EDECMO Podcast: Recent Episodes
Zack Shinar, MD
The ED ECMO Project is the work of Zack Shinar and Jon Marinaro to bring extracorporeal life support to EDs and ICUs around the world. This site aims to be the ultimate resource for the background, logistics, and evidence for resuscitative ECMO.
EDECMO 105: Becoming an ECMO Coordinator?In this episode, hosts Zack Shinar and Jon Marinaro are joined by Jonathan Goldstone, ECMO Coordinator at Sharp Memorial Hospital, and Rachel Wallace, ECMO Coordinator at the University of Minnesota ECMO Program, to explore one of the least understood but most important roles in an ECMO program—the ECMO coordinator.
The discussion begins with recent advances in their own programs, including dramatic reductions in ECPR cannulation times at Sharp through improved teamwork, standardized equipment, and streamlined workflows. This sets the stage for a broader conversation about how successful ECMO programs are built and sustained.
Rachel provides a detailed overview of the ECMO coordinator’s responsibilities, including onboarding and training ECMO specialists, competency assessment, simulation education, quality assurance, ELSO registry management, physician education, equipment evaluation, and research support. Jonathan emphasizes that while coordinator responsibilities vary between institutions, the central mission is always the same: ensuring there are no weak links in the ECMO system that could compromise patient care.
The panel clarifies the often-confusing distinctions between perfusionists, ECMO specialists, ECMO coordinators, and ECMO managers, highlighting that ECMO specialists may come from nursing, respiratory therapy, perfusion, or advanced practice backgrounds, while coordinators oversee education, quality, systems improvement, and program development.
The conversation explores how hospitals should think about hiring an ECMO coordinator, arguing that programs should invest in leadership early—even before case volumes become large—to build the infrastructure necessary for safe and sustainable growth. The guests also discuss how coordinators influence equipment purchasing, mobile ECMO development, process optimization, billing, and multidisciplinary collaboration.
A recurring theme throughout the episode is that ECMO is fundamentally a team sport. The guests stress that efficient ECPR depends less on individual expertise and more on standardized processes, constant communication, simulation, and shared mental models among physicians, nurses, respiratory therapists, perfusionists, and ECMO specialists.
Finally, the discussion turns to professional development for new coordinators. The guests encourage listeners to leverage the ECMO community through conferences, podcasts, ELSO resources, WhatsApp discussion groups, and mentorship from experienced programs. They conclude by emphasizing that ECMO practice continues to evolve rapidly, requiring coordinators and physicians alike to remain curious, adaptable, collaborative, and committed to continuous improvement.
Key takeaways:
- The ECMO coordinator is the operational leader who integrates education, quality improvement, data management, research, equipment, and systems engineering into a cohesive ECMO program.
- Successful ECMO programs depend on standardized processes, simulation, and multidisciplinary teamwork rather than individual heroics.
- Every hospital must develop an ECMO program tailored to its own personnel, patient population, and resources rather than simply copying another institution’s model.
- Continuous learning, collaboration, and engagement with the broader ECMO community are essential for building and sustaining high-performing ECMO programs.
Jon Marinaro interviews Dr. Eric Nadler along with Dr. Gary Schwartz our guest for the second episode in a row
Key Takeaways* Cancer is increasingly becoming a chronic, manageable disease. * ECMO may be appropriate in carefully selected oncology patients. * Close collaboration between oncologists and ECMO teams is essential. * Modern cancer therapies can work rapidly enough that ECMO may meaningfully change outcomes. * Awareness and education gaps exist on both sides: + intensivists may underestimate modern oncology, + oncologists may underestimate ECMO capabilities.
Eric Nadler, M.D., MPP, is board certified in medical oncology. He serves as a medical director of US Oncology Health Outcomes. He remains active in US Oncology Network and Texas Oncology research committees in lung cancer, head and neck cancer, and sarcoma. Dr. Nadler’s passions are oncology research and oncology education.
Critical Care ECMO with Dr. Jon Marinaro, Dr. Gary Schwartz and Dr. Cedrick Spak – Episode 103Key Points: ECMO in HIV/AIDS Patients
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HIV Is No Longer a Strong Contraindication to ECMO
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Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO.
- With modern antiretroviral therapy (ART), outcomes have dramatically improved.
- Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy.
- Therefore, HIV alone should not exclude patients from ECMO candidacy.
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Immune Reconstitution Makes Recovery Possible
-
ART can rapidly suppress viral load and restore immune function.
- Patients with very low CD4 counts (even <10) can recover to normal CD4 counts (>800) over time.
- This means even severely immunocompromised patients may recover if given time and support.
- ECMO can act as a bridge to immune recovery.
-
ECMO Functions as a “Pause Button”
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ECMO stabilizes respiratory or cardiac failure while clinicians:
- Treat infections
- Start ART
- Manage complications
- This buys time for reversible disease processes to recover.
- Major Cause of Respiratory Failure: Pneumocystis Pneumonia
Common features in HIV patients requiring ECMO:
- Pneumocystis jirovecii pneumonia (PJP)
- Severe respiratory failure
- Cystic lung destruction
- Frequent bronchopleural fistulas and pneumothorax
Ventilation can worsen these conditions.
