SCCM Resource Library-Staying Alive: Resuscitative Devices to the Rescue

Video Transcription

My name is Scott Weingarten. I'm an emergency intensivist from New York. I'll be co-moderating this session with John. John, introduce yourself to the folks.  I'm John Wickham, professor and director of nursing here. What he's saying is he, unfortunately, his mic is not working. It's John Wickham. He is a professor and director of nursing  at Clinton in South Carolina. And we'll introduce our first speaker, Paul Pepe, who's going to talk to us about mechanical CPR devices.  Paul's the retired chair of emergency medicine from UT Southwestern. He is a medical director of countless organizations, including Dallas County EMS and Public Safety.  He co-founded the National Association of EMS Physicians. And I can't go through all of the accolades that are on his CV, so we'll just leave it there. That's right. Good plan.  Good to see you. Yeah, today I'm representing the Riverside Homeowners Association. So all right, let's see what we got. Oh, I can see the slide from here.  So before the main talk, as usual, you got to give the four inevitabilities of life, what death, taxes, where's the other stuff? Kale and disclosures, right?  So I have absolutely no disclosures, except for that I'm not a morning person, et cetera. But having said that, today I think I was brought here because I absolutely  know very little about mechanical ventilation and was actually brought up to basically make the other speakers look good. But that there is a rationale for me being here.  We're going to whip through this. It's got to be pretty quick talks to get through the whole hour here. But like this, most veterinary students for equine medicine,  taking care of horses, broken leg, whatever, shoot, shoot. So we're going to start breezing through chapter 9 here. All right, so two main mechanical devices,  when people think about mechanical CPR devices, people generally think about these two products that are out there. There are some others, but I'm going  to focus because most of the studies have been in this area. The one on your left is called the AutoPulse machine. And you'll see it's a band that goes around the chest.  It tightens up and then goes on around the chest. I'll show you an example. And the other is called the Lucas device, which I can't remember what L-U-C-A-S stands for,  but it's an abbreviation. So here's how the AutoPulse works. It's a band that goes around. And essentially, it's the thoracic pump model.  Pejoratively, people have called it the geezer squeezer or whatever. But what it's like, kind of a turkey baster. And it does a better job, perhaps,  than basic CPR in terms of squeezing down a larger part of the chest and thorax. And then you get a release, which helps to suck air and blood in, presumably.  And that's the so-called thoracic pump model. Of course, you're getting a little bit of a jolt coming out from the pressure coming down on the compression part as well.  But that emphasizes what's really nice is you get a good recoil with this, which is exactly what you need to do during CPR. The Lucas device is more of a piston type of thing.  And the models that have been out that many of you are actually using, I see it in emergency departments and ICUs a lot, is a thing that sort of has like a,  I don't know what you want to say, like a plunger device at the end. On the other hand, it doesn't do a complete recoil.  Or it does complete recoil, but doesn't go beyond the recoil. Originally, the concept was to actually not only compress down, but to actually suck up a little bit with it.  But that's just starting to happen with some later models that are out there. This is going to be quick regarding these two things.  There have been several trials that have been done, and I want to mention the ones that most people refer to, Aspire, Circlink, and there were some others.  Bottom line in all these studies, and I had to do a review for the FDA recently, was that they saw no difference from if you're doing quality CPR.  Now, if you weren't doing quality CPR, and like myself, they were found to be insignificant, okay?  So, any of that, that is pretty funny actually. I think I'm down to .212 now, right? Something like that. But any event, so the problem with that, if you go over those studies,  because I've seen these work pretty well in the laboratory, for example, is that there's so many confounding variables out there when you're doing studies.  One of the big ones was that it took original people doing some of these studies so long to get these things on  that you weren't getting any perfusion whatsoever. Some of the more recent studies that I'm about to show you actually have these things where they get the thing,  like they have videos out you can download, where you can get the Lucas device on between five and 10 seconds, and they really got it nailed down in some cities  like West Palm, Palm Beach County, for example, and done a good job. So, that's why I want to talk about stuff that's now, that's the evidence.  So, when we were out there doing the work for the FDA to say, what should we think about these, the general conclusion in the end was, well, no difference, but maybe it's safer  to do CPR on the way back to the hospital, so we'll approve it for those purposes, et cetera. And one of the things that Tom Ofterhardy,  if you don't know him, he's just like one of the people with the highest integrity that I know in the scientific world, and he's fantastic,  and been a science editor for the Heart Association and various others. And we wrote a paper called Evidence-Based Medicine versus Experience-Based Medicine,  which we kind of come across the point that there is evidence out there, and it's the best available evidence, but sometimes there are these confounding variables  that may throw it out, and our experience says, this thing actually works, but what went wrong here? So, a good example is in some of the early studies  that we've reviewed with clinical trials, whether it was intubation, epinephrine, or whatever it was, nobody was controlling for ventilation,  and everybody in this room, since you're in critical care, knows that positive pressure ventilation, especially if you do a lot of it, can knock out cardiac output,  particularly if you're hypovolemic or have other flow problems like CPR. So, what happened was they were overzealously ventilating in many of these cases, and in fact,  where studies were done, they went back and saw that they were giving like 30 breaths per minute when you probably should only be giving  like six per minute, probably, with good lung inflation.  So, a nice paper that came out recently to look at some of those studies was talking about the quality of CPR effect. One study that was done where to enter into the study,  you had to be doing good CPR, and yet, when you look back at it, only 80%, I mean, in 80% of the cases, the CPR was inadequate,  and adequate was actually very liberal, the definition. So, the quality out there in real life was maybe not so good. One good example of that was there a study  of a thing called the impedance threshold device, which is, actually, I'll mention it. When you do, like, say, the squeeze on the chest, and you release, you know, it goes,  and air and blood rush in, in a sense, you know, physiologically, but if you were to squeeze down and now cap the airway, it was like sucking through a straw in a milkshake,  and it tugs a little bit more blood in, but it's just there, the valve is just there for a second. It's a quick pop off, and it does fine. In any event, where I'm going with this  is that there was a study done, and it was a perfect gold standard study, New England Journal of Medicine, multiple cities. Everybody got an ITD, impedance threshold device,  except half were inactivated. Just elegant study design, it didn't show any difference. But what we found was is that if you looked  at the ones who got the sham ITD, the inactivated one, we found a sweeter spot where the quality of CPR was better, and you had better outcomes.  So, the quality of CPR was important. And, in fact, when you put the ITD in, now you looked at those 20% of cases that had pretty good CPR being done,  and, in particular, included those now, you could see that it almost doubled survival rates. So, I think the point to take home here  is that there are a lot of confounding variables, ventilations, quality of CPR, and when we make decisions, whether this mechanical device is good or bad,  or any device, any intervention, everybody goes, you know, it's good or bad. And they think in a binary manner, and it depends when it comes down,  is it being used right, is the timing right, and so on. And so, that's part of the problem, I think, and I've been getting more and more into recently.  And so, anyways, to move on there. If you're not with me, people get contentious about this stuff, if you're not with me, then you're my enemy, and as Obi-Wan wisely says,  only a Sith deals in absolutes, so, okay? All right, so, we were left with this thing  that this stuff is good for transport, and that's probably where it is, and so we're going on. Although, more recent studies, a little bit not well designed  in a sense, have anecdotally shown us better outcomes. And I'll give you a couple examples, maybe later on. However, there are other types of mechanical ventilation  that I want to quickly show you about. This is, in a sense, mechanical, and it's actually now not only compressing, but decompressing. It's going beyond the recoil and helping the,  this has been around for a long time, and the combination of that with the ITD was shown in a very nice study on the Lancet a few years ago, in which one year survival is improved  neurologically intact by 50%. And so, you have to ask yourself, why did that work? Was it that the ITD didn't make any difference? Well, they obviously had good quality CPR  during that study, which was, when you went back and looked at it, the quality CPR was generally better. What has happened since then?  We've added in a component of adding the head up,  and one of the things we found out is that you need to add the head up maybe a little later. You prime the pump with those other gadgets,  but with the ITD, with a pump, like this Lucas pump example, in the laboratory, we did that. And we did, in the laboratory, what we found  was that the thing at the bottom here, I wish I can, maybe I can get my pointer to work, yeah. This thing at the bottom, this is cerebral perfusion pressure  you go into a rest, this is in the laboratory in pigs, and then you use CPR over a period of time. Why does the CPR get worse here? Why are you looking worse?  Well, the cerebral perfusion goes over with CPR over 20 minutes because you're losing your peripheral vascular tone, oxygen, and you just don't generate pressure.  The head up is better because it helps drain blood out of the head and into the chest.  And then what happens is you see it still fades off. With the after compression decompression device coupled with the ITD, it actually sustains it and it's a little bit better.  What's interesting is if you add the head up, it's not additive, but synergistic, because they're all three different mechanisms that pull blood out of the head and into the chest.  And so, you know, when you do standard CPR, you're doing pressure waves that go up the arterial side and also up the venous side, so it's not so efficient.  Obviously, the arterial side kind of wins out, but over a period of time, it's less efficient. By pulling blood out, we get better flows.  So to quickly wrap this up, Palm Beach County, Florida, did a reverse trend Bellenburg, which is very rudimentary. They waited a few minutes to start doing it.  This was published last year in Critical Care, and what they did was double the survival rates almost in a matter of months when they started implementing this thing.  More recently, though, in terms of mechanics, there's a new device that's out, I don't know what company makes it or whatever, but I've used it in a laboratory.  And what we're finding is that thing I showed you before is it gradually elevates the head over two or three minutes. This is called DAXI, device-assisted control  with sequential elevation. And that thing basically has improved, this is just PEA-assistly patients, and you're getting over 75,  these are numbs resuscitated getting to the hospital. We didn't have the hard data yet as far as neurological outcomes yet. But it generally improved it from supine  to the rudimentary form to now doing this assisted thing. And what's interesting is that within five minutes of putting this on, they're generating normal CO2s  in about three quarters of the patient, even though most of these people are asystolic or whatever else. So on the roads of the 22nd century,  I hope that we shield that with some of these devices that dead shall be raised, and we'll make life better for future generations. I'm Paul Pepe, and I approve this message.  Thank you. Okay.  or a question or two, why don't you come up to the microphones if you have anything you'd like to ask Dr. Pepe. Don't make it too hard. I'll be scared to answer. Here comes someone.  Hey.  Any data on patients who are severely hypothermic, just having gone through this, whether any of the devices are better than CPR or manual CPR and so on? Actually, I don't have any.  Personally, I don't know of any. It may have been done. If anybody else knows of any, please speak up. I'm not aware of any where they specifically were hypothermic to begin with.  I mean, in fact, what's interesting is that the hypothermia, particularly in drowning, has always been considered a thing.  And this has been used in, for example, warm water drownings where the kids were under the water for over 45 minutes and then we got them back neurologically intact  because we're generating such good flows. So that's the only, I'm sorry I can't give you the answer about hypothermia, though. Appreciate it. But it's a cool idea. So, sorry.  I'm sorry about that. Can we have these panelist microphones on as well, my friends in back?  Yeah. I have a question for you. Sure. Okay. Whatever that was. I have a question for you, which is I've seen most of the literature coming from the pre-hospital environment.  Has anyone looked at the benefits in the hospital environment where you don't want to take dedicated staff and just leave them there for 45 minutes? Yeah, yeah.  No, and I'm not aware of any of that. But I think what happens is that I think it's been adopted and adapted, no one's really studied it per se.  And that's, you know, as far as I know, again, that's the problem with me is that I just don't know very much or either I've forgotten it or I'm just not old enough or,  you know, whatever. But I'm too old to remember anything. That's what it is. No, but I don't know. But a lot of people have adopted these things.  And I'm actually okay with that because I've seen it work and it does, and in fact, that was what we did decide at the FDA that for transport purposes,  particularly if you have CPR or you're going up to the cath lab or whatever, it seems to be very efficient. It guarantees, and that paper I did show you,  there are several models and some clinical situations where it's been shown that it's probably a good adjunct to use during that period of time.  It's just that the studies never showed it improved outcomes. But again, I think they were tainted. They had some, you know, design issues.  And I think today we're doing a better job. And this latest thing, as much as it's a historical control, I think it's been done in a very stepwise fashion  as have been very useful for me. And I'm now convinced, you know. You know, what isn't spoken about in any of the literature I've seen, and maybe you have advanced notice of some,  is it facilitates the ability to do things like ECMO or any of the procedures we want to do during arrest. And it's a huge benefit that's totally not discussed  in the literature for its advantage. Do you have any idea if anyone's looking at that specifically? Well, yes. For example, in Minneapolis, they, and again, it's,  it actually is seen as these things, like using a device and the ITD and the whatever I just showed you today, has been seen as part of a bridge study.  For example, Yiannopoulos' study where he brought people right to ECMO, et cetera, and then he went to, up to the cath lab  in those refractory VF cases, which only had 3 or 4% chance of survival neurologically. Now they're up to 40%. That, they specifically designed that study to use it  as a bridge to get there. To use these devices to get to the ECMO and then upstairs, et cetera. So, okay. Thanks for bringing that up, because that's a good point.  Alright. I think we'll, we'll close out the mechanical CPR. If anyone thinks of any questions, we will have a little bit of time at the end.  Let's have one more round of applause for Dr. Pepe. Yeah. Thanks. Thanks. I hope that was okay for you. Alright. Can we have the next set of slides up?  Here we go. Alright. So, the conference organizers for this device session wanted a lecture on Reboa, but not for its primary purpose, traumatic arrest, but for medical arrest.  And no one wanted to give this talk, and so I just volunteered to throw myself on the sword, because there's not enough data, I think, to speak towards this yet.  So, I'm going to give you a three-minute brief overview of where we stand, and then you can make your own decisions if it's ready for prime time.  So, this is the most commonly used Reboa catheter in the United States. Reboa stands for resuscitative endovascular balloon occlusion  of the aorta, and essentially what we're doing is we're putting this catheter through a femoral arch sheath, sending it up the aorta, just above the diaphragm,  and then we're inflating a balloon to completely occlude distal blood flow through the aorta itself, and therefore, hopefully, increase afterload, cerebral perfusion,  and coronary perfusion. That's the idea. So, you're accessing the common femoral artery, and you're sending it up. It's actually now a very simple procedure.  When I was first trained on this, it was pretty complex. It's been made a lot easier by commercial adaptations, and we have animal literature that does indeed show things  like increased cerebral and heart blood flow, things like increased ROSC. Unfortunately, the human data is scant. Really, the only thing we have beyond case reports is a series  by Breede in Norway, and he was actually doing this pre-hospital in the freezing cold. They would access the femoral artery with ultrasound, place up the roboa, and then inflate it,  intra-arrest in the field. And the results, pretty impressive. Six out of 10 patients who were already receiving standard ACLS for a mean time of around 45 minutes got ROSC.  That's good. These patients, despite all the advanced cardiac life support, were not coming back, and all of a sudden, they did. So, that might make you enthused,  at least preliminarily, that this is a beneficial treatment. Unfortunately, the second they deflated the balloon, four out of six re-arrested, and that's problematic.  And you cannot keep these balloons up ad infinitum, because you actually lose the blood flow to all of the organs that are distal to the balloon.  So, it's a problem, and even though you get some gains when you deflate and they re-arrest, you haven't really gotten anywhere, which I think leads me  to the conclusion that at this stage of the game, RBOA is only appropriate for medical arrest on patients when you don't have a better option.  And I think, if you're in a shop that's capable, eCPR is that better option. And we're going to hear from two speakers in just a minute about that very technique.  Now, RBOA may very well turn out to be a bridge, potentially in the field in places that have advanced practitioners like EMS physicians,  or at outside hospitals that are going to do a transfer, just akin to what we're doing now for trauma patients. The unfortunate limitation we're dealing  with right now is, as I mentioned, beyond about 30, 45 minutes, you've basically led to an intractable situation of organ death for everything distal to that balloon.  Now, there is new technology coming out, partial flow RBOA that allows a little trickle of blood to go past the balloon and therefore continue to perfuse all of the organs distal.  That might be a better option for this. But right now, I'd say too soon to really adopt. So, there you go. If you want to see the references that went  into this, come to mcrit.org slash ACLS dash RBOA. All right. So, now let's bring up our next speaker to talk about what I think is the superior technology  for intractable cardiac arrest, Joseph Tona. He's the section head of cardiothoracic critical care at the University of Utah. He's the medical director of the cardiovascular ICU.  He is the associate director of their ECMO program. And he is, I think, the person to watch for emergency ECMO research. Joe, come on up and talk to them.  Round of applause for Joe Tona, please. All right. Thanks, Scott and John and the organizing committee for having me out here. So, these are my disclosures.  Notable for today is that a lot of this research is funded by the NHLBI. And I'm the chair of the Extracorporeal Life Support Organization, SOC, the Scientific Oversight Committee.  So, some of the data comes from here. The other thing is that ECMO use in this discussion is entirely off-label for the way we're talking about it.  So, we're going to talk a little bit about what eCPR is. You guys, for the most part, probably know this already. So, we'll talk about observational survival  and what factors influence a decision to use eCPR. How differences in those factors, then, likely influence outcomes. We'll talk a little bit about survival after eCPR.  And we'll talk a very little bit about how eCPR management, so everything after cannulation, varies.  So, as you guys know, this is eCPR. So, cardiac arrest is treated traditionally with closed chest compressions. eCPR is the application of an ECMO circuit during cardiac arrest,  during CPR, to a patient. It provides full cardiopulmonary support when you do this. The motivation for why we consider eCPR comes very nicely from this slide.  This was a great study by Goto from the Journal of the American Heart Association, showing the probability of neurologically intact survival  and survival overall precipitously falls off with increasing duration of CPR. Now, people who get ROSC at, say, five minutes of CPR, self-select out of this group.  And so, what you have is people who are in this curve are still in cardiac arrest at all time points. But if you take a look at 20 minutes of CPR, which is a point  at which most patients who have cardiac arrest get to, the probability of neurologically intact survival at 20 minutes of continuous CPR is less than 2%. So, it's very poor.  And so, this is what motivated this study. So, this was probably the first seminal paper in eCPR that got the public's attention, outside of some earlier stuff from the 70s,  by Dr. Chen et al., published in 2009 in The Lancet. And you guys all probably saw this. So, in this propensity match study,  where they took conventional CPR patients, eCPR patients, combined them, and looked at the outcome of neurologically intact survival.  In just under 200 patients that they were able to match, the probability of neurologically intact survival was dramatically higher with the eCPR group. So, this was very impressive,  and got a lot of people's attention. And so, what we saw in the literature after this came out was three important studies by Sakamoto, Yiannopoulos,  and Stubb in resuscitation, Jack, and in resuscitation, again, that showed their center's experience with eCPR, and the survival after, from those centers.  And you can see that the survival here is simply incredible across these centers. And so, this got people very excited about it. But I want us to stop at this point,  and to look a little more at the data, and how we get these numbers. So, if you look at populations that get eCPR versus populations that get cCPR, there is a difference in survival  in most studies, with more survivors in the eCPR group. The problem is that these are observational studies. And so, for all we know, the selection  for patients is dramatically different between who gets eCPR and who gets cCPR. And the patients who are getting eCPR may be very healthy,  and the patients who are getting regular CPR, or rather, not getting eCPR, may be much sicker. And so, this is why we thought that this might be going on.  And so, we set out to kind of examine this. So, we took data from the American Heart Association, over 350,000 patients with adult cardiac arrest. And we looked at those patients.  And we went through a long process where we excluded patients to try and come up with a relatively homogenous cohort. And what that homogenous cohort looked  like was these were patients who got either conventional CPR or eCPR at a hospital where eCPR was available, at a time in that hospital's life where that eCPR was available.  We wanted to really understand, what are the differences in patients who get eCPR versus those who get cCPR? And how do the patient characteristics influence that decision?  So, looking at some of that data, this is a nice heat map of hospital location and patient type for patients who get conventional CPR.  And you can see that it doesn't matter what these patients are, but particular groups of patients and particular locations of the hospital get eCPR or get CPR.  If you then look at eCPR, it's a very different location and a very different patient type within the hospital.  And so, this suggests to us that, you know, eCPR is not used equally compared to cCPR. It's not like you have a patient who's getting cCPR and you say,  oh, I'm just going to decide to use eCPR on them. You're using characteristics of that patient and that arrest to make that decision.  And those characteristics are likely influencing their outcome. So, this was another study we did in resuscitation back in 2016, just looking at patients  with our centers across the country who had programs for eCPR for out-of-hospital cardiac arrests. And what's important about this figure is that there's not many dots.  There were very few centers across the country at that time that were doing it. If you then look at the AHA data, of the 813 hospitals  in the data set, only 213 actually were doing eCPR. So, about a quarter of them. And if you compare the characteristics of those hospitals, they're very different.  The hospitals were larger. They had more cardiac ICU beds. They were teaching hospitals. They were more likely to be urban. Also, the patients at those hospitals were different.  They were older. They had more comorbidities. And all these differences were significant. So, moving on, if you look at when cCPR is offered, it's all times of day.  That's because people are arrested all times of day. If you look at when eCPR is offered, it's daytime, during procedural hours, and it's weekdays.  It's not offered as much at night. It's not offered as much on weekends. And this likely reflects the availability of people who can actually do eCPR.  It may also reflect some of the patient selection. So, we then did case mix adjustment to actually look at which of these characteristics were durable. It's a way to try and ensure  that the patients we're comparing are adjusted for all these things that I've just told you. So, adjusted for their age, the type of patient they are,  where they are in the hospital, all those factors. And after case mix adjustment, we found that many, many characteristics remained highly significant in the decision to use eCPR.  So, patients got eCPR more if they were younger, if they were cardiac surgery patients, if they were mechanically ventilated or in an ICU.  And they got eCPR less if they were a black racer of women. So, for anyone who doesn't believe that there's, you know, subtle bias and unconscious bias, look at this.  There is absolutely.  So, we looked at the hospital characteristics. The patients who got eCPR were at centers that had more cardiac ICU beds compared to regular beds, so different centers.  Likewise, they had lower inpatient Medicare days. So, they had a different payer mix. They were also less likely to be minor teaching hospitals.  So, there were real differences between the eCPR and the cCPR patients. So, we took this a little bit further, and then we looked at the patients,  the thousand of them who received eCPR. We then looked at what predicted their survival, and we found that all these characteristics influenced their survival.  The ones in red increased the probability of death. The ones in black increased the probability of survival. And likewise, the duration of CPR prior to the initiation  of eCPR, prior to cannulation, was significantly associated with their probability of survival. The shorter the duration of cCPR, the more likely you were to live.  And so, this is consistent with the previous literature that I showed you on probability of survival after cardiac arrest.  So, we want to take this a little bit further, and eCPR is complex. It's not just the cannulation. If you look at the cannulation here, it's that little blue box up there.  Everything outside of that blue box happens to an eCPR patient, but happens outside of that moment of cannulation. And so, we wanted to see which of these factors  actually then influence patient's outcome. So, the first step we did was we took data from the ELSO registry. We took over 4,000 adult eCPR patients across the world,  and we wanted to look at how much characteristics of their management. So, after the moment of cannulation, we actually varied across center,  and we sorted the centers by their volume, and then we color-coded them. You can see that it doesn't show super well up there, but on the far right side of the screen is red.  These are high-volume centers. There's blue just left of that, and then most of the centers up there are green. They're low-volume centers.  And what we found is if you look across centers, the red lines differentiate their, kind of the peak mean, or the peak median to the bottom median of the groups.  And you can see that there's profound variation across centers in how they target mean arterial pressure and how they target ECMO blood flow. So there's no consistency.  And likewise, when you get to the higher volume centers, something like mean arterial pressure becomes more homogeneous across centers and there's less variation,  but ECMO blood flow does so also, but less so.  And so one of the other things I'll try and end with here is if you look at then how these factors actually influence their survival,  what we found is that things like myocarditis and arrhythmia were significantly associated with the probability of improved survival. And this just gets to what people,  what I always tell people when they ask me, who should we do CPR or ECPR and who should we do ECMO on? ECMO, in my opinion, should be used  for acute reversible refractory cardiopulmonary failure. You need to meet all of those to really be a good ECMO candidate. And myocarditis and arrhythmias  are both acute reversible refractory problems. We found that the use of a distal perfusion catheter was significantly associated with survival. So as you guys know,  when you put a large ECMO cannula in an artery, it occludes that artery. And so if you don't do anything, you then have the possibility of distal leg ischemia  due to arterial occlusion. So this catheter goes in distal to the side of insertion to provide a limited amount of blood flow to the limb.  This is what it looks like in practice. We also found that a lower FiO2 on ECMO was significantly associated with improved survival. And what was interesting about this is,  this fits in with animal data. We don't have great human data for this, but animal data over 20 years shows that lower FiO2s are associated with less alveolar injury  and less lung damage. We also found that the median odds ratio of survival was 1.47. And what that means is that a patient at one randomly selected hospital in this dataset  would have a 47% probability of increased survival  by moving to another hospital. So there's huge variability across hospitals and that's after case mix adjustment. So that's after controlling for the hospitals.  And so in summary, what I'll leave you with is that eCPR is very selectively used. So any conclusions that people have about the benefit of eCPR versus cCPR  need to be taken in context of heterogeneous use until we have randomized control trial data, which is coming out. eCPR survival can accurately be predicted  and I hope to have that data out soon. There is management variation across centers and that management is also associated with survival. So, thanks very much.  I'm gonna ask you to hold questions. I'm gonna ask you to hold questions. We're gonna have our next speaker also speak about eCPR  and then we'll have questions for both of them afterwards. So our next speaker is Daniel Herr. He's the Chief of Critical Care  at the University of Maryland and the Shock Trauma Center. He's the Director of ECMO and the Cardiac Surgery ICU. And it gives me a real honor to introduce him  because he's one of my mentors and he's just brilliant. Yes, yes. So round of applause for Dan Herr. Thank you. All right. So my talk's gonna be more on the practical side.  That's the first time I've heard Joe's presentation. And I gotta tell you, I think what we see at our institutions is exactly what he's predicting.  So I'm gonna go through the 10 hints for successful, maybe successful in-house resuscitation with eCPR. And actually this is in backwards.  Okay. So just so you know, this is also data for runs by year and you can see adult eCPR is increasing. So is adult CARDS and adult pulmonary.  And slowly the PEDS kids are slowly disappearing because they've got better ways to fix kids these days. But eCPR is certainly increasing. So certainly we gotta talk about it.  This is our system. We're about up, last year we did, I mean 2018, we did 185 ECMOs. We're kind of busy at our place. This year we hit 200. And our in-house eCPR averages about one  every one and a half weeks.  So one thing that you really have to make sure of is you have to make this multidisciplinary. If you don't, you're making a mistake.  We have all these little silos all over the place. So almost nine years ago, I saw this coming and I said, listen, we're gonna put everybody  in the same room and we're gonna work out what we do. So we have a critical care advisory committee. It assesses all our policies and procedures. The heart surgeons are involved.  The ER docs are involved. Everybody's involved. We formed an ECMO team, but this is just incredibly important because even nursing's involved.  They know exactly where we're headed, what we're doing. We review data, we do grade analysis. It's the perfect thing. The other really important thing  is you have to have indications. I really don't care what they are, but make sure that everybody in your teams knows what they are. Because it's the only way you're gonna find out  if you're doing something wrong. If you keep varying away from your indications. These are our exclusions. We're pretty strict about them. Everybody knows them.  When we have an eCPR event, we use a phone system and we're all online right away. This is our pick. You can pick it or not take it. It's up to you. But here are indications to do.  And I think it almost matches what Joe was saying. We are a little bit particular, but certainly if it's cardiac ischemia, massive pulmonary embolism,  moderate to severe hypothermia, and toxins, we've been very happy with toxins in eCPR.  But the other supportive features, I think, is the eCPR time, less than 15 minutes from time of activation. Patient has to be in ventricular fibrillation  or ventricular tachycardia, continues to be. Our entile CO2, we're really strict about that. We feel that if you sit with a low entile CO2  that your chances of good neurological outcome is gonna be very low. But then again, too, the other thing that our buddies in Prague who are doing an eCPR out of hospital study,  is you have to have some sign of life. Some sign. I mean, pupils work, something works. Even if you only have intermittent ROSC.  The third thing is, I think you just need to be organized. ECMO's not just in the ICU, it's everywhere. I mean, we're running around, going to the OR,  we're going to the emergency room, we're in the trauma bays. It's ubiquitous, and everybody knows we're out there waiting to do one. So we decided to adopt the exact same system  as a in-hospital EMS system. If you look at our resuscitation team, we have a Lucas machine where if you're stable, you're transported to an area that does ECMO initiation.  This is something I don't think a lot of hospitals do. I don't know if you've tried to cannulate somebody in a semi-private room or a small room. It just doesn't work.  And if using the Lucas or any one of these devices works for the EMS people, why wouldn't it work inside the hospital? We find that we just get people into a certain area.  We're lucky enough to have an area called the Critical Care Resuscitation Unit, which I could talk a whole talk on. But essentially, this is an area  where we resuscitate any time-sensitive disease, whether it's ARDS or whatever. So majority of our eCPRs get on the Lucas and they go to this area.  Obviously, you can have one in your hospital. It doesn't matter where it is, just as long as they're good at it. This is our setup.  We took our resuscitation team, our rapid response team, and called them resuscitation team because they just weren't busy enough.  And now they know they come running just like an EMS system and they're all trained in EMS. We do the stretcher. We put the stretcher up. We actually bring them down to the CCRU  and we cannulate them there or else in the cardiac surgery ICU. We rehearse, rehearse, rehearse. We have sims all over the place. This is our standard configuration.  Everybody knows where they're supposed to stand. Everybody knows where the pump goes. Everybody knows where the table goes. When you're doing 100 and some of these a year,  you get pretty good at it. We have an ECMO tote that we bring along just in case and we also have a cart in the room. I'm not gonna go into all that.  Like Joe said, a lot of these patients, ECPR are post-cardiac surgery patients. I think one of the things we've really learned and taught our surgeons is that,  number one, we have a CALS program. I don't know if you know what CALS is. It's essentially a program to do ACLS for open heart patients.  We rehearse this every year, about every two months. Every person in the CSICU has to go through this course once a year.  The important thing of this is that we are organized and our surgeons understand where we're going when we have an ECPR, at least in the cardiac surgery.  This is kind of different for you folks. We really believe in preparing the family for ECMO. This is something we just started about six months ago.  I don't know how many people have gotten into the situation where you're doing ECPR and there's no hope of survival. Now you're trying to figure out how to get the ECMO  off the patient with the family understanding. I don't know. We have an ECMO acknowledgement situation where we actually bring people in the room within 72 hours of the event  until we get a good feel for the patient. We do what we call an ECMO acknowledgement conference. We don't make people sign this, but I want you to bring your attention  to the last thing we say is ECMO is not meant to be used as long-term as treatment to extend absent transplant or in conditions that may be found to be irreversible  once medical evaluation and diagnosis are completed. This is really, believe it or not, families knowing up front that this might not work is really important.  And we have had some very successful, wonderful withdrawals of ECMO. Prepare for complications.  This is bad ECMO.  This was an ECMO that we did an ECPR and then we wanted to get down and do a quick head CT and the cannula came out. This is the only time, by the way,  in 10 years that we lost a cannula, so I'm pretty proud of it, but I have to show the picture.  Remove complications is really important. You know, we make too much of a deal, I think, with anticoagulation. You know, if there's a question of amount  about how much anticoagulation, don't do it. Don't give the 10,000 or 5,000 bolus. It's not that necessary. And if you have a little bit of a clot formation  immediately after cannulation, fine, just turn everything out and redo it. Ultrasound, as we all know, has become your best friend. If you don't have a portable ultrasound machine,  your EMS, or in-house EMS, as we call it, system, you're making a mistake. Percutaneous insertion, I think we're all aware that that's the way to go.  I think you need to avoid any procedure in the first 24 to 48 hours. I don't care if they have a big pericardial, I mean, a big pleural fusion, or whatever. Leave it alone.  Try not to sedate. And try just to practice good Bayesian. If the outcome's not gonna be what you expect, then don't do it.  Here's the other thing that I think is really important in eCPR is left ventricular overload. We see it all the time. Most places talk about Impella.  We, at our institution, hate Impellas, pretty much.  If the, the only time we really use Impellas is if we have no pulse pressure at all. But generally speaking, we are a big septosomy group.  Our cardiologists are very, very good at it.  So we usually do this very early on. If we start seeing the picture that you see there, we're headed down to the cath lab and we're putting in a hole in your heart.  It's a wonderful way. And then when we walk VA ECMOs and stuff like that, so we get everything out of here and we can just walk them and it's just a, we just don't have to worry.  We don't have an Impella, we don't have to worry. This is the other thing that's just coming out  of the literature and I thought I'd say something about and this whole thing about von Willebrand's factor. There is, there is definitely a problem  with von Willebrand's factor in acute ECMO therapy. And this is the one that really scared us because all patients with acute von Willebrand syndrome,  within hours of starting to make, all the patients were hypoaggregate, have an inability to aggregate. This is really important. This is why we're really starting to start limiting  our heparin dosing, right, when we go on.  