71: Should We Prioritize VV-ECMO over ECPR?

In this episode, we dive into the abyss of resource allocation.  Much of the world is saying that the limited number of ECMO circuits should be used for COVID induced lung injury.  This means that ECPR initiatives have been shut down or severely limited.  Is this the right thing to do?  What does the data say?  What strategy gives the most benefit to the most people?  Zack invited Brian Grunau to discuss these topics as well as a recent ECPR paper out of Norway and study dealing with signs of life during CPR.

 

Oslo Study

Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, Bendz B, Andersen GØ, Fiane A, Hagen OA, Kramer-Johansen J. Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol. Resuscitation. 2021 Feb 10;162:35-42. doi: 10.1016/j.resuscitation.2021.01.038. Epub ahead of print. PMID: 33581226.

Signs of Life Study

Debaty G, Lamhaut L, Aubert R, Nicol M, Sanchez C, Chavanon O, Bouzat P, Durand M, Vanzetto G, Hutin A, Jaeger D, Chouihed T, Labarère J. Prognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest. Resuscitation. 2021 Feb 17:S0300-9572(21)00077-0. doi: 10.1016/j.resuscitation.2021.02.022. Epub ahead of print. PMID: 33609608.

69: 2020 Synopsis

2020 was a crazy year.  This month Zack goes through the biggest ECMO lessons learned in 2020.  This is a short concise run through of ECPR, ECMO for COVID, Imaging, and Aortic Dissection.  It's a reminder of how organization is so critical to the outcome of your ECMO program.  He also reminds us how improvement in these systems of care can lead to survival rates even the believers in ECMO thought were unattainable.

 

 

68: ARREST – The First Randomized ECPR Trial Ever

 

 

 

 

 

 

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

 

67: Da DO2: Fundamental ECMO Physiology with Sage Whitmore

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

64: Contraindicated??? – Long Live the Aortic Dissection with Garrett Sterling

Aortic Dissection is a contraindication for ECMO….or is it?  In this episode, Zack Shinar and Garrett Sterling discuss the sticky topic of ECMO for aortic dissection.  They discuss a recent case where Joe Bellezzo, Karl Limmer, Craig Larsen, and the entire Sharp team save a Type A aortic dissection with cardiac arrest.

Zack and Garrett traverse the details around ECMO in aortic dissection ranging from VA ECMO in ECPR to VVECMO for pulmonary edema.  They go through the literature on the subject and make some conclusions based on this data. The ultimate question – “Is Aortic Dissection a Contraindication for ECMO?”

Joe's interview of Michael – Great to hear his memory of the event.

Michael's podcast on his experience – The Heart of the Matter

 

 

Hou XT, Sun YQ, Zhang HJ, Zheng SH, Liu YY, Wang JG. Femoral artery

cannulation in Stanford type A aortic dissection operations. Asian Cardiovasc

Thorac Ann. 2006 Feb;14(1):35-7. PubMed PMID: 16432116.

 

Kelly C, Ockerse P, Glotzbach JP, Jedick R, Carlberg M, Skaggs J, Morgan DE.

Transesophageal echocardiography identification of aortic dissection during

cardiac arrest and cessation of ECMO initiation. Am J Emerg Med. 2019

Jun;37(6):1214.e5-1214.e6. doi: 10.1016/j.ajem.2019.02.039. Epub 2019 Feb 27.

PubMed PMID: 30862393.

 

Yukawa T, Sugiyama K, Miyazaki K, Tanabe T, Ishikawa S, Hamabe Y. Treatment of

a patient with acute aortic dissection using extracorporeal cardiopulmonary

resuscitation after an out-of-hospital cardiac arrest: a case report. Acute Med

Surg. 2017 Dec 19;5(2):189-193. doi: 10.1002/ams2.324. eCollection 2018 Apr.

PubMed PMID: 29657734; PubMed Central PMCID: PMC5891112

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.

 

 

 

62: Jason Bartos Take 2: The Future of ECPR Now

Last month you heard Jason talk about the ECPR program at the University of Minnesota.  This month Zack and Jason talk about post initiation care and the crazy ECPR realities that Demetris, Jason and U of M have created.  The sky is the limit for their team!

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, less is more
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