Thus ECMO is used to:
- Reduce ventilator pressure
- Prevent further lung damage
- Allow lung healing.
- Ventilator Strategy: Minimize Positive Pressure
Typical strategy:
- Rapid ECMO initiation if ventilation causes lung injury
- Attempt early extubation
-
If needed:
- tracheostomy
- minimal ventilator settings
Example “rest settings” described:
- Driving pressure ≈ 10
- PEEP ≈ 10 (often reduced further)
- FiO₂ ≈ 50%
Goal: avoid further lung trauma.
- ECMO Candidate Selection
Primary question:
Is the disease reversible?
If yes → ECMO should be considered.
Factors supporting ECMO:
- Young patient
- Treatable infection
- Potential immune recovery
Possible relative contraindications:
- Severe fungal infection
- Multiple uncontrolled opportunistic infections
- Extreme cachexia or severe systemic deterioration.
- Early ART Should Be Started
Modern approach:
- Start antiretroviral therapy during acute illness
- Do not delay until after ICU discharge
Benefits:
- Rapid viral suppression
- Faster immune recovery
Risk:
-
Immune Reconstitution Inflammatory Syndrome (IRIS)
- Temporary worsening of infection due to immune rebound.
- Circuit and Infection Complications
Important ECMO considerations in HIV patients:
- Increased risk of circuit thrombosis
- Possible fungemia
-
If fungemia occurs:
- circuit replacement
- possible re-cannulation
These complications require careful monitoring.
- Cannulation Strategy
Example high-volume center approach:
-
Bilateral femoral VV ECMO cannulation
- Fast
- Reliable flow
- Allows later neck access if needed
Used especially during high-volume periods (e.g., COVID).
- Outcomes and Indication Expansion
ECMO indications are evolving:
- Older age
- Longer ventilator times
- HIV/AIDS
- Cancer patients
All are examples of “indication creep” as experience grows.
The key principle remains:
ECMO should be used if there is a realistic chance of recovery.
- Resource and Program Considerations
Decision-making must consider:
- Resource availability
- Program experience
- Institutional risk tolerance
High-volume ECMO centers can often accept higher-risk patients.
- Broader Lesson
Medical contraindications often change with new technology and therapies.
Example given:
- HIV was once a contraindication for kidney transplantation
- Now it is accepted due to improved treatment.
The same evolution may be happening with ECMO indications.
We need a major change in the way we think about the brains of ECPR patients. We have been duped into thinking that they are the same as regular resuscitation patients, and the answer is that they are not. On EDECMO 102, we learn about this idea from two wonderful people: Ingrid Magnet and Michael Poppe. In addition to the inspirational ECPR program they have created in Vienna, they have published a paper showing just how different these two groups of patients are. They show that ECPR patients improve their neurologic function tremendously over the six months following their event. This really changes the way we need to think about these patients and how we discuss options with their families in the hospital.
How do we improve survival from cardiac arrest? Does Head-Up CPR improve outcomes? Paul Pepe, the premier expert in the field, gives us the data and reasons why head-up CPR can improve outcomes. Dr. Pepe also discusses estrogen and it’s potential to improve resuscitation outcomes.
On this 100th episode of EDECMO, Sydney’s very own Nat Kruit tells us how they organized a prehospital system. She and her crew have a wonderful job organizing a cadre of new cannulators to now have a functional system that can provide the residents of Sydney the opportunity to benefit from ECPR. Take a listen, she’s fantastic.
EDECMO – Episode 99 is a gem. Charles Bruen tells us how he has become an ECPR cannulator within the prestigious Minnesota Mobile Resuscitation Consortium. He shares pearls about cannulation as well as the next steps for Minnesota’s innovative approach to bringing ECPR to largest population that is possible.
A couple of pearls from Dr. Bruen’s cannulation piece are holding pressure in the groin with the ultrasound probe, understanding that the inguinal fold does not represent the inguinal ligament, inserting the needle at a 45-degree angle, and insertion at the common femoral artery.
Who Really Gets VV ECMO? Numbers, Nuance, and the Human Factor
Is VV ECMO purely a numbers game? Or is there a softer, more human side to deciding who receives this life-saving therapy? In this candid and insightful interview, Jon Marinaro sits down with the legendary Dr. Eddy Fan—one of the most published and respected voices in the field of critical care.
Together, they unpack the hard data and the gray areas: prognostic scoring, patient selection, and the ethical dilemmas that come with scarce resources. They also dive into the “sticky” dynamics of ECMO programs, including the subtle (or not-so-subtle) influence that a cannulating specialist can have on who actually gets the therapy.
This is a must-listen for anyone working at the intersection of critical care, ethics, and real-world ECMO decision-making.
Rubin J, Witkin AS, Crowley JC, Michel E, Furfaro DM, Teijeiro-Paradis R, Ilg A, Seethala R, Zhao S, Fan E. Venovenous Extracorporeal Membrane Oxygenation Candidacy Decision-Making: Lessons and Hypotheses From a Single-Center Observational Analysis. Chest. 2024 Sep;166(3):491-501. doi: 10.1016/j.chest.2024.02.042. Epub 2024 Feb 27. PMID: 38423278.
Combes A, Schmidt M, Hodgson CL, Fan E, Ferguson ND, Fraser JF, Jaber S, Pesenti A, Ranieri M, Rowan K, Shekar K, Slutsky AS, Brodie D. Extracorporeal life support for adults with acute respiratory distress syndrome. Intensive Care Med. 2020 Dec;46(12):2464-2476. doi: 10.1007/s00134-020-06290-1. Epub 2020 Nov 2. PMID: 33140180; PMCID: PMC7605473.
Is it better to rely on a few highly trained specialists—or an army of less experienced proceduralists? In this episode, Joe Bellezzo and Zack Shinar delve into the evolution of ECPR (Extracorporeal Cardiopulmonary Resuscitation), exploring the pros and cons of each cannulation model.They examine how different cities face unique challenges and opportunities when implementing ECPR systems. San Diego’s approach, in particular, offers a replicable framework that may work for other urban centers. Joe and Zack break down the specific strategies that helped San Diego develop a successful and sustainable model.
Zack Shinar interviews Pranay Oza, an intensivist from Mumbai, and Simon Sin, an intensivist from Hong Kong, about the insights, necessities, and opportunities for ECPR in India and China. Both of these physicians are leading the charge in places where ECPR is exploding. Listen to this podcast to learn how they optimize their skills and resources to utilize this powerful tool.
Jon interviews Dr. Stephen Wall from NYU on the podcast where they discuss the need for organs and how ECPR inclusion criteria can significantly impact the problem.
Stephen P. Wall, MD MSHS MAEd, is Tenured Associate Professor in the Departments of
Emergency Medicine and Population Health, NYU Grossman School of Medicine. Dr Wall was
project manager and lead methodologist for the NYC uncontrolled donation after circulatory death
(uDCD) program that attempted to increase kidney donation opportunities by considering those who
die unexpectedly outside hospitals. Results showed the public was supportive of uDCD, so long as
permission is obtained prior to any invasive procedures being performed on the deceased. Lessons
learned from the Kidney uDCD program provided justification to attempt in-hospital Lung uDCD in
NYC, a project funded by NHLBI (R61/R33HL156890 – PIs Wall and Robert Montgomery, MD PhD).
These projects involve cross-disciplinary collaborations with bioethicists, clinical experts from
medicine, surgery, emergency medicine, and transplantation, both within and external to hospitals
and academic medical centers. Dr. Wall’s research was covered in news media including NPR,
NBC, and the Atlantic.
In our last episode, Trina Augustin discussed whether we should use a blender in ECPR patients citing the Blender Trial. This month we got the first author of the Blender Trial, Aidan Burrell, to give us insight into the use of blenders for not only ECPR patients but also thoughts on patients on VA for cardiogenic shock and VV patients. Jon Marinaro interviews Aidan for this wonderful addition to this complex decision.
Blender Trial – Burrell A, Ng S, Ottosen K, Bailey M, Buscher H, Fraser J, Udy A, Gattas D, Totaro R, Bellomo R, Forrest P, Martin E, Reid L, Ziegenfuss M, Eastwood G, Higgins A, Hodgson C, Litton E, Nair P, Orford N, Pellegrino V, Shekar K, Trapani T, Pilcher D. Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial: Study Protocol and Statistical Analysis Plan. Crit Care Resusc. 2023 Aug 4;25(3):118-125. doi: 10.1016/j.ccrj.2023.06.001. Erratum in: Crit Care Resusc. 2024 Feb 01;26(1):60. doi: 10.1016/j.ccrj.2024.01.003. PMID: 37876374; PMCID: PMC10581278.
Trina’s editorial – Augustin K, Shinar ZM, Dos Reis Miranda D. Correspondence by Augustin et al. regarding the article “Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation”. Intensive Care Med. 2025 Jan 21. doi: 10.1007/s00134-025-07791-7. Epub ahead of print. PMID: 39836262.
This seems like such a basic question and yet the answer is not an answer at all. Rather it is an educated opinion. Today we ask the question – Should we blend ECPR patients?
Here’s the basic problem. We think hyperoxemia in critically ill patients is bad (Remember hyperoxemia is high oxygen in blood, hyperoxia is high oxygen in the tissue). We think that hypoxemia in critically ill patients is bad. So if a patient gets put on ECMO and we can make the oxygen level coming out of the machine whatever level we want, what level should we set it at?
Well, today, Trina Augustin teaches how this seemingly simple problem is actually quite complex. Trina is an ECMO superstar. She practices at Mayo in Rochester as CV Intensivist with a background in CC/EM. She teaches the most complex part of Reanimate – post pump critical care and yes she cannulates patients as well. Listen to Zack and Trina banter over this complex topic specifically focusing on the release of the Blender Trial.
