Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: In the previous episode of Critical Matters, we discussed current respiratory support for patients with ARDS.
Speaker: Lung protective ventilation, prone position, and other therapeutic interventions have made significant impact on outcomes in patients with respiratory failure and ARDS.
Speaker: However, there is still a subset of patients that, despite these interventions, do not respond well.
Speaker: In today's episode of the podcast, we will discuss the role of ECMO, Extracorporeal Membrane Oxygenation and ARDS.
Speaker: Our guest is Dr. Craig Radley, a practicing pulmonary critical care physician.
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.
Speaker: Dr. Rackley is a recognized clinician, educator, and researcher with an interest in respiratory failure, ARDS, and ECMO.
Speaker: A true honor to have him today on Critical Matters.
Speaker: Craig, welcome to the podcast.
Speaker: Thank you, Sergio.
Speaker: Thanks for having me.
Speaker: Absolutely.
Speaker: So I would like to start with a question, and we're kind of talking about this before we start recording.
Speaker: Not every program, not every listener that follows us may have an ECMO program or ECMO capability in their hospital.
Speaker: Many do.
Speaker: But the question really is, why should critical care clinicians care about ECMO at programs where there is no ECMO capability?
Speaker: That's a great question and one that comes up all the time.
Speaker: I think the answer I would like to give you is that ECMO is the future of the management of respiratory failure.
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.
Speaker: But I think that is hopefully the answer I can give you 10, 15 years from now.
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.
Speaker: And these are folks with severe respiratory failure and ARDS.
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.
Speaker: And if you know...
Speaker: who those patients are, you identify them early, you potentially can save their life.
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.
Speaker: One of the things that
Speaker: I always hate to see is when we get called too late.
Speaker: A patient has been on a ventilator at high ventilator settings for a really long period of time.
Speaker: They're now developing multi-organ failure.
Speaker: We're not able to achieve adequate oxygenation and ventilation.
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
Speaker: or go out and place that person on ECMO to bring to us.
Speaker: And so it is time sensitive and it's important to identify the right patients early so that they can derive that benefit.
Speaker: And so knowing that, building those relationships, I think is the answer to that question today.
Speaker: Perfect.
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.
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.
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.
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.
Speaker: And, you know,
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.
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.
Speaker: And so there really was...
Speaker: very little utilization of ECMO.
Speaker: When we're talking about ECMO today, we're primarily talking about VV ECMO for acute respiratory failure.
Speaker: So there's virtually no use of VV ECMO for adult respiratory failure in the 70s, 80s, 90s, and even into the 2000s.
Speaker: There was a fair bit of utilization in pediatrics and neonates where there was some evidence and experience.
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.
Speaker: One was the technology was beginning to improve.
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,
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.
Speaker: So all of that became much more streamlined around health.
Speaker: the mid-2000s to the mid-2015s, smaller machines, better technology, more ease of use for the regular provider.
Speaker: The second thing that came along was the influenza pandemic, the H1N1 pandemic.
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.
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.
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.
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.
Speaker: And they showed that it did.
Speaker: It improved outcomes by, you know, 10 to 20 percent in this cohort of patients.
Speaker: They all didn't receive ECMO.
Speaker: So the the
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?
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.
Speaker: There was an Australian experience with H1N1 showed that
Speaker: 75 plus percent of patients who had severe ARDS with influenza who went on ECMO survived.
Speaker: So you're taking a group that you didn't think was going to be able to survive without ECMO.
Speaker: They go on ECMO and they survive.
Speaker: So we have a little more confidence.
Speaker: We have better technology.
Speaker: We have a little bit of data.
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.
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.
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.
Speaker: Could you talk a little bit about EOLIA and what we learned from it?
Speaker: Yeah, I think that Aeolia set out to answer the question that Caesar did not.
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?
Speaker: And the answer to that was yes.
Speaker: And so
Speaker: The only is sought out to see is ECMO the thing that makes the difference.
Speaker: And I think this was a very well designed study.
Speaker: They had good criteria for when someone should go on.
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.
Speaker: Most of the patients were managed using the best practice at the time, low tidal volume ventilation, prone positioning, neuromuscular blockade.
Speaker: Most of the studies that supported those interventions were after the CSER trial.
