ED ECMO presentation - Saint John Regional Hospitalsjrhem.ca/wp-content/uploads/2017/01/ED-ECMO-James-Gould-Dec-2015.pdf · EMCO used in the arresting patient has been referred to

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Ecmo isessentially oxygenationoutsideofthebodyWhenwerefertoVV– wearetalkingaboutremovingdeoxygenatedvenousblood,oxygenatingitandreturningittothevenoussideWhenwerefertoVA– wearetalkingaboutremovingdeoxygenatedbloodfromthevenousside,oxygenatingitandreturningittothearterialECMOusedintheemergent/emergencydepartmentsettingisbetterrefered toasECLSEMCOusedinthearrestingpatienthasbeenreferredtoasECPR

WhenIrefertoEDECMOIwillberefering toVA- ECMO,andforthispresentationitwillbeinthearresting/peri arressting patient– ECPR– notVV-ecmo althoughanothertalkinitself

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Has beenusedintheORsettingsincethe50’s- throughthe70’swesawsuccesscasesforbothVVandVAinadultsandneonates

TookoffasameansoftreatingneonatallungissueswithVVPortablesystemsthatusedpercutanous acesss tofemoralvesselstookthisoutoftheORandintothehospitalsetting.

ECLSbeenevolvingsincethentomanagehospitalizedpatientswithlifethreateningCPcollapse

Today– commonplaceintheORforsurgeryandinhospitalinICUsetting– makingitswayintotheemergencydepartmentandmorerecentlyintotheEMSsetting.

Vieanna austria hasbeenusingitintheED alongsidewithCVsurgeonsfor10years–integratingintoPREhospitalsetting– willgetintotheirwork

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Very simpleexampleforhowthisworksbutcanseesetupTraditionallysameleg– butmovingtor andleft– willexplainnext

Imaginethatveno venousissamejustonthevenousside

Reminder– EDsettingisusuallyVA-ecmo andECPRisVAECMO– IwilllimitthistalktoVA– ECMOintheEDforECLSmostlyECPRorthearrestingpatient

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Soyourflowisgoingupthefemoralvessel intoaorta– perfusing theheartretrogradeandallotherorgans.Thedistalipsilateral legcangetlowflowandthusischemia–herparized andadditionalcannula placedlater– aswellasusingLlegforvenousaccess

LVpressure/afterload isincreased,canbackintolungscauseinjurygive– ionotropy,baloon pumpsandfixthedysrythmias

Patientstayonvent– preventards,reducesatelectasis,pneumoniasetc.

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Vv- typicallyinrespiratory failure,icu settingforARDS,thesecandidates/criteriaarelayed outbytheCESARtrial

Murrary score– Pao2/fio2on100%o2,numberofinfiltratedquadrants,peepbeingused,compliance(TV/PIP-PEEP)– calculatesscore

VA- Goal:providecardiovascularsupportduringcardiacfailureorshockIndications:bridgetotherapy)PCI,transplant,LVAD),refractoryshock,cardiacarrest(requiringoneofthosebridgetherapies),overdose,hypothermia/arrythmias

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Patient hastobehealthypriortoarrest– thisistheglobalassessment,thegestaltthatgoesintohowwedecidetoapproachendoflifeissuesCurativeintentisselfexplainatoryReversiblecause– classicexampleisthepatientcomplainingofchestpainwhohaselectrocardiogramfindingsofmycardial infarction,arrestsinEDoronroute,ECPRtobridgethemtocath lab.– French’scaseWitnessedwithbystanderCPRInitiatedwithin60minutesofdowntime

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Again– thesedifferbetween sites– thisisgeneraltrend

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WasusedinBelezzo paperonEPinitiated ECMO- ECPRfrom2012inresusicationThereisavariationinwhoisacandidatedependingonshop/country,ems systeminplaceetc.

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Fortherestofthistalk, includingwhatequipmentwillbeneededandtheevidence/howtowillfocusonECPR– usingVAecmo inthearrestingpatientinitiatedbyEP

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TechnicalSkillrequired:Accessingfemoralvesselsvenousandarterialusingultrasoundguidance

Whichallemergencyphysicians alreadyknowhowtodoSoobviouslyneedUSmachine

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Listoftheequipment usedforECPRNotethattheirinitialequipmentlistincludes5- 9french sizedcathetersfortheinitialinsertion– thisisimportantwhenwegettothestagesofECPRintroductionSHARPmedicalhospitalkit

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Aterial from8-20/23frenchVenous8-29french

Thesearetheactualecmo cannulasTypicallyaattheendofsetupforecpr youwillhave(foraverageadult)Venous17-21andarterial15-19

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TheportableECLSunitiscomprisedofacentrifugalpump(Rotaflow,Maquet,Bridgewater,NJ),aheatexchanger(whichcanbeusedtowarmorcool),andanoxygenator(Quadrox iD,Maquet,Bridgewater,NJ)thatareheparin-lined(Bioline,Maquet,Bridgewater,NJ).ThesecomponentsresideonaportablecartthatcanbeeasilyrelocatedtotheED.

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Thisistheecmo.org group.Theypublishedtheirfirstpaper2012aboutECPR–outliningtheiralgorithmforinitiationofECPR– outliningtheir3steo approachwhichIwillhighlightinstartingECPRinthearrestingorperi-arrestpatient

ApplicationissameforestablishingVA-ECMO butstreamlinedforECPR

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Directlyfromthatpaperfrom2012Essentially thereare2physiciansrunningthecode– oneisthe“resus”docandtheotheristhelinedoc.Idealsettingispatientiswheeledinperi arrestorwithongoingCPRtorightofbed.Linedocgownedgloved,withsterileUSonoppositesideofbedAssoonaspatientistransferredthelinedocestablishesaccesstotheRfemoralvesselsunderUS– theUSthenbecomesavailabletotherestoftheteamfordiagnosic purposes.

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Asmentionedfemoral acess first(becauseitsharder)with5fart9fvenous– inarresttheveinwillswellandarteryshrink

Accessfemart2cmdistaltoinguinallig – ASIStopubicsymp – iftolowyouwillendupaccessthesuperficialFemart.Goodforartlinebutupsizingtoecmo cannula willfail.

Handlingtheneedleduringpulsechecks,orapredictablelucas device(automated),reducetheriskofneedlestickandimprovesuccessrate.

Serveasconduitsfortheplacementoftheecls cannulas,orjustcriticalcareaccesstobeusedintheresuscitation– ArtBP,givingmeds,etcGoodtobreakthisstepupbecauseu avoidinitiallyopeningtheexpensiveecmo kitasu maynotneedtouseit

TheECMOsupplies/cart/machineperfusionist isonitswaytotheED(ifnotalreadythere)duringstage1

IfROSCnotobtainedbyendofstageoneyoumovetostage2

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Now ifyouhavent achievedrosc andyouhavemovedtostep2BothartandvenfemorallinesarereplacedwithlongECLSwires

Cannulas choosedn andsized- Againadult:V17-21reallylongcannula – sizefromgrointoxyphoid,A15-19– goestotheHub

Largeincisionsmade– sequentialdilation- parralell tovessel– placethecannula,pullthewire

Pullthedialator – andclamprightbehinditwithatraumatic clamp

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ECLSmachinetobeside(ifnotalreadytherebetweenstage 1-2,Thecircuitisprimed- floodedwithfluid(e.g isolyte)

Eachconduitistoppedoffwithsaline,tubingconnected.PumpedturnedonTissueperfusionpressure40(MAPminusCVP),cardiacindex2Settoacertainflowbasedonbodysurfacearea,changedbasedonSvO2measurements,andMap(goal>70and>65).ChangestooxygenatorbymeasuringPaCO2goalofCO2lesss 50.

Securethecannula – silk-0

HowtotroubleshootthesepumpswithregardtoMAP,o2andco2– checkoutEDECMO.org podcastseries– episode20

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300,000cardiac arrestsinUSeachyear,92%die,75-85%haveacardiacrelatedevent21.6%pronouncedprehospital26%survivaltohospitaladmit,9.6%survivaltohospitaldischarge

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Incanada overallOHCA– 5%survivalto hospitaldischarge

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Singlecenterprospectiveobservationalstudyover1year– 42arrests.2012Includedpatientspersitant arrestdespiteacls.ShockSBP10min,totalarrest>60,shockfromsepsisorbleed,preexistingneuro issues

Intervention– 3stageapproachwetalkedaboutOutcome– couldtheyinitiatedECPR/survivaltohospitaldischargeneurologicallyintact

Results– 42patients,18metinclusion,stage1in100%,stage288%,stage312people(67%).Of8wereitwasinitiated– 5hadsurvivalwithgoodneurologicaloutcome– 63%So5additionallivessavedof42=12%more

5patientswer – LADocclusionrefrac VF,RCAocclusionrefractVF,Severecardiomyopathy,hypothermicwithrefrac VF,andaorticdissec typeAtheywentforPCI,PCI,LVAD,rewarming,graft/av repair

Remembertheseareallpatientsthatwouldhaveotherwisebeendeclareddead

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2014Multicenter(46)prospectiveobservationalstudyCompared betweenonehospitalthatdidECPRandonethatdidconventional•Goal– examinetheneurologicaldifferenceusingOPCat1&6monthsinpatientswhohadVF/VTarrestoutofhospital– goodneuro was1or2•454totalpatients(234inECPRgroup,159inCPRgroup)•Neurologicallyintactat1month– 12.3%ECPRvs.1.5%CPR•Neurologicallyintactat6months– 11.2%ECPRvs.2.6%CPR

Note– bias inthatsiteperformingECPRmayjustbeprovidingbetterresusus care

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Singlecenterposthocanalysisfromprospectiveobservationalcohortjapan 2000-2004•PrimaryOutcome– neurologicallyintactat3monthsaftercardiacarrest•ComparedECPRvs.conventionalCPR•Propensityscoringwasusedtocompare24patientsfromeachgroup•Neurologicallyintactat3months– 29%ECPRvs.8.9%CPR

Popensity patched24patientswhohadoutofhospitalcardiacarrestswhogotCPRvsECPR – selectionbias

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In-hosptial arrest!!

3yearprospectiveobservationaltrial975patients,CPRlongerthan10minpropensitymatched59ECPR,113conventionalNeuro intact(CPC 1or2):23.7vs 10.6%atdischarge,15.3and8.9% at1year

Noted patients– ORorinternalmed

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CHEERtrialMechanicalCPR,hypothermia,ECMOandearlyrepurfusion – abundletherapy,singlecenterprospectiveobservationaltrialRefractoryinandoutofhospitalarrest

Results:26 patients11ocha,15ihca.14dischargedwithCPC1-2– 54%neuro intact

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BESTNewest,biggestmixofinandout ofhospitalarrestsintheED

Retrospectivechart reviewstudyfromanemergencydepartment.209patientswithcardiacarrestdotorefrac v fib60patientswereenrolledwithv fibrefrac toresus formorethan10min.40gotconventionalCPRcontinuedvs 20withecpr

Results:survival35%,18%DCwithgoodneuro outcomeCPC1or2(high),CPRtwiceaslonginECPRgroupECPRvs CPR:

Survival– atdischarge50vs 27.5,at1year50%,20%Neuro intact;40%vs 7.5%

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EMS systemsandtheirprotocolsforohca differTheconceptsofloadandgovs stayandplayrefertotheseAstayandplayapproachhasbeenadoptedovertheyears– meaningthattheystaydoacls andterminateeffortsinfield– thishasbeendonebecauseasscopeincreasedparamedicsintubate,doacls,andessentiallytheemergencydepartmentdidn’taddanythingmoretothecare,andcpr acls effortsworsenedduringtransportTheloadandgowasessentiallytheopposite– youscoopandruntotheEDThestayandplayapproachisnowbeingbroughtintoquestionbecauseinfact maybewedohavesomethingnewtoofferintheED– ECPRands

