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Who Gets ECPR and Who Doesn’t?
Great question! This may be the hardest question we deal with when a patient arrives and ECPR is a consideration.
This episode is broken down into three parts:
- Who exactly do we consider an appropriate candidate for ECPR?
- TOR = Termination of Resuscitation in the pre-hospital arena and why we HATE it!
- Pre-hospital ECPR – REALLY?
1. Love this podcast! Keep up the good work.
2. Once we have a better handle on who will most likely benefit from ECPR we can identify whom to “stay and play” with and whom to “load and go.”
3. We need to figure out what “load and go means.” It probably doesn’t make sense to scoop up a fresh arrest and run them down to the ambulance because ECMO is only for patients who fail ACLS. We have to give good ol’ CPR and defib a chance! Scooping and running immediately would cause an unacceptable delay in CPR. Furthermore, effective chest compressions are nearly impossible in a moving ambulance so this strategy would likely require EMS to utilize a mechanical CPR device. (Which will be cost prohibitive in many areas)
4. The field physician model sounds good but it will be difficult to identify viable arrests. The sort of arrests you are targeting are not the sort of arrests that EMS is dispatched to. Arrests that would benefit from ECMO–witnessed, VF/VT, young patient arrests–don’t usually get dispatched as arrests and you wouldn’t send physicians to every cardiac or difficulty breathing call! Even if the medics were to request the physician to respond the response times would likely negate much of the benefit. Your best bet may be to have paramedics cannulate.
5. Transportation of patients on ECMO is currently being done by a handful of centers.
Mike, the best example of how this functions is the Alfred hospital in Australia in the course of Stephen Bernard’s Cheer trial. They got a LUCAS machines for EMS allowing immediate movement to the bus.
Mike, I agree! I am a huge fan of mechanical chest compression devices. I’ve personally used LUCAS with ECPR and I think its the way to go. We did a brief trial with LUCAS and will be moving to that device very soon (disclaimer: ZERO financial interest!) To your 4th point, I agree: dispatching MD’s to a scene would entail extremely tight inclusion/exclusion criteria and we are working those out now, lest we waste time and MD resources. I have a team of ERMDs ready to go though! To your 5th point, lots of places are transporting on ECMO – ours included…so that’s not a barrier at all. Thanks for listening!
As a current critical care transport nurse on the helicopter, you say that lots of places are trasnporting ECMO, Is this being done by ground or air? Also, of the programs actually flying ECMO patients in the US at this time I would love to hear about the type of aircraft and configuration of the flight crews etc.
Thanks you for the great educational site and podcasts , I look forward to learning more.
Scott, thanks for following us! To better answer your question I reached out to Suzanne Chilcott RN, who heads our Mechanical Circulatory Department (ECMO, ECPR and LVAD) at our facility. Here was her response:
“Ground is obviously the easiest and most frequent method of transport. We have done plenty of them and we use the “bariatric” transport rig when we do them. It is both longer and wider than a standard ambulance with bench setting along both sides for all of the personnel needed. We have had the back of this rig outfitted with tie down straps on the walls to hold down our ECMO cart on one side and an IABP on the other side if needed. Both Marcia and I have done lectures for the transport RN’s on how to transport these patients and with Dean we even made a little video that they use for training new staff how to get it all loaded in the rig. The best thing ever is they just recent got a new rig for us with a huge lift in the back that is able to lift the ECMO and IABP in one lift, much safer and easier on the back compared with what we use to have to do.
Air transport is another matter. We have only had to do it once, it was a patient from Hawaii and amazingly Dr. Dembitsky (ed: CT surgeon at our shop) was able to hook us up with a military transport plane (I think it was a C-130- some huge thing). This was over 20 years ago and thankfully we have not had to do it since. Our ECMO machine would not fit in a helicopter or a standard critical care fixed wing transport. For a while we were working with Dr. David Willms (ed: intensivist at our shop) to try and make a transport gurney that we could load the components of ECMO under the gurney, the challenge was that you could not lower the gurney for the ride because all of the equipment was under it so it made the patient on top pretty unstable. I have heard of them using the Cardiohelp for air transport in Europe and they just put it on the foot of the gurney.”
At Columbia in New York we use a large critical care ambulance of transport ECMO. Because of the logistics in NYC helicopters are out. We have also used military transports in the past.
Stryker makes a tray that attaches to the foot of the stretcher. We usually put the monitor and pump on the tray and we secure the oxygenator to the side of the stretcher. That may help alleviate some of your problems. Certainly safer than leaving the pump on the foot of the stretcher!
Great recommendation, Mike.
In Norway, we can do ECMO transfers by road in a ‘fat truck’ (the non-PC name for a bariatric ambulance). Often, the distance dictates fixed wing. So far, we’ve used a ‘fat truck’, driven it into a C-130 Hercules military transport plane, flown it to its destination airport and driven the truck out and to the hospital. Pretty resource intensive, but it works.
We have also started doing helicopter ECMO transfers. That usually includes a Maquet Cardiohelp, which is small enough to fit into a medium sized helicopter like the AW-139, and certainly the larger SeaKing’s we still have flying for the coast guard.
When I worked for Sydney HEMS in Australia, they did ECMO transfers on fat trucks, and started using the AW-139 once the ECMO equipment was certified for helicopter use. They also have centers doing ECMO retrievals in small ambulance planes. Again, the size and ease of operation of the Cardiohelp is key.
Yes, the Maquet Cardiohelp is a marvelous unit and thus far is the best ECMO machine for transports. Its about the size a cardiac transport monitor. A downside is that the circuits (disposables) are pretty damn expensive when compared to the circuits we currently use, which are custom built for us by Maquet.
Thanks for another great episode! I love how you’re up-front on the issues of starting out a program like this. That it needs tight inclusion criteria and pretty wide exclusion criteria to get success to get the program up and running. To prove to yourselves and management that it works.
On the stay-and-play/load-and-go debate, going out to the patient sounds exciting, but I’m more a fan of bringing them in. It seems to take some time to put them on pump, and the patient might need additional treatment in that time frame. For transport, this is what the LUCAS was made for. It might not do compressions better than a good human pump, but for transport, it’s superior. And it doesn’t tire.
I’m thinking ambulances close to these ECMO resus centers should have focus on short scene time, strapping on the LUCAS and giving the old ACLS a brief chance before early considering loading the patient and taking them in for ECMO.
But just my thoughts. Exciting times!
I 100% agree with all of your thoughts, Thomas. I’m a big fan of the LUCAS2 for this exact reason.
There are other advantages to LUCAS2 that are more intangible: for example, in our hands the LUCAS2 generates focused chest compressions with much less of the wave of energy that seems to occur with human compressions. This translates into less movement at the groin during ECPR cannulation, and that’s a big benefit. And when real estate is tight there are two fewer human bodies crowded in the room doing chest compressions.
Good points! Goes with my feeling that LUCAS is more for better logistics than getting better compressions (which is kind of what the LINC trial showed as well). And from what you say, better logistics lead to better management, and possibly even better outcome in settings like this.
You mention the problem the femoral artery from the vein is difficult in cardiac arrest. How big a problem is paradox/retrograde pulsation of the vein during compressions? Do you tend to identify the vessels based on medial/lateral location, vessel size or wall thickness or do you use other tricks to differentiate vein from artery with UL for cannulation during arrest?
PS. I can’t really find the show notes?
In British Columbia we operate a HEMS Bell 412 out of Kamloops with Critical Care Paramedics. We have moved one ECMO patient by air from Kelowna to Vancouver (1.5 hrs) this past year and one by road from the eastern part of the province to Kelowna (5 hrs) in which we brought ECMO to the patient. The layout in the 412 does provide for this type of transport albeit it’s very tight. The team at KGH has a transport ECMO unit and we are currently working with our colleagues there to address the specialized transport needs and requirements to better facilitate this type of transport. This is the future of transport medicine and we hope to be able to help drive that inititiative here!
Thanks for the comments Mike. I agree that ECLS/ECPR will be a component in the future of resuscitation…and transporting these patients to facilities that can manage them is paramount. Our facility is committed to managing patients who are started on ECLS remotely and transferred in. Please keep us updated on your experiences up there. Joe
Really enjoying this whole series! By any chance would you be willing to post any of the papers you discussed from Japan? I would really enjoy reading.