EDECMO Podcast

“Let me tell you, PEA is just a bunch of bullshit.” -Joe Bellezo aka @edecmo http://t.co/2cFCjizhYe — Rob Orman (@emergencypdx) November 13, 2014 This is the first episode where all three of the EDECMO boys are together–yeah! Today we talk about a bunch of PEA stuff. Scott proposes 2 new terms to bring us into the modern era: PREM-pulseless with a rhythm and echocardiographic motion PRES-pulseless with a rhythm and echocardiographic standstill Joe asks why we shouldn’t just treat the latter like asystole, and he’s probably right. But what of the former? What should we do with that? Listen to the episode. Jim Manning’s talk at GSA HEMS On Youtube Here’s the Littmann Article on PEA A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity Update Our friend Gregor Posen performed this excellent Pseudo-PEA (PREM) Paper  Bibliography In this episode, Joe was “Orating via the Anus” while Zack and Scott took a more evidence-based approach: Larabee, T. M., et al. (2008). “A swine model of pseudo-pulseless electrical activity induced by partial asphyxiation.” Resuscitation 78(2): 196-199 Paradis, N. A., et al. (2012). “Coronary perfusion pressure during external chest compression in pseudo-EMD, comparison of systolic versus diastolic synchronization.” Resuscitation 83(10): 1287-1291. Prosen, G., et al. (2010). “Impact of modified treatment in echocardiographically confirmed pseudo-pulseless electrical activity in out-of-hospital cardiac arrest patients with constant end-tidal carbon dioxide pressure during compression pauses.” J Int Med Res 38(4): 1458-1467 Paradis, N. A., et al. (1992). “Aortic pressure during human cardiac arrest. Identification of pseudo-electromechanical dissociation.” Chest 101(1): 123-128. A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity   Update This new study seems to demonstrate that stratification by ecg width may not be evidence-based   TrackBacks “PEA is just a bunch of BULLSHIT!”  Joe talks about the FALLACY OF PEA on the ER Cast podcast with Rob Orman… How we’re taught to manage PEA is BS. Here’s a way that makes sense http://t.co/o8KUtblRA8 @edecmo joins ERcast to stop the madness — Rob Orman (@emergencypdx) November 29, 2014

Both of these articles are fantastic. We review these two articles and describe their impact on the ECMO World: Article 1: Conventional CPR vs. ECPR for In-House Cardiac Arrest (CPS Chen Lancet Study) Identification: Title:  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis Authors: Chen, Lin, et al. Location: National Taiwan University Hospital; Taipei, Taiwan Source: Lancet 2008; 372: 554-61 ClinicalTrials.gov #: NCT00173615 Introduction: Problem: Comparing ECPR to conventional CPR for in-hospital cardiac arrest. Prior studies that showed a  benefit of ECPR over conventional CPR may have had selection bias. Prior studies also included all causes of arrest whereas this study attempts to focus on arrest of cardiac origin. Purpose:  Is ECPR superior to conventional CPR for in-hospital cardiac arrest of cardiac origin? Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for in-house arrest. Methods: Study Type:  Prospective Observational with Propensity-Score analysis matching Single-Center 3 years 975 total patients; 172 patients: conventional CPR = 113; ECPR = 59 Subjects:  18-75 YOA; witnessed cardiac arrest of cardiac origin who underwent CPR for longer than 10 min. Matching based on propensity-score; CPR team: senior medical resident, junior residents, RT, several ICU RN’s. *residents were cannulating! Primary End-Point: Survival to hospital discharge, with sub-analysis of neurologic outcomes. Analysis: Intention to treat Results/Conclusions:  Main conclusion: Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin. Survival to Hospital discharge: Unmatched: 28.8% ECPR vs. 12.3% conventional CPR Matched: 32.6% ECPR vs. 17.4% conventional CPR ****THE BOTTOM LINE:  EDECMO Critical Assessment: Good study that showed a benefit of ECPR over conventional CPR for in-house arrest for short and long-term patient-oriented outcomes. Propensity matching method reasonably mitigated selection bias 3 patients in the ‘conventional CPR’ arm were later put on ECMO because of persistent shock > Is there an implied benefit of ECMO for the post-cardiac arrest syndrome? Criticisms/Confounders Single-Center Patients in the ECMO group had higher incidence of LVAD, intervention, and heart transplant. first documented rhythm of VT/VF (49% ECPR vs. 32% CPR) was significantly higher in ECPR group; and asystole (22% ECPR vs. 27% CPR) was higher in the CPR group: ? selection bias? Location of arrest/CPR may make a difference (Emergency Department vs. ICU/Operating room) Failed conventional CPR was defined as CPR without ROSC at 30 minutes – is this timeframe too short.  What if conventional CPR were continued for 60 min? No TTM or hypothermia in either group.   Article 2:  CPR vs. ECPR for Out-of-Hospital Cardiac Arrest (SAVE-J) Identification: Title:  Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study Authors: Sakamoto, Morimura, Nagao, Asai, Yokota, Nara, Hase, Tahara, Atsumi, SAVE-J Study Group Location: Yokohoma City University Graduate School of Medicine, Yokohama, Kanagawa, Japan Source:  Resuscitation 2014 Jun;85(6):762-8 Introduction: Problem: Does ECPR improve patient-oriented outcomes after OHCA? Prior to this study, the effects of ECPR on long-term neurologic outcomes were unknown. Purpose:  To determine whether ECPR is better than conventional CPR for short and long term neurologic recovery for patients who suffer OHCA Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for OHCA. Methods: Study Type:  Prospective Observational; multi-center: 46 centers: 26 ECPR, 20 non-ECPR 3 years 454 patients: Conventional CPR = 194; ECPR = 260 Subjects: 20-75 YOA; VF/VT arrest; <45 total arrest time; Primary End-Point: Rate of favorable outcomes (CPC 1 or 2) at 1 and 6 months after OHCA. Analysis: Intention to treat Results/Conclusions:  Main conclusion: In OHCA due to VF/VT, a treatment bundle of ECPR, TH (TTM?), and IABP was associated with improved neurologic outcomes at 1 and 6 months. Intention-to-treat Analysis: 1 month: ECPR  = 12.3% Non-ECPR = 1.5% 6 months ECPR = 11.2% Non-ECPR = 2.6% Per-protocol Analysis: 1-month ECPR = 13.7% Non-ECPR = 1.9% 6-month ECPR = 12.4% Non-ECPR = 3.1% ****THE BOTTOM LINE:  EDECMO Critical Assessment: Excellent multi center study a benefit of ECPR over conventional CPR for OHCA for short and long-term patient-oriented outcomes. Criticisms/Confounders: Rate of use of TTM/TH and IABP were higher in ECPR group. Choice of ECPR vs Non-ECPR was dependent on individual centers with each center doing one or the other but not both.  In other words, does the quality of care at an ECPR center trump the quality of care at a non-ECPR center and does that impose bias?

