EDECMO Podcast

In this episode, we tackle the subject of organ transplantation on ECMO.  2017 featured several articles showing the efficacy of ECMO for organ transplantation.  In Italy, 56% of total potential patients were successfully transplanted.  The success of these transplants have been comparable to patients not on ECMO.  Zack Shinar interviews Lionel Lamhaut, ECMO specialist from Paris, and Cyrus Olsen, ethicist from the University of Scranton, to dive into some of the deeper questions including financial implications, ethical angles, and research extrapolations.  Join Zack, Lionel and Cy at Big Sick 18 (bigsick18.org) in Zermatt Switzerland on February 7-9th,, 2018!!   1: Christopher DA, Woodside KJ. Expanding the Donor Pool: Organ Donation After Brain Death for Extracorporeal Membrane Oxygenation Patients. Crit Care Med. 2017 Oct;45(10):1790-1791. doi: 10.1097/CCM.0000000000002633. PubMed PMID: 28915178. 2: Bronchard R, Durand L, Legeai C, Cohen J, Guerrini P, Bastien O. Brain-Dead Donors on Extracorporeal Membrane Oxygenation. Crit Care Med. 2017 Oct;45(10):1734-1741. doi: 10.1097/CCM.0000000000002564. PubMed PMID: 28640022. 3: Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, Citerio G. Organ donation in cardiac arrest patients treated with extracorporeal CPR: A single centre observational study. Resuscitation. 2017 Sep;118:133-139. doi: 10.1016/j.resuscitation.2017.06.001. Epub 2017 Jun 12. PubMed PMID: 28596083. 4: Dalle Ave AL, Bernat JL. Donation after brain circulation determination of death. BMC Med Ethics. 2017 Feb 23;18(1):15. doi: 10.1186/s12910-017-0173-1. PubMed PMID: 28228145; PubMed Central PMCID: PMC5322624. 5: Larsson M, Forsman P, Hedenqvist P, Östlund A, Hultman J, Wikman A, Riddez L, Frenckner B, Bottai M, Wahlgren CM. Extracorporeal membrane oxygenation improves coagulopathy in an experimental traumatic hemorrhagic model. Eur J Trauma Emerg Surg. 2017 Oct;43(5):701-709. doi: 10.1007/s00068-016-0730-1. Epub 2016 Nov 4. PubMed PMID: 27815579; PubMed Central PMCID: PMC5629226. 6: Dalle Ave AL, Shaw DM, Gardiner D. Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest-An ethical analysis of an unresolved clinical dilemma. Resuscitation. 2016 Nov;108:87-94. doi: 10.1016/j.resuscitation.2016.07.003. Epub 2016 Jul 20. Review. PubMed PMID: 27449821. 7: Fan X, Chen Z, Nasralla D, Zeng X, Yang J, Ye S, Zhang Y, Peng G, Wang Y, Ye Q. The organ preservation and enhancement of donation success ratio effect of extracorporeal membrane oxygenation in circulatory unstable brain death donor. Clin Transplant. 2016 Oct;30(10):1306-1313. doi: 10.1111/ctr.12823. Epub 2016 Sep 5. PubMed PMID: 27460305. 8: Jasseron C, Lebreton G, Cantrelle C, Legeai C, Leprince P, Flecher E, Sirinelli A, Bastien O, Dorent R. Impact of Heart Transplantation on Survival in Patients on Venoarterial Extracorporeal Membrane Oxygenation at Listing in France. Transplantation. 2016 Sep;100(9):1979-87. doi: 10.1097/TP.0000000000001265. PubMed PMID: 27306536. 9: Migliaccio ML, Zagli G, Cianchi G, Lazzeri C, Bonizzoli M, Cecchi A, Anichini V, Gensini GF, Peris A. Extracorporeal membrane oxygenation in brain-death organ and tissues donors: a single-centre experience. Br J Anaesth. 2013 Oct;111(4):673-4. doi: 10.1093/bja/aet323. PubMed PMID: 24027145.

In this episode Zack and Joe discuss the 3-stages of Extracorporeal Membrane Oxygenation (ECMO) - or put another way, this is how to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Emergency Department (ED). It's been 4 years since we talked about these basic premises of ECPR. But this time, its highlighted in a very special story.

EROCA - University of Michigan - Gunnerson/Shinar Should Emergency Physicians initiate ECMO on arresting patients?  That is the question that Kyle Gunnerson from the University of Michigan (UMich) is asking with their new trial - EROCA.  UMich has had a robust ECMO program for over 30 years and recently they have received a grant to fund an out of hospital cardiac arrest protocol for emergency physician initiated ECPR.  In this episode, Zack asks Kyle how this trial is being undertaken with key side points on how to start a program, how to train the personnel, and how to circumnavigate the many roadblocks we commonly face in the development of an ECMO program.  They talk about the limitations of running a trial with physicians with no prior experience in ECPR initiation as well as the novel resuscitation strategies that UMich is deploying in all of their cardiac arrest patients.

In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?”  Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important.  Guillaume's data shows importance of short low times, lower lactates and higher pH values.  The real question is what number for each of these should we consider a hard stop on initiation.  This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial.  He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions.  With many ECMO studies having average arrest to initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide.  This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65.   We  conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival.  This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this.

Mini episode - This is a great example of where a little persistence with your colleagues can help save someone's life.  Dr. Andrew Karl Terry, having had only limited exposure to ECMO, was able to encourage his Cardiologists to put a witnessed VF patient on ECMO.  The rest is history!

This episode is all about ECMO in trauma - not the usual ARDS, TRALI VV-ECMO - we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now.

Jake is an Emergency Physician from Santa Cruz California whose interest in resuscitation was put to the fullest test when his own son had a cardiac arrest. This is the amazing retelling of that day in November when what Jake learned in an EDECMO workshop was utilized in a dramatic fashion. This is a story of two heros: Jake and his son Nate.

The University of Minnesota Cath Lab Cannulation Method

In this podcast episode, Zack interviews Demetri Yannopoulos from the University of Minnesota. Demetri has organized Minneapolis into arguably the most impressive ECPR city in the world. He has changed the mindset of out of hospital refractory ventricular fibrillation care from “stay and play”, the philosophy that medics should stay at the scene and provide care until ROSC (return of spontaneous circulation) or until the patient is pronounced dead. In Minneapolis, a patient who who arrests in  Yannopoulos’ catchment area gets three shocks. If the patient does not get ROSC then they are immediately transported to the University of Minnesota using LUCAS mechanical chest compression device. The patient bypasses the emergency department and goes directly to the cath lab. In the cath lab, Demetri, or one of his partners, cannulates and initiates ECMO with an average time of 6 minutes!!! In his first 90 patients he has had a 45% neurologically intact survivorship. Patients are getting to the cath lab on average 60 minutes after their arrest. In this cohort, you would expect a less than 1% survival. We can use Dr. Yannopoulos’ model to expand the use of ECPR in many other systems. The real question is do we have champions like Demetri who will rise to the calling!

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is used to gain proximal control over non-compressible hemorrhage below the diaphragm. In this episode, Zack takes a deep dive into REBOA implementation, physiology, and complications with four of the biggest movers in the world of REBOA: