EDECMO Podcast

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 Demetris, Jason and U of M have created.  The sky is the limit for their team!

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 <18, paO2 >50,ETCO2>10   References: Bartos JA, Grunau B, Carlson C, Duval S, Ripeckyj A, Kalra R, Raveendran G, John R, Conterato M, Frascone RJ, Trembley A, Aufderheide TP, Yannopoulos D. Improved Survival with Extracorporeal Cardiopulmonary Resuscitation Despite Progressive Metabolic Derangement Associated with Prolonged Resuscitation. Circulation. 2020 Jan 3. doi: 10.1161/CIRCULATIONAHA.119.042173. [Epub ahead of print] PubMed PMID: 31896278. Bartos JA, Carlson K, Carlson C, Raveendran G, John R, Aufderheide TP, Yannopoulos D. Surviving refractory out-of-hospital ventricular fibrillation cardiac arrest: Critical care and extracorporeal membrane oxygenation management. Resuscitation. 2018 Nov;132:47-55. doi: 10.1016/j.resuscitation.2018.08.030. Epub 2018 Aug 29. PubMed PMID: 30171974.

     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, less is more 12. Understanding Cardiac Prognostication / Stunning 13. Understanding Neuro Prognostication 14. Protection/Ownership 15. In it for the Long Haul  

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 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 Albuquerque Bean Dip!!  Love this organization from cleanse to cannulation   Update: News story

Over the last several years, data has suggested that partial or intermittent REBOA may have benefit over complete REBOA.  How to do this and how to use our current imperfect catheters in this arena is still in question.  Dr. Matthew Martin and his colleagues at Madigan Medical Center have published the first study using Prytime’s new catheter for partial REBOA.  Zack interviews Matt in this episode about this latest paper in Journal of Trauma and Acute Surgery as well as several other papers he’s published in the field.  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.         Efficacy of intermittent versus standard resuscitative endovascular balloon occlusion of the aorta in a lethal solid organ injury model. Kuckelman J, Derickson M, Barron M, Phillips CJ, Moe D, Levine T, Kononchik JP, Marko ST, Eckert M, Martin MJ. J Trauma Acute Care Surg. 2019 Jul;87(1):9-17. doi: 10.1097/TA.0000000000002307. PMID: 31259868 TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS. Forte D, Do WS, Weiss JB, Sheldon RR, Kuckelman JP, Eckert MJ, Martin MJ. J Trauma Acute Care Surg. 2019 May 21. doi: 10.1097/TA.0000000000002378. [Epub ahead of print] PMID: 31135770 Resuscitative endovascular balloon occlusion of the aorta induced myocardial injury is mitigated by endovascular variable aortic control. Beyer CA, Hoareau GL, Tibbits EM, Davidson AJ, DeSoucy ED, Simon MA, Grayson JK, Neff LP, Williams TK, Johnson MA. J Trauma Acute Care Surg. 2019 Sep;87(3):590-598. doi: 10.1097/TA.0000000000002363. PMID: 311453810 Selective Aortic Arch Perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of non-compressible torso hemorrhage. Hoops HE, Manning JE, Graham TL, McCully BH, McCurdy SL, Ross JD. J Trauma Acute Care Surg. 2019 Apr 18. doi: 10.1097/TA.0000000000002315. [Epub ahead of print] PMID:  31211744

Marc Dickstein, an anesthesiologist from Columbia University, shares his expertise on managing patients on ECMO. He highlights the critical decisions between fluids, pressors, and flow to optimize outcomes. The discussion covers the complexities of left ventricular recovery post-arrest, and how hemodynamics impact oxygen delivery. Dickstein explains the importance of pulmonary artery catheters and the challenges of heart distension after cardiac arrest. His insights emphasize the necessity of understanding ECMO physiology for effective patient care.

In a deep dive into anticoagulation management, Troy Seelhammer, an intensivist and co-director of the ECMO program at Mayo Clinic, shares his expertise. He challenges traditional views on the use of heparin, discussing when to be aggressive or conservative with anticoagulants. Conversations about the evolution of heparin-coated cannulas and the potential of bivalirudin add depth. Troy emphasizes the necessity of tailored anticoagulation strategies to enhance patient outcomes while minimizing complications during ECMO therapy.

In this episode, Sacha Richardson talks with Zack about a problem common to all ECPR programs- how do we confirm the placement of the wires?  During chest compressions and even in patients with a pulse, confirmation of which vessel you have cannulated can be difficult.  Sacha shares some tricks and trips on how to get real time confirmation of the wires.  Sacha also gives us a preview of some of the exciting endeavors that he has undertaken in Melbourne with pre-hospital ECMO.

  In this episode, we again explore the world of the distal perfusion catheter.  You heard from Joe Dubose the vascular surgeons point of view; now let’s see how non-surgeon resuscitationists are dealing with this problem.  You will hear from Chris Couch, a critical care trained emergency physician from Dallas Texas and his colleague Omar Hernandez who have some novel thoughts and experiences related to when and how we insert these catheters.  You will hear about checking compartment pressures, poor man’s way to “fluoro” your catheter, and much more.   Great summary of supporting literature – DPC Lit Search