In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a “nurse-run” ECLS program.  There is no lack of enthusiasm over the concept of doing ECPR in the Emergency Department.  As most of you already know, we think ECPR is the wave of the future for resuscitation. Suzanne Chillcott BSN, RNMechanical Circulatory Support Lead So you think  you want to set up the next ED/ICU ECPR program?  You think you want to do ECPR in your Emergency Department or ICU?  But where to begin? Hopefully this episode will hopefully answer many of those questions: ECLS Program Models Physician resuscitationists cannulate. But you need an “ECMO team” to prime the circuit, help initiate bypass, trouble-shoot the machine, and manage the patient after bypass is initiated.  But who is going to do that?  Who has jurisdiction over your ECMO program?  Well, if you are working at an institution with an active cardiothoracic surgery program, chances are you already have these roles established; and I  recommend you speak to the Chief of your CT surgery team.  But for the sake of argument lets pretend you are starting an ECMO/ECLS/ECPR program de novo. What are your options? Well, whomever is going to do this MUST be “in-house.”  In the ED, Emergency Physicians should be cannulating because we are already right there. We are running the code. We should be the ones doing the cannulation. And the same goes for intensivists in the ICU.    There simply isn’t time to call in a specialist to cannulate. The same goes for your ECMO team: they must be “in-house.” It would seem to make sense that perfusionists would be the first-responder ECMO team, however at many institutions (ours included) perfusionists aren’t “in-house 24/7.”  So there are now 3 main ‘models’ to address this: Perfusionist-based: Some facilities, usually teaching hospitals with very active ECMO programs, have in-house perfusionists.  In those cases the perfusionist is usually the “first-responder.”  In some cases the perfusionists handle all bedside activities from start to finish. In other cases the perfusionists help initiate ECMO and RN’s or respiratory therapists (RT’s) will ‘babysit” the machine when active adjustments aren’t being made. RT-based: When Shinar and I were at the University of North Carolina Chapel Hill, we witnessed this type of program.  While the perfusionists there are doing all the heavy lifting, they have trained their RT’s in supervising ECMO. Nurse-based: ICU nurses  are cross-trained in ECMO.  This is the model we use at Sharp Memorial Hospital in San Diego.  ICU nurses are trained in all aspects of ECMO and the ICU staffing is setup such that there is always at least 2 RN’s in the SICU who are ECMO-ready.  If we have an ECPR case in the ED we call the SICU. Quickly those nurses temporarily hand-off their assignments and come to the ED. Establishing an ECMO Program at Your Hospital Key Players: CT Surgery Nursing Perfusionists Hospital Administration The SMH Mechanical Circulatory Support Team These are the key components. Of course, if you are doing ECPR in your ED then you also need an ED doctor champion.  If you are reading this, I assume that will be you. So welcome to your new role! Who Cannulates? CT surgeons Interventional Cardiologists Intensivists/Pulmonologists Interventional Radiologists Emergency Physicians The Sharp Memorial Hospital ECMO Nursing Training Program Staffing: SICU nurses must apply to be on the ECMO team Coveted position + financial differential (the RN’s get paid to cross-cover ECMO) RN works a regular SICU assignment but must also respond to ECPR Training: Training Manual One-on-one class: 10-12 hours of training per RN RN must be able to establish circuit within 10 min Ongoing Competency Evaluation every other month to maintain skills: MAD (mechanical assist device) Lab Day = wet-loop training Direct wet-loop training in the SICU Manage a real live patient Costs: Capital = Hardware (pump head, heater/cooler, blender, SVO2 monitor) is reusable These are hard costs that are not billable to a patient. Roughly $100,000 per unit. We house 2 unit  = $200,000 Disposables (The Circuit and the Cannulae): Used on each patient and billable to the patient. Nursing: Shift coverage (12 hours shifts, 2 RN’s always on-shift) = 25 fully trained nurses Training: 25 nurses @ 10 hours of training @ $50/hr =  $12,500 Continuing Competency Evalution training =  2 hrs ever other month @ $50/hr = $600 x 25 nurses = $15,000/yr for ongoing training Premium differential paid to SICU nurses to be on the ECMO team Perfusionist coverage: This is often a contracted rate with a local perfusionist team A Day in the Life of an RN ECMO Team Member: 2 ICU RN’s are always staffed in the SICU staffed so the RN’s are working at opposite