EMCRIT ECMO Podcast with Trina that is awesome! – CV-EMCrit – MCS Minute Series: Differential Gas Exchange on Peripheral Femoral VA ECMO with Trina
Bibliography:
Winiszewski H, Guinot PG, Schmidt M, Besch G, Piton G, Perrotti A, Lorusso R, Kimmoun A, Capellier G. Optimizing PO2 during peripheral veno-arterial ECMO: a narrative review. Crit Care. 2022 Jul 26;26(1):226. doi: 10.1186/s13054-022-04102-0. PMID: 35883117; PMCID: PMC9316319.
Bureau C, Schmidt M, Chommeloux J, Rivals I, Similowski T, Hékimian G, Luyt CE, Niérat MC, Dangers L, Dres M, Combes A, Morélot-Panzini C, Demoule A. Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study. Anesthesiology. 2024 Jul 1;141(1):87-99. doi: 10.1097/ALN.0000000000004962. PMID: 38436930.
Burrell A, Ng S, Ottosen K, Bailey M, Buscher H, Fraser J, Udy A, Gattas D, Totaro R, Bellomo R, Forrest P, Martin E, Reid L, Ziegenfuss M, Eastwood G, Higgins A, Hodgson C, Litton E, Nair P, Orford N, Pellegrino V, Shekar K, Trapani T, Pilcher D. Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial: Study Protocol and Statistical Analysis Plan. Crit Care Resusc. 2023 Aug 4;25(3):118-125. doi: 10.1016/j.ccrj.2023.06.001. Erratum in: Crit Care Resusc. 2024 Feb 01;26(1):60. doi: 10.1016/j.ccrj.2024.01.003. PMID: 37876374; PMCID: PMC10581278.
EDECMO episode 92 features Dr. Mark Dennis, a cardiologist from Sydney, who has published extensively in the field of ECPR. Zack and Mark talk about so many subjects including pre-hospital considerations, algorithmic management of post ECMO initiation cardiac arrest patients, ventilation management of ECPR patients and much more.
Prof Dennis would like to thank all the ambulance paramedics, ED docs, intensive care specialists, surgeons, radiologists, nurses and cardiologists across Sydney. Without their support none of the work would be possible.
Also very special thanks to Natalie Kruit and Brian Burns for their immense efforts to bring ECPR to Sydney.
Blender Trial – Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation | Intensive Care Medicine
CO2 Drop in VA ECMO – ELSO Registry – Critical Care Medicine
Should we keep cardiac arrest patients on the scene when we have the ability to put them on ECMO in the hospital? That is the question we tackle this month on EDECMO. Brian Grunau and the great crew from Prague published a study looking at the Hyperinvasive trial data. They make some profound observations about the benefits of ECPR and some data supporting transporting patients early in functional ECPR systems. Saul Levine and Jonathan Goldstone from the SDRC join the podcast this month to give their insight into the formation of ECPR receiving centers as well as the paper.
Grunau’s Paper
- The time-dependent yield of invasive vs. standard resuscitation strategies: A secondary analysis of the Prague out-of-hospital cardiac arrest studyGrunau, Brian et al.Resuscitation, Volume 0, Issue 0, 110347
Editorial
Shock, Shock, Go
In this episode of the ED ECMO Podcast, hosts Zack Shinar and Jon Marinaro interview Dr. Powell & Dr. O’Connor from Baltimore Shock Trauma, exploring ECMO’s critical role in trauma care and its impact on patient outcomes. They discuss patient selection criteria for ECMO, managing hemorrhage and anticoagulation considerations, choosing between veno-arterial and veno-venous ECMO, practical insights on vascular access, and strategies for team coordination during ECMO emergencies. This discussion is essential for trauma surgeons, emergency physicians, critical care teams, perfusionists, and anyone involved in trauma care or ECMO deployment.
With the growing prevalence of ECPR, it is now more important than ever for all individuals in the medical community to understand what ECMO is, not just those providers who are directly involved with its use. In this new podcast series, Zack Shinar and Jon Marinaro help Nathaniel Dennis-Benford, a first-year medical student, explore what a medical student should know about ECMO and ECPR. In this first episode of the series, we start from the basics: what is “cardiac arrest”, how is it traditionally managed, and finally what even is ECMO?
AHA recommendations for ECPR at 2A – see article here
Free link for Zack and Dinis editorial on Lactate use here
If you are running or starting a US ECMO program, this episode is a must listen. John Mehall from Innovative ECMO Concepts goes through the financial aspects of ECMO care. He covers everything from hospital charges to physician reimbursement to areas where hospitals commonly fail. We all know that you cannot have a successful ECMO program unless you have sufficient funding to keep it going. Jon Marinaro, Zack Shinar, and an entire audience of Reanimate 9 attendees join the episode to ask questions and give their own insight.
Web Pricer (cms.gov) – your hospital weight. Times it by DRG to get your hospital ECMO compensation.
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 – https://web.cvent.com/event/ae91fbc7-6d71-45f9-8a6f-41fe973bfd23/summary
Oct – Prague ECPR School – https://www.ecprprague.com/
Nov – Reanimate Reanimateconference.com
Zack and Jon’s Editorial about Sakuraya PE trial
https://www.resuscitationjournal.com/article/S0300-9572(23)00267-8/pdf
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 and her army of 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 ELSO is setting up standards for ECMO programs to try to make ECMO care at all hospitals to be safer. She talks about how she works also with the device industry. This involves working with the FDA as well as for future innovations. 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!
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.
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. 2018 Jun;84(6):831-837. doi: 10.1097/TA.0000000000001895. PMID: 29538235.
The Netherlands has undertaken a monumental task: provide ECPR to 100% of their country. Dinis Reis Miranda and his team have put in place an unbelievably organized and robust project to improve the survival from cardiac arrest for their entire country. Listen to Dinis explain about the project, their struggles, and this world changing experiment going on right now in the Netherlands.
Here is their projects website and some of its content – https://onscenetrial.com/
In this short episode, Zack makes two points. One, it was tough to get to where we are with ECMO acceptance. Two, cardiac arrest patients in PEA should be considered for ECPR. Below is the full editorial Zack and Alice did recently in the Journal of Resuscitation on the topic. It was born out of a fantastic German article centered looking at registry outcomes for PE and ECMO.
Full Free Link to Editorial (until January 2022) - https://authors.elsevier.com/a/1eAXK_6ryqqpRd
Article link - https://www.resuscitationjournal.com/article/S0300-9572(21)00403-2/fulltext
Have you ever pondered whether all the work over ECPR was worth it? Even if you did save a few patients, does this really make sense from a societal standpoint? Am I giving up my life on a project where my efforts could be better elsewhere? Then this episode is for you (and me). This month I talk with Melissa Barnes and Ryan Coute about the economics of cardiac arrest and specifically ECPR. Ryan has just published a great paper in Resuscitation on the costs on OHCA. We will talk with Ryan and Melissa Barnes, ECMO manager at Sharp Memorial Hospital about benefits and costs to society of OHCA and ECMO. I learned several pearls from Ryan's paper as well as a paper by Grosse that Ryan references. Below are the links to both papers with a couple graphs to try to wrap your head around.
Wait...ECPR works?
To the believers, this has been a foregone conclusion. To the rest of the world, the question of whether ECPR improves cardiac arrest survivorship has been in question. Jan Belohlavek and his Prague colleagues just presented their 8 year data showing better outcomes in cardiac arrest patients that got a grouped therapy of early transport, prehospital hypothermia, mechanical chest compressions, and ECMO over those who got a traditional resuscitation. This study is key and contrasts to the Oslo study that we reviewed just a few months earlier. Jan speaks with Zack about the details of the results and what were the keys to their success.
Hyperinvasive trial study proposal - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492121/
Jan's slides on Hyperinvasive Results
Heparin has been the mainstay of anticoagulation for ECMO patients for years. In recent years, this has been challenged. Bivalirudin has b ecome a potential better anticoagulant. Troy Seelhammer in EDECMO episode 55 gave us some insight into this. This month Ryan Rivosecchi and his crew at UPitt have released their findings in Critical Care Medicine. This retrospective study suggests great improvement in major bleeding in patients who received Bivalirudin compare to Heparin (40.7% vs 11.7%, p < 0.001). Listen to Ryan and Zack discuss anticoagulant use in ECMO patients in this month's episode.
Rivosecchi RM, Arakelians AR, Ryan J, Murray H, Padmanabhan R, Gomez H, Phillips D, Sciortino C, Arlia P, Freeman D, Sappington PL, Sanchez PG. Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin. Crit Care Med. 2021 Mar 15. doi: 10.1097/CCM.0000000000004944. Epub ahead of print. PMID: 33711003.
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In this episode, we dive into the abyss of resource allocation. Much of the world is saying that the limited number of ECMO circuits should be used for COVID induced lung injury. This means that ECPR initiatives have been shut down or severely limited. Is this the right thing to do? What does the data say? What strategy gives the most benefit to the most people? Zack invited Brian Grunau to discuss these topics as well as a recent ECPR paper out of Norway and study dealing with signs of life during CPR.
In this episode Joe Bellezzo talks with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) expert Zaf Qasim about NON-TRAUMA applications of aortic compression for control of non-compressible non-trauma torso hemorrhage.
2020 was a crazy year. This month Zack goes through the biggest ECMO lessons learned in 2020. This is a short concise run through of ECPR, ECMO for COVID, Imaging, and Aortic Dissection. It's a reminder of how organization is so critical to the outcome of your ECMO program. He also reminds us how improvement in these systems of care can lead to survival rates even the believers in ECMO thought were unattainable.
The ARREST Trial is published! Demetris Yannopoulos, Jason Bartos and their army of rockstars have done it! This is the first randomized ECPR trial and it showed tremendous benefit of ECPR compared to traditional therapies. Zack explores this paper and their concurrent publication of process with Demetris. Their two Lancet papers are below
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32338-2/fulltext https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30376-X/fulltext
In the news, Jenelle Badulak and her crew at UW saved a hypothermic mountaineer in Seattle. Story here.
https://www.bbc.com/news/world-us-canada-54959874
Have you ever wondered about how initiating ECMO changes the cardiovascular physiology? Have you wondered what metrics you should be looking at when resuscitating a patient that has a beating heart and a ECMO flow? Dr. Sage Whitmore, an ED Intensivist from Nashville with ECMO training from UMichigan, leads us through the basic to the tough questions of ECMO physiology. Zack Shinar
Have you ever wondered how you would crash someone onto VV ECMO? Have you ever wondered where is the best place to put the cannulas? Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO? Then this is the episode for you!! After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject. Zack gets critical care physician David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO.