ObservationalstudythataimedtoidentifyincidenceofpatientsthatfulfillloadandgocriteriaforECLSintheEDUsedaregistrytheyhaveforcardiacarres;lookedforcriteria-

Paris 2011-20127patientsgotPHECLS- teamincludedadoctorandorintensivist,paramedicConceptisthatearliercannulation andthusECPRmaybebetterSamecriteriaasnormal– ecpr 57mins postarrest1patienthadCPC1– therestdied– 3braindeath,1refractoryMOF,1anoxiccoma,1cpr thoracictraumaandhemorragic shock.

Parishasmobileecmo team.1ambowithdocdoingcannulation – theecmo machinecomingbehindthem– OHCA30%neuro intact

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Published letterinBMJInterestatalocallevel

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Inconsideringthisevidence,rememberthisconcept.After reviewingthisliteratureIfoundmyselfintriguedandimpressedbytheperceivedNNT– forsurvivalandgoodneuro outcomewhenweuseECPR.ButIthinkasimportantofastatisticishowmanypeoplewereputonthepumpthathadapoorneuro outcome– OPC3-5Arethesethepeopleweharmed,westopCPRwhenwefeelanyfurtherisjustgoingtoyieldapatientwithnoneuro status.Maybetheneuro statusofa3,beingdependent,forsomepeopleisbetterthanbeingdead,but a4and5– persistentcomaandbraindeadrespective,wouldbeaharminmymind– onecouldcounterandsaythatthosearepotentialorgandonorsbutthat’squitetheethicalissue.

Iwouldliketoseethisrepresentedinthesetrials..Whats yourNNTforagoodneurooutcome1or2andwhats yourNNHindoingECPR

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1. Prev establishedecmo program– thusalreadyhavingtheequipment,thestafftooperate,aprocessbywhichtokeeptheprogramup

2. Cost– about1600dollarstoactuallyputsomeoneecmo,doesn’ttakeintoaccountthatICUbedwillbeused,theresourceitoccupiesintheED.Butargumentcouldbethatthosecostsperbedareastaticcost.TheICUdoesn’teverhaveidlebeds,sooccupyingitwithabodydoesn’treallyaddcost.TheadditionalcostIfitwas1600,thecostperlifesavedwouldbeverylow– sinceweareessentiallyselectingpeoplewewouldotherwisepronounce,- 100%RRRiftheylive

3. Lotsofresourcesneeded– newstaffperfusionist,ortrainednursestorunthemachine,againtiesupmultipleemerg docsinoneroomandmultiplenurse– aswegetbetterandtechnologyimprovesthiscouldbestreamlined

4. Buyin– lotsofdifferentspecialtiesinvolved– postnotably– needbuyin from1. CVsurgeryforsupportastheywouldbetheexperts,aswellasfromyour2. ICUintensivists whoprobablyalreadydoalotofthisifitsanECMOcenter,

andtosupportyouinacceptingthesepatientsafter3. EMSsystems– tooptimizeecpr mightneedamoreconservativeloadand

gothenthecurrentstayandplay– importantnottomaketheEMSpersonnelfeelasthoughtheyaredoingapoorjob– theyhaveexcellentsystemsbuiltandtheystayandplaybecausewedonobetterthenthem.Butimportanttomakesuretheyknownit’sacollaborativeapproachandtheyinputandcollaborationinimportant.

4. Finallyfromtheemerg community– aswithanynewandcontroversialadditiontoscopeofpractice.

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ULTIMATELY– needthesepeopletositdowninaroomandworkthroughestablishmenttogether

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