ED ECMO presentation - sjrhem.ca
Transcript of ED ECMO presentation - sjrhem.ca
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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.ShockSBP<70refractorytostandardtherapiesExclusion:inasystole,nocompressionwithin10minofarrest,transport>10min,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- <75,witnessohca,vforvt,norosc within15minofaclsResults:6%ofpatientsmetcriteria- 11%weretransportandonly17%ofthosemetthecriteria
StartofabaseofliteraturethatsaystheincidenceofidealpatientsforECPRandpotentialguidelinesforEMScrews
NOTE:thisgroup– thevienna austria ecmo group– hasbeendoingthisfor10yearsintheirED– theycurrentlyinitiatinganRCTforEDECPR
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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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