This month we tackle a number of topics. Garrett Sterling is back again with Zack Shinar to talk about cutting edge resuscitation, ECMO, and the interplay between the two. Dual sequential defibrillation, CT after ECMO initiation, should you perform bystander CPR in the era of Covid, some US ECMO data, and an awesome 3D modeling for ECPR training models. All in one 30 minute podcast!
In this episode, Zack Shinar introduces a new physician to the podcast - Garrett Sterling. Garrett and Zack discuss the sticky topic of ECMO for aortic dissection. This traverses everything 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?"
"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 get to play as we begin the surge of Covid 19 in the United States. 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 who we should put on ECMO with Covid.
Hosts - Zack Shinar, Jenelle Badulak
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 Demetri, 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.
Today's episode focuses on the differences between ECMO physiology in the patient in cardiogenic shock versus the one in cardiac arrest.
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.
Over the last two years, partial or intermittent REBOA has been thought to be a significant advantage over complete REBOA. How to do this and how to use our current imperfect catheters in this arena is still in question. Matthew Martin and his colleagues at Madigan Medical Center have published the first study using the Prytime's new catheter for partial REBOA. Zack interviews Matt in this episode about his latest paper in Journal of Trauma and Acute Surgery. 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.
A post arrest patient just got initiated on ECMO. Do you give fluids, add pressors, or increase flow? Marc Dickstein, an anesthesiologist from Columbia University and an expert in the physiology of ECMO, talks with Zack about how to manage these patients, what diagnostics we need and how to optimize your use of the machine. This talk is a must for everyone starting ECPR in their departments.
Do you give heparin to your ECMO patients? Well, let's rethink this. This episode is All Things Anticoagulation! Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester. He manages ECMO patients in his daily practice there. He has become a master of the subject of anticoagulation. He will talk about heparin, bilvalirudin, or maybe no anticoagulation. He talks about the when to be aggressive and when to cut back. Below is a wonderful synopsis of Troy's thoughts on anticoagulation on pump.
In this episode, Sacha Richardson talks with Zack about a problem common to all ECPR programs- how do we confirm the placement of the wires? During chest compressions and even in patients with a pulse, confirmation of which vessel you have cannulated can be difficult. Sacha shares some tricks and trips on how to get real time confirmation of the wires. Sacha also gives us a preview of some of the exciting endeavors that he has undertaken in Melbourne with pre-hospital ECMO.
In this episode, we again explore the world of the distal perfusion catheter. You heard from Joe Dubose the vascular surgeons point of view; now let's see how non-surgeon resuscitationists are dealing with this problem. You will hear from Chris Couch, a critical care trained emergency physician from Dallas Texas and his colleague Omar Hernandez who have some novel thoughts and experiences related to when and how we insert these catheters. You will hear about checking compartment pressures, poor man's way to "fluoro" your catheter, and much more.
Episode 53 is all about the distal perfusion catheter12. We are inserting a 15-19 Fr catheter into the femoral artery. This limits the flow of blood to the affected extremity. Many institutions have gone to mandatory distal perfusion catheters. This episode is all about those catheters - when, how, which, and where. Joe Dubose, the world reknown vascular and trauma surgeon, joins us to discuss the details of this important piece of post pump initiation.
We've all heard of therapeutic hypothermia. Some of us have heard of deep hypothermia for traumatic arrest. But what about deep regional hypothermia of brain for cardiac arrest! Zack interviewed Rob Schultz, a CT surgeon resident from Calgary who is doing research on deep hypothermia of the brain using some of the tactics that are utilized in operating room. His stuff is mind blowing!
You've heard of ECMO for cardiac arrest- utilizing a mechanical pump to aid in perfusion of the coronaries. What if you can't do ECMO? What if your resources are such that simply can't lug a 10 kilogram machine out into the field? Well, Jostein Brede may have something for you to consider. He and several other places worldwide are on the forefront of using a REBOA catheter to occlude the proximal aorta during chest compressions in hopes that coronary perfusion pressure increases. This would subsequently improve chance of return of spontaneous circulation and overall survivorship. Maybe this is the band-aid that can be used in austere environments like rural Norway where the temperatures are extreme, the people are sparse, but the physicians are motivated.
This is part 2 of Transport of ECMO patients. Mikael Broman is one of the world's leaders on ECMO transport. He works at the Karolinska institute in Sweden and has and continues to publish in the arena of ECMO transport. As you will see, he offers a world of experience and certainly some critical information that we would all benefit from listening to. I'm a smarter ECMO-tologist as a result of Micke!
This month we are looking at how to transport patients from one facility to another on ECMO. This is difficult task full of potential catastrophes. Zack interviews Leon Eydelman, an ER/Critical Care physician from Chicago, and Michael Broman out of Karolinska in Sweden. Leon will be bringing us up to speed on what to do, potential fails, and how to start the process of setting up a transport process for ECMO patients. Dr. Eydelman will be teaching a new section at Reanimate this January specifically geared toward the transport of patients. So if you are a nurse, medic, perfusionist, RT, or physician involved in the transport of ECMO patients you will not want to miss Leon's section Sign up at Reanimateconference.com. Part 2 of this podcast includes the interview with Dr. Broman which will blow your mind. So much great stuff in both of these interviews.
n this episode, Zack Shinar interviews Zaf Qasim about the recent controversies with ACEP and ACS about who can do REBOA. Zaf is one of the world's experts on REBOA and he's an ER doc! Zaf works at the University of Pennsylvania, trained in London
as well as Shock Trauma in Baltimore and teaches at Reanimate. When you come to the essence of this episode, the question is what is the emergency physician's role in the trauma resuscitation? Both Zaf and Zack agree; we need to be the resuscitationist in the trauma suite. We need to manage the airway and then quickly take over the arterial and venous access, interpret the transduced pressures, manage the massive transfusion protocol and be ready to insert the REBOA catheter while the trauma surgeon is involved with the left chest, the source of bleeding and where the next destination for this patient will be.
This part two of August 2018. We are now tackling the difficult question of when to transport cardiac arrests if I have ECMO available? Brian Grunau is an expert in this question. Brian has become a giant in the world of ECMO. His research, leadership and experience have pushed the Canadian ECPR contingency to the forefront. Brian gives us some insight on what factors I should consider and when should I transport.
Over this last year we have had episodes on organ donation and decision to transport. This month we are revisiting two topics with two amazing people in two separate episodes. Here, I interviewed Velia Marta Antonini. Velia works in Italy where several of the great ECMO donation papers have originated. She explains why this research is coming from Italy, what the process looks like, and the implications of this for other countries. Check out her slides below.
Well, it only took us seven years to figure this one out. The wire assistant has been the key advancement of 2018 for placement of ECMO cannulas. In this episode, Zack and Joe talk through this process after an interview with Alyssa Baldini. Alyssa was one of our first true wire assistants and has been instrumental in getting cannulas in faster and safer. We discuss how the wire assistant aids in sterility and getting the artery on the first stick. Bottom line - train someone at your shop to be an expert wire assistant.
In this episode, Zack talks with Heidi Dalton about ECMO use in Sepsis. This is another controversial area with pediatric literature showing strong results while the adult results have been less impressive. Heidi has been a key figure in both adult and pediatric ECMO. She is the former chair of the yearly ELSO conference. She is a professor at both George Washington University and Virginia Commonwealth University. Her background is in pediatric critical care. She currently works at INOVA in Virginia where she is the director of adult and pediatric ECMO. So the question for today is should we be utilizing ECMO for sepsis?
In this episode, Zack interviews Bob Bartlett from the University of Michigan. He is truly the godfather of ECMO and has revolutionized the world with his leadership and innovation. They discuss the history of ECMO and roller pumps and bubble oxygenators were clearly inferior to their current counterparts - centrifugal pumps and hollow fiber oxygenators. They also discuss anticoagulation and how Bob feels direct thrombin inhibitors are superior. They also discuss the future of ECMO and how peristaltic pumps may be where we are headed.
In this episode, Alice Hutin of the Paris SAMU talks about the modified cutdown approach to cannula insertion. She is an emergency physician who is one of four physicians who take call on the pre-hospital ECMO ambulance. She describes the process of their modified cutdown. First, incision through the skin is made 2 cm below inguinal crease. Second, blunt dissection down through the soft tissue. This is best done with your fingers. Third, place a needle through the distal skin and visualize it pass into the vessel. From there, you cannulate as with percutaneous. Alice’s recent paper shows a 6% failure rate with this technique in skilled hands.
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.
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:
In this episode, Joe talks with Dr. Sean Deitch, a non-academic Emergency Physician practicing in San Diego, California. Dr. Deitch attended REANIMATE 3 - which just finished 2 weeks ago...and has an amazing story to tell. You'll have to listen to the episode...
REANIMATE 4 is September 21-22, 2017 and features guest faculty member Stephen Bernard - coming all the way from Melbourne, Australia - and best know from the original therapeutic hypothermia trials and CHEER. R3 was amazing and R4 will be even better!!
In this episode of the EDECMO podcast, Zack describes how to use the concept of 'TEAM PLAY", much like the gang from the classic novel "Bringing Down the House" by Ben Mezrich, to optimize outcomes after cardiac arrest....with, or without, ECPR.
In this episode we explore two very different applications of the Impella® device - a percutaneously-placed temporary ventricular assist device (VAD) sold by Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which is typically placed by interventional cardiologists under fluoroscopy. The inlet of the pump is placed in the ventrical while the outlet rests just above the aortic valve.
Here is a case of a young man who presented to the Emergency Department with profound anaphylaxis. This was a "CAN Intubate/CAN'T VENTILATE" scenario:
Max Epinephrine Max antihistamines Max steroids Max ventilator What options do you have? Find out in this episode.
Joe interviews Torvind Naesheim, an intensivist and cardiothoracic anesthesiologist from Norway, on the management of accidental hypothermic arrest using ECMO
Zack talks with the ED ECMO team from the University of Utah about how they established their ECPR program.
This is a real-world case of a multi-drug overdosed patient that would have died without ECMO. We talk about ECMO being a bridge to an intervention. Well, sometimes ECMO is a bridge to metabolism of drug/med that they OD'd on.
Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago.
In followup to our discussion with Jim Manning MD (@JManning_UNC) and Lionel Lamhaut (@LionelLamhaut) MD of the Service d’Aide Médicale Urgente (SAMU) for EDECMO Episode 25, the guys spent the last few days 'just hanging out in Paris."
In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut from the famed French SAMU (Service d'Aide Médicale Urgente). REBOA. SAAP. Pre-Hospital ECMO. Its all here.
In this episode, Zack and Joe talk with Deirdre Murphy, the Deputy Director of the ICU, director of the cardiothoracic ICU at the Alfred Hospital in Melbourne, Australia. The Alfred has put itself on the map in so many ways over the past decade. Home to Stephen Bernard (of the original Hypothermia after ROSC without RONF fame), Chris Nickson (@precordialthump, @I_C_N, @intensiveblog, #SMACC, lifeinthefastlane.com), and good friends Jason McClue, Steve McGloughlin, Josh Ihle, Paul Nixon, and Deirdre Murphy, The Alfred is becoming a mecca for advanced resuscitation and ECMO/ECPR. In this episode we sat down with Dr. Murphy to discuss the nuances of weaning a patient from ECMO.
As ED Docs, Zack and I find ourselves at the heroic end of the resuscitation spectrum when the dying patient goes on pump...but what happens at the other end? What happens in the hours, days, and weeks that follow? Listen to this episode to find out...
Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015. How it all unfolded is amazing. Listen to this episode to hear the details...
In this episode Scott, Zack and Joe were all in the same room...in a conference room at the University of North Carolina, Chapel Hill - where we were doing ECPR studies in an animal model of cardiac arrest with Jim Manning. We spoke with legendary toxicologists Leon Gussow and Steve Aks about the role of ECMO and ECPR in the overdosed tox patient.
REANIMATE is a 2-day conference that will teach you everything about Resuscitative ECMO and Extracorporeal Cardiopulmonary Resuscitation (ECPR). The conference will be hosted by Zack Shinar, Scott Weingart, and Joe Bellezzo
In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing "Load & Go" (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. "standard care" (staying on scene until the patient achieves either ROSC or is pronounced dead). Zack and Andreas talk about the impact this could have on the future of ECPR for OHCA.
In this episode, Joe talks about that first critical hour on Heart-Lung Bypass. What are the most common and critical clinical scenarios that the ECMO operator faces in that first hour on pump? Listen to this episode to find out.
Using parts purchased at Home Depot, Zack took apart a Tall Paul Anatomy Mannequin and built the whole thing from scratch. This is how it went down!
Tetsuya Sakamoto is the principal investigator of a multi-center prospective observational study that was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Sakamoto during the 2014 AHA RESS conferences and talked all things ECPR. After that, Shinar sat down with Dr. Sakamoto to get his take on how the Japanese EMS system is setup and how they are able to implement ECPR into their resuscitation protocols.
In this episode Zack & Joe talk with Graham Nichol about how to use remote ischemic conditioning to reduce ischemia-reperfusion injury after cardiac arrest.
In this short segment that was generously produced and offered by the EM:RAP team, Zack and Joe recap some the the big topics from the American Heart Association 2014 conference in Chicago.
In this episode Zack talks with Lionel Lamhaut, a physician who is heading up their pre-hospital ECMO program. Yes, they are really doing ECMO in the field.
Zack & Joe talk with Dr. Cyrus Olsen about the challenges of deciding who does, and who doesn't, get advanced resusctition.
In this episode Zack and Joe discuss the CHEER Trial (mechanical CPR, Hypothermia, ECMO, and Early Revascularization) and follow up with Dr. Stephen Bernard with a few more questions about ECMO at the Alfred.
In today's episode, Joe and Zack interview Dr. Stephen Bernard about Extracorporeal Cardiopulmonary Resuscitation (ECPR) and how they do it the Alfred in Melbourne, Australia.
Zack and Joe and discuss two high-impact articles that compare conventional CPR to ECPR.
In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a "nurse-run" ECLS program.
Video Promo for the "Bring Me Back to Life" conference coming up on October 21, 2014 in Montreal!
~Based on a listener voicemail message, this episode focuses on the cognitive task analysis of ultrasound during ECPR.
When your only option is to put the horse before the cart you focus on the basics: like history and physical exam, not ECMO!
Joe talks with Peter Rosen, one of the Godfathers of Emergency Medicine, on the topic of life & death
In this episode we talk about how protocols, defined roles, and pre-planned choreography of a medical code works. And we also do a few things different than you...
Who Gets ECPR and Who Doesn't? This may be the hardest question we deal with when a patient arrives and ECPR is a consideration.
In this episode, Joe and Zack discuss some of the terminology and basics of ECMO and ECLS.
In this episode you'll hear why we started the EDECMO project and a little bit about what we hope to offer.