This month Zack gives some pearls from his travels to Prague for Jan Behlolavek’s ECPR school, Poland to meet with Marek Dabrowski, and ELSO with the entire crew.  Zack also interviews Saul Levine for the first of what may be a recurring conversation about the San Diego Resuscitation Consortium.  His efforts along with Kristi Koenig, Shawn Evans, Todd Baumbacher, and many others have paved the way for an OHCA ECPR protocol that may change more than just San Diego cardiac care.  Listen to Saul explain how the first 3 months of this process has expanded the minds of what cardiac arrest care can look like.

 

This episode is a follow up to last month’s episode with Nichole Bosson.  Zack interviews Vadim Gudzenko about the in-patient aspects and critical care doctor perspective on the Los Angeles OHCA ECPR program.  A few take homes are that EMS is critical to any OHCA ECPR program.  Nurses need support for these intense patients with high mortality.  And emergency physicians need to buy in to the idea of ECMO for cardiac arrest to make a successful program.

 

Upcoming Events

Sept – ELSO – Summary – 34th Annual ELSO Conference (cvent.com)

Oct – Prague ECPR School – https://www.ecprprague.com/

Nov – Reanimate Reanimateconference.com

 

Zack and Jon’s Editorial about Sakuraya PE trial

https://authors.elsevier.com/a/1hlr514RWGNg8s

 

One of the biggest questions in ECPR right now is how do we organize our system to provide ECPR in an effective and streamlined approach?  Nichole Bosson, Dave Shavelle and the army of L.A. ECPR enthusiasts have successfully implemented a multi-hospital ECPR receiving center program in Los Angeles.  In this episode, Zack talks with Dr. Bosson about how they started, what they learned, and where they are going.

 

A little about Dr. Bosson

• She is the Assistant Medical Director at the Los Angeles County EMS Agency. She is an Associate Clinical Professor at David Geffen School of Medicine at UCLA and faculty and EMS fellowship director in the Department of Emergency Medicine at Harbor-UCLA.

 

• Here is the link to her paper

Bosson N, Kazan C, Sanko S, Abramson T, Eckstein M, Eisner D, Geiderman J, Ghurabi W, Gudzenko V, Mehra A, Torbati S, Uner A, Gausche-Hill M, Shavelle D. Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest. Resuscitation. 2023 Jun;187:109711. doi: 10.1016/j.resuscitation.2023.109711. Epub 2023 Jan 30. PMID: 36720300.

 

• And here is Jason Bartos’ editorial

Bartos JA, Yannopoulos D. Starting an Extracorporeal cardiopulmonary resuscitation Program: Success is in the details. Resuscitation. 2023 Jun;187:109792. doi: 10.1016/j.resuscitation.2023.109792. Epub 2023 Apr 10. PMID: 37044354.

 

 

Jon Marinaro takes EDECMO through another great podcast.  This time he interviews Christine Stead, the CEO of ELSO.  She talks about how ELSO is setting up standards for ECMO programs to try to make ECMO care at all hospitals safer.  She talks about how she works also with the device industry.  This involves working with the FDA for future innovations and CMS for reimbursement issues.  She talks about the website and how to get your program certified.  Christine as a person is amazing.  She and her 5 person team runs an organization that has its hands in so many different areas.  Also, she is avid runner having completed 12 Boston Marathons!

 

ELSO website – www.elso.org

Annual ELSO conference in Seattle

Reanimate 9 is nearly sold out.  November 2023.  Check it out here

In this episode Jon Marinaro joins the ED ECMO team and interviews his colleague Sundeep Guliani, MD about the use of an ECMO first strategy for Massive Pulmonary Embolism. Jon and Sundeep review the data and processes from their institution and from other institutions in the United States.  Could it be that ECLS could move the survival needle on this high mortality disease? Listen and find out!

Hobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP,
Gori T, Münzel T, Konstantinides S, Keller K. Clinical use and outcome of
extracorporeal membrane oxygenation in patients with pulmonary embolism.
Resuscitation. 2022 Jan;170:285-292. doi: 10.1016/j.resuscitation.2021.10.007.
Epub 2021 Oct 12. PMID: 34653550.

Shinar Z, Hutin A. Pulmonary ECMO-ism: Let’s add PEA to ECPR indications.
Resuscitation. 2022 Jan;170:293-294. doi: 10.1016/j.resuscitation.2021.11.004.
Epub 2021 Nov 10. PMID: 34774708.

Pudil J, Rob D, Smalcova J, Smid O, Huptych M, Vesela M, Kovarnik T,
Belohlavek J. Pulmonary embolism related refractory out-of-hospital cardiac
arrest and extracorporeal cardiopulmonary resuscitation: Prague OHCA study post-
hoc analysis. Eur Heart J Acute Cardiovasc Care. 2023 May 12:zuad052. doi:
10.1093/ehjacc/zuad052. Epub ahead of print. PMID: 37172033.

Karami M, Mandigers L, Miranda DDR, Rietdijk WJR, Binnekade JM, Knijn DCM,
Lagrand WK, den Uil CA, Henriques JPS, Vlaar APJ; DUTCH ECLS Study Group.
Survival of patients with acute pulmonary embolism treated with venoarterial
extracorporeal membrane oxygenation: A systematic review and meta-analysis. J
Crit Care. 2021 Aug;64:245-254. doi: 10.1016/j.jcrc.2021.03.006. Epub 2021 Mar
24. PMID: 34049258.

In this episode, Jon Marinaro and Zack Shinar go through the hot off the press Inception trial.  The trial was touted as a negative ECPR study though many reasons make this trial different then the ARREST trial.  They go through several important take home points for practitioners starting or running an ECPR/ECMO program.