sides of the unit so an ECPR case won’t debilitate any arm of the ICU by calling RN’s away. ER doctor calls the SICU when a potential ECPR case arrives to the ED ECMO RN’s bring, from the SICU (located on the 2nd floor at our facility) to the ED: The ECMO cart – mobile ECMO hardware = pump head, heater/cooler, blender, SVO2 monitor The ECMO supply cart – carries all the disposables (circuits, cannulae, various supplies Suzanne describes the logistics of priming the pump, connecting the patient to the circuit, and starting the pump ***PEARL: the goal at initiation of bypass is maximize flow while minimizing RPMs, so the nurse will dial up the RPM until flow is maximized, but no further. SVO2 goal = 70 ECMO RN calls OR to summon the perfusionist. In our system the perfusionist is on-call and has an established response time ECMO RN hands off the pump duties to the Perfusionist and then goes back to their SICU assignment Policies and Procedures Please contact any of us if you want to take a look at our policies and procedures  – we are more than happy to share this stuff. The Late Great Tony Gwynn Could Teach us Something About Success: Suzanne says it best:  ” The way you gotta look at it…the patients we put on pump are all 100% dead when you start with them. You can’t make them more dead. You can’t make it worse. All you can do is possibly make it better…” Established success rates, for long-term survival neuro-intact is 27-30% for in-hospital cardiac arrest.  That is significantly better than historical established success of non-ECPR ACLS of 17%.  So even though we almost double the survival of these patients, fully 70% still don’t survive or have neurologic recovery. To take that even further, for out-of-hospital cardiac the survival is dismal…and at this time we don’t even initiate ED ECMO until ACLS has failed – the point at which you would pronounce the patient dead.  So by definition, our starting point 0% survival. So any success is meaningful. We really need to remind everyone that ECPR success is much like batting averages – a batting average over .300 will get you into the Baseball Hall of Fame!!  One of the greatest baseball hitters of all-time, San Diego favorite Tony Gwynn, FAILED 70% of the time and was one of the greatest hitters of all time; and elected to the Baseball Hall of Fame in Cooperstown. So lets setup appropriate expectations from the beginning!  And remember, even the great Tony Gwynn occasionally went several ‘at-bats’ without a hit.     Do you have Questions for Suzanne?  You may email her directly at suzanne.chillcott@sharp.com  Announcements: Aug 18-21: Emergency Medicine Update.  Bellezzo is speaking on “Resuscitation: State of the Art” October 21: Bring Me Back to Life conference in Montreal, Canada  

    To Register:    http://www.bringmebacktolife.ca/ #BMBTL14  

Paris ECMO Course The excellent lecturer was Dr. Guillaume Lebreton, Associate Professor and Cardiothoracic Surgeon Director of the CPB and ECMO program, Department of Cardio-Thoracic Surgery Pitié Salpêtrière Hospital How Not to Frack Up DO NOT ADAPT TECHNIQUE TO YOUR CAPACITY Fixed Point for Wire–meaning wire must be held stationary as you dilate, otherwise dilator will back wall through vessel with anything but the stiffest guidewire. We get a false sense of security from smaller line placement. Discussed being fooled by echo They do cutdowns for all ECPR Inflow Crap flow if too small If you measure from the puncture site directly to the middle of the sternum, that should be your insertion. Too deep is better, with Maquet you want the tip in the RA 24-29 F with 25 being the sweet spot 55 cm Maquet for all adults When the holes are through the vessel, PULL Back the Dilator Outflow Hemolysis if too small 17-21 F for VA 19-23 F for VV IJ catheter length-15 cm on right, 23 cm on left Don’t pull back dilator for arterial placement Placement Pad behind buttocks to straighten vessels 4″ or so Needle bevel facing up and wire’s j facing up Gentle Angle for  Needle Placement Guidewire-go fast and it goes straight Always use the 150 cm guidewire. Leave 1 meter out, 50 cm in pt Scalpel-1 cm cut and plunge Doesn’t bother rotating the dilators VV-do the femoral first as it is harder to knock out Femoral-Femoral VV Return close to tricuspid, not multi-stage Drainage as central as possible, but in IVC, not RA Put in both guidewires first Put the longer cannula (return) in first Inflow-21-23 short insertion, but same length cannula (Maquet) Outflow-17-19, single stage (Medtronic) TroubleShooting If at the same speed, decreased flow–think thrombosis Starting VVECMO Clamp on tubing Start slow, 2000 rpm then slowly declamp Start sweep at 6 lpm (or 1:1 with flow) Go up to the max flow you can get at first to see your max You want to provoke reflow You should be able to get big flows (6-7 lpm) Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture) You should be able to get to 100% sat quickly If you are seeing recirc, pull back inflow slightly (max 1-3 cm) Treat the pt not the xray when it comes to cannula positioning Factors that increase Recirc Proximate venous tips Low CO Hypovolemia Increased pump flow rates Avalon Turn Head all the way to the left to align IVC and SVC VA FEM/FEM do venous 1st if doing cutdown Image by Cedric Lange

