Ed Ecmo

In this short episode, Zack makes two points.  One, it was tough to get to where we are with ECMO acceptance.  Two, cardiac arrest patients in PEA should be considered for ECPR.  Below is the full editorial Zack and Alice did recently in the Journal of Resuscitation on the topic.  It was born out of a fantastic German article centered looking at registry outcomes for PE and ECMO. Full Free Link to Editorial (until January 2022) - https://authors.elsevier.com/a/1eAXK_6ryqqpRd Article link - https://www.resuscitationjournal.com/article/S0300-9572(21)00403-2/fulltext

Have you ever pondered whether all the work over ECPR was worth it?  Even if you did save a few patients, does this really make sense from a societal standpoint?  Am I giving up my life on a project where my efforts could be better elsewhere?  Then this episode is for you (and me).  This month I talk with Melissa Barnes and Ryan Coute about the economics of cardiac arrest and specifically ECPR.  Ryan has just published a great paper in Resuscitation on the costs on OHCA.  We will talk with Ryan and Melissa Barnes, ECMO manager at Sharp Memorial Hospital about benefits and costs to society of OHCA and ECMO.  I learned several pearls from Ryan's paper as well as a paper by Grosse that Ryan references.  Below are the links to both papers with a couple graphs to try to wrap your head around.

Here is the conclusion for the interview of Jan Belohlavek and his Hyperinvasive Trial

Wait...ECPR works? To the believers, this has been a foregone conclusion.  To the rest of the world, the question of whether ECPR improves cardiac arrest survivorship has been in question. Jan Belohlavek and his Prague colleagues just presented their 8 year data showing better outcomes in cardiac arrest patients that got a grouped therapy of early transport, prehospital hypothermia, mechanical chest compressions, and ECMO over those who got a traditional resuscitation.  This study is key and contrasts to the Oslo study that we reviewed just a few months earlier.  Jan speaks with Zack about the details of the results and what were the keys to their success. Hyperinvasive trial study proposal - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492121/ Jan's slides on Hyperinvasive Results

Heparin has been the mainstay of anticoagulation for ECMO patients for years.  In recent years, this has been challenged.  Bivalirudin has b ecome a potential better anticoagulant.  Troy Seelhammer in EDECMO episode 55 gave us some insight into this.  This month Ryan Rivosecchi and his crew at UPitt have released their findings in Critical Care Medicine.  This retrospective study suggests great improvement in major bleeding in patients who received Bivalirudin compare to Heparin (40.7% vs 11.7%, p < 0.001).  Listen to Ryan and Zack discuss anticoagulant use in ECMO patients in this month's episode. Rivosecchi RM, Arakelians AR, Ryan J, Murray H, Padmanabhan R, Gomez H, Phillips D, Sciortino C, Arlia P, Freeman D, Sappington PL, Sanchez PG. Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin. Crit Care Med. 2021 Mar 15. doi: 10.1097/CCM.0000000000004944. Epub ahead of print. PMID: 33711003. .

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.

In this episode Joe Bellezzo talks with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) expert Zaf Qasim about NON-TRAUMA applications of aortic compression for control of non-compressible non-trauma torso hemorrhage. 

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.

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

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.  Zack Shinar

Have you ever wondered how you would crash someone onto VV ECMO?  Have you ever wondered where is the best place to put the cannulas?  Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO?  Then this is the episode for you!!  After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject.  Zack gets critical care physician David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO.

This month we tackle a number of topics.  Garrett Sterling is back again with Zack Shinar to talk about cutting edge resuscitation, ECMO, and the interplay between the two.  Dual sequential defibrillation, CT after ECMO initiation, should you perform bystander CPR in the era of Covid, some US ECMO data, and an awesome 3D modeling for ECPR training models.  All in one 30 minute podcast!

In this episode, Zack Shinar introduces a new physician to the podcast - Garrett Sterling.  Garrett and Zack discuss the sticky topic of ECMO for aortic dissection.  This traverses everything 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?" The post 64: Contraindicated??? – Long Live the Aortic Dissection with Garrett Sterling appeared first on ED ECMO.

"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 get to play as we begin the surge of Covid 19 in the United States.  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 who we should put on ECMO with Covid. Hosts - Zack Shinar, Jenelle Badulak 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 E

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 Demetri, Jason and U of M have created.  The sky is the limit for their team! The post 62: Jason Bartos Take 2: The Future of ECPR Now appeared first on ED ECMO.

Jason Bartos and his crew at the University of Minnesota have revolutionized the concept of ECPR for out of hospital cardiac arrests.  His crew are interventional cardiologists who take OHCA straight to the cardiac cath lab.  They have initiate times of around 6-8 minutes and have neurologically intact survival rates higher than 30%.  Below are two of Jason’s recent papers which every person who considers themselves an ECPR fan should pour over with a fine-toothed comb.  There is so much in these papers.  We split this interview into two pieces because there is so many pearls in it. Outcomes Resuscitation paper - 48% survival in 100 patients Circulation paper 2020– 33% vs. 23% ALPS Cohort who had VF/VT and one shock vs. a cohort who had VF/VT and failed to ROSC at the scene, in the ambulance, and then all the way to the hospital. OHCA - > Straight to the Cath lab --> Get on ECMO --> Go to CCU under Cards care. Inclusion criteria - Vf/vt, lactate 50,ETCO2>10 References: Bartos JA, Grunau B, Carlson C, Duval S,

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 The post 60: ECPR 2.0 with Scott Weingart appeared first on ED ECMO.

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. The post 59: Partial REBOA and US PreHospital ECPR Revisited appeared first on ED ECMO.

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 post 58: First U.S. Pre-Hospital ECPR Program appeared first on ED ECMO.

Over the last two years, partial or intermittent REBOA has been thought to be a significant advantage over complete REBOA.  How to do this and how to use our current imperfect catheters in this arena is still in question.  Matthew Martin and his colleagues at Madigan Medical Center have published the first study using the Prytime's new catheter for partial REBOA.  Zack interviews Matt in this episode about his latest paper in Journal of Trauma and Acute Surgery.  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. The post 57: The New REBOA catheter – Perfecting the Partial Occlusion appeared first on ED ECMO.