 

Inception Trial

https://www.nejm.org/doi/full/10.1056/NEJMoa2204511

In this podcast, Joe Tonna tells us how to approach hypothermia with ECPR patients.  He also goes through his paper RESCUE-IHCA giving us an immediate way to prognosticate in patients to use of ECMO or not.

Hypothermia – Resuscitation

Nakashima T, Ogata S, Noguchi T, Nishimura K, Hsu CH, Sefa N, Haas NL, Bĕlohlávek J, Pellegrino V, Tonna JE, Haft J, Neumar RW. Association of intentional cooling, achieved temperature and hypothermia duration with in-hospital mortality in patients treated with extracorporeal cardiopulmonary resuscitation: An analysis of the ELSO registry. Resuscitation. 2022 Aug;177:43-51. doi: 10.1016/j.resuscitation.2022.06.022. Epub 2022 Jul 3. PMID: 35788020.

Hypothermia Meta-Analysis

Duan J, Ma Q, Zhu C, Shi Y, Duan B. eCPR Combined With Therapeutic Hypothermia Could Improve Survival and Neurologic Outcomes for Patients With Cardiac Arrest: A Meta-Analysis. Front Cardiovasc Med. 2021 Aug 13;8:703567. doi: 10.3389/fcvm.2021.703567. PMID: 34485403; PMCID: PMC8414549.

In Hospital Cardiac Arrest and ECPR Inclusion

Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, Zhang C, Rycus P, Keenan HT; American Heart Association Get With the Guidelines–Resuscitation Investigators. Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation. JACC Cardiovasc Interv. 2022 Feb 14;15(3):237-247. doi: 10.1016/j.jcin.2021.09.032. Epub 2022 Jan 12. PMID: 35033471; PMCID: PMC8837656.

In this episode,  Zack interviews Florian Schmitzberger who just published a fantastic study that incorporates fourteen leaders within the ECPR community to hash out the specific procedural steps associated with ECPR.

 

INCLUSION
• Age <75 years
• Witnessed arrest
• Initial rhythm is shockable rhythm (VF / VT)
• ECPR can be initiated within 60 minutes of the arrest, though a longer interval may be considered circumstantially (e.g. hypothermic arrest)
• Aggressive ICU care consistent with patient wishes
• No prolonged downtime without CPR
• End-tidal CO2 ≥ 10 mmHg (unless pulmonary embolism is suspected)
• Treating physician/surgeon agreement to proceed
EXCLUSION
• Contraindication to anticoagulation
• Cannot perform activities of daily living at baseline
• Advanced comorbidities / known irreversible organ failure
• Advanced COPD or other pulmonary comorbidities
• Metastatic malignancy
• Major stroke or neurologic impairment
• Do-not-resuscitate / Do-not-intubate status

 

The Paper

Schmitzberger FF, Haas NL, Coute RA, Bartos J, Hackmann A, Haft JW, Hsu CH, Hutin A, Lamhaut L, Marinaro J, Nagao K, Nakashima T, Neumar R, Pellegrino V, Shinar Z, Whitmore SP, Yannopoulos D, Peterson WJ. ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation. Resuscitation. 2022 Oct;179:214-220. doi: 10.1016/j.resuscitation.2022.07.003. Epub 2022 Jul 8. PMID: 35817270.

This month Zack gives a few pearls from the recent Reanimate courses and annual ELSO meeting in Boston before he interviews Gowry Mork from Aarhus University about her fantastic recent paper.

• Pearl #1 is about hand placement in cannulation.  Hold the ultrasound in your left an
  d needle in right.  Once in the vessel, drop the US probe and take your left hand and gently hold the needle. With your right hand grab the wire far enough up to be to insert into the vessel in one push.
• Gowry’s paper has many interesting points.  Probably the biggest is the reasonable survivorship for prolonger arrests.  This is tied to equality of care for patient who live far from the closest ECMO center.

 

 

Gowry’s paper – 

Mørk SR, Bøtker MT, Christensen S, Tang M, Terkelsen CJ. Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support. Resusc Plus. 2022 Apr 6;10:100230. doi: 10.1016/j.resplu.2022.100230. PMID: 35434669; PMCID: PMC9010695.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9010695/

Gowry’s Twitter

@MSivagowry –  https://mobile.twitter.com/msivagowry

This month we are honored to have Neville Vlok on the show.  Neville has been one of the key physicians pushing for ECPR in South Africa.  In this episode, we explore what medicine and resuscitation looks like in South Africa, how ECMO has been utilized, and whether ECMO even makes sense in developing countries.

 

Vlok N, Hedding KA, Van Dyk MA. Saved by the pump: Two successful resuscitations utilising emergency department-initiated extracorporeal cardiopulmonary resuscitation in South Africa. S Afr Med J. 2021 Mar 2;111(3):208-210. doi: 10.7196/SAMJ.2021.v111i3.15366. PMID: 33944740.

Using ECMO for traumatic patients has had some promising papers through the years, but the data overall is still poor.  Justyna Swol has teamed up with ELSO to improve this deficiency by making a trauma carve out of the ELSO registry.  In this episode, Zack discusses with Justyna the many facets of ECMO in trauma.  A few pearls and references are below: Anticoagulation in ECMO is not mandatory.  A reasonable strategy is heparinized circuit with a titrating dose of systemic heparin as necessary in the trauma patient.  This includes everyone from isolated pulmonary contusions to intracranial hemorrhage. VV-ECMO similar to ARDS in medical causes can be used and likely offers survival benefit to those patients with post traumatic lung injury.  Initiating early (maybe PaO2 of 80 on 100% FiO2) is likely best. ECPR can be done in the traumatic arrest.  Best when done in parallel to the other resuscitative needs of the patient.  Data is promising in case series.  Need for bigger data sets is clear.