Speaker: So they were managed with the best practice of that time.
Speaker: They had strict criteria for who went on and they really had strict criteria for who could cross over.
Speaker: though they had a large amount of crossover, you really had to almost be dying to cross over into the ECMO group.
Speaker: And many of them did have cardiac arrest who were crossing over into the ECMO group.
Speaker: And this study showed a benefit, a 10 to 15% improvement in survival.
Speaker: If you look at the final line of the New England Journal paper, the study was stopped early for futility.
Speaker: And so if you just read it that you say, well, ECMO doesn't really work.
Speaker: But I don't think that's the takeaway from this study.
Speaker: It just wasn't powered to demonstrate the benefit to give you a comparator.
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.
Speaker: This had an 11% survival benefit, but was only 250 patients.
Speaker: to enroll a thousand patients would have caused this trial to go on for another many years and just was not actually feasible.
Speaker: 25% of people crossed over into the treatment group.
Speaker: So if you look at survival or death or crossover, there was clearly a difference or benefit to EOLIA.
Speaker: And I think most people walked away from that feeling
Speaker: that yes, there likely is a survival benefit to ECMO and very severe ARDS.
Speaker: Most people have adopted the EOLIA criteria as their criteria for determining when someone needs ECMO.
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.
Speaker: Which leads me to the next topic I wanted to ask you about.
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.
Speaker: And obviously, we then had COVID, which was...
Speaker: I would say logarithmic scales above of that in terms of our exposure.
Speaker: But also there was a lot of discussion and publications regarding the use of ECMO in these COVID ARDS patients.
Speaker: Could you tell us what we learned from COVID, Craig?
Speaker: Yeah, we, gosh, it would take us several hours to think of all the things we learned from COVID.
Speaker: For sure.
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.
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.
Speaker: COVID-19 was patients...
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
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
Speaker: 30, 40, 50, 60, 70, 80 days, survive, come off ECMO, and ultimately recover.
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.
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.
Speaker: I think we saw a strain on resources in some places.
Speaker: There were a million things that came with that.
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.
Speaker: Perfect.
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.
Speaker: Any comments on those?
Speaker: Yeah, I think there's...
Speaker: There are a few things.
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.
Speaker: But they did have reasonable survival.
Speaker: They had much longer runs.
Speaker: We saw that piece.
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.
Speaker: And then there was a meta-analysis that combined Aeolia and Caesar to give bigger numbers and showed a survival benefit.
Speaker: I think all of those taken together
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.
Speaker: over conventional management.
Speaker: That is a patient who would otherwise meet the Aeolia criteria.
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.
Speaker: And in reality, that's not the case.
Speaker: ECMO provides a survival benefit, but it's not ECMO or death.
Speaker: For sure.
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.
Speaker: So you mentioned the EOLIA criteria as a reference for indications, but maybe you could just give us more detail.
Speaker: How do you think or what do you think are clear indications for considering ECMO in a patient with ARDS?
Speaker: Yeah, so I think in a general term, I would say...
Speaker: ECMO is indicated when you can't oxygenate or ventilate a patient with safe ventilator settings.
Speaker: Safe being as best we can define that using previous studies.
Speaker: Plateau pressures of 30 or less, driving pressure of 15 or less, and low tidal volume ventilation.
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
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.
Speaker: ECMO is not risk-free and probably has a 5 to 10% chance of killing you just because you're on ECMO.
Speaker: So I think if you're able to manage that and achieve that, that person probably shouldn't go on ECMO.
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.
Speaker: And I'm very much a proponent of setting safe ventilator settings.
Speaker: And if I can't achieve oxygenation and ventilation,
Speaker: using the EOLIA criteria, which I think are pretty simple and straightforward.
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.
Speaker: So
Speaker: You're proning, you're using safe ventilation, you're not meeting those criteria, then you just keep doing what you're doing.
Speaker: If you're meeting those criteria on safe settings, on proning, then you should go to ECMO.
Speaker: I think one mistake that people make is they will allow their driving pressure in their plateau to get a little higher.
Speaker: So they'll allow it to be 33, 34.
Speaker: And they'll feel, well, I'm just barely above that upper limit.
Speaker: And then three, four days go by and you've had this person on injurious ventilator settings.
