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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,… Read more »
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 –… Read more »
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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.