63: Covid and ECMO – Who do we cannulate? with Jenelle Badulak

“Normal life is changing.  It is now a covid 19 life” – Bin Cao

I write this with some trepidation as well as pride in the role we all get to play in Covid 19.  The sure in the US and many other places worldwide is just beginning.  It is on us to seek guidance from those who have gone through this already.  Today we will address the use of ECMO in Covid with an expert in ECMO who is in the throws of the worst outbreak of the United States – Seattle, Washington.  Jenelle Badulak and I give you a short yet powerful discussion about what Covid patients should receive ECMO.

Take homes for decision to initiate- comorbidities (HTN, DM especially), single organ dysfunction, young age, trajectory of course

Hosts – Jenelle Badulak, Zack Shinar

 

ECMO guidance for Coronavirus

  • MERS ECMO Data
    • Alshahrani MS, Sindi A, Alshamsi F, Al-Omari A, El Tahan M, Alahmadi B, Zein A, Khatani N, Al-Hameed F, Alamri S, Abdelzaher M, Alghamdi A, Alfousan F, Tash A, Tashkandi W, Alraddadi R, Lewis K, Badawee M, Arabi YM, Fan E, Alhazzani W. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care. 2018 Jan 10;8(1):3. doi: 10.1186/s13613-017-0350-x. PubMed PMID: 29330690; PubMed Central PMCID: PMC5768582
  • Chinese Society of Extracorporeal Life Support. [Recommendations on extracorporeal life support for critically ill patients with novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 9;43(0):E009. doi: 10.3760/cma.j.issn.1001-0939.2020.0009. [Epub ahead of print] Chinese. PubMed PMID: 32035430.
    • http://rs.yiigle.com/yufabiao/1180132.htm
    • Inclusion criteria under this paper are–>
    • Under optimal ventilation conditions (FiO 2 ≥ 0.8, tidal volume 6 ml / kg, PEEP ≥ 10 cmH 2 O), ECMO can be started if there are no contraindications and one of the following conditions is met 7 , 8 , 14 , 16 , 17 , 18 ] : (1) PaO 2 / FiO 2 <50 mmHg for more than 3 h; (2) PaO 2 / FiO 2 <80 mmHg for more than 6 h; (3) FiO 2 = 1.0, PaO 2 / FiO 2 <100 mmHg; (4) Arterial blood pH <7.25 and PaCO 2 > 60 mmHg for more than 6 hours, and respiratory rate> 35 times / min; (5) When respiratory rate> 35 times / min, blood pH <7.2 The plateau pressure was> 30 cmH 2 O; (6) severe air leak syndrome; (7) combined with cardiogenic shock or cardiac arrest.

 

 

 

EDECMO 31 – Anaphylaxis & Epi-Pens. Are we ready for VV-ECMO in the Emergency Department?

Is There EVER a Role for Veno-Venous ECMO (VV-ECMO) in the Emergency Department?

Here is a case of a young man who presented to our Emergency Department in June, 2106 with profound anaphylaxis. This was a rare “CAN Intubate/CAN'T VENTILATE” scenario:

  1. Max Epinephrine
  2. Max antihistamines
  3. Max steroids
  4. Max ventilator

…and you still cannot ventilate.  PaCO2 is going up. pH is going down.

What options do you have? Find out in this episode.

 

Here is the video produced by Sharp Memorial Hospital (@SharpHealthcare) about this case:


Special thanks to:

Kevin Shaw MD Intensive Care Sharp Memorial Hospital

Kevin Shaw MD
Intensive Care
Sharp Memorial Hospital

Andrew Eads MD Emergency Medicine Sharp Memorial Hospital

Andrew Eads MD
Emergency Medicine
Sharp Memorial Hospital

Melissa Brunsvold MD Department of Surgery University of Minnesota

Melissa Brunsvold MD
Department of Surgery
University of Minnesota

Conrad Soriano

Conrad Soriano

Brynn Shinar Cutest Girl on Earth

Brynn Shinar
Cutest Girl on Earth

Evid-ECMO 2: Veno-Venous ECMO in ARDS – The CESAR Trial & ANZ-ECMO

Episode 2 of Evid-ECMO features  Dr. David Willms, who is the Director of Critical Care Medicine at Sharp Memorial Hospital. Dr. Willms has over 25 years of experience with VA and VV ECMO and is an amazing resource for us at our hospital. Dr. Willms has been a key player in the development of our highly successful ECMO program at Sharp. Zack and Dave discuss two of the “big” articles in VV-ECMO for ARDS:

 

CESAR TrialArticle 1: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

PDF: cesar-trial

Identification: 

Title:  Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

Authors:  Giles J Peek, Miranda Mugford, Ravindranath Tiruvoipati, Andrew Wilson, Elizabeth Allen, Mariamma M Thalanany, Clare L Hibbert, Ann Truesdale, Felicity Clemens, Nicola Cooper, Richard K Firmin, Diana Elbourne, for the CESAR trial collaboration

Location: UK-based multi-center trial

Source: Lancet. 2009 Oct 17;374(9698):1330

PMID: 19762075

Introduction:

Problem:  Does ECMO provide improved safety, efficacy and cost-effectiveness, when compared to traditional therapy, in patients with severe ARDS?

Significance: This is the first positive RCT that shows a statistically significant benefit of VV-ECMO for severe ARDS.

Methods:

Study Type: Randomized Controlled Trial

Subjects: 180 adults with severe ARDS were randomized to receive conventional management or referral to ECMO center.

Primary End-Point: Death or severe disability at 6 months.

Analysis: Intention to treat

Results/Conclusions: 

    • Main conclusions: 
      • 6 month survival without disability: 63% ECMO group vs. 47% conventional group.
      • Quality-adjusted life years at 6 months: ECMO group showed a gain of 0.03 gain

****THE BOTTOM LINE:  EDECMO Critical Assessment:  If you need a paper to support your use of VV ECMO for severe ARDS, this is your ammunition.

 


 

Screen Shot 2014-09-25 at 10.11.17 PMArticle 2:  Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

PDF:  ANZ ECMO

Identification:

Title: Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

Authors: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators*

Location: Australia and New Zealand

Context:  The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO).

Source: JAMA, November 4, 2009—Vol 302, No. 17

Introduction:

Purpose: To describe the characteristics of all patients with 2009 influenza A(H1N1)– associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes.

Significance: 

Methods:

Study Type: Retrospective Observational Study

    • Subjects: All patients with 2009 influenza A (H1N1)- associated ARDS treated with ECMO

****THE BOTTOM LINE:  EDECMO Critical Assessment:  In 2009, VV ECMO was used with success to combat severe ARDS caused by Influenza A (H1N1).

David Willms MD Board Certified in Critical Care and Pulmonary Medicine

David Willms MD
Board Certified in Critical Care and Pulmonary Medicine

If you have a question for Dr. Willms you may post it in the comments section below or email him directly at david.willms@sharp.com