Based on a voicemail message we received from Justin Cook, an Emergency Physician out of Portland, Oregon, this episode focuses on the cognitive task analysis of using ultrasound during ECPR. When your patient hits the door with CPR in progress, what is your ultrasound priority? Diagnostics? Ultrasound-guided line placement?  This episode of the EDECMO podcast attempts to answer that question. pericardial tamponade due to aortic transection > ECMO save. This is a snapshot of a patient we discussed who presented with tearing chest pain and arrested with HR 180 narrow-complex. pericardial tamponade relieved with drain placed by Bellezzo.  Still no pulses. We put him on ECMO and he was taken to the OR: he had back-dissected into his AV.  After ECMO the patient was taken to the OR where his AV was resuspended and the ascending aorta grafted.  He left the hospital neuro-intact.  In this case, diagnostic US took precedence over line placement. But this is a caveat to the usual rule that US-guided line placement is most urgent. And here is a video clip of the tamponade: dissection video from Joe Bellezzo on Vimeo.   Thanks for listening! Hey! wait!  while you’re here give us a call on the listener voicemail line! Comments, Criticisms, or Questions may be incorporated into future episodes:  1-470-ED ECMO 1 (470-333-2661). Or leave your comments below.  

This is an exciting and unique experience! – In April 2014 Zack went to visit his brother Joshua, who is working on information technology systems in Cameroon, Africa. While there Zack had the opportunity to teach, interact with their medical community, be a guest speaker on a local radio show, and interview one of their resuscitation specialists. We’ve tried to include a little of each of these experiences in this episode of the EDECMO podcast.  Yes, this is a little off-topic from our usual content; but we hope you’ll enjoy it.  Maybe medicine in the Third World is archaic and barbaric. Or maybe our First World medicine is just completely over the top? Medicine and Resuscitation in the Third World In this episode Zack spoke with Christian  Ngem, who is a Nurse Anesthetist/Anesthesiologist/intensivist in Cameroon, Africa. Christian Ngem Christian Ngemt, Nurse Anesthetist (Cameroon, Africa) Nurse Training – BVH 2002-2004 Baptist Hospital, Banso – Scrub nurse 2004-2007 Nurse Anesthetist School  – 2007 – present “End of Life” care is much different in other cultures. “African Engineered” = African Ingenuity Having to utilize limited resources to take care of really sick patients, they have been creatively using drugs we all know and love. For example, the concept of sub-dissociative-dose Ketamine has been going on for a long time! Drugs: Ketamine = “The Magic Drug” Thiopental Morphine Halothane succinylcholine Physical Exam = I forgot what that was until I heard Christian’s talk here. ECPR is a “WASTE OF TIME!” – While they truly believe in resuscitation, they also believe in letting go when the time is right.  Cultural perspectives play a huge role here and there is a definite emphasis on allowing death with dignity. Are we wasting time, resources, money, and effort with our Western extravaganza? Maybe we are.  Let’s open the discussion!   Chest Tube Placement  

Dr. Jim Manning The ED ECMO crew left the www.edecmo.org World Headquarters in May 2014 to meet with Dr. Jim Manning at the University of North Carolina Chapel Hill to do some animal experiments incorporating ECMO.  Dr. Manning is an Emergency Department attending physician at UNC-Chapel Hill and has a distinct interest in endovascular resusscitation. Specifically, Jim is working with a new catheter called the “Selective Aortic Arch Perfusion” (or SAAP) catheter in non-compressible abdominal and pelvic trauma. The SAAP catheter functions much like REBOA (resuscitative endovascular balloon occlusion of the Aorta) and we will compare and contrast those two technologies in the near future. Dr. Manning’s expertise in animal models of resuscitation drew us to North Carolina. The experience was far beyond anything we could have expected and much much more will be posted over the coming months! Dr. Manning, Zack Shinar, Shane McCurdy, and Joe Bellezzo The Experiments Joe Bellezzo MD   “PRIME TIME!” ~Nuances of priming the ECMO circuit with Greg Griffin, the Chief Perfusionist at UNC-Chapel Hill Greg Griffin, Chief Perfusionist – UNC Chapel Hill The folks at UNC-Chapel Hill have a very active inpatient ECMO program. While they aren’t yet doing ECPR in the ED (and we hope to help change that!), they do a lot of ECMO.  