Podcast 057 – Resuscitative Extra-Corporeal Life Support (ECMO)

Resuscitative Extra-Corporeal Life Support for Cardiac Arrest (ECMO)

Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works.

What is ECMO?

ECMO is actually a misnomer. Extra-corporeal life support (ECLS) is probably a better term. If a catheter is placed in a major artery and a major vein (VA ECMO), the patient can be provided with full hemodynamic and respiratory support, aka cardiopulmonary bypass. If catheters are placed in two major veins (VV ECMO), the patient’s respiratory status can be maintained, but without the hemodynamic augmentation. Dr. Bellezzo’s shop is using VA ECMO to treat refractory cardiac arrest patients.

This is not the first attempt to use ECMO in this patient group, (see the articles in the EMCrit Hypothermia/Post-Arrest Section) but I think this is the first ED physician initiated service.

Which patients are they crashing on to ECMO?

What are the stages to placing a patient on ECMO?

Stage I-get catheters into a femoral artery and femoral vein

Stage II-exchange these catheters for the enormous ECMO catheters vias guidewire and serial dilations

Stage III-attach them to the ECMO machine, which is run by specially trained ICU nurses for the first 45-60 minutes and then by a perfusionist.

Don’t you have a video?

Dr. Bellezzo was kind enough to let me post this video

If you have any questions, place them in the comments and anything I can’t answer, I’ll forward to Dr. Bellezzo

Now, on to the Podcast:

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Comments

  1. I’m very interested in how this plays out with EMS transport of cardiac arrest victims. Many areas have finally reached the point where they’ve stopped treating cardiac arrests as “load and go” and their survival to discharge numbers are getting better. I wonder how you’d orchestrate the movement and transport safely (while maintaining the CPP everybody was working hard on) without something like mechanical CPR support. Do the EMS agencies in Dr. Bellezo’s service area use mechanical CPR devices on cardiac arrest transports?

    Some of the papers on ECLS out of France and Japan are pretty interesting too. I wonder how feasible it would be to get a doc out to the scene in a fly-car with a mini-ECMO setup?

    • Joe Bellezzo says:

      Christopher, these are great thoughts and we discuss these exact issues every time we the topic of “who to transport” comes up. Our EMS community does not use mechanical CPR machines. So its a tough question. As yet we have no county protocol to make these decisions but they are on the horizon. I do think that mechanical CPR devices will be the key to effective transport of these patients.

  2. Fletch S. says:

    Isn’t part of the point of CPP to keep continues compressions going and get to the hospital as fast as possible?
    I think the idea needs to be load and go. Place a LMA, IO and start the drugs and get to the ED where you have more help.

    Maybe the new thing is to have a Code team respond to the ED for assistance on patients with a possibility of survival with criteria of activating the team like the one above.

    The idea of load and go needs to be pushed as well as the usage of air ambulances. However the idea of a flight nurse trained on ecmo would help but then their is the need of gaining access.

    • You really can’t perform the same quality of compressions in a moving ambulance like you can on scene. Nor do you have nearly the same amount of room to work (excluding situations where you’re working them in bathrooms, etc).

      My biggest concern, however, is moving the patient from the scene to the truck can sometimes take more than a few minutes. The first 10 minutes are vital for the patient and the quality of resus care early likely dictates their survival to discharge. My last code took 4 minutes to get from the house to the truck, but we’d achieved ROSC prior to movement so the patient didn’t go that time without compressions.

      If you need more help, wake up another unit or station (they weren’t doing anything anyways, right?). Wake County NC sends additional engine crews and ambulance crews to ensure the patient has enough providers to ensure continuous, effective compressions.

      I do agree though, bringing the resources to the patient is the next logical step if you lack continuous mechanical compressions!

  3. As Chrisotpher alludes to, many leading services have moved to full on-scene resus. FDNY has everything I have in the ED including hypothermia. ECMO is the first reason I could give for why shorter scene times may be superior. Fletch may be right, the ideal solution may be sending a doc with ECMO set-up to the scene.

  4. I agree with Christopher in regards to the logistical difficulties in transporting these pts quickly to hospital without mechanical CPR. Here in Melbourne, we perform full resus on scene including hypothermia and are currently trialling therapeutic cooling during CPR as opposed to post ROSC. We consistently have ~60% survival to hospital and ~30% survival to discharge for pts presenting in shockable rhythms. Outside the paediatric population, CPR to hospital very rarely occurs here due to the inability to perform effective CPR as well as the inherent danger to the paramedics inside.