Speaker: You've set them back more.
Speaker: You've increased their risk of mortality and prolonged their ultimate ECMO course.
Speaker: So rather than do that, that is the point where I think someone should be going on.
Speaker: Perfect.
Speaker: And what about contraindications?
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?
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.
Speaker: So someone has progressive pulmonary fibrosis, cannot get a transplant,
Speaker: or someone who has a very limited expected survival.
Speaker: So they have widely metastatic cancer that is not treatable in a prognosis less than a few months.
Speaker: That person probably should not go on ECMO.
Speaker: Almost everything else is a relative contraindication.
Speaker: Coagulopathy can be a relative contraindication depending on the cause and the reversibility of it.
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.
Speaker: But as you start to
Speaker: stack things up, that's when you begin to try to make those decisions about how much benefit are they going to derive.
Speaker: We often use the word candidate for ECMO, which I really don't like.
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.
Speaker: The way I like to frame it is
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.
Speaker: And if it's not, then it doesn't.
Speaker: We don't always know that for certain, but we're trying to make the most educated guess we can.
Speaker: So if you've got a, you know, age is a relative contraindication.
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.
Speaker: It's probably going to reverse fairly quickly.
Speaker: He was reasonably healthy before this happened.
Speaker: If you've got a
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.
Speaker: They're likely not going to derive a survival benefit.
Speaker: Craig, I wanted to ask you additional considerations for selecting, I mean, ECMO.
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.
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?
Speaker: That's a great question.
Speaker: And, you know, in reality, there's no perfect answer.
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.
Speaker: But there are many caveats to that.
Speaker: The person who is
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.
Speaker: It doesn't mean that had they gone on ECMO earlier, they would have then done significantly better.
Speaker: There's not been the study that randomized people to going on very early versus going on a little bit later.
Speaker: So there are many caveats to that.
Speaker: I think
Speaker: I don't have an absolute day number.
Speaker: And I think it's hard to say that six days and 23 hours is different than seven days and one hour.
Speaker: So making a seven day cut point or whatever doesn't make a lot of sense to me.
Speaker: I also take into account days of non-invasive support.
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.
Speaker: So number of days on non-invasive and invasive mechanical ventilation and what the settings have been.
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.
Speaker: But if you've got a...
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.
Speaker: It's just going to be a longer course because of what they're dealing with.
Speaker: So no absolute day.
Speaker: And I think it's hard to say that
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.
Speaker: It should be taken in the context of all the other variables that may impact outcome.
Speaker: And I think that's a very important point.
Speaker: Like you said, the seven days is more of a reference.
Speaker: It's not an absolute.
Speaker: And on one hand, you have the extreme of people calling for ECMO too late.
Speaker: What about the other extreme on the other side of calling too early?
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.
Speaker: Yeah, I almost don't believe in calling too early.
Speaker: It's easy to have that conversation with the team at the outside.
Speaker: I think if someone is meeting criteria for prone positioning, that's probably the time where you should call.
Speaker: And then it may mean, okay, we're going to follow up tomorrow.
Speaker: Your patient's P to F ratio is 120.
Speaker: They've got strep pneumo.
Speaker: They're on a little bit of presser.
Speaker: And you're starting to prone them.
Speaker: They seem like they're starting to get a little bit worse.
Speaker: Okay, let's prone them.
Speaker: Call us back.
Speaker: 12 hours later, let us know how things are.
Speaker: You've proned them.
Speaker: Now this person is on my radar.
Speaker: I'm thinking about, you know, most ECMO referral centers don't have unlimited beds, unlimited resources.
Speaker: We may see, okay, I have a bed available.
Speaker: I want to get that person here now.
Speaker: And if they don't need ECMO, wonderful.
Speaker: They get better and that's okay.
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.
Speaker: It may be that, you know, we talk the next morning and they did fantastically well with proning.
Speaker: They're off all pressers.
Speaker: Their PDF is 215.
Speaker: And...
Speaker: you touch base with the other hospital and you say, hey, this sounds great.
Speaker: If they start to get worse, anything changes, call us back, but otherwise keep doing what you're doing.
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
Speaker: um, later in the course where you're trying to scramble and figure out how to, how to pull things together.
