Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
ECMO for Respiratory Failure
29 Plays2 years ago
In this episode, Dr. Zanotti is joined by Dr. Craig Rackley to discuss the role of ECMO – extracorporeal membrane oxygenation in supporting patients with acute respiratory failure. Dr. Rackley is a practicing pulmonary critical care physician and an associate professor of Medicine at Duke University School of Medicine. He is the medical director of Adult ECMO in the Duke Division of Pulmonary, Allergy, and Critical Care Medicine. Dr. Rackley is also a recognized clinician, educator, and researcher interested in respiratory failure, ARDS, and ECMO.
Additional Resources
Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. The CESAR Trial. Lancet 2009: https://pubmed.ncbi.nlm.nih.gov/19762075/
Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. The EOLIA Trial. N Eng J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1800385
Bertini P, Guarracino F, Falcone M, et al. ECMO in COVID-19 Patients: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2022: https://pubmed.ncbi.nlm.nih.gov/34906383/
Books mentioned in this episode
Endurance: Shackleton’s Incredible Voyage. By Alfred Lansing: https://bit.ly/43g71C1
South!: The Story of Shackleton’s Last Expedition 1914-1917. By Ernest Shackleton: https://bit.ly/49NyJbU
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Overview of ARDS Treatments
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
00:00:32
Speaker
In the previous episode of Critical Matters, we discussed current respiratory support for patients with ARDS.
00:00:38
Speaker
Lung protective ventilation, prone position, and other therapeutic interventions have made significant impact on outcomes in patients with respiratory failure and ARDS.
00:00:46
Speaker
However, there is still a subset of patients that, despite these interventions, do not respond well.
Role of ECMO in Respiratory Failure
00:00:52
Speaker
In today's episode of the podcast, we will discuss the role of ECMO, Extracorporeal Membrane Oxygenation and ARDS.
00:00:59
Speaker
Our guest is Dr. Craig Radley, a practicing pulmonary critical care physician.
00:01:03
Speaker
He is the medical director of Adult ECMO in the Duke Division of Pulmonary, Allergy and Critical Care Medicine and also an associate professor of medicine at Duke University School of Medicine.
00:01:13
Speaker
Dr. Rackley is a recognized clinician, educator, and researcher with an interest in respiratory failure, ARDS, and ECMO.
00:01:20
Speaker
A true honor to have him today on Critical Matters.
00:01:22
Speaker
Craig, welcome to the podcast.
00:01:24
Speaker
Thank you, Sergio.
00:01:25
Speaker
Thanks for having me.
00:01:27
Speaker
Absolutely.
00:01:28
Speaker
So I would like to start with a question, and we're kind of talking about this before we start recording.
00:01:34
Speaker
Not every program, not every listener that follows us may have an ECMO program or ECMO capability in their hospital.
00:01:44
Speaker
Many do.
00:01:45
Speaker
But the question really is, why should critical care clinicians care about ECMO at programs where there is no ECMO capability?
00:01:54
Speaker
That's a great question and one that comes up all the time.
00:01:57
Speaker
I think the answer I would like to give you is that ECMO is the future of the management of respiratory failure.
00:02:05
Speaker
That one day we will see our patients going on ECMO as opposed to going on a ventilator and you lose all the complications that go along with the ventilator and all the complications that go along with ECMO have gotten better.
00:02:20
Speaker
But I think that is hopefully the answer I can give you 10, 15 years from now.
00:02:25
Speaker
I think the answer I would give you now is that there are a good number of patients who can derive a survival benefit from ECMO.
00:02:37
Speaker
And these are folks with severe respiratory failure and ARDS.
00:02:41
Speaker
And the key, I think, to them deriving that benefit is that they have the least amount of physician-induced, ventilator-induced, self-induced lung injury by the time they go on to ECMO, and that we are putting the right people on ECMO, the ones who are really likely to benefit.
00:03:04
Speaker
And if you know...
00:03:06
Speaker
who those patients are, you identify them early, you potentially can save their life.
00:03:12
Speaker
And I think identifying them early, building a relationship with an ECMO center so that you can reach out early enough in the course so that that patient can be transferred if need be or optimized prior to needing ECMO.
00:03:28
Speaker
One of the things that
00:03:31
Speaker
I always hate to see is when we get called too late.
00:03:35
Speaker
A patient has been on a ventilator at high ventilator settings for a really long period of time.
00:03:40
Speaker
They're now developing multi-organ failure.
00:03:43
Speaker
We're not able to achieve adequate oxygenation and ventilation.
Evolution and Adoption of ECMO
00:03:49
Speaker
We're being called about ECMO and logistically we are 12 to 24 hours away from being able to either transport the patient to our center
00:03:58
Speaker
or go out and place that person on ECMO to bring to us.
00:04:03
Speaker
And so it is time sensitive and it's important to identify the right patients early so that they can derive that benefit.
00:04:13
Speaker
And so knowing that, building those relationships, I think is the answer to that question today.
00:04:19
Speaker
Perfect.
00:04:20
Speaker
And I wanted to get that out of the way because I know that a lot of people who are listening might think, well, I don't do ECMO, but I think it's still a very relevant discussion for all critical care clinicians.
00:04:31
Speaker
Could you give us maybe some general considerations regarding ECMO for ARDS, a little bit of maybe historical perspective, and then we can, and where it stands today, and then maybe we can dive into some of the important studies that have come up over the last decade shaping how we think about this.
00:04:48
Speaker
Yeah, I think I will, I think this is a fascinating history dialing back to when, you know, the technology of ECMO comes out of the technology from cardiopulmonary bypass that has been around for, you know, approaching 75 years.
00:05:04
Speaker
And ECMO in its, I wouldn't say in its current form, but in the idea of the way we provide ECMO now has been around for around 50 years.
00:05:15
Speaker
And, you know,
00:05:17
Speaker
There was initially promise in adults, there was hope in adults, but the early studies from the 70s really showed no benefit to providing ECMO to patients with severe respiratory failure.
00:05:30
Speaker
The caveat being those were the sickest of the sick patients placed on VA ECMO, and almost all of them died in the ECMO or the non-ECMO group.
00:05:41
Speaker
And so there really was...
00:05:42
Speaker
very little utilization of ECMO.
00:05:46
Speaker
When we're talking about ECMO today, we're primarily talking about VV ECMO for acute respiratory failure.
00:05:52
Speaker
So there's virtually no use of VV ECMO for adult respiratory failure in the 70s, 80s, 90s, and even into the 2000s.
00:06:02
Speaker
There was a fair bit of utilization in pediatrics and neonates where there was some evidence and experience.
00:06:11
Speaker
And then you come to the late 2000s, so around 2009, I think we saw a confluence of three main things that came together in my mind.
00:06:24
Speaker
One was the technology was beginning to improve.
00:06:28
Speaker
As I went, when we first started doing ACMO for adults for respiratory failure, and I'd go to the PICU to try to learn how to do this,
00:06:36
Speaker
And it's this massive machine with multiple rollers and all of these different connections tied in that's really overwhelming relative to almost anything else we do in adult critical care.
00:06:50
Speaker
So all of that became much more streamlined around health.
00:06:54
Speaker
the mid-2000s to the mid-2015s, smaller machines, better technology, more ease of use for the regular provider.
00:07:05
Speaker
The second thing that came along was the influenza pandemic, the H1N1 pandemic.
00:07:11
Speaker
where you had really young, healthy individuals who just could not be kept alive on conventional mechanical ventilation, and they were starting to go on to ECMO.
00:07:23
Speaker
And then I think we'll talk a little bit about some of the trials, but the first of those clinical trials that was published showing a potential benefit was the seizure trial out of the United Kingdom.
00:07:34
Speaker
So you've got better technology, you've got a global pandemic that is impacting young, healthy people, and now you have some clinical trial evidence demonstrating a potential benefit to the use of ECMO.
00:07:48
Speaker
And so what that CESAR trial was, was an interesting study in that it was designed really to show whether or not transferring someone to an ECMO center improved their outcomes.
00:08:02
Speaker
And they showed that it did.
00:08:03
Speaker
It improved outcomes by, you know, 10 to 20 percent in this cohort of patients.
00:08:08
Speaker
They all didn't receive ECMO.
00:08:10
Speaker
So the the
00:08:11
Speaker
criticism of that study is that was it just that they did a better job of managing people on a ventilator or was it the ECMO part that made the difference?
00:08:21
Speaker
I think regardless of that critique, we saw that people could receive ECMO and do as well or better than those who didn't.
00:08:33
Speaker
There was an Australian experience with H1N1 showed that
00:08:38
Speaker
75 plus percent of patients who had severe ARDS with influenza who went on ECMO survived.
00:08:45
Speaker
So you're taking a group that you didn't think was going to be able to survive without ECMO.
00:08:49
Speaker
They go on ECMO and they survive.
00:08:52
Speaker
So we have a little more confidence.
00:08:53
Speaker
We have better technology.
00:08:54
Speaker
We have a little bit of data.
00:08:56
Speaker
And from 2009 until now, we've just seen an exponential growth in the use of ECMO in the adult world, both cardiac and respiratory.
00:09:08
Speaker
And you mentioned, obviously, the CESAR trial as, I think, an inflection point in our ability to study and start understanding the application of ECMO for respiratory failure in adults.
Clinical Trials on ECMO Benefits
00:09:22
Speaker
The other trial I wanted to ask you about, which is 10 years later, is the EOLIA trial, which obviously is another very important landmark in the evidence-based evaluation of ECMO.
00:09:34
Speaker
Could you talk a little bit about EOLIA and what we learned from it?
00:09:38
Speaker
Yeah, I think that Aeolia set out to answer the question that Caesar did not.
00:09:44
Speaker
Caesar answered the question, are you more likely to survive if you are cared for in a high-volume respiratory failure center with the capability of ECMO?
00:09:55
Speaker
And the answer to that was yes.
00:09:57
Speaker
And so
00:09:58
Speaker
The only is sought out to see is ECMO the thing that makes the difference.
00:10:03
Speaker
And I think this was a very well designed study.
00:10:06
Speaker
They had good criteria for when someone should go on.
00:10:10
Speaker
Someone had to have pretty refractory respiratory failure with a PaO2 less than 50 for a couple of hours or less than 80 for six hours or refractory respiratory acidosis.
00:10:24
Speaker
Most of the patients were managed using the best practice at the time, low tidal volume ventilation, prone positioning, neuromuscular blockade.
00:10:35
Speaker
Most of the studies that supported those interventions were after the CSER trial.
00:10:40
Speaker
So they were managed with the best practice of that time.
00:10:44
Speaker
They had strict criteria for who went on and they really had strict criteria for who could cross over.
00:10:50
Speaker
though they had a large amount of crossover, you really had to almost be dying to cross over into the ECMO group.
00:11:00
Speaker
And many of them did have cardiac arrest who were crossing over into the ECMO group.
00:11:06
Speaker
And this study showed a benefit, a 10 to 15% improvement in survival.
00:11:13
Speaker
If you look at the final line of the New England Journal paper, the study was stopped early for futility.
00:11:20
Speaker
And so if you just read it that you say, well, ECMO doesn't really work.
00:11:25
Speaker
But I don't think that's the takeaway from this study.
00:11:29
Speaker
It just wasn't powered to demonstrate the benefit to give you a comparator.
00:11:35
Speaker
The ARMA trial, which is the low tidal volume ventilation trial from 2000, had a 9% survival benefit, but over a thousand patients, that was a significant difference, and that has dramatically changed the way we manage folks with ARDS.
00:11:52
Speaker
This had an 11% survival benefit, but was only 250 patients.
00:11:59
Speaker
to enroll a thousand patients would have caused this trial to go on for another many years and just was not actually feasible.
00:12:08
Speaker
25% of people crossed over into the treatment group.
00:12:16
Speaker
So if you look at survival or death or crossover, there was clearly a difference or benefit to EOLIA.
00:12:24
Speaker
And I think most people walked away from that feeling
00:12:27
Speaker
that yes, there likely is a survival benefit to ECMO and very severe ARDS.
00:12:33
Speaker
Most people have adopted the EOLIA criteria as their criteria for determining when someone needs ECMO.
00:12:44
Speaker
And I think that was really an important study moving things forward, especially as a couple of years later, we end up in the COVID pandemic.
00:12:55
Speaker
Which leads me to the next topic I wanted to ask you about.
00:12:59
Speaker
You had mentioned earlier about the H1N1 pandemic, right, and how we all of a sudden were exposed to young patients with very severe ARDS.
00:13:09
Speaker
And obviously, we then had COVID, which was...
00:13:13
Speaker
I would say logarithmic scales above of that in terms of our exposure.
00:13:18
Speaker
But also there was a lot of discussion and publications regarding the use of ECMO in these COVID ARDS patients.
00:13:26
Speaker
Could you tell us what we learned from COVID, Craig?
00:13:30
Speaker
Yeah, we, gosh, it would take us several hours to think of all the things we learned from COVID.
00:13:36
Speaker
For sure.
00:13:39
Speaker
I think, I'll be honest, I think one of the biggest benefits in the management of ARDS that came from COVID was widespread adoption of prone positioning for patients with ARDS, which is not exactly ECMO, but I think it was a side benefit that probably will end up saving many people's lives going forward.
00:13:59
Speaker
I think there's almost no comparison between the flu and COVID in terms of how they presented, the patients they presented, and how patients did.
00:14:09
Speaker
COVID-19 was patients...
00:14:16
Speaker
didn't get as sick as quickly so they tended to be on non-invasive ventilation the high flow oxygen for several days before getting intubated and then going on to ecmo their course was very prolonged if you look i mean for us internally our average ecmo run prior to covid was
00:14:39
Speaker
you know seven to ten days with covid it was three to three and a half weeks on average so they tended to take much much longer the longer you're on ecmo the more likely you are to have a bleeding complication an infectious complication or any other complication from being that critically ill in the icu the other thing that we saw is the patients would be on ecmo for
00:15:05
Speaker
30, 40, 50, 60, 70, 80 days, survive, come off ECMO, and ultimately recover.
00:15:15
Speaker
So I think we learned a lesson of patience with COVID that we were beginning to learn just as our experience grew with ECMO.
00:15:25
Speaker
But we really, you had to, if you were in it to do ECMO for COVID, you were in it for the long haul because it took patients a really long time to improve and get better.
00:15:43
Speaker
I think we saw a strain on resources in some places.
00:15:49
Speaker
There were a million things that came with that.
00:15:53
Speaker
But I would say the one thing we really learned there was that patience and people became more comfortable with putting someone on ECMO for 30, 60 days and allowing them to recover.
Indications and Contraindications for ECMO
00:16:06
Speaker
Perfect.
00:16:07
Speaker
And before we move on into more of the clinical discussion of patient selection and management, I also know that post-COVID, there's been more recently, there's been some meta-analysis that have looked at the question of ECMO and ARDS.
00:16:24
Speaker
Any comments on those?
00:16:27
Speaker
Yeah, I think there's...
00:16:29
Speaker
There are a few things.
00:16:30
Speaker
So there were the big cohorts, which aren't meta-analyses, but the big cohort studies that came out of also looking at COVID patients who received ECMO and showed that they survived with outcomes of about 50 to 55% survival, which is lower than what we normally would see.
00:16:50
Speaker
But they did have reasonable survival.
00:16:52
Speaker
They had much longer runs.
00:16:54
Speaker
We saw that piece.
00:16:56
Speaker
There was a meta-analysis of that COVID-19 studies, all the ones that were out there, many of them quite small, that did appear to show a survival benefit.
00:17:10
Speaker
And then there was a meta-analysis that combined Aeolia and Caesar to give bigger numbers and showed a survival benefit.
00:17:21
Speaker
I think all of those taken together
00:17:25
Speaker
How I think about it, how I frame it when talking to patients or providers is I think in the right patient with severe ARDS, ECMO provides probably a 10 to 15 percent survival benefit.
00:17:41
Speaker
over conventional management.
00:17:43
Speaker
That is a patient who would otherwise meet the Aeolia criteria.
00:17:46
Speaker
And I think that's something that we talk with our surgeons about and some of our perfusionists and other things who often think it's ECMO or death.
00:17:56
Speaker
And in reality, that's not the case.
00:17:58
Speaker
ECMO provides a survival benefit, but it's not ECMO or death.
00:18:06
Speaker
For sure.
00:18:07
Speaker
And I think you mentioned something very important, which is in the right patient, and also probably that involves timing, and we'll talk about both of those.
00:18:15
Speaker
So you mentioned the EOLIA criteria as a reference for indications, but maybe you could just give us more detail.
00:18:24
Speaker
How do you think or what do you think are clear indications for considering ECMO in a patient with ARDS?
00:18:31
Speaker
Yeah, so I think in a general term, I would say...
00:18:36
Speaker
ECMO is indicated when you can't oxygenate or ventilate a patient with safe ventilator settings.
00:18:45
Speaker
Safe being as best we can define that using previous studies.
00:18:49
Speaker
Plateau pressures of 30 or less, driving pressure of 15 or less, and low tidal volume ventilation.
00:18:56
Speaker
So if you can manage a patient within those parameters, and there's discussion of how much oxygen percentage plays into that, but let's say
00:19:06
Speaker
60 to 70% oxygen or less, plus those other parameters, if you can maintain that and adequately oxygenate and ventilate your patient, then you're probably gaining the harm of ECMO without the benefit of ECMO by putting that patient on ECMO.
00:19:21
Speaker
ECMO is not risk-free and probably has a 5 to 10% chance of killing you just because you're on ECMO.
00:19:28
Speaker
So I think if you're able to manage that and achieve that, that person probably shouldn't go on ECMO.
00:19:34
Speaker
If you can't achieve that, if you can't achieve that oxygenation ventilation goal without putting that person in unsafe vent settings, then you should put them on ECMO.
00:19:46
Speaker
And I'm very much a proponent of setting safe ventilator settings.
00:19:52
Speaker
And if I can't achieve oxygenation and ventilation,
00:19:56
Speaker
using the EOLIA criteria, which I think are pretty simple and straightforward.
00:19:59
Speaker
You've got a PDEF less than 80 for more than six hours, less than 50 for more than two hours, or a pH less than 725 with a PCO2 greater than 60.
00:20:09
Speaker
So
00:20:11
Speaker
You're proning, you're using safe ventilation, you're not meeting those criteria, then you just keep doing what you're doing.
00:20:16
Speaker
If you're meeting those criteria on safe settings, on proning, then you should go to ECMO.
00:20:22
Speaker
I think one mistake that people make is they will allow their driving pressure in their plateau to get a little higher.
00:20:29
Speaker
So they'll allow it to be 33, 34.
00:20:32
Speaker
And they'll feel, well, I'm just barely above that upper limit.
00:20:35
Speaker
And then three, four days go by and you've had this person on injurious ventilator settings.
00:20:41
Speaker
You've set them back more.
00:20:43
Speaker
You've increased their risk of mortality and prolonged their ultimate ECMO course.
00:20:49
Speaker
So rather than do that, that is the point where I think someone should be going on.
00:20:57
Speaker
Perfect.
00:20:58
Speaker
And what about contraindications?
00:21:00
Speaker
Are there patients in whom, despite maybe meeting those criteria, you as a medical director of a NECMO program would say, well, this is not somebody that I would put on NECMO?
00:21:09
Speaker
I would say the only real absolute contraindications would be someone who is going on ECMO because of complications of end-stage lung disease and it's not a bridge to anywhere.
00:21:23
Speaker
So someone has progressive pulmonary fibrosis, cannot get a transplant,
00:21:29
Speaker
or someone who has a very limited expected survival.
00:21:33
Speaker
So they have widely metastatic cancer that is not treatable in a prognosis less than a few months.
00:21:41
Speaker
That person probably should not go on ECMO.
00:21:44
Speaker
Almost everything else is a relative contraindication.
00:21:48
Speaker
Coagulopathy can be a relative contraindication depending on the cause and the reversibility of it.
00:21:55
Speaker
Other organ failures are, again, relative pause and reversibility, bleeding, even intracranial hemorrhage in the setting of trauma or other things is a relative but not absolute contraindication to ACMO.
00:22:12
Speaker
But as you start to
00:22:14
Speaker
stack things up, that's when you begin to try to make those decisions about how much benefit are they going to derive.
00:22:23
Speaker
We often use the word candidate for ECMO, which I really don't like.
00:22:29
Speaker
I think it seems as though there's something we could give you that would benefit you and we're withholding it because we don't think you're a good candidate.
00:22:36
Speaker
The way I like to frame it is
00:22:39
Speaker
We don't think it's going to provide a survival benefit because if it is going to provide a reasonable survival benefit, then it probably makes sense to do it.
00:22:47
Speaker
And if it's not, then it doesn't.
00:22:49
Speaker
We don't always know that for certain, but we're trying to make the most educated guess we can.
00:22:55
Speaker
So if you've got a, you know, age is a relative contraindication.
00:22:58
Speaker
If you've got a 74-year-old who's previously healthy, was running marathons and aspirated when he was induced to get a knee surgery, then that may make sense to put that person on ECMO.
00:23:10
Speaker
It's probably going to reverse fairly quickly.
00:23:12
Speaker
He was reasonably healthy before this happened.
00:23:16
Speaker
If you've got a
00:23:17
Speaker
60-year-old who's been on a vent for eight days and now has renal failure and bacteremia, those things may be stacking up to where it doesn't make sense.
00:23:26
Speaker
They're likely not going to derive a survival benefit.
00:23:31
Speaker
Craig, I wanted to ask you additional considerations for selecting, I mean, ECMO.
00:23:39
Speaker
Duration of mechanical ventilation, you mentioned earlier that obviously this is a time-sensitive intervention and that delays will decrease the probabilities that would help.
00:23:49
Speaker
Do you have a cut or numbers that you can give us to anchor or are there, sometimes you get a call and the patient's been too long on mechanical ventilation that you really don't think that you're past that window?
00:24:02
Speaker
That's a great question.
00:24:03
Speaker
And, you know, in reality, there's no perfect answer.
00:24:07
Speaker
What we know is that the longer people have been on a ventilator before they go on ECMO, the less likely they are to survive and the longer the duration of their ECMO course.
00:24:17
Speaker
But there are many caveats to that.
00:24:19
Speaker
The person who is
00:24:22
Speaker
on a ventilator for eight, ten days without getting better has self-selected for someone who is not necessarily going to do as well.
00:24:31
Speaker
It doesn't mean that had they gone on ECMO earlier, they would have then done significantly better.
00:24:37
Speaker
There's not been the study that randomized people to going on very early versus going on a little bit later.
00:24:43
Speaker
So there are many caveats to that.
00:24:46
Speaker
I think
00:24:47
Speaker
I don't have an absolute day number.
00:24:51
Speaker
And I think it's hard to say that six days and 23 hours is different than seven days and one hour.
00:24:56
Speaker
So making a seven day cut point or whatever doesn't make a lot of sense to me.
00:25:02
Speaker
I also take into account days of non-invasive support.
00:25:06
Speaker
So if you're on BiPAP for seven days, breathing 40 times a minute at a liter of breath, you're probably going to have a far, far, far worse outcome than a person who's been on a ventilator controlled with good tidal volumes and good management for seven days.
00:25:21
Speaker
So number of days on non-invasive and invasive mechanical ventilation and what the settings have been.
00:25:26
Speaker
If they've been on safe mechanical ventilation throughout that whole time, then I think the number of days is a lot less important than if someone has been on really high levels of ventilator support and is now beginning to develop other organ failure.
00:25:40
Speaker
But if you've got a...
00:25:41
Speaker
previously healthy 24-year-old and single organ failure that's been on high vent support for 10, 12 days, you would still likely put that person on because they still have a good likelihood of surviving the acute illness.
00:25:56
Speaker
It's just going to be a longer course because of what they're dealing with.
00:26:00
Speaker
So no absolute day.
00:26:02
Speaker
And I think it's hard to say that
00:26:04
Speaker
Many of the studies have used seven days as the cut point, which I think is not completely unreasonable, but I think it shouldn't be a hard and fast rule.
00:26:13
Speaker
It should be taken in the context of all the other variables that may impact outcome.
00:26:19
Speaker
And I think that's a very important point.
00:26:22
Speaker
Like you said, the seven days is more of a reference.
00:26:24
Speaker
It's not an absolute.
00:26:26
Speaker
And on one hand, you have the extreme of people calling for ECMO too late.
00:26:31
Speaker
What about the other extreme on the other side of calling too early?
00:26:35
Speaker
I think that also that is something that is worth discussing in terms of proper referral and engagement with an ECMO center if you're not one of them.
00:26:44
Speaker
Yeah, I almost don't believe in calling too early.
00:26:49
Speaker
It's easy to have that conversation with the team at the outside.
00:26:56
Speaker
I think if someone is meeting criteria for prone positioning, that's probably the time where you should call.
00:27:04
Speaker
And then it may mean, okay, we're going to follow up tomorrow.
00:27:07
Speaker
Your patient's P to F ratio is 120.
00:27:11
Speaker
They've got strep pneumo.
00:27:13
Speaker
They're on a little bit of presser.
00:27:16
Speaker
And you're starting to prone them.
00:27:18
Speaker
They seem like they're starting to get a little bit worse.
Strategic Engagement with ECMO Centers
00:27:22
Speaker
Okay, let's prone them.
00:27:24
Speaker
Call us back.
00:27:26
Speaker
12 hours later, let us know how things are.
00:27:28
Speaker
You've proned them.
00:27:30
Speaker
Now this person is on my radar.
00:27:32
Speaker
I'm thinking about, you know, most ECMO referral centers don't have unlimited beds, unlimited resources.
00:27:38
Speaker
We may see, okay, I have a bed available.
00:27:41
Speaker
I want to get that person here now.
00:27:43
Speaker
And if they don't need ECMO, wonderful.
00:27:46
Speaker
They get better and that's okay.
00:27:49
Speaker
If they do need ECMO, it's far easier for us to mobilize and put someone on ECMO when they're already here and do it quickly than if we hear about it at that moment.
00:28:01
Speaker
It may be that, you know, we talk the next morning and they did fantastically well with proning.
00:28:07
Speaker
They're off all pressers.
00:28:08
Speaker
Their PDF is 215.
00:28:09
Speaker
And...
00:28:12
Speaker
you touch base with the other hospital and you say, hey, this sounds great.
00:28:16
Speaker
If they start to get worse, anything changes, call us back, but otherwise keep doing what you're doing.
00:28:23
Speaker
So I personally like to hear earlier so that I can think about all those variables, transporting, bed availability, staffing, et cetera, rather than hearing about it
00:28:37
Speaker
um, later in the course where you're trying to scramble and figure out how to, how to pull things together.
00:28:42
Speaker
Sometimes there's, you know, you, you get called when you can't, when you, when you get called, sometimes things get worse a lot more quickly than others and, and you deal with that.
00:28:51
Speaker
But ideally, I, I, I rarely have been upset that someone has called too early.
00:28:58
Speaker
Great point.
00:29:00
Speaker
And I think that the other point in terms of doing this is, like you said, is the first couple of steps, right, should be optimizing all patients, like use the right tidal volume, keep the plateau pressure below 30.
00:29:12
Speaker
If they meet criteria, prone them, but engage the ECMO team, whether it's in your own institution or outside the institution, right, early so you have an ongoing conversation and can
00:29:24
Speaker
Can can plan plan accordingly.
00:29:26
Speaker
So that was very, very insightful.
00:29:28
Speaker
Thanks for sharing that.
00:29:29
Speaker
Let's talk a little a little bit about general management of ECMO.
00:29:34
Speaker
Any any words on cannulation and cannulation configuration that we should be aware of?
00:29:39
Speaker
Yeah, I think there are there are.
00:29:43
Speaker
there are multiple different ways that you can configure someone for ECMO.
00:29:47
Speaker
VA ECMO seems to almost have an infinite number of configurations beyond what I can even understand.
00:29:53
Speaker
But VV is a little more straightforward, but still has a number of ways you can configure it.
00:30:00
Speaker
For the person that doesn't do this a lot, the first letter of this is where the blood comes from, a large central vein, and the second is where it returns, another large central vein in the setting of a VV ECMO.
00:30:13
Speaker
The most common configurations you'll see are a drainage catheter, meaning that the blood is leaving the patient from a femoral vein and returning either to an IJ, typically the right side, or to the other femoral.
00:30:29
Speaker
So we would say fem-IJ or fem-fem configuration, and it's drained from one fem, returned to the IJ or the other fem.
00:30:40
Speaker
You can use a dual lumen catheter.
00:30:43
Speaker
I think these tend to be
00:30:47
Speaker
Popular with with some folks you think you're you're only putting in one catheter so it is a little bit more a little bit safer in that setting however it's a bigger catheter so there's more potential for injury and it has to be placed either under fluoroscopy or continuous TEE to make sure it's in the right place the right position
00:31:11
Speaker
I think the benefit to dual site configuration is you can typically have more flow.
00:31:19
Speaker
You can put in while the overall catheter is smaller than it is with the dual lumen catheter,
00:31:26
Speaker
the internal diameter of the drainage and the return is much greater.
00:31:31
Speaker
So you can achieve six liters or maybe even a little bit more of flow with dual lumen or with, sorry, with dual site cannulation more easily than you can with a dual lumen catheter, which you're often limited to maybe four and a half to five liters of flow by placing the biggest ones that are out there.
00:31:52
Speaker
That's especially important when you're thinking about
00:31:56
Speaker
a relatively young, relatively large adult patient with severe ARDS and perhaps sepsis.
00:32:05
Speaker
We may have a really high cardiac output, very poorly functioning lungs, and need pretty much everything you can get out of the ECMO circuit.
00:32:15
Speaker
The smaller catheters, the dual lumen catheters, can be more useful when it's primarily hypercapnia, an asthmatic patient that's requiring ECMO or someone who has really more of a dead space issue who's requiring ECMO and has more of a ventilation problem than an oxygenation problem.
00:32:38
Speaker
I'm not here to say one of those is better than the other.
00:32:41
Speaker
Dual cannulas tend to be cheaper than the dual lumen catheters, which tend to be a fair bit more expensive and require a little bit more expertise to place.
00:32:53
Speaker
But it really comes down to the comfort of the providers placing the cannulas and their experience with it.
00:33:01
Speaker
And you can typically manage
00:33:04
Speaker
Most patients will with either as long as you pick a large enough size.
00:33:09
Speaker
The issue we run into, I think, is poor positioning where the drainage cannula is placed too low or the drainage and the return are too close to each other.
00:33:19
Speaker
So you end up with something called recirculation where the blood that you suck out of the patient is the same blood that you just put back into them.
00:33:27
Speaker
So you're not getting much deficiency from your ECMO circuit.
00:33:32
Speaker
or the cannulas that were chosen are too small and you can't achieve enough flow.
00:33:37
Speaker
You've got a big adult with sepsis and you can only get two to three liters of flow, your ECMO is not going to be doing nearly enough to get you the benefit that you need.
00:33:49
Speaker
And in terms of cardiovascular support or cardiovascular support for VV ECMO, is it common that you have to convert to VA or how do you think about that in general with ARDS?
00:34:03
Speaker
It's very uncommon.
00:34:04
Speaker
So it's very common to see a person with ARDS from an infection with a stunned myocardium, an EF of 30 to 40%, who's on a couple of pressors at the time they go on to VB ECMO.
00:34:20
Speaker
As we all know, the sepsis-induced cardiomyopathy typically improves significantly over just a few days.
00:34:27
Speaker
And once you correct their hypoxemia, you correct their respiratory acidosis, you treat their underlying infection, their vasopressor requirement goes down, and they begin to improve.
00:34:41
Speaker
And so that person tends to do okay with VV ECMO.
00:34:47
Speaker
The person who has severe sepsis-induced cardiomyopathy with high cardiac output need
00:34:53
Speaker
And persistent sepsis that goes on to VA ECMO typically does very poorly.
00:34:59
Speaker
So we don't convert that person early on to VA ECMO who has that combined severe cardiopulmonary failure in the setting of really bad sepsis and sepsis-induced cardiomyopathy.
00:35:16
Speaker
which would be different than perhaps a viral-induced cardiomyopathy where the primary problem is systolic heart failure and not a combined severe ARDS and sepsis that you might see with, you know, really bad MRSA bacteremia or something.
00:35:34
Speaker
The second one where I think there is debate and really a lack of clarity on what the right thing to do is the prolonged person on ECMO.
00:35:45
Speaker
You've got a patient who's been on VV ECMO for three, four, five weeks and is beginning to develop worsening RV dysfunction.
00:35:57
Speaker
So you have worsened pulmonary hypertension in the setting of prolonged ARDS and you start to develop right heart
00:36:05
Speaker
failure.
00:36:06
Speaker
If the person survives and the lung heals, that gets better typically.
00:36:12
Speaker
And we know that from more historical studies looking at RV dysfunction and ARDS and the absence of ECMO.
00:36:20
Speaker
And different places approach this differently.
00:36:22
Speaker
Some places will convert folks to what's called a VPA or a VP ECMO.
00:36:31
Speaker
There is a catheter that can do this, what's called a PROTEC DUO catheter, which is a percutaneous ARVAD, which is a catheter that drains from the right atrium and returns blood into the pulmonary artery.
00:36:47
Speaker
The downside to this in the setting of pulmonary hypertension is you're not fixing your pulmonary vascular resistance.
00:36:55
Speaker
So you're just trying to force the blood harder into the lungs, which can worsen pulmonic insufficiency and also pulmonary hemorrhage.
00:37:07
Speaker
Though some people use this and find that it is helpful in this population, others will convert this person to VAV ECMO, where you're draining from a central vein and you're returning both on the venous side and the arterial side to give the patient time to heal the lungs, reduce that pulmonary vascular resistance, right heart to improve and recover.
00:37:34
Speaker
When patients get to that point, their overall mortality is relatively high, and it comes down to resources and skill with that subset of patients.
00:37:47
Speaker
So it's a really challenging group that requires a lot of resources and has generally a poor outcome overall.
00:37:59
Speaker
Perfect.
Technical Aspects of ECMO Management
00:38:00
Speaker
In terms of a general ECMO management, once they're on ECMO, could you talk a little bit about the gas exchange dynamics and what are we titrating on the ECMO circuit?
00:38:12
Speaker
Yeah, so that's a great question.
00:38:13
Speaker
And the nice thing about ECMO itself is that it's really, really simple.
00:38:19
Speaker
The machine has one knob on it, and that knob turns the RPMs up or down.
00:38:26
Speaker
And it has a second
00:38:29
Speaker
ability to provide a gas source.
00:38:32
Speaker
So it really ultimately ends up with just two knobs.
00:38:35
Speaker
One changes RPMs, which gives you blood flow, and one changes the flow of gas through there, which most people will call a sweep gas flow.
00:38:44
Speaker
The sweep gas is providing an oxygen source, but it's predominantly removing CO2.
00:38:52
Speaker
The faster the air is flowing through the oxygenator or the gas exchanger, the more CO2 is being extracted.
00:38:59
Speaker
Kind of like minute ventilation.
00:39:00
Speaker
The faster you breathe, the more CO2 you blow off.
00:39:04
Speaker
And the blood flow, the higher your blood flow, the more of your cardiac output you're capturing.
00:39:09
Speaker
So the more of that blood that actually gets oxygenated.
00:39:13
Speaker
So you will achieve better oxygenation by going up on blood flow.
00:39:19
Speaker
To a certain point, you will be limited either due to the size of your cannulas or the overall volume status of the patient or vessel size.
00:39:29
Speaker
And so you go up on blood flow for oxygenation and sweep gas flow for ventilation.
00:39:36
Speaker
In terms of managing the ventilator going along with that, it's not totally clear all people who
00:39:45
Speaker
I would say almost everyone in this field agrees that a patient should definitely be on lung protective ventilation, i.e.
00:39:52
Speaker
a plateau less than 30, lower tidal volumes, driving pressure, et cetera, all the factors we talked about earlier.
00:39:58
Speaker
There is discussion of what is, I think, sort of currently mislabeled as ultra lung protective ventilation.
00:40:07
Speaker
We don't know that it is ultra lung protective.
00:40:09
Speaker
We do know that it is ultra low pressure, ultra low volume.
00:40:14
Speaker
and so some would argue for using a plateau pressure target of around 24 driving pressure of 10 to 12 and a reasonable amount of peep whether you get ultra lung protection relative to simple lung protection has not really been proven
00:40:34
Speaker
The more you lower the ventilator support, the more you have to achieve from the ECMO circuit, which can make it sometimes harder to wake the patient, mobilize the patient, et cetera.
00:40:45
Speaker
So there's a balance there.
00:40:47
Speaker
I think certainly lung protective ventilation, perhaps lower is even better, but we really just don't know yet.
00:40:55
Speaker
on that piece.
00:40:56
Speaker
I'd say the one other thing I want to make sure and highlight as you're doing that, when someone goes on ECMO, they may have significantly elevated CO2 and they may have respiratory acidosis.
00:41:09
Speaker
If that is corrected too quickly, there is an increased risk of head bleed.
00:41:15
Speaker
So if someone goes on, you want to correct that hypercapnia relatively slowly over a 24-hour period or more if your blood pressure and pH will allow as to not cause rapid shifts in blood flow to the brain that can lead to intracranial hemorrhage and death.
00:41:36
Speaker
And what would be your targets for oxygenation and for CO2 in general?
00:41:42
Speaker
So we talked about that rapid change as being potentially dangerous with the CO2.
00:41:48
Speaker
But what would be your targets and where are you measuring those?
00:41:52
Speaker
Good question.
00:41:52
Speaker
So you're with your oxygenation, you're measuring that from an arterial blood gas.
00:41:58
Speaker
It's much less complicated in VV ECMO than it is in VA ECMO.
00:42:02
Speaker
So you're measuring, you've got an arterial line in the wrist or the femoral or wherever you have it, it doesn't really matter.
00:42:09
Speaker
You're checking that and you want a PAO2 typically in the range that you would have for anyone on ARDS, somewhere 55 to 80.
00:42:17
Speaker
Sometimes that's just not achievable in someone with really severe ARDS, even on ECMO.
00:42:24
Speaker
And in that scenario, you have to ask yourself,
00:42:27
Speaker
is the risk of whatever it is I'm going to do to improve their oxygenation greater than the benefit I gain.
00:42:35
Speaker
So if someone has a mental status, they're peeing, their lactate is normal, then their oxygenation is probably adequate.
00:42:44
Speaker
Their oxygen delivery is probably adequate.
00:42:46
Speaker
And trying to push the ventilator more or giving them other medications or transfusing a lot of blood may be harmful when you don't really need to do that.
00:42:57
Speaker
We've had patients with an oxygen sat in the 70s, even in the 60s for days who didn't have a lactate, who were peeing, who were mentating, who recovered and had sort of a cognition in line with any critical illness survivor afterwards.
00:43:16
Speaker
And we would have really probably caused more harm by putting in more cannulas, transfusing lots of blood, doing all these other things to try and chase that number.
00:43:27
Speaker
So generally the same thing we would use for ARDS, but sometimes you have to tolerate a little bit lower.
00:43:33
Speaker
From a PCO2 standpoint, again, if you're looking at a blood gas and an arterial blood gas and really targeting a pH,
00:43:43
Speaker
as much as you would with standard mechanical ventilation for ARDS.
00:43:50
Speaker
One thing that I think can be helpful, if you're trying to wake up the patient who's on ECMO and they're a little bit acidemic,
00:44:01
Speaker
they're going to be harder to wake up.
00:44:03
Speaker
They're going to have an increased drive to breathe, which is going to cause you issues with ECMO blood flow, with tidal volumes, etc., and hinder your ability to wake them up.
00:44:13
Speaker
So one, I guess, little pearl that I always try to do is if I'm going to wake up a patient on ECMO, I'm now five, seven days into it, I will try to get their pH into about a 7.45 or just a little bit alkalemic so they have less
00:44:28
Speaker
of a acidemic drive to breathe as they start to wake up and are inevitably somewhat delirious.
00:44:36
Speaker
But generally, you're targeting a pH rather than an absolute PCO2 number.
00:44:42
Speaker
Perfect.
00:44:43
Speaker
Another area, obviously, that is very important for our intensivists managing ECMO is antichryrolation.
00:44:50
Speaker
Could you give us just, I mean, your approach and how you manage antichryrolation on ECMO patients?
00:44:57
Speaker
Yeah, anticoagulation is, if you asked 15 different people how they anticoagulate someone on ECMO, you were liable to get at least 10 different answers.
00:45:09
Speaker
There's really no perfect answer, which is unfortunately the answer to many of the questions around ECMO.
00:45:17
Speaker
But we know as the higher level of anticoagulation you give, the more likely you are to bleed, the less likely you are to clot.
00:45:24
Speaker
The lower the levels of anticoagulation you give, the more likely you are to clot, the less likely you are to bleed.
00:45:33
Speaker
And with that and newer circuits, most people have trended towards using slightly lower levels of anticoagulation than maybe they did 10 years ago with patients with VV ECMO on ARDS.
00:45:47
Speaker
There are many patients who can actually be managed without anticoagulation at all who are having bleeding complications.
00:45:57
Speaker
And there are people now that are looking at whether or not you can get by with simply using DVT prophylaxis while someone is on ECMO.
00:46:08
Speaker
Our current approach is
00:46:10
Speaker
is to use a lower target range of PTT for anticoagulation with a primary anticoagulant of heparin.
00:46:21
Speaker
And we would target a PTT of 40 to 50 while on a continuous heparin infusion.
00:46:30
Speaker
Some folks will use direct thrombin inhibitors, use anti-10A levels, Rotem or TEG to monitor anticoagulation.
00:46:41
Speaker
You can get as complex as you like.
00:46:43
Speaker
I think my personal opinion is the simpler the better based on what we know now.
00:46:52
Speaker
And I hope that I can give you a completely different answer in five or 10 years because it will mean that we've moved the field forward.
00:47:00
Speaker
Perfect.
00:47:02
Speaker
What about complication and troubleshooting the circuit?
00:47:05
Speaker
Anything that you want to share with our listeners that can be of practical use?
00:47:12
Speaker
I think one of the most feared complication for me is the intracranial hemorrhage.
00:47:18
Speaker
Almost everything else you can work with, oftentimes that is catastrophic and devastating and someone who otherwise may have survived and walked away.
00:47:29
Speaker
So that is the complication that I fear the most, I think,
00:47:33
Speaker
appropriately managing your anticoagulation, having your patients as awake as possible so that you can early detect any kind of potential injury is what you're looking at there.
00:47:46
Speaker
I would say that two of the most common things that come up with patients in terms of troubleshooting is often flow interruption or chugging, where the flow is being interrupted as the patient wakes up, coughs, takes a deep breath, etc., which can lead to then more sedation, more fluid, which leads to volume overload, which worsens outcomes, which leads to more sedation, more delirium, prolonged courses.
00:48:16
Speaker
And really taking a step back and thinking about that, that chugging typically happens because our flow is high and our volume may not be super high.
00:48:31
Speaker
But we may not want our volume to be super high.
00:48:33
Speaker
Flood and flood and flood patients so I can get tons and tons of flow, but I'm just going to make them worse in the long run.
00:48:39
Speaker
So really thinking about how much flow do I need?
00:48:42
Speaker
Can I tolerate simply a little bit less flow
00:48:46
Speaker
and get away from the complications of all those things I'm going to do to try to achieve this higher level of flow I'm trying to achieve, trying to get.
00:48:55
Speaker
So really being thoughtful about that.
00:48:56
Speaker
If you're having issues with flow, your first question should be, do I need this much flow?
00:49:02
Speaker
And if you do, then you have to work with it.
00:49:04
Speaker
But if you don't, then you may be able to get rid of all the issues that you're dealing with.
00:49:09
Speaker
The second one is as you begin to develop a ECMO-related coagulopathy.
00:49:15
Speaker
Those are really challenging things.
00:49:19
Speaker
lead to bleeding, lead to other complications.
00:49:22
Speaker
And I think if there was a pearl to that, it would be treating the patient, not the circuit.
00:49:29
Speaker
If the circuit is causing a lot of the problems, it may mean that that circuit just needs to be changed.
00:49:35
Speaker
Even if you're close to coming off of ECMO, even if you are
00:49:40
Speaker
You have to take into account that additional cost that may come that may be the right thing to do at that time.
00:49:50
Speaker
And what about, Craig, in terms of fluid management, you talked about obviously how sometimes, I mean, in the goal of optimizing flow, we can overload patients, but these patients also probably have a high risk of renal failure.
00:50:02
Speaker
When you need to do renal replacement therapy, is that something that you just connect through the ECMO circuitry, or do you need a separate CRT machine for these patients?
00:50:10
Speaker
How do you usually deal with this?
00:50:13
Speaker
So you would use a different, there are a million different ways that that can be set up.
00:50:19
Speaker
And it's kind of institution dependent on how you approach it.
00:50:22
Speaker
Our approach has been to
00:50:25
Speaker
Minimize touching our circuit.
00:50:28
Speaker
We put the circuit in with as few connectors as possible and we rarely access that circuit.
00:50:34
Speaker
We don't check daily blood gases from the circuit.
00:50:37
Speaker
We don't transfuse through the circuit typically.
00:50:40
Speaker
We don't do dialysis through the circuit.
00:50:43
Speaker
All those are opportunities to introduce air or infection which can worsen your outcome.
00:50:50
Speaker
we will place a separate dialysis catheter and dialyze that way.
00:50:54
Speaker
Other places will run dialysis off of the ECMO circuit.
00:50:59
Speaker
So they'll have connectors in so the blood flows from the ECMO circuit to the dialysis machine and back.
00:51:06
Speaker
There aren't great studies to say which one is better.
00:51:10
Speaker
Short answer is you can do it a number of different ways, and it's figuring out what makes most sense for your institution and your individual patient until we have any better data to support one way or the other.
00:51:24
Speaker
Perfect.
00:51:25
Speaker
I wanted to ask you a question that actually relates more to ventilator management.
Proning Patients on ECMO: A Discussion
00:51:32
Speaker
If you were to ask me a couple of years ago, should we prone a patient with ARDS who's on ECMO, I would have said, I don't think so.
00:51:39
Speaker
But I'm not sure that's the right answer these days.
00:51:42
Speaker
What do we know about that?
00:51:45
Speaker
Yeah, there was just a recent study published that did not show a benefit to proning people on ECMO.
00:51:52
Speaker
And so I think that's
00:51:56
Speaker
sets us back a little bit in that area.
00:51:59
Speaker
I think it probably means that there is a narrow group of patients who probably still continue to benefit from prone positioning while on ECMO, but maybe it's not something that needs to be done for everyone.
00:52:15
Speaker
If you look at the
00:52:17
Speaker
Proceva study, really the benefit was there whether your oxygenation got better, worse, whether your ventilation got better or worse, stayed the same.
00:52:25
Speaker
Really everyone derived a survival benefit from prone positioning.
00:52:29
Speaker
So it would seem that that would also play over into ECMO, but it's probably not totally true.
00:52:37
Speaker
So I think the person who is
00:52:40
Speaker
persistent refractory hypoxemia while on ECMO, and you're already deeply sedated, perhaps paralyzed, there's probably very little harm in proning them, and there may be benefit.
00:52:53
Speaker
If this is someone who you could otherwise have awake, mobilizing, maybe even extubated, then the need for deep sedation proning
00:53:05
Speaker
may be less beneficial.
00:53:06
Speaker
It may simply prolong their course and give them worse outcomes.
00:53:11
Speaker
So I think the jury is still out.
00:53:14
Speaker
I think that some patients may benefit universally.
00:53:18
Speaker
It may not be the right thing to do.
00:53:21
Speaker
And I think it's an important also evolution in our understanding of prone positioning because I think a lot of people still believe that oxygenation is the main objective there, but we also know that it can protect the lungs from injury in ARDS, and that's what you were alluding to, that in placebo, even if the oxygen does not go up, if oxygenation does not improve, they still derive benefit.
00:53:45
Speaker
Absolutely.
00:53:46
Speaker
Absolutely.
00:53:47
Speaker
Let's talk a little bit about separation and decannulation.
00:53:51
Speaker
So how do you assess when somebody is ready for weaning?
00:53:54
Speaker
How do you and how you start?
00:53:56
Speaker
I mean, thinking about weaning and separating them from the ECMO support.
00:53:59
Speaker
And what do you do with the ventilator as you're doing that?
00:54:03
Speaker
Yeah, a great question, and that's something we have thought immensely about.
00:54:08
Speaker
And we've tried to model our approach after SBTs and SATs, and even followed in that vein and naming it.
00:54:17
Speaker
So we call it a sweep-off trial or an SOT.
00:54:21
Speaker
So we set objective criteria on when someone has improved enough to where
00:54:29
Speaker
we could test them.
00:54:31
Speaker
We've set a clear protocol for how to test them and criteria for failure.
00:54:38
Speaker
So very similar to those other SAT, SPT approach.
00:54:43
Speaker
So for us, if you have a pH greater than 7.3 on ECMO, you are on only 40% oxygen on the vent.
00:54:57
Speaker
while you're on ECMO, and your tidal volumes are at least four cc's per kilo.
00:55:02
Speaker
If they are, then we will fairly rapidly turn your sweep down to almost completely off.
00:55:10
Speaker
And if you're not in respiratory distress with very little sweep, we will turn it off.
00:55:17
Speaker
And we will monitor you there.
00:55:18
Speaker
We don't go up on the ventilator support.
00:55:21
Speaker
I think the whole point of ECMO is protecting the lungs.
00:55:25
Speaker
So we don't
00:55:26
Speaker
crank up the ventilator to test you coming off.
00:55:29
Speaker
We leave it on safe lung protective ventilation.
00:55:34
Speaker
We do turn up the oxygen a little bit because that gives us an opportunity to see, you know, because we're really gauging what's the risk of liberating this person from ECMO versus continuing to keep them on ECMO.
00:55:48
Speaker
And if someone is having a lot of bleeding complications and other issues related to ECMO, you may take them off ECMO a little sooner than someone who's having no issues whatsoever and is gradually getting better.
00:56:02
Speaker
There are several published protocols out there other than ours that take a more stepwise approach, a more, I would say, complex approach to doing this.
00:56:14
Speaker
I don't think any of those are necessarily wrong.
00:56:17
Speaker
I just always like to think of things in the simplest possible way that you can do it.
00:56:23
Speaker
I think the big question right here around this topic is,
00:56:28
Speaker
what should be coming away first?
00:56:31
Speaker
Should the person be liberated from ECMO first or should the person be liberated from the ventilator first?
00:56:38
Speaker
I don't know the answer to that.
00:56:39
Speaker
You will find many different opinions out there regarding this.
00:56:44
Speaker
My personal thought is
00:56:46
Speaker
When a person is ready to liberate from one, I try to ask myself which of these is causing the most problems right now.
00:56:54
Speaker
If my person is agitated, coughing a lot, really struggling to communicate, is not having any real issues with ECMO, and it may make sense to get them off the ventilator first.
00:57:05
Speaker
If my person has persistently low platelets, they're oozing from everywhere, they're having pulmonary hemorrhage, they're having a GI bleed or some other complication, then it may make a lot more sense to get them off of ECMO first.
00:57:21
Speaker
And I think this is another area we're going to learn a lot in the next five to 10 years, and we'll probably be practicing very differently at that time than we are now.
00:57:31
Speaker
And I think it's also a great example of how approaches have evolved because sequentially you think, okay, I intubate, then I put on ECMO, then I would take off ECMO, and then I would take off the ventilator.
00:57:45
Speaker
But like you're saying, maybe in some patients, you don't have to follow that mirror sequence.
00:57:52
Speaker
Yeah, that's right.
00:57:55
Speaker
Any technical aspects regarding the cannulation that you want to comment on?
00:58:01
Speaker
Not really.
00:58:02
Speaker
I think that this is going to be varying slightly based on the person who's doing the decannulation, the surgeon, the operator that is doing that.
00:58:10
Speaker
It's a venous site, so it's less complicated closure than VA ECMO.
00:58:17
Speaker
And depending on the size of the cannula that's in place, whether or not a really small return catheter might simply need pressure like you were pulling a dialysis catheter, whereas a larger one may require a suture.
00:58:31
Speaker
But typically not different closure devices or going to the ORs.
00:58:35
Speaker
You often have to do with more complicated VA, ECMO, and grafts and other things that are related to that.
00:58:43
Speaker
Perfect.
00:58:44
Speaker
As we close the clinical discussion, Greg, for those who are interested in obviously learning more or maybe at their institution they're starting to do ECMO, any suggestions on sources of education or things that you'd recommend?
00:59:03
Speaker
Yeah, and a bit of self-promotion, I guess.
00:59:07
Speaker
The American College of Chest Physicians puts on what I think is an excellent ECMO course, an ECMO and mechanical circulatory support.
00:59:17
Speaker
In disclosure, I'm one of the chairs of that course, but I think it's an excellent two-day course that really gives an overview and a bit of a dive into what
00:59:26
Speaker
VA ECMO, VB ECMO, and other forms of mechanical circulatory support.
00:59:32
Speaker
There's even a cannulation course that is affiliated with that.
00:59:36
Speaker
The Extracorporeal Life Support Organization, or ELSO, puts on, I think, an outstanding conference every year that has a lot of information for anyone in this field, from an ECMO specialist to a physician,
00:59:53
Speaker
across the spectrum of adults, peds, VA, and VV ECMO.
00:59:58
Speaker
It's always a very, very good conference with really good, really good content.
01:00:05
Speaker
Those are, I think, a couple of the best things that are out there that people can reach to.
01:00:12
Speaker
ELSO has a lot of online resources as well, and it's just in general, I think, an excellent
01:00:18
Speaker
organization that has done a lot to improve the field of ECMO, grow the field of ECMO, support patients and providers who are dealing with ECMO.
01:00:28
Speaker
Perfect.
01:00:28
Speaker
And we will definitely add links on the show notes.
01:00:32
Speaker
So Craig, this was a wonderful, I think, overview and discussion about where we stand today with VV ECMO and ARDS.
01:00:41
Speaker
We usually like to close the podcast with a couple of questions that are unrelated to the clinical topic.
01:00:45
Speaker
Would that be okay?
01:00:47
Speaker
Sure.
01:00:48
Speaker
So the first question relates to books.
01:00:51
Speaker
Are there any, is there any book or books that have influenced you significantly or you have gifted often to other people?
01:00:58
Speaker
That's a great question.
01:00:59
Speaker
And I would,
01:01:01
Speaker
I would say there is a story that I tell, that I use as an example a lot in the ICU, and especially in patients who are on ECMO, that is encompassed really in two different books.
01:01:14
Speaker
And it's the story of Ernest Shackleton, who was a early 20th century explorer, was one of the first
01:01:24
Speaker
was going to be the first to do an expedition completely across Antarctica in 1914.
01:01:30
Speaker
And they left from England and went down there for this journey, and their ship, the Endurance, was trapped in the ice and ultimately crushed in the ice there in Antarctica.
01:01:46
Speaker
And so they were stuck for almost 18 months
01:01:51
Speaker
in Antarctica, adrift on sea ice, and made a 500-mile journey through the ocean to South Georgia Island, and then crossed South Georgia Island, which had never really been done before.
01:02:09
Speaker
And no one in his expedition died.
01:02:13
Speaker
And I think it is a wonderful experience
01:02:18
Speaker
It encompasses the human will to survive.
01:02:23
Speaker
and it's also a great leadership tale.
01:02:26
Speaker
But I think as we're often in the ICU, we look at someone who seems to be in a miserable situation that we're having a hard time seeing our way out of, and this just shows the tremendous human desire to live in the spirit.
01:02:44
Speaker
And so the first book is called South.
01:02:47
Speaker
It was written by Shackleton after he returned.
01:02:51
Speaker
And the second one is a much more recent telling of the story called Endurance.
01:02:58
Speaker
And I think that it's just an incredible journey that as you read, you think a million times, oh my God, how in the world did they survive this?
01:03:08
Speaker
I could have never kept going as they did.
01:03:11
Speaker
So it's worth at least reading the Wikipedia version of the story so that you familiarize yourself with it.
01:03:18
Speaker
And I think both books are also really good.
01:03:21
Speaker
Awesome.
01:03:21
Speaker
No, I agree.
01:03:23
Speaker
I did not read South.
01:03:24
Speaker
I definitely picked that up.
01:03:25
Speaker
But during COVID, I did read Endurance.
01:03:28
Speaker
And it was just a reminder every time I complained, right?
01:03:31
Speaker
I mean, oh my God, these guys were floating on an iceberg, right?
01:03:34
Speaker
And everyone survived.
01:03:36
Speaker
So I think it's a great recommendation.
01:03:39
Speaker
And we'll definitely put links in the show notes.
01:03:42
Speaker
The second question, Greg, relates to something you believe to be true in medicine or in life that many other people don't believe or don't act like they believe.
01:03:54
Speaker
This one, I think, is a little tougher, but I think as...
01:03:58
Speaker
As we've talked about so much of this in ECMO, it's really unknown.
01:04:03
Speaker
How do we do this?
01:04:04
Speaker
How do we manage anticoagulation?
01:04:06
Speaker
Do we take off ECMO first or the ventilator first?
01:04:10
Speaker
I always encourage people to be willing to change your practice.
01:04:14
Speaker
You're admitting when you do that that the way you're doing it before was wrong.
01:04:19
Speaker
And you may have been harming people.
01:04:22
Speaker
And I think that's why people often have a hard time changing their practice.
01:04:26
Speaker
But that is okay.
01:04:28
Speaker
And I think seeing the opportunity that we are now going to be helping more people is a better approach.
01:04:35
Speaker
I'm always hoping that I'm doing something different.
01:04:39
Speaker
five years from now than I am now, because that means I will have learned something and I'll be better at it then than I was now.
01:04:45
Speaker
So always be willing to change your practice as the evidence evolves and don't see it as a prior failing, but as an opportunity to move forward.
01:04:55
Speaker
Absolutely.
01:04:55
Speaker
I think it's attributed to Albert Einstein, but the quote is something along the lines of that the real sign of a high intellect is your ability to change your mind when faced with new facts, right?
01:05:08
Speaker
And I think in medicine, we love the confirmation bias.
01:05:12
Speaker
We love being stick with our previous positions.
01:05:16
Speaker
And sometimes we're not curious or humble enough to really say, hey, maybe I was doing it the wrong way and there's a better way to do this.
01:05:23
Speaker
I think that's a great, great point.
01:05:26
Speaker
Finally, is there anything you would want every listener that's on the podcast today to know could be a quote or fact or just a departing thought?
01:05:36
Speaker
So I thought about this and there is a famous ECMO doctor named Polly Palmer from Sweden who's had more experience with some of these really prolonged ECMO and transport, etc.
01:05:50
Speaker
And I was speaking with him and he was giving a lecture last year at the ELSO meeting and he had one of the best quotes I've seen as it relates to much of what we do in critical care.
01:06:02
Speaker
And he said, it's the disease that determines the outcome for our patients unless we do something stupid.
01:06:10
Speaker
And I think that is so true.
01:06:11
Speaker
We think we have so much influence on what is going on for our patients, but really if we are just...
01:06:20
Speaker
Do the best we can for them.
01:06:22
Speaker
Don't make dumb errors in management.
01:06:25
Speaker
Call early when someone may need ECMO.
01:06:28
Speaker
It's really going to be the disease that makes the ultimate decision on whether or not that person survives or not.
01:06:35
Speaker
And it's just our job to not hurt them.
01:06:39
Speaker
I love that quote.
01:06:40
Speaker
I have not heard it before, but I think it speaks tremendous truth, right?
01:06:45
Speaker
I mean, power to truth there, and I think it's a perfect place to stop.
01:06:50
Speaker
Craig, thank you so much for sharing your expertise and your time with us.
01:06:55
Speaker
Hope to have you back on the podcast to discuss more topics on ECMO and other topics in critical care.
01:07:01
Speaker
My pleasure, Sergio.
01:07:02
Speaker
Thanks so much for having me.
01:07:05
Speaker
Thank you for listening to Critical Matters, a sound podcast.
01:07:08
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
01:07:14
Speaker
Sounds transforming the way critical care is provided in hospitals across the country.
01:07:19
Speaker
To learn more, visit www.soundphysicians.com.