 1000 Easy Steps!!!

How to build a REBOA Model is 1000 Easy Steps… from Joe Bellezzo on Vimeo.

 

Here is the video on how the REBOA models are built for #REANIMATE

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

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:

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

Upcoming EVENTS:

REANIMATE 3 Conference: March 2-3, 2017 (sold out! but click the link to go to the wait list)

REANIMATE 4 Conference: September 21-22, 2017  (registration will open on March 21, 2017. Add your name to the REANIMATE wait list for first chance at R4 tickets)

Castlefest 2017: April 10-14, 2017

Resusfest 2017: April 13-14, 2017

Essentials of Emergency Medicine 2017 at the Cosmopolitan Hotel in Las Vegas, Nevada: May 16-18, 2017

 

Bringing Down the House:

 

The REANIMATE 3 Fellowship Contest – 2017

The #REANIMATE 3 Fellowship Contest

Calling all future resuscitationists: medical students, PGY3/4 residents and fellows-in-training desiring the ultimate experience in Endovascular Resuscitation training: we are officially offering one ***FREE*** ticket (currently a $3200 value) to the winner of the #REANIMATE3 essay contest.

#REANIMATE3 is March 2-3, 2017 in San Diego, California.

Here is what you need to do:

Write a short essay in 300 words or less, on:

  1. The future management of cardiac arrest. Better chest compressions? ECPR?  or something altogether new and different? Bonus point for thinking way outside the box here.
  2. Why you would be the best choice for the #REANIMATE fellowship.

Here is what you get:

  1. One ***FREE*** ticket to #REANIMATE3 (a $3200 value) in San Diego, California on March 2-3, 2017
  2. A bunch of cool #REANIMATE3 schwag
  3. An experience like no other:  this will give you one-on-one experience with world-leaders in resuscitation…and a behind-the-scenes look at how #REANIMATE is created.
  4. An 8×10 glossy autographed glossy photo of Zack Shinar (this would be worth the effort alone! shirtless or not is entirely at your discretion)

Why are we doing this? We want to find the most motivated, brightest, most innovative young minds in Emergency Medicine & Critical Care. Lets face it, #REANIMATE3 is not cheap! So we decided to support young brilliance and bring them under our wing.

But be forewarned, the #REANIMATE3 Fellowship is no easy job. But its an experience you will never forget.

 

Send all essays to: reanimatefellow@gmail.com

 

Note: This opportunity is limited to medical students, PGY3/4 residents, and fellows-in-training only. 

Building REANIMATE 1: a video montage

While preparing for #REANIMATE16 there were no simulators for ECPR. There were no commercially available models for ECPR cannulation. There was nothing.

We had to build it. From scratch.

This short video documents the building of #REANIMATE16: the first international endovascular resuscitation conference.

*special thanks to Jeremy Haywood for producing this video: jeremyhaywoodphotography.com

 

Thinking back on #REANIMATE16, I couldn't help but think of the iconic American movie ‘It's a Wonderful Life', featuring Jimmy Stewart. Although the audio soundbytes in this video may seem out of context, I hope the concept of ‘building' something from nothing was preserved:

~Joe

 

It's a Wonderful Life is a 1946 American Christmas fantasy drama film produced and directed by Frank Capra, based on the short story “The Greatest Gift”, which Philip Van Doren Stern wrote in 1939 and published privately in 1945. The film is now among the most popular in American cinema and because of numerous television showings in the 1980s has become traditional viewing during the Christmas season.

The film stars James Stewart as George Bailey, a man who has given up his dreams in order to help others, and whose imminent suicide on Christmas Eve brings about the intervention of his guardian angel, Clarence Odbody (Henry Travers). Clarence shows George all the lives he has touched and how different life in his community of Bedford Falls would be had he never been born.

Despite initially performing poorly financially because of high production costs and stiff competition at the time of its release, the film has come to be regarded as a classic. Theatrically, the film's break-even point was $6.3 million, approximately twice the production cost, a figure it never came close to achieving in its initial release. An appraisal in 2006 reported: “Although it was not the complete box office failure that today everyone believes … it was initially a major disappointment and confirmed, at least to the studios, that Capra was no longer capable of turning out the populist features that made his films the must-see, money-making events they once were.”[7]

It's a Wonderful Life is one of the most acclaimed films ever made, praised particularly for its writing. It was nominated for five Academy Awards including Best Picture and has been recognized by the American Film Institute as one of the 100 best American films ever made,placing number 11 on its initial 1998 greatest movie list, and number one on AFI's list of the most inspirational American films of all time. Capra revealed that the film was his personal favorite among those he directed, adding that he screened it for his family every Christmas season.

 

shinar bellezzo

REANIMATE 2: September 12 & 13, 2016

REANIMATE 1 is now behind us. And it was a “yoooooooge” success (Reanimators from R1 will get that one!) On February 25 and 26, 2016 physicians, nurses and paramedics from around the globe met at the UCSD Simulation Center/Center for the Future of Surgery and immersed ourselves in the art and science of Endovascular Resuscitation: ECMO, ECPR, REBOA, bleeding-edge resuscitation, and more.    From  the entertaining (and for Bellezzo maybe a little humiliating!) didactic sessions to hands-on down-and-dirty sim sessions, participants were given the opportunity to train with the best educators in the world of resuscitative science. And now we are ready to make it even better!

REANIMATE 1 sold out one week after opening registration. Those who couldn't get into REANIMATE 1 made it onto a  waiting list for R2, which  is selling out fast. Register NOW and don't miss out!

Check out the video: