EDECMO Podcast

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    

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.