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.
Speaker: But ideally, I, I, I rarely have been upset that someone has called too early.
Speaker: Great point.
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.
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
Speaker: Can can plan plan accordingly.
Speaker: So that was very, very insightful.
Speaker: Thanks for sharing that.
Speaker: Let's talk a little a little bit about general management of ECMO.
Speaker: Any any words on cannulation and cannulation configuration that we should be aware of?
Speaker: Yeah, I think there are there are.
Speaker: there are multiple different ways that you can configure someone for ECMO.
Speaker: VA ECMO seems to almost have an infinite number of configurations beyond what I can even understand.
Speaker: But VV is a little more straightforward, but still has a number of ways you can configure it.
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.
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.
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.
Speaker: You can use a dual lumen catheter.
Speaker: I think these tend to be
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
Speaker: I think the benefit to dual site configuration is you can typically have more flow.
Speaker: You can put in while the overall catheter is smaller than it is with the dual lumen catheter,
Speaker: the internal diameter of the drainage and the return is much greater.
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.
Speaker: That's especially important when you're thinking about
Speaker: a relatively young, relatively large adult patient with severe ARDS and perhaps sepsis.
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.
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.
Speaker: I'm not here to say one of those is better than the other.
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.
Speaker: But it really comes down to the comfort of the providers placing the cannulas and their experience with it.
Speaker: And you can typically manage
Speaker: Most patients will with either as long as you pick a large enough size.
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.
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.
Speaker: So you're not getting much deficiency from your ECMO circuit.
Speaker: or the cannulas that were chosen are too small and you can't achieve enough flow.
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.
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?
Speaker: It's very uncommon.
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.
Speaker: As we all know, the sepsis-induced cardiomyopathy typically improves significantly over just a few days.
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.
Speaker: And so that person tends to do okay with VV ECMO.
Speaker: The person who has severe sepsis-induced cardiomyopathy with high cardiac output need
Speaker: And persistent sepsis that goes on to VA ECMO typically does very poorly.
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.
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.
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.
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.
Speaker: So you have worsened pulmonary hypertension in the setting of prolonged ARDS and you start to develop right heart
Speaker: failure.
Speaker: If the person survives and the lung heals, that gets better typically.
Speaker: And we know that from more historical studies looking at RV dysfunction and ARDS and the absence of ECMO.
Speaker: And different places approach this differently.
Speaker: Some places will convert folks to what's called a VPA or a VP ECMO.
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.
Speaker: The downside to this in the setting of pulmonary hypertension is you're not fixing your pulmonary vascular resistance.
Speaker: So you're just trying to force the blood harder into the lungs, which can worsen pulmonic insufficiency and also pulmonary hemorrhage.
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.
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.
Speaker: So it's a really challenging group that requires a lot of resources and has generally a poor outcome overall.
Speaker: Perfect.
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?
Speaker: Yeah, so that's a great question.
Speaker: And the nice thing about ECMO itself is that it's really, really simple.
Speaker: The machine has one knob on it, and that knob turns the RPMs up or down.
Speaker: And it has a second
Speaker: ability to provide a gas source.
Speaker: So it really ultimately ends up with just two knobs.
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.
Speaker: The sweep gas is providing an oxygen source, but it's predominantly removing CO2.
Speaker: The faster the air is flowing through the oxygenator or the gas exchanger, the more CO2 is being extracted.
Speaker: Kind of like minute ventilation.
Speaker: The faster you breathe, the more CO2 you blow off.
Speaker: And the blood flow, the higher your blood flow, the more of your cardiac output you're capturing.
Speaker: So the more of that blood that actually gets oxygenated.
Speaker: So you will achieve better oxygenation by going up on blood flow.
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.
Speaker: And so you go up on blood flow for oxygenation and sweep gas flow for ventilation.
Speaker: In terms of managing the ventilator going along with that, it's not totally clear all people who
Speaker: I would say almost everyone in this field agrees that a patient should definitely be on lung protective ventilation, i.e.
Speaker: a plateau less than 30, lower tidal volumes, driving pressure, et cetera, all the factors we talked about earlier.
Speaker: There is discussion of what is, I think, sort of currently mislabeled as ultra lung protective ventilation.
Speaker: We don't know that it is ultra lung protective.
Speaker: We do know that it is ultra low pressure, ultra low volume.
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
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.
Speaker: So there's a balance there.
Speaker: I think certainly lung protective ventilation, perhaps lower is even better, but we really just don't know yet.
Speaker: on that piece.
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.
Speaker: If that is corrected too quickly, there is an increased risk of head bleed.
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.
Speaker: And what would be your targets for oxygenation and for CO2 in general?
Speaker: So we talked about that rapid change as being potentially dangerous with the CO2.
Speaker: But what would be your targets and where are you measuring those?
Speaker: Good question.
Speaker: So you're with your oxygenation, you're measuring that from an arterial blood gas.
Speaker: It's much less complicated in VV ECMO than it is in VA ECMO.
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.
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.
Speaker: Sometimes that's just not achievable in someone with really severe ARDS, even on ECMO.
Speaker: And in that scenario, you have to ask yourself,
Speaker: is the risk of whatever it is I'm going to do to improve their oxygenation greater than the benefit I gain.
Speaker: So if someone has a mental status, they're peeing, their lactate is normal, then their oxygenation is probably adequate.
Speaker: Their oxygen delivery is probably adequate.
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.
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.
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.
Speaker: So generally the same thing we would use for ARDS, but sometimes you have to tolerate a little bit lower.
Speaker: From a PCO2 standpoint, again, if you're looking at a blood gas and an arterial blood gas and really targeting a pH,
Speaker: as much as you would with standard mechanical ventilation for ARDS.
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,
Speaker: they're going to be harder to wake up.
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.
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
Speaker: of a acidemic drive to breathe as they start to wake up and are inevitably somewhat delirious.
Speaker: But generally, you're targeting a pH rather than an absolute PCO2 number.
Speaker: Perfect.
Speaker: Another area, obviously, that is very important for our intensivists managing ECMO is antichryrolation.
Speaker: Could you give us just, I mean, your approach and how you manage antichryrolation on ECMO patients?
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.
Speaker: There's really no perfect answer, which is unfortunately the answer to many of the questions around ECMO.
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.
Speaker: The lower the levels of anticoagulation you give, the more likely you are to clot, the less likely you are to bleed.
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.
Speaker: There are many patients who can actually be managed without anticoagulation at all who are having bleeding complications.
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.
Speaker: Our current approach is
Speaker: is to use a lower target range of PTT for anticoagulation with a primary anticoagulant of heparin.
Speaker: And we would target a PTT of 40 to 50 while on a continuous heparin infusion.
Speaker: Some folks will use direct thrombin inhibitors, use anti-10A levels, Rotem or TEG to monitor anticoagulation.
Speaker: You can get as complex as you like.
Speaker: I think my personal opinion is the simpler the better based on what we know now.
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.
Speaker: Perfect.
Speaker: What about complication and troubleshooting the circuit?
Speaker: Anything that you want to share with our listeners that can be of practical use?
Speaker: I think one of the most feared complication for me is the intracranial hemorrhage.
Speaker: Almost everything else you can work with, oftentimes that is catastrophic and devastating and someone who otherwise may have survived and walked away.
Speaker: So that is the complication that I fear the most, I think,
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.
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.
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.
Speaker: But we may not want our volume to be super high.
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.
Speaker: So really thinking about how much flow do I need?
Speaker: Can I tolerate simply a little bit less flow
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.
Speaker: So really being thoughtful about that.
Speaker: If you're having issues with flow, your first question should be, do I need this much flow?
Speaker: And if you do, then you have to work with it.
Speaker: But if you don't, then you may be able to get rid of all the issues that you're dealing with.
Speaker: The second one is as you begin to develop a ECMO-related coagulopathy.
Speaker: Those are really challenging things.
Speaker: lead to bleeding, lead to other complications.
Speaker: And I think if there was a pearl to that, it would be treating the patient, not the circuit.
Speaker: If the circuit is causing a lot of the problems, it may mean that that circuit just needs to be changed.
Speaker: Even if you're close to coming off of ECMO, even if you are
Speaker: You have to take into account that additional cost that may come that may be the right thing to do at that time.
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.
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?
Speaker: How do you usually deal with this?
Speaker: So you would use a different, there are a million different ways that that can be set up.
Speaker: And it's kind of institution dependent on how you approach it.
Speaker: Our approach has been to
Speaker: Minimize touching our circuit.
Speaker: We put the circuit in with as few connectors as possible and we rarely access that circuit.
Speaker: We don't check daily blood gases from the circuit.
Speaker: We don't transfuse through the circuit typically.
Speaker: We don't do dialysis through the circuit.
Speaker: All those are opportunities to introduce air or infection which can worsen your outcome.
Speaker: we will place a separate dialysis catheter and dialyze that way.
Speaker: Other places will run dialysis off of the ECMO circuit.
Speaker: So they'll have connectors in so the blood flows from the ECMO circuit to the dialysis machine and back.
Speaker: There aren't great studies to say which one is better.
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.
Speaker: Perfect.
Speaker: I wanted to ask you a question that actually relates more to ventilator management.
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.
Speaker: But I'm not sure that's the right answer these days.
Speaker: What do we know about that?
Speaker: Yeah, there was just a recent study published that did not show a benefit to proning people on ECMO.
Speaker: And so I think that's
Speaker: sets us back a little bit in that area.
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.
Speaker: If you look at the
Speaker: Proceva study, really the benefit was there whether your oxygenation got better, worse, whether your ventilation got better or worse, stayed the same.
Speaker: Really everyone derived a survival benefit from prone positioning.
Speaker: So it would seem that that would also play over into ECMO, but it's probably not totally true.
Speaker: So I think the person who is
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.
Speaker: If this is someone who you could otherwise have awake, mobilizing, maybe even extubated, then the need for deep sedation proning
Speaker: may be less beneficial.
Speaker: It may simply prolong their course and give them worse outcomes.
Speaker: So I think the jury is still out.
Speaker: I think that some patients may benefit universally.
Speaker: It may not be the right thing to do.
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.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: Let's talk a little bit about separation and decannulation.
Speaker: So how do you assess when somebody is ready for weaning?
Speaker: How do you and how you start?
Speaker: I mean, thinking about weaning and separating them from the ECMO support.
Speaker: And what do you do with the ventilator as you're doing that?
Speaker: Yeah, a great question, and that's something we have thought immensely about.
Speaker: And we've tried to model our approach after SBTs and SATs, and even followed in that vein and naming it.
Speaker: So we call it a sweep-off trial or an SOT.
Speaker: So we set objective criteria on when someone has improved enough to where
Speaker: we could test them.
Speaker: We've set a clear protocol for how to test them and criteria for failure.
Speaker: So very similar to those other SAT, SPT approach.
Speaker: So for us, if you have a pH greater than 7.3 on ECMO, you are on only 40% oxygen on the vent.
Speaker: while you're on ECMO, and your tidal volumes are at least four cc's per kilo.
Speaker: If they are, then we will fairly rapidly turn your sweep down to almost completely off.
Speaker: And if you're not in respiratory distress with very little sweep, we will turn it off.
Speaker: And we will monitor you there.
Speaker: We don't go up on the ventilator support.
Speaker: I think the whole point of ECMO is protecting the lungs.
Speaker: So we don't
Speaker: crank up the ventilator to test you coming off.
Speaker: We leave it on safe lung protective ventilation.
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.
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.
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.
Speaker: I don't think any of those are necessarily wrong.
Speaker: I just always like to think of things in the simplest possible way that you can do it.
Speaker: I think the big question right here around this topic is,
Speaker: what should be coming away first?
Speaker: Should the person be liberated from ECMO first or should the person be liberated from the ventilator first?
Speaker: I don't know the answer to that.
Speaker: You will find many different opinions out there regarding this.
Speaker: My personal thought is
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.
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.
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.
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.
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.
Speaker: But like you're saying, maybe in some patients, you don't have to follow that mirror sequence.
Speaker: Yeah, that's right.
Speaker: Any technical aspects regarding the cannulation that you want to comment on?
Speaker: Not really.
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.
Speaker: It's a venous site, so it's less complicated closure than VA ECMO.
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.
Speaker: But typically not different closure devices or going to the ORs.
Speaker: You often have to do with more complicated VA, ECMO, and grafts and other things that are related to that.
Speaker: Perfect.
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?
Speaker: Yeah, and a bit of self-promotion, I guess.
Speaker: The American College of Chest Physicians puts on what I think is an excellent ECMO course, an ECMO and mechanical circulatory support.
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
Speaker: VA ECMO, VB ECMO, and other forms of mechanical circulatory support.
Speaker: There's even a cannulation course that is affiliated with that.
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,
Speaker: across the spectrum of adults, peds, VA, and VV ECMO.
Speaker: It's always a very, very good conference with really good, really good content.
Speaker: Those are, I think, a couple of the best things that are out there that people can reach to.
Speaker: ELSO has a lot of online resources as well, and it's just in general, I think, an excellent
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.
Speaker: Perfect.
Speaker: And we will definitely add links on the show notes.
Speaker: So Craig, this was a wonderful, I think, overview and discussion about where we stand today with VV ECMO and ARDS.
Speaker: We usually like to close the podcast with a couple of questions that are unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So the first question relates to books.
Speaker: Are there any, is there any book or books that have influenced you significantly or you have gifted often to other people?
Speaker: That's a great question.
Speaker: And I would,
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.
Speaker: And it's the story of Ernest Shackleton, who was a early 20th century explorer, was one of the first
Speaker: was going to be the first to do an expedition completely across Antarctica in 1914.
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.
Speaker: And so they were stuck for almost 18 months
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.
Speaker: And no one in his expedition died.
Speaker: And I think it is a wonderful experience
Speaker: It encompasses the human will to survive.
Speaker: and it's also a great leadership tale.
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.
Speaker: And so the first book is called South.
Speaker: It was written by Shackleton after he returned.
Speaker: And the second one is a much more recent telling of the story called Endurance.
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?
Speaker: I could have never kept going as they did.
Speaker: So it's worth at least reading the Wikipedia version of the story so that you familiarize yourself with it.
Speaker: And I think both books are also really good.
Speaker: Awesome.
Speaker: No, I agree.
Speaker: I did not read South.
Speaker: I definitely picked that up.
Speaker: But during COVID, I did read Endurance.
Speaker: And it was just a reminder every time I complained, right?
Speaker: I mean, oh my God, these guys were floating on an iceberg, right?
Speaker: And everyone survived.
Speaker: So I think it's a great recommendation.
Speaker: And we'll definitely put links in the show notes.
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.
Speaker: This one, I think, is a little tougher, but I think as...
Speaker: As we've talked about so much of this in ECMO, it's really unknown.
Speaker: How do we do this?
Speaker: How do we manage anticoagulation?
Speaker: Do we take off ECMO first or the ventilator first?
Speaker: I always encourage people to be willing to change your practice.
Speaker: You're admitting when you do that that the way you're doing it before was wrong.
Speaker: And you may have been harming people.
Speaker: And I think that's why people often have a hard time changing their practice.
Speaker: But that is okay.
Speaker: And I think seeing the opportunity that we are now going to be helping more people is a better approach.
Speaker: I'm always hoping that I'm doing something different.
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.
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.
Speaker: Absolutely.
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?
Speaker: And I think in medicine, we love the confirmation bias.
Speaker: We love being stick with our previous positions.
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.
Speaker: I think that's a great, great point.
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?
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.
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.
Speaker: And he said, it's the disease that determines the outcome for our patients unless we do something stupid.
Speaker: And I think that is so true.
Speaker: We think we have so much influence on what is going on for our patients, but really if we are just...
Speaker: Do the best we can for them.
Speaker: Don't make dumb errors in management.
Speaker: Call early when someone may need ECMO.
Speaker: It's really going to be the disease that makes the ultimate decision on whether or not that person survives or not.
Speaker: And it's just our job to not hurt them.
Speaker: I love that quote.
Speaker: I have not heard it before, but I think it speaks tremendous truth, right?
Speaker: I mean, power to truth there, and I think it's a perfect place to stop.
Speaker: Craig, thank you so much for sharing your expertise and your time with us.
Speaker: Hope to have you back on the podcast to discuss more topics on ECMO and other topics in critical care.
Speaker: My pleasure, Sergio.
Speaker: Thanks so much for having me.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sounds transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