    Ideally, getting a doc out with ECMO setup would be the go but that also takes time, and I dare say if the crew was slick and you were in a metropolitan area, you could have the pt in hospital and perform the procedure in a more suitable environment.

  5. Awesome stuff- this will probably be the next frontier in emergency medicine. This could change out of hospital arrest back to a load and go situation unless we can find logistical ways of bringing ECMO to patients in the field as others have mentioned. One question I have- what is the rate of line infection and sepsis in these patients who have these harpoon sized catheters placed in a crash situation?

    I am encouraged by the fact that the centers who offer this are carefully selecting their patients. The one pitfall I can see with this technology is that we start applying it to the wrong people. In otherwise healthy people who suffer massive cardiac insults who are either witnessed with immediate CPR or in front of a healthcare provider this can be the lifesaver that we have been looking for. However, let’s not make sure that we don’t start applying it indiscrimintely to the point where “no one dies without an ECMO trial”. Let’s make sure that we use it in the right people and we aren’t giving it to elderly nursing home patients with dementia or those with terminal cancer and so on.

  6. Joe Bellezzo says:

    Resuscitation Center Model???

    Now that we have the ability to do ED ECMO in the US, we are considering the options – in terms of managing the out of hospital arrest. After much discussion on this topic, its unlikely that it will be possible to establish a model where an ‘on call ECMO doctor’ would be able to go to the scene and initiate ECMO in the field. While the technology is there (LifeBridge and Maquet have self-contained self-priming ECMO machines now), this model won’t likely survive in the US – primarily due to financial issues.

    But what about the idea of a Resuscitation Center Model? In this model, specific patients who meet specific criteria (ie young-ish patient, witnessed arrest, CPR initiated immediately, medic arrival within 10 min, EMS resuscitation <10 min, initiate cooling en route, anticipated transport time < 10 min to the resuscitation center). The Resuscitation Center would be an ED that has an ECMO trained ERMD, the appropriate ECMO machinery and would also likely be a STEMI Receiving Center. This model would carve out a specific subset of patients who may benefit from ECMO as a bridge to the cath lab, yet would otherwise die. All other patients get managed no differently than they are today.

    • The fact that we have a specific STEMI Receiving Center is nice for the patient, but is only part of the reason it works. I think an integral part of my area’s STEMI system is the prompt and actionable feedback given on each case to everyone involved; whether it was a field activation coming in by EMS or an inter-facility transfer. They’re able to provide useful feedback because the data (my ECG) is provided with the patient.

      Where a Resuscitation Center would shine would be prompt and actionable feedback for the EMS crews, using data downloaded from their monitors. If this process was streamlined it could even be done immediately upon arrival (compression time fraction, ventilation rate, hands-off-the-chest time, etc). Even if it was done out of band, a hospital-EMS feedback loop should be in place from the start.

      Empowering your field providers, through education and feedback, is a quick way to build support for these systems.

    • Good day Dr. Bellezo.

      For at least 4 years I have been involved in the development of ECMOJet, Or ECMO Flight…with real ECMO temas with CCP, Neonatologist or surgeon, RN and all the necessary support, that will allow us to in many instances, go to the patient, cannulate and transfer already on ECMO. The technology is here and we are precisely looking for a center like yours to offer our support.
      We are in the process of redesigning our medical interior to make it sufficient for all the necessary equipment.

      We have been primarily looking to serve the neonatal population but adult ECMO is now here and we will adapt.

      I will be available to discuss this further, along with our perfusionist who can explain to you the mechanics and details of what we do.

      Hope to hear from you soon. All members are equally invited to share your ideas and needs and I am sure we will have a Flying ECMO at your disposal in no time.

      Manny Nunez

  7. soren rudolph says:

    Very interesting concept. Does the ECMO lines interfere with cardiac catheters used for PCI in STEMI patients?

    • Joe Bellezzo says:

      Soren, while the cardiologists indeed also typically use the femoral artery for access, the arterial ECMO cannula only extends up to the renal vessels and is typically a smaller caliber cannula than the venous line (the venous flow is the rate-defining catheter and therefore needs to be larger), so both can be present. In fact, we sometimes also insert an IABP into the aorta as well, also through the femoral artery…yes, three big lines in the aorta! In an ideal ED ECMO case, both venous and arterial ECMO catheters are placed on the same side, giving the cardiologist a clean slate on the contralateral side. That said, we take whatever access we can get in a chaotic code and quite often we end up with a venous cannula on one side and the artery on the other.

