60: ECPR 2.0 with Scott Weingart

     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.

 

 

 

 

ECPR 2.0

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
12. Understanding Cardiac Prognostication / Stunning
13. Understanding Neuro Prognostication
14. Protection/Ownership
15. In it for the Long Haul

 

59: Partial REBOA and US PreHospital ECPR Revisited

This month we discuss two different topics we've recently had on the podcast.  Albuquerque had started the first US prehospital ECPR program…. and now they have the first patient as well.  Jon and Darren will share with us the exciting news.  Second, we recently had Matt Martin on the podcast talking about partial REBOA.  We got tons of email about this.  This month Zaf Qasim and Austin Johnson come on to talk about some of the controversial aspects of partial REBOA.  Zaf also gives us a great update on the state of REBOA in the world.

 

58: First U.S. Pre-Hospital ECPR Program

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

 

Update:

News story

57: The New REBOA catheter – Perfecting the Partial Occlusion

Over the last several years, data has suggested that partial or intermittent REBOA may have benefit over complete REBOA.  How to do this and how to use our current imperfect catheters in this arena is still in question.  Dr. Matthew Martin and his colleagues at Madigan Medical Center have published the first study using Prytime's new catheter for partial REBOA.  Zack interviews Matt in this episode about this latest paper in Journal of Trauma and Acute Surgery as well as several other papers he's published in the field.  Dr. Martin is extensively published in the field and offers his insight in the specific flows that maximize survival within the conflicting problems of hemorrhagic shock and lower body ischemia.

 

 

 

 

Efficacy of intermittent versus standard resuscitative endovascular balloon occlusion of the aorta in a lethal solid organ injury model.

Kuckelman J, Derickson M, Barron M, Phillips CJ, Moe D, Levine T, Kononchik JP, Marko ST, Eckert M, Martin MJ.

J Trauma Acute Care Surg. 2019 Jul;87(1):9-17. doi: 10.1097/TA.0000000000002307.

PMID: 31259868

TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS.

Forte D, Do WS, Weiss JB, Sheldon RR, Kuckelman JP, Eckert MJ, Martin MJ.

J Trauma Acute Care Surg. 2019 May 21. doi: 10.1097/TA.0000000000002378. [Epub ahead of print]

PMID: 31135770

Resuscitative endovascular balloon occlusion of the aorta induced myocardial injury is mitigated by endovascular variable aortic control.

Beyer CA, Hoareau GL, Tibbits EM, Davidson AJ, DeSoucy ED, Simon MA, Grayson JK, Neff LP, Williams TK, Johnson MA.

J Trauma Acute Care Surg. 2019 Sep;87(3):590-598. doi: 10.1097/TA.0000000000002363.

PMID: 311453810

Selective Aortic Arch Perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of non-compressible torso hemorrhage.

Hoops HE, Manning JE, Graham TL, McCully BH, McCurdy SL, Ross JD.

J Trauma Acute Care Surg. 2019 Apr 18. doi: 10.1097/TA.0000000000002315. [Epub ahead of print]

PMID:  31211744

55 – Anticoagulation of the ECMO Patient with Troy Seelhammer

Do you give heparin to your ECMO patients?  Well, let's rethink this.  This episode is All Things Anticoagulation!  Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester.  He manages ECMO patients in his daily practice there.  He has become a master of the subject of anticoagulation.  He will talk about heparin, bilvalirudin, or maybe no anticoagulation.  We talk about how TEG can affect our management.  We talk about PCC and Protamine when bleeding just won't stop.  He talks about the when to be aggressive and when to cut back.  Below is a wonderful synopsis of Troy's thoughts on anticoagulation on pump.

 

Goal Heparin levels are far from perfect but some suggestions

APTT 1.5 to 2.5 times normal

ACT level – 180-220 seconds

Antithrombin Levels – next generation

 

Seelhammer doc on BivalirudinBivalirudin & TEG During ECMO

 

54: Confirmation of Wire Placement with Sacha Richardson

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.

53b: Resuscitationist Inserted Distal Perfusion Catheter with Chris Couch

 

In this episode, we again explore the world of the distal perfusion catheter.  You heard from Joe Dubose the vascular surgeons point of view; now let's see how non-surgeon resuscitationists are dealing with this problem.  You will hear from Chris Couch, a critical care trained emergency physician from Dallas Texas and his colleague Omar Hernandez who have some novel thoughts and experiences related to when and how we insert these catheters.  You will hear about checking compartment pressures, poor man's way to “fluoro” your catheter, and much more.

 

Great summary of supporting literature – DPC Lit Search

 

51 – Proximal Balloon Occlusion for Cardiac Arrest

 #tbs19 The Big Sick—-  You've heard of ECMO for cardiac arrest- utilizing a mechanical pump to aid in perfusion of the coronaries.  What if you can't do ECMO?  What if your resources are such that simply can't lug a 10 kilogram machine out into the field?  Well, Jostein Brede may have something for you to consider.  He and several other places worldwide are on the forefront of using a REBOA catheter to occlude the proximal aorta during chest compressions in hopes that coronary perfusion pressure increases.  This would subsequently improve chance of return of spontaneous circulation and overall survivorship.  Maybe this is the band-aid that can be used in austere environments like rural Norway where the temperatures are extreme, the people are sparse, but the physicians are motivated.  12

1.
Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. T. 2017;35(5):731-736. doi:10.1016/j.ajem.2017.01.010
2.
Aslanger E, Golcuk E, Oflaz H, et al. Intraaortic balloon occlusion during refractory cardiac arrest. A case report. R. 2009;80(2):281-283. doi:10.1016/j.resuscitation.2008.10.017

50b Inter-Facility Transport of ECMO patients Part 2 of 2

This is part 2 of Transport of ECMO patients.  Mikael Broman is one of the world's leaders on ECMO transport.  He works at the Karolinska institute in Sweden and ha

s and continues to publish in the arena of ECMO transport.  As you will see, he offers a world of experience and certainly some critical information that we would all benefit from listening to.  I'm a smarter ECMO-tologist as a result of Micke!1234

 

 

 

 

ELSO transport guidelines -https://www. elso.org/Portals/0/Files/ELSO%20GUIDELINES%20 FOR%20ECMO%20TRANSPORT_May2015.pdf

 

1.
Bryner B, Cooley E, Copenhaver W, et al. Two Decades’ Experience With Interfacility Transport on Extracorporeal Membrane Oxygenation. T. 2014;98(4):1363-1370. doi:10.1016/j.athoracsur.2014.06.025
2.
Javidfar J, Brodie D, Takayama H, et al. Safe Transport of Critically Ill Adult Patients on Extracorporeal Membrane Oxygenation Support to a Regional Extracorporeal Membrane Oxygenation Center. A. 2011;57(5):421-425. doi:10.1097/mat.0b013e3182238b55
3.
Broman LM. Inter-hospital transports on extracorporeal membrane oxygenation in different health-care systems. J. 2017;9(9):3425-3429. doi:10.21037/jtd.2017.07.93
4.
Ericsson A, Frenckner B, Broman L. Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation. Prehosp Emerg Care. 2017;21(4):448-455. [PubMed]

49 – You Can’t Spell REBOA without the ER – Endovascular Resuscitation of the Trauma Patient – Zaf Qasim

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.