ED ECMO Zack Shinar, MD

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.



 







Reynolds HN, Cottingham C, McCunn M, Habashi NM, Scalea TM. Extracorporeal lung support in a patient with traumatic brain injury: the benefit of heparin-bonded circuitry. Perfusion. 1999 Nov;14(6):489-93. doi: 10.1177/026765919901400612. PMID: 10585157.



Bein T, Scherer MN, Philipp A, Weber F, Woertgen C. Pumpless extracorporeal lung assist (pECLA) in patients with acute respiratory distress syndrome and severe brain injury. J Trauma. 2005 Jun;58(6):1294-7. doi: 10.1097/01.ta.0000173275.06947.5c. PMID: 15995487.



Parker BM, Menaker J, Berry CD, Tesoreiero RB, O'Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg. 2021 Jun;87(6):949-953. doi: 10.1177/0003134820956360. Epub 2020 Dec 9. PMID: 33295187.



Bosarge PL, Raff LA, McGwin G Jr, Carroll SL, Bellot SC, Diaz-Guzman E, Kerby JD. Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg. 2016 Aug;81(2):236-43. doi: 10.1097/TA.0000000000001068. PMID: 27032012.



Mazzeffi M, Kon Z, Menaker J, Johnson DM, Parise O, Gelsomino S, Lorusso R, Herr D. Large Dual-Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage. ASAIO J. 2019 Sep/Oct;65(7):674-677. doi: 10.1097/MAT.0000000000000917. PMID: 30398981.



Lorusso R, Belliato M, Mazzeffi M, Di Mauro M, Taccone FS, Parise O, Albanawi A, Nandwani V, McCarthy P, Kon Z, Menaker J, Johnson DM, Gelsomino S, Herr D. Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database. Crit Care. 2021 Mar 17;25(1):107. doi: 10.1186/s13054-021-03533-5. PMID: 33731186; PMCID: PMC7968168.



Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, Matteucci M, Fina D, Heuts S, Bidar E, Natour E, Sels JW, Delnoij T, Lorusso R. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J. 2021 May 1;67(5):476-484. doi: 10.1097/MAT.0000000000001216. PMID: 32657828.



Trivedi JR, Alotaibi A, Sweeney JC, Fox MP, van Berkel V, Adkins K, Condley C, Alwair H, Slaughter MS. Use of Extracorporeal Membrane Oxygenation in Blunt Traumatic Injury Patients with Acute Respiratory Distress Syndrome. ASAIO J. 2022 Apr 1;68(4):e60-e61. doi: 10.1097/MAT.0000000000001544. PMID: 34352816.



Swol J, Brodie D, Napolitano L, Park PK, Thiagarajan R, Barbaro RP, Lorusso R, McMullan D, Cavarocchi N, Hssain AA, Rycus P, Zonies D; Extracorporeal Life Support Organization (ELSO). Indications and outcomes of extracorporeal life support in trauma patients. J Trauma Acute Care Surg.