EDECMO Podcast

Heparin has been the mainstay of anticoagulation for ECMO patients for years.  In recent years, this has been challenged.  Bivalirudin has become 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? Make sure to get CPR Certification Cleveland so you can always be prepared in case of any emergency. 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. Find more information about CPR Certification Wichita to keep saving lives and helping people in need.   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.

January 1, 2021: The year following COVID19 Global Pandemic brings us a new horizon – lets appreciate what has happened, learn from our mistakes and begin to look forward.   In this episode Joe Bellezzo talks with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) expert Dr. Zaf Qasim about NON-TRAUMA applications of aortic compression for control of non-compressible non-trauma torso hemorrhage.     Dr. Qasim is a world expert in REBOA and has been on the podcast: edecmo.org/35 – REBOA revisited edecmo.org/49 – the ACEP-ACS joint statement controversy edecmo.org/59 – Partial REBOA   REBOA in Hemorrhagic Shock from NON-Trauma Mechanisms: This episode is highlighted by a remarkable case, managed by Emergency Physician Dr. Garrett Sterling, of a 77 year old patient who suffered non-traumatic hemorrhagic shock from an Iliac artery pseudo-aneurysm that had fistulized to the urinary tract.  The patient was bleeding to death from a fistula between the common iliac artery and the ureter. You have to listen to Dr. Sterling describe this case. The patient was resuscitated with REBOA and her pathology was fixed by an Iliac Artery stent placed in Interventional Radiology. We discuss this case which highlights the benefit of REBOA as a bridge to definitive hemorrhage control. Amazing patient who had an Iliac pseudo-aneurysm causing hemorrhagic shock through the urinary tract, resuscitated using REBOA.                                       Joe and Zaf talk about: brief history of managing hemorrhagic shock with aortic occlusion ‘Knee REBOA’ Resuscitative thoracotomy REBOA in trauma REBOA in non-trauma hemorrhagic shock   REFERENCES: https://pubmed.ncbi.nlm.nih.gov/29922894/ https://pubmed.ncbi.nlm.nih.gov/31799415/ https://pubmed.ncbi.nlm.nih.gov/32707397/ https://pubmed.ncbi.nlm.nih.gov/31668242/ https://tsaco.bmj.com/content/4/1/e000376 https://pubmed.ncbi.nlm.nih.gov/29421694/ https://www.jsomonline.org/FeatureArticle/20202110O’Dochartaigh.pdf        

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       Demetris Yannopoulos and Jason Bartos  

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

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 and ECMO director Dr. David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO.   online pharmacy                                 Aortic Dissection recent paper and Editorial https://www.resuscitationjournal.com/article/S0300-9572(20)30309-9/fulltext https://www.resuscitationjournal.com/article/S0300-9572(20)30435-4/pdf  

This month we tackle a number of topics.  Garrett Sterling is back again with Zack 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! Reverse CPR – better systolic BPs Brown J., Rogers J., Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001;50:233–238. [PubMed] [Google Scholar] Mazer S.P., Weisfeldt M., Bai D. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279–285. [PubMed] [Google Scholar] DOI:  10.1016/s0300-9572(03)00037-6 Wei J., Tung D., Sue S.H., Wu S., van Chuang Y.C., Chang C.Y. Cardiopulmonary resuscitation in prone position: A simplified method for outpatients. Journal of the Chinese Medical Association. 2006;69:202–206. [PubMed] [Google Scholar] SLides on Prone CPR https://www.slideshare.net/logon2kingofkings/prone-cpcr Risk to providers of CPR in Covid https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169929/   Fear of Covid in CPR Witnesses still providing CPR in Covid era – 53 vs. 49% in Paris https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195282/ Witnesses didn’t provide in Sydney https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151522/ Dual Sequential Defibrillation (DSD) Columbus Ohio Paramedics – http://dx.doi.org/10.1016/j.resuscitation.2016.08.002 San Antonio Texas – no benefit of DSD – http://dx.doi.org/10.1016/j.resuscitation.2016.06.011 Damaged Defibrillator from DSD – DOI: 10.1016/j.annemergmed.2017.04.005 Toronto – Cheskes RCT -DSD and vector change better than standard defibrillation –  https://doi.org/10.1016/j.resuscitation.2020.02.010 National Data on ECMO use in US J. Hadaya, et al., National trends in utilization and outcomes of extracorporeal support for in- and out-of-hospital cardiac arrest, Resuscitation (2020), https://doi.org/10.1016/j.resuscitation.2020.02.034 Early CT after ECMO https://doi.org/10.1016/j.resuscitation.2019.11.024 3d printed  ECPR modeling https://doi.org/10.1016/j.resuscitation.2020.01.032

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

“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.   Good overall webinar – ECMO considerations start – http://iv.docbook.com.cn/record/app-name/46020/2020-03-19-20-45-14_2020-03-19-21-40-14.mp4 Slides here – Ning Zhou-The application of ECMO in severe Covid-19 patients ELSO Guidance Document