But the really interesting thing is once you come off ECMO, then you become hypercoagulable. So it's a really difficult situation. I just thought I'd bring it out there  and I don't think a lot of people consider von Willebrand's factor in the treatment of ECMO. By the way, the stuff that treats it is really expensive.  It's Humate, it costs about 5,000 bucks. We rarely use it unless you're bleeding to death. Peripheral versus central, I think this is more about ECPR and the cardiac surgery unit.  We have finally convinced our surgeons  that they're not that good at getting a cannula in the order without it bleeding. The big problem with ECPR is when you're in a cardiac  surgery with an open chest, they're trying to, you squeeze, squeeze, squeeze, and then you stop squeezing because you're trying to put this in and that in.  We have now standardized this. When you have an open chest, cardiac ECPR, we do cardiac compressions with your hand. We do not worry about putting cannulas in.  We do peripheral cannulation. Just think how nice that is. You maintain your entire CO2 the entire time.  If you need to find the artery, you just give an extra little squeeze to the heart and off it comes in your ultrasound.  These are just some papers that we showed that we've actually increased ability at survival and we've increased neurological outcome by doing  early percutaneous in ECPR in open heart patients. I think this is another important point that you really have to watch. You have to watch your value cost.  Here's some of the changes we made over the few years. In the first year, in 2013, we spent like 15,000 in blood or something like that. We dropped it down by 48%.  When you're talking about therapies, and the guy just before the session before us was talking about value cost ratios. In my state, this is incredibly important.  We are a capitated state, so we only get so much money for the whole year. And if you talk about value, look at that. If your expired patients go from 52% down to 29%,  I think that's a huge value.  I don't know how to put weight on that. Some people do. I think it's $150,000 a year for quality of life or something like that. But if you show decreased cost and increased value,  your administration's gonna love you. So if you're showing those kind of things. I think be lean, be Bayesian. I think it's time.  Our ECMO machines, I'm sorry, we're not a cardio help person, we do not use cardio help. We feel it has too many bells and whistles. It's too expensive.  We have a simple Quadrox setup with a Rotaflow.  Watch out on your labs. Why do you do need some labs? We do our labs only twice a day. Don't make anticoagulation difficult. PTT works, that's what you should use.  And the success of ECMO is always about no bleeding, patient mobilization, and patient comfort. If you do those three things, you're gonna have a very successful ECP program.  Protect the brain, get the patient on early. I think that's still pretty much what we talk about. We've done some looks at this. What we're really concerned about is this, though.  Yes, we have a lot of good neurological, 23 people had good neurological outcome in this cohort, but this is the part that bothers us. What happens after you get somebody on ECMO?  A lot of our patients are dying of multi-organ dysfunction. We're not sure what that's all about. Of those, many of them are infections. It's just really interesting.  We just can't get quite a grip on it. I don't know if it's because of their pre-morbid state, but we're working on that.  I'm gonna skip that because we're moving along. I think, finally, you gotta remove hospital legends. You know, there's urban legends. Well, there's hospital legends.  You know, ECMO's just for the dying. That's not so true. I think what we've incorporated in our hospital is a program that's very prophylactic, so we don't have to do a lot of ECPR,  like our VSDs and everything. They all get on ECMO early. ECMO is not expensive, if you do it right. The use of INO is one of those expensive things  that we haven't used in five years, and yet our mortality rate is about 20% better than the ELSA database. Patients must be sedated. They don't.  ECMO is complicated. It's not. I could go on and on. You can read them for yourself. I think that's where we are. I think if it all else fails, I think it's really important, again,  to pay respects to the family, the ECMO acknowledgement document that we use, and then we always have a quiet moment for the family when a patient passes.  I get like 30 people in a room to just have a quiet moment and say something important to the family. And that's the end of my talk, and I thank you very much,  and I hope you gave me some pointers to take home with you. All right. Fantastic stuff. So now we have about 10 minutes for questions for Dr. Tona and Dr. Her.  Come on up to the microphones. Can we stay here? Yes, you can. Sir. Great presentation. Thank you. My question is, how do you know when a patient is going to die?  How do you know when a patient is going to die?  Sir. Great presentation. Thank you. My question is, how do you decide how early to put patients on eCPR? If you have a young gentleman, reversible cause,  you know, overdose on beta blocker or arrhythmia, I understand if it's 20, 30 minutes, you might not want to do it, but how early?  So I'm going to say something very controversial, maybe. If you're young, we don't care. We're going to put you on.  We have about a 25% organ donation rate on the patients that don't make it. So we feel that we're ethically justified by putting young people on,  even if we don't have a shot sometimes. And if you look at the Spanish results, over there you are a donor and you can be put on eCPR without permission of the family.  So our thought process, and we have been very, especially with drug overdoses, you know, it's amazing. The drugs sometimes really cloud the neurological picture.  So you end up, you know, leaving the person on for days. Now, I've fought some battles with my neurologist about keeping people on. But on the other hand,  you do have the possibility of having a donation.  But do you wait for one run of CPR? So I'm sorry. So we usually do one run of CPR. In the open heart population, we use the CALS approach.  So if they get two epi's, they get their chest open. As soon as they get their chest open, they're going on eCPR. No doubt about it. On the floors, we usually wait  and see one of our criteria pops up. If we see signs of life, we're going for it early. We don't do a lot of brain working at the bedside. We just decide we're gonna do this.  And don't forget, we put them on the Lucas and we don't try to cannulate in the rooms. We try to get the patient to the place where we can do a really nice, clean,  sterile, wonderful, ultrasound-guided professionals putting somebody on ECMO. So we have that time on the Lucas to watch the patient as we're moving through. That's the other point.  Does that answer your question? Yes. Okay.  Sir? Hi, Conor Myler from Penn State. And my own disclosures, I work in a heart and vascular ICU and also do ECMO cannulation and also management.  I guess my question is about both of these mostly focused on it seems like in-hospital arrest. And I'm curious about your thoughts on the European Heart Journal,  the out-of-hospital arrest, their registry and their outcomes and how, if any, effect that's had on your own out-of-hospital arrest ECMO use.  I mean, the largest data sets are from in-hospital. And so that I think is some influence. I'm not individually familiar with the European study that you're referring to.  Most, there are differences between in-hospital and out-of-hospital arrests. There's differences in predictors of outcome between those two groups.  But I think that we're still so early in the field that the differences are gonna kind of fall out.  So my response to that is that if you pick the right group of people to put them on, my mantra over the last 40 years has been the earlier the intervention, the better results.  And in some areas, for example, in the cardiac restroom where they have the refractory VFs, like in Paris, you know, where you got the famous stories  where they do it in the Louvre or in the subway or whatever, metro, is largely because of traffic trying to get back, et cetera. There's some real problems there.  And so it's been actually makes sense to do it from their point of view. And it's the people that do it in the hospital are going out there to do it.  Same thing is happening even on the streets here. There are programs being developed in places like Columbus.  And actually more interestingly for me is Albuquerque's developed a new program that's been pushed by the critical care people. And they're getting out there  and they have a hand crank version actually that firefighters will do for you. So I agree, we don't have the data yet. But to me intuitively, we're following that.  And I think it makes sense to do it in particularly the right circumstances with right patients. So that's my response. I would say stay tuned.  The people in Prague with their new system is going to be published probably in the next six months. And they use a pure Lucas or CPR system bring them into the hospital.  And the interesting thing about them is they also have this very cool app on their phones that I'll immediately tell the ECMO team exactly what's going on in the scene.  So I think you're right. I think the earlier the better, but also it's a lot to do with filtering.  One thing I just wanted to mention really quickly talking about the Lucas and then the mechanical devices, I didn't add that in because of time,  but I think it's a little bit timely here, is that where you place various tools or how you place your hands can actually affect the outcome.  You might put it high over an outflow pattern. So one of the cool things that they're doing at Joe's shop is they're actually doing TEEs early on.  They're actually looking at the right hand position where they get the best ejection from in a given case. And it just so there's more fine tuning to be done  and it'll be really interesting.  Hi there. I'm an intensivist that works in the cardiac ICU mainly. I actually had the opportunity to work with Dr. Herr at University of Maryland with a brief rotation.  And I'm at a smaller hospital now that has ECMO capability, but we're working on developing our ECMO program. And eCPR is something that's been brought up.  Our initiative right now is we're trying to introduce eCPR selectively to certain parts of the hospital. So cath lab and ER for the most part.  If you could give me, you know, top three things that you think are important to successfully implement limited eCPR at this hospital with somewhat limited resources, I would say,  what do you think those would be?  Oh boy. Thank you. That was a great question. Great question.  I just never had the opportunity to be limited. So I don't know. It's not my personality to be limited. So I'll stick my foot out and say that I don't think  that an eCPR program should exist if you don't have an ECMO program up and running and in high volume. I think it's too difficult.  I think eCPR is great. I think that there's a future for it, but I think that you first have to have an extant ECMO program. And then from that, you grow an eCPR program.  I want to take a slightly countervailing view. I think the cannulate and ship option is going to become very feasible as people really nail down the logistics.  And I agree with Joe, you don't want to leave a patient for their long-term eCPR and ECMO management at a small shop for all the reasons you've shown.  But that doesn't mean they can't get cannulated and transferred. And with EMS systems really taking ownership of this now. Do you disagree with that, Joe? No, I think that's fair.  If you can do it safely and quickly.  What, say something, Paul? I have a question. Just FYI, we're really, I think the Spoke and Hub and like the Duke system does,  I think it's a really good system for that type of thing. You know, you have certain hospitals that can't do anything and you have certain hospitals that at least can put you on  but don't have cardiopulmonary bypass or any of that in their hospital. So you have at least four categories. I think that's the way to go. I think Joe's right.  We didn't start doing eCPR at all for the first two or three years. I think that's the way to go. I think that's the way to go. We didn't start doing eCPR at all  for the first two or three years. I mean, we didn't even think about going to codes. Only, and part of the problem was we didn't have a really good resuscitation team.  That was a huge key. To teach EMS to our resuscitation team and have an in-house EMS system made the big difference.  Sir? Yeah, this question's for Joe. So Joe, once during eCPR, once they're actually on ECMO, but if they actually haven't regained contractility, do you continue compressions?  What's your end point for stopping compressions once they're on ECMO?  We assume that they are going to gain contractility once they are perfused on the ECMO circuit. And every time that happens, we then stop external compressions.  In the few cases that do not gain a perfusing contractile rhythm within two minutes of full ECMO flow, we will continue chest compressions  and make a very difficult decision about what to do  that I can talk to you later about. Do you still maintain like a hundred or do you actually do like a lesser rate just to try to get some emptying of the LV?  Oh, I just look to make sure that they have at least five to 10 millimeters of mercury systolic to diastolic difference. And then ideally, if I have a TEE  and I just want to see the valve open, the aortic valve. Yeah, we do intermittent.  We'll pump every so often. Don't know if that's right.  Thanks, Dr. Herr. And thanks, Joe. Thanks for your talk. I'm Neal Chasen from Cleveland Clinic.  The question that I have actually is we also have virtually unlimited resources, but our problem actually is that like many of you, we have a big population of people  who are transported into the hospital from outlying places. And when we're triaging those patients, a significant portion of our declines are because they're unstable for transport  at the time of resuscitation.  And we don't think either it's, obviously Cleveland has not got the best weather. They can't fly. What do you do with those patients?  Do you guys go out and get them and cannulate there? Or do you say sorry?  Sorry.  Yeah, so we have a kind of a, where we are geographically, there's a lot of hospitals kind of within a couple states. Ideally, what we want is to have a stable patient  shipped already on ECMO. And so if the surgeons there have the ability to put the patient on ECMO, because most of our patients are cardiac surgery patients, then we do that.  There have been situations where we will go out and cannulate, but it's a much more complex. I think the best model I've seen for that is Legacy Hospital in Portland  has an excellent program where they went out and they would go and cannulate in a multi-state radius. But it's a complex endeavor. Yeah, we have not walked out on the plank yet  of going and getting patients.  We probably will. But again, we feel that if we can coach the stabilization at the other hospital and get them on a Lucas or something like that, we can get them into the hospital  and get them fixed as fast as possible. And again, we have a very good phone system where three people get on, the ICU guy gets on, the CCRU guy gets on,  and a heart surgeon gets on. And we make very deliberate decisions.  Do you want to take one more? I think we are, unfortunately, well, let's just take the question. If they kick us out, they kick us out.  We'll make this the last question, please, ma'am. Thank you very much. Candace Adkins, CVICU, University of Louisville. I know you talked mostly about in-hospital arrests  and the eCPR. I just wanted to kind of divert a little bit to eCPR for hypothermia, if you guys are doing that. And my specific question was about, again,  endpoints of resuscitation if a patient is,  if you have a temperature endpoint, if the patient's still asystole or not contracting.  Go for it.  I think in all things being equal, eCPR or ECMO for hypothermia is a great therapy.  You can warm, you provide full cardiopulmonary support. I think the second part of your question is like, how long would you continue it? I think that's a complex question  that involves hemodynamic stability of the patient and neurologic outcome. And then the other part of your question was with asystole.  If the patient after being warmed and being on ECMO with full perfusion is not contracting,  the heart must contract or it will clot. So you have to come up with a way to get the heart to contract or withdraw support.  Agree. Do you have a temperature goal?  Once they're on ECMO, I think it depends on what your indication for going on was. If they're in arrest, we tend to keep them cold. If they were not in arrest,  we keep them in normal temperature.  All right. And I guess we will conclude there. Let's have a round of applause for our panelists.

Video Summary

The panel discussion focused on the topic of eCPR, or extracorporeal cardiopulmonary resuscitation. The panelists discussed the use of mechanical devices such as the Lucas machine and the use of ECMO, or extracorporeal membrane oxygenation, in resuscitation efforts. They highlighted the importance of a multidisciplinary approach and the need for clear indications and protocols for eCPR. The panelists also emphasized the need for careful patient selection and the consideration of factors such as age, underlying cause of arrest, and signs of life. The importance of organized systems and protocols for eCPR implementation was stressed, as well as the need for ongoing training and simulation exercises. The panelists also touched on the challenges and complexities of eCPR, such as the management of anticoagulation and the prevention of complications such as left ventricular overload. Overall, the panelists agreed that eCPR can be a valuable tool in resuscitation efforts, but its use should be based on careful patient selection and a coordinated approach.

Asset Subtitle

Resuscitation, Procedures, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Evaluate the literature on the use of mechanical cardiopulmonary resuscitative devices in cardiac arrest
Describe the use of extracorporeal cardiopulmonary resuscitative devices in cardiac arrest
Determine the applicability of the resuscitative endovascular balloon occlusion of the aorta (REBOA) device in different resuscitation scenarios

Mechanical CPR Devices: Are They for Everyone With Cardiac Arrest?

Paul E. Pepe

REBOA for Medical Arrest

Scott D. Weingart

ECPR: Who, What, When, and Why?

Joseph E. Tonna

10 Hints for Successful In-house eCPR

Daniel L. Herr

Meta Tag

Content Type Presentation

Knowledge Area Resuscitation

Knowledge Area Procedures

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Cardiopulmonary Resuscitation CPR

Tag Extracorporeal Membrane Oxygenation ECMO

Tag Return of Spontaneous Circulation ROSC

Tag Cardiothoracic Critical Care

Year 2020

Keywords

eCPR

extracorporeal cardiopulmonary resuscitation

Lucas machine

ECMO

extracorporeal membrane oxygenation

multidisciplinary approach

patient selection

protocols

organized systems

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