      One caveat, in the case of the patient in the above video, who happens to be the same patient that was discussed in the podcast, I placed the ECMO catheters in his right femoral vein and artery. But it turns out I inadvertantly back-walled the artery and the pump wouldn’t start. So we went to the other side and placed another ECMO cannula in the left femoral artery. So the cardiologist had ‘no access’. So we had IR come in and gain access via the left brachial artery, in the arm. PCI was done through this access point.

  8. Holly Nakano says:

    This is awesome. I think i recognize that man in the video.

  9. Van Chu says:

    Sharp ER docs are brilliant!

  10. James DuCanto, M.D. says:

    Joe, (Call me Jim), I have placed cannulas this large in the right internal jugular vein for veno-veno bypass (liver transplantation), and I cannot emphasize how important it was to use ultrasound for vessel location, initial wire insertion, etc… Most certainly you are using ultrasound during femoral cannulation?

    What you are doing is the logical trajectory of our technology. I have a “loaner” LUCAS2 in my training lab, and am running simulation scenarios involving its use with continuous ventilation using the Oxylator. There are case reports of LUCAS2 use during PCI with good results, so I am networking with my cardiac cath lab to determine their openness and willingness to begin utilizing such technology. Automated CPR does solve the problem of consistent CPR during pre-hospital patient transport. Any comments about these automated CPR units?

    Jim

    • Joe Bellezzo says:

      Jim, great questions. Here are my thoughts:

      1. Ultrasound guidance: I totally agree. In fact, once the heart stops beating (VFIB) the femoral vein becomes huge in comparison to the artery. We sometimes find that we need to approach the artery at an angle because the vein starts to obstruct direct access to the artery. Ultrasound is the only way to accomplish this. Limited sticks in these vessels is crucial. So trying this ‘blind’ (without US) is not recommended. As an aside, we recently had a firefighter with asthma who crashed despite being intubated and all the usual meds. She was put on VV ECMO using a dual port catheter via her Jugular – placed with US guidance. She back to fighting fires again!

      2. Automated CPR: There is no question that this is the way to maintain good chest compressions during transport. I’m lobbying our EMS system to consider it. I haven’t seen the LUCAS2 yet. Do you have any data? Feel free to email me directly at emergency.md@gmail.com.

      Joe

  11. Joe Bellezzo says:

    I realize that for many followers of Scott’s amazing podcast ED ECMO simply isn’t an option – you just don’t have a mobile ECMO program at your facility. However, if you do find that your hospital supports an in-house ECMO program, and you are interested in mobilizing it to your ED, I would be more than happy to help you sort out the details. We’ve spent the last 1.5 years optimizing our ED ECMO program, improving fast access to the vessels, and protocolized the whole thing. I would be happy to share with any of you.

    As Scott mentioned in the podcast, the newest portable ECMO machines are now self-priming and ultra portable (about the size of a transport monitor and less than 10 kg). This opens many possible opportunities. Here are some thoughts on possible applications:

    1. Field ECMO. medics start the resuscitation and an ED ECMO physician could place the patient on pump in the fieldj.

    2. Crashing patient with refractory shock (massive PE, BB overdose, cardiogenic shock) who shows up at a community hospital. The patient could be put onto portable ECMO for transport to a facility like ours that supports these patients)

    3. Air Ambulance for remote applications.

    Any questions or comments? I encourage you to post your thoughts on the podcast so we can all benefit from questions and answers. If you have a question for me directly I also welcome your email. emergency.md@gmail.com

    Thanks,

    Joe

    • Minh Le Cong says:

      Hi Joe
      Great discussion. ECMO for air ambulance is in its infancy still. I know of one long distance ECMO retrieval from Vanuatu to Sydney last year. At that presentation at an aeromedical meeting, the retrieval team said it required a perfusionist, cardiac surgeon, anaesthetist and another retrieval doctor. In your suggested concept of a field EMS physician going out to start ECMO, is it with only one doctor, or do you mean to go out with a trained nurse/perfusionist as well?

      I am impressed you have perfected USS guided arterial line placement during CPR! Was it a steep learning curve?

      • Joe Bellezzo says:

        Minh,

        So sorry I missed your question! I was reviewing some ECMO stuff and re-reading the comments here and realized I never responded to your questions.

        I look at your questions of ‘field ECMO’ as having two components that need to be addressed. The first is line placement. You can easily do it! Its quite simple and can be done blind (without US) in the field. I would add that you should attempt the arterial access if and when any pulse is available. once the pulse is lost…the artery is tough to grab! But the catheters are nothing more than HUGE femoral lines. puncture > wire > dilate > catheter. Just like a cordus only bigger!

        The second component involves running the machine. Our current machine is somewhat complicated and therefore is very helpful to have either an ECMO-trained RN or a perfusionist. (Its likely not practical that you use either of these though!) So Maquet now has a machine called the ‘Cardiohelp’. Its small (about the size of a transport monitor), self-priming and easy to use. Admittedly I have only seen them and touched them…but never used them on an actual patient. There is a significant cost barrier to entry on these – the disposables for them are very expensive right now. That said, this is the machine I would take into the field. Lifebridge also offers a similar unit…but I’m more familiar with the Maquet stuff.

        Anyway I hope that answers your questions and I am more than happy to discuss more.

        BTW, I’m considering starting an ECMO-based resusc podcast/blog so if you get your program going please let me know!

        Joe

        • amazing comments, Joe. Folks Joe wrote an issue for EM Critical Care Journal on the topic, coming soon. His paper has just been published in Resuscitation as well.

        • Minh Le Cong says:

          Hey Joe
          thanks for the eventual response. You have been busy! Its quite coincidental too as about a week ago I got notice that our service is looking to fit our aircraft out to carry ECMO devices..not sure which ones yet. The paediatric retrieval teams from Brisbane are trialling an ECMO retrieval model. I know of a few cases in the last year that would have benefited from ECMO retrieval so I encourage the work and research that you are doing!

          • Joe Bellezzo says:

            Minh, you may want to take a look at the Maquet Cardiohelp (I have no affiliation!). We just met with them tonight and the unit looks very promising. Small, self-priming, self-adjusting, portable, and can be initiated by the same practitioner who places the lines. We are putting together a study in our ED using the unit. If that flies, then we may be looking at doing our own field-ECMO trial…eventually! Good luck and please keep me in the loop on this stuff. Please feel free to email me directly at emergency.md@gmail.com as well.

  12. Joe Howton MD says:

    Has ECMO ever been used for the ARDS presentation of patients with fulminant influenza? With Novel H1N1 and H5N1 the patients are often younger, healthy with no co-morbidity, seemingly good candidates for ECMO.

    • Joe Bellezzo says:

      Yes. ECMO has been used on these patients. Great candidates. Of course, these patients are already intubated…on pressors…and still circling the drain. ECMO is life saving for these folks too. You may have to decide between a VV ECMO solution (only oxygenation support) or VA ECMO (O2 and blood pressure support). For VV ECMO we have single catheters with dual ports that are usually placed in the IJ – ports in the upper SVC and lower IVC are taking blood from the patient and into the ECMO circuit…oxygenating the blood and returning the blood to a port that is ideally right at the right atrium. For VA ECMO you need two catheters as outlined in this podcast…

      Joe

    • You’ll find an interesting paper about ECMO-use during a flu-epidemic here:
      http://www.ncbi.nlm.nih.gov/pubmed/21465083
      (10 patients overall)

  13. At the Department of Emergency Medicine at the Vienna General Hospital (Austria/Europe) ECMOs are being used for resuscitation at the ED at least since 1998, supposedly even longer.

  14. Very interesting indeed. What kind of overall survival rates are you seeing? What percentage of stroke or bleeding complications do you see? Also, what is the average length of ECMO support?

  15. Unrelated to ecmo in resus situations, but are any of you aware of any cases of ecmo being used as a bridge to lung transplantation in patients with severe interstitial lung disease such as idiopathic pulmonary fibrosis, if mechanical ventilation is ineffective?

    I have found several papers describing that it is possible to use ecmo as a bridge to LTx, any thoughts on this if the patient is otherwise healthy other than the respiratory failure caused by the IPF?

  16. Jeremy Webb M.D. says:

    Are there any training options available in the U. S. for non-surgeon ED docs to obtain training in resuscitative ECMO?

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