Greg Griffin has been the Chief Perfusionist at UNC-Chapel Hill for the past 3 years and has been a perfusionist at their facility for over 20 years. While in Dr. Manning’s lab, Zack had the opportunity to sit down with Greg and talk in depth about ECMO, the Maquet Cardiohelp ECMO machine, and some pearls and pitfalls of “priming the pump!” Introduction The ECMO circuit consists of: The machine: which is basically a centrifugal pump (a machine that generates forward blood flow via centrifugal force), an oxygen supply, and a water bath to control the temperature. Simple. The circuit: the circuit is a.) the tubing that the blood flows through, b.) a membrane oxygenator (a small plastic box that contains a membrane…blood flows across that membrane while oxygen is added to the blood and CO2 is removed), and c.) the pump head (a plastic chamber that transfers the centrifugal forces from the pump to generate forward blood flow). The combination of the tubing, oxygenator and pump head are also referred to as the “disposables,” because they come into contact with the patient’s blood, and are later disposed of. The cart: which is the support structure that holds all the equipment. Definitions: Priming the circuit = filling the entire circuit with fluid. Priming is done by hanging the fluid higher than the circuit and letting gravity fill the entire circuit.  At the present time, we prime with a crystalloid solution. De-Airing: removing all air bubbles from the circuit. The nuances of this are discussed in this episode. The Formula One Racetrack Analogy When the circuit is set up and the pump is flowing, a maze of tubes seems to spread haphazardly about the machine.   What appears complicated and confusing is really quite simple:  The circuit is nothing more than a big oval tube with blood flowing around the oval, not unlike an oval auto racetrack. When priming the pump you run the “cars” through the oval until you are ready to initiate bypass and add your patient to the circuit. Priming involves filling the circuit with fluid and de-airing the entire system. When it comes time to put your patient on bypass, you divert the “cars” from the “racetrack” and have them take a detour into the “pit,” which is your patient. Oxygenated blood that has just left the oxygenator exits the oval “racetrack” via detour-tubing, enters the arterial cannula, and enters the patient’s arterial system.  Deoxygenated venous blood that is returning to the heart is captured by the venous cannula (who’s tip is at the right atrial inlet) and directed back onto the “racetrack”.  The circuit once again passes the blood through the centrifugal pump (generating forward blood flow) and then, again, through the oxygenator. At any time you can elect to run your “race cars” through the circuit only (staying on the track), or through your patient. One or the other…but not both at the same time.   In keeping with the “North Carolina” theme, here is the Charlotte Motor Speedway in Charlotte, North Carolina: Charlotte Motor Speedway   Now, lets take another look at a diagram of the whole circuit:   Enjoy the Interview:

Hey there Pump Heads, Today, I got to talk with Dr. Dan Herr, director of the CSICU at the Shock Trauma Center. We discuss two topics: who is a candidate for VV ECMO and when you should think about weaning the ECMO. Please leave your comments and questions below

Today I sat down with Dr. Peter Rosen to talk about the topic of life and death. Peter is a close friend and one my mentors throughout my training and career. I trained under Peter as a resident at UCSD and I whenever Peter is in town I try to meet up with him to talk about anything BUT emergency medicine!  He usually tries to goat me into a tennis match but I’ve been beat up too many times to take the thrashing anymore! Today I convinced Peter to go on-the-record with me and talk a little bit on the topic of life and death, since the topic is so important to what we are doing with ECPR.  Peter has spent decades watching gadgets, toys, and technology come and go – and carries a very understandable skepticism toward any process that artificially prolongs life.  I’m not sure I convinced him during this session but my career goal will be to show him that ECPR works in the right patient population. Hearing Peter talk is always fascinating and I hope to have him on regularly on the podcast. Enjoy the Episode: