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: Today's episode is part two of our discussion on mechanically circulatory support in the ICU.
Speaker: In part one, we cover the different types of devices available for temporary mechanical circulatory support.
Speaker: We discuss clinical indications, pathophysiology of shock, and other general considerations for the intensivist.
Speaker: Today, we will dive deeper in the medical management and troubleshooting of patients on temporary mechanical circuitry support.
Speaker: Our guest is again, Dr. Bindu Akhanti, an associate professor in the Division of Pulmonary Critical Care and Sleep Medicine at UT Health in Houston.
Speaker: Dr. Akhanti is the Medical Director of the Heart Failure ICU, the Director of Critical Care for the Heart and Vascular Institute of Memorial Hermann Texas Medical Center.
Speaker: Bindu, welcome back to Critical Matters.
Speaker: Thanks for having me again.
Speaker: And I think we will continue with our conversation on this really fascinating emerging aspect of critical care support, which is mechanical circulatory support.
Speaker: And I would like to maybe start by framing the role of the intensivist in the care of patients with MCS.
Speaker: So how can intensivist add value and how can they best interact with cardiology and CT surgery colleagues?
Speaker: So one of the things that I think that is different in different programs is who is actually leading this care of MCS patients, right?
Speaker: Because when you look at it from the inpatient perspective, okay, so you have on the floor in many hospitals, hospitalists that will call it cardiology consults.
Speaker: And then as this patient progresses in their advanced heart failure, then advanced heart failure will be involved.
Speaker: And these patients are taken to the medical review board or their complex care conferences.
Speaker: and then decisions are made how to escalate care.
Speaker: So if it's a cardiogenic shock patient that's coming to the ICU, this patient may be in the CCU, they may be housed in a mixed ICU or CV ICU.
Speaker: I think from the quaternary care center's perspective, most of the time it's a well oiled machine, but I want to take back and go, let's take your tertiary care centers, because that's where MCS is gonna really proliferate
Speaker: even more so in the coming decade than it had in the last decade.
Speaker: There, I really think MCS intensivists
Speaker: their main goal is going to be that central figure in coordinating between cardiology, cardiac surgery, nursing, and these other disciplines in ensuring that this patient progresses in their care.
Speaker: And I think that comes naturally to intensivists anyway.
Speaker: But I think the exciting aspect of it is using the expertise and continuous monitoring and interpretation of all these hemodynamics to
Speaker: and predicting, hey, this patient, I know he's posted for like, let's say five, five, two days from now, but he's not doing well today.
Speaker: AST, ALT or lactate may be still normal, but I know based on everything that we have done, because despite CVVHD, look at the CVP.
Speaker: So I think bringing the case together and ensuring that active escalation happens,
Speaker: It comes naturally to us because of our sepsis knowledge about our just, I mean, you know, so many things like whether you take ARDS or sepsis.
Speaker: And we apply it, and I think that ability to quickly troubleshoot and intervene is there's no question that's our backbone, but to predict and prevent, now that's a completely different skill set that we use on an ongoing basis, but we don't really leverage it, especially when it comes to this new field of MCS critical care.
Speaker: And the other aspect that I think comes naturally to us is they lead these units, right?
Speaker: They lead them by having these relationships with the nurses, the nurse educators, and across the hospital with other ICUs, hey, you're doing this.
Speaker: How can we kind of incorporate and do this in the same way?
Speaker: And I think that's the education and training piece.
Speaker: So together, by coordinating care, leveraging their understanding of hemodynamics,
Speaker: and predicting and preventing harm and the ability to troubleshoot and I think really be able to look at the team together and say, this aspect we need ongoing education on, that's, I think that's something that we need to really harness.
Speaker: And that's the reason that I think intensivists play a crucial role in these multidisciplinary meetings or care of these patients.
Speaker: Absolutely.
Speaker: Yeah, one other thing.
Speaker: Go ahead.
Speaker: I was going to say that one of the things that we bring to the table, obviously, Bindu is presence in the ICU, right?
Speaker: And that, I think, is an opportunity to lead the team and connect all the dots and make sure everybody's on the same page.
Speaker: The other thing I was going to ask you was about as these patients become sicker, we also have a lot of other issues to deal with.
Speaker: A lot of them might be on mechanical ventilation.
Speaker: A lot of them might have other critical care issues unrelated to the heart or associated to other organ systems.
Speaker: And I think our expertise there definitely also is a plus for the team.
Speaker: Yeah.
Speaker: And I wanted to get to that, you know, beyond the mechanical ventilator, I think the other aspect is this entire concept of prehab, right?
Speaker: We know that, for instance, an ex-patient's eventual home is a durable LVAD.
Speaker: Now that particular patient is on two drips,
Speaker: us to go there, we know in our head that, hey, you know, if the chest x-ray is still white, it will probably take us another five days to really diurease this patient.
Speaker: It'll probably take us another two days after that to be able to safely extubate.
Speaker: And I think providing that kind of insight and perspective will really help the heart team navigate these waters, right?
Speaker: The second thing is really having like development of joint protocols and guidelines for your ICU.
Speaker: That's another thing that comes naturally to the intensivist.
Speaker: And I think adhering to these standard protocols may be difficult in a fast changing world of MCS.
Speaker: For instance, you may have an ICU that just started doing Impella, for instance.
Speaker: And I think like buddying up with other programs that have done it
Speaker: and asking for those best practices and saying, hey, do you already have established protocols about anticoagulation management, about transport of these patients, whether it is a VV ECMO, whether it is a VA ECMO or an Impella patient, who is accompanying these patients on transport, let's say an Impella 5.5 patient,
Speaker: needs to immediately have a CT.
Speaker: Who is going to go with that patient?
Speaker: Is it the bedside nurse?
Speaker: Does the hospital have resources?
Speaker: And if they have resources, then who is that team?
Speaker: Should they do a brief huddle before transport, making sure everything is okay?
Speaker: Should they do a brief huddle after the transport, especially with
Speaker: ECMO, you know, I'm sure, Sergio, you've seen it where something as simple as, hey, connect him back to the gas, it does help to have a checklist after visit.
Speaker: Because we can't say we are going to walk every VV ECMO patient, but if you suddenly change that culture, then you need to have a checklist before and after ambulation.
Speaker: And I think that's another role that the intensivists play with the team is
Speaker: He's developing these best practices with cardiology and cardiac surgery.
Speaker: And our nursing colleagues, our physical therapists, social workers, dietitians, I think that is we are like effective communicators with families.
Speaker: But I really think our communication skills are truly about care.
Speaker: navigating with colleagues.
Speaker: How do we, how do we persuade, come to a middle ground and kind of help the field move faster?
Speaker: Absolutely.
Speaker: You mentioned protocols and checklist, Bindu.
Speaker: In terms of the daily management and daily rounds, is there a particular daily checklist that you follow with your patients on MCS?
Speaker: So we don't have a formal checklist, but I think one thing I was just speaking to this at SIO recently,
Speaker: We had a VAD university, a pre-course university, and I was thinking about, they asked me about how do you manage these patients that have multi-system issues.
Speaker: And I was telling them that I think you need to go back to your own training and look at the way you write notes, right?
Speaker: Most intensivists are system-based approach.
Speaker: So for me, the checklist is going system-based, for instance, and if you say, no, I prefer to do it as a daily checklist, one suggested way could be whether you want to do device-based, for instance, you can say,
Speaker: I want to write my note for a durable LVAD patient the way I think about them or an ECMO patient the way I separate VV ECMO and VA ECMO management.
Speaker: So a typical system-based approach would be, let's start with, it doesn't matter what device, the complications are the same, right?
Speaker: So for neurologic, in my mind, I am focusing on, is there a possibility of stroke, right?
Speaker: All these devices, even VVACMO, by the way, you know, these patients may have had hypoxic incels and they are at risk for neurological injury.
Speaker: The second thing is obviously, obviously, this physical deconditioning and how do you get them out of bed?
Speaker: The third thing is physical injury or harm just by being in the intensive care, which goes along with, for instance, there could be foot drop on patients that have been on prolonged support that are in bed.
Speaker: The second injury is if you do have upper extremity devices, then you want to make sure that their strength
Speaker: with the, you know, with the neurological changes that have that are happening in the, in just for instance, just when you do the finger exercises, you want to make sure that their grip is okay.
Speaker: It's very, very rare to have any kind of nerve injury.
Speaker: But I think if you have an expanding hematoma, you want to be able to make sure that
Speaker: their strength is preserved in the upper extremities.
Speaker: The durable LVAC patients, when you look at them and you're looking at, okay, I know how to pick up like major devastation, right?
Speaker: Like you suddenly have a paralyzed patient and things of that sort.
Speaker: But what may be subtle is simple, like, you know, I was doing okay yesterday, but I'm having some word-finding difficulties.
Speaker: I feel a little weak on this upper extremity, then you do have to take time and do a thorough physical exam.
Speaker: One of the best practices is to identify a neurologic neurology consultant that gets familiar with these devices alongside you as the ICU team is growing.
Speaker: So for me, neuro is in that bucket.
Speaker: The third one for neuro for patients with MCS is somebody that has already had a neurologic injury, whether it is a small subarachnoid or a subdural patient.
Speaker: and neurology and neurosurgery are like, okay, let's just do follow-up hit CTs, and when it's stable, we're going to restart heparin for anticoagulation.
Speaker: A typical recommendation they give is when the heparin is therapeutic, we would want another CT brain.
Speaker: So those things you need to keep track of, right?
Speaker: Because now the PDT is 60, the patient has not changed necessarily,
Speaker: and now you're about to move the patient and downgrade them onto floors, you want to be able to provide that, okay, right before they left the ICU, the patient's subdural status is X, so that the teams that are picking up these patients know what they are having to deal with.
Speaker: The next system is cardiopulmonary, which is the big one, right, depending upon the device.
Speaker: And there are many ways to do it in cardiology and pulmonary.
Speaker: So I've seen colleagues do.
Speaker: For me, I keep it simple with cardiac space.
Speaker: I just say preload, you know, inotropic support, afterload management, rhythm management, and then overall recovery.
Speaker: strategy in whatever device.
Speaker: For instance, if we say, let's say that we are talking about a veno-artereo-lecmo patient, then the patient is on veno-artereo-lecmo support.
Speaker: So then at the bedside for your checklist is, you know, what is the speed that you've set the patient at?
Speaker: What is the flow that you're getting?
Speaker: What was the flow for the same speed yesterday?
Speaker: And then at every patient, just like you do your sedation assessment, SBT and SATs, you need to ask, what is the patient ready for weaning?
Speaker: Is the patient ready for weaning?
Speaker: Especially when it comes to wean arterial ECMO because you have a cannula in the aorta that is basically throwing strokes.
Speaker: So the sooner that it goes in, the sooner that it needs to come out.
Speaker: So when you're at the bedside, you're really assessing
Speaker: What was the initial reason that you put in the veno-arterial ECMO?
Speaker: What is the patient's preload, the native hearts?
Speaker: What is the patient's native heart squeeze?
Speaker: And you can look at the hemodynamics, right?
Speaker: The patient has an arterial line.
Speaker: What is the difference between the systolic and the diastolic?
Speaker: And that's basically your pulse pressure.
Speaker: Now, if the patient's pulsatility has changed and has determined by, like, let's say,
Speaker: less than 15 and now it's less than 10, you know intrinsically that there may be smoke happening in the left ventricle or the atrium and that could potentiate strokes, right?
Speaker: So that patient may need venting.
Speaker: So those are the strategies like, so you have veno arterial ECMO, you've seen what the native heart is, you know what the pump is doing, how the actual management of the pump in itself for device integrity, right?
Speaker: So all checking all the connections,
Speaker: ensuring secure attachments, the patency, any kind of alarms and warnings regardless of the device over the last 24 hours, ensuring appropriate anticoagulation and adjusting based on those values.
Speaker: And then as you're checking the sites, making sure that there's no sites of infection at the cannula or implant sites,
Speaker: ensuring that, you know, these, number one, you have a strategy, and number two, addressing any barriers for physical therapy on these patients.
Speaker: Okay, what are the nurses concerned about of the devices?
Speaker: Then for the respiratory section, similarly, you're like, okay, what is the sweep act?
Speaker: What am I looking at it in the x-ray?
Speaker: If the x-ray shows black lungs, then...
Speaker: You know, honestly, you could do all these sophisticated measures, but if they're black and on the vent, you have good lung compliance, then the patient is being vented, right?
Speaker: So I think those are simple things that you can look at.
Speaker: And there is no reason to keep these patients intubated if you can avoid it.
Speaker: So you want to be able to always try to see what are the barriers towards extubation, right?
Speaker: Head of bed elevation sometimes becomes tricky in these patients if they have large femoral cannulas.
Speaker: So typically, you know, we do reverse Trendelenburg about 30 degrees and see if that alone will suffice.
Speaker: And as you're navigating on this patient, so for a veno-arterial ECMO, you do need to see if there is pulmonary edema, if they need venting.
Speaker: For a 5-5-impeller patient, if you suddenly see a patient that was well diuresing, that was well vented, and now he has opacity, so he or she has more pulmonary edema, then you go back to step two for cardiac management and go, okay, am I venting the ventricle enough?
Speaker: Why did this happen, right?
Speaker: And then from the pulmonary support, you know, what is the sweep gasser?
Speaker: One of the frequent mistakes that you could potentially see is like, you know, the patient is at 7, 4, 5 pH and you still have the patient on sweep.
Speaker: And you're like, well, you know, if you are to the point of metabolic alkalosis, you shouldn't need sweep.
Speaker: So you start coming down and the patient's.
Speaker: Inherent respiratory cycle will eliminate the CO2 and we want to come down to 0.5 because sometimes, especially in the veno arterial ECMO patients, you can't assess the lungs necessarily, right?
Speaker: Because you can't turn off the sweep gas.
Speaker: So you need to, you can't do a true shunt run.
Speaker: So you want to be able to look at the X-ray, make sure that the lung mechanics can hold it.
Speaker: and see your PAO2s.
Speaker: And in different devices, you want to look at PAO2 in different ways, but most commonly, you know, as a general rule of thumb, if you just remember that having an ABG helps and that an ART line is absolutely fruitful, that's a step one.
Speaker: And if you want to separate it out in a veno-arterial ECMO patient, how do you assess for oxygenation and ventilation?
Speaker: We recommend a best practice is right radial art line.
Speaker: And the reason for that is you have the flow being delivered in the distal aorta, right?
Speaker: So if that oxygen molecule, let's just follow that molecule, is able to come down across the aortic arch all the way,
Speaker: then you know that your brain, the carotids are well oxygenated.
Speaker: But however, if the mixing cloud from your native ventricle and the ECMO are beyond the carotids, then you are at risk for hypoxemia in the patient.
Speaker: especially with anoxic injury, so that's called north-south syndrome or the Harlequin syndrome.
Speaker: So those are the patients you would not have picked up if you didn't have that right radial art line.
Speaker: But in some patients, yes, there are many ways.
Speaker: You could just put in a pulse oxmeter.
Speaker: You could just put in a pulse ox probe on the right ear, for instance.
Speaker: But the bigger thing is, just like you're approaching preload, squeeze, afterload, pulsability in the heart for the lungs, you're looking at what is my gas exchange, the native lung gas exchange.
Speaker: You're looking at what is my compliance doing?
Speaker: What is the volume status?
Speaker: Is there pulmonary edema in these lungs?
Speaker: And what is the big picture, right?
Speaker: What is my exit?
Speaker: So if they have cardiopulmonary issues and these lungs are not getting better, you will not be able to, for instance, clear them for an LVAD because now you have pulmonary, you really need to get that better.
Speaker: Now for we know venous ECMO, when you look at the pulmonary issues, and this is not the intent of MCS, this podcast, but like you're able to lean down on the ventilator, you're able to get them to awake ECMO.
Speaker: Then you start weaning down on the flow and the sweep to be able to get to a shunt run.
Speaker: So you can actually see, hey, you know, he's maintaining his PAO2.
Speaker: We don't need this ECMO anymore.
Speaker: The next thing that we look at is, you know, infection control.
Speaker: Now, there's really no robust RCTs on infection control practices in MCS.
Speaker: So the intensivist role does become more important.
Speaker: In the past, in the very distant past, we used to actually do vancomycin because it's a big cannulas.
Speaker: And then we looked at patients that are on just doxy alone, and then the infection rate was the same.
Speaker: So we do prophylaxis doxy.
Speaker: There are some sites that don't do anything, and they just do local control for ECMO cannulas.
Speaker: Same with Impella.
Speaker: Some of the best practices are actually don't do antibiotics if they don't need it.
Speaker: And I think local control, local management of cannulas and local, basically the graft site monitoring is really the key.
Speaker: And daily imaging in terms of whenever they do physical therapy to make sure that the device is positioned and it has not migrated, that depends upon the strength of your ICU team.
Speaker: Once you get comfortable, you may go down on the need for daily imaging.
Speaker: And then the next system is GI.
Speaker: Now, from the standpoint of durable LVADs for MCS, yes, they come in with GI bleeds.
Speaker: There are multiple etiologies, including the one, the Libren factor, the shear stress, the hemolysis, the AV malformations that may happen.
Speaker: But from the acute shock standpoint, gastritis, previous ulcers that are bleeding, new ulcers, they're all, you know, these patients, it depends upon your length of stay.
Speaker: If they're a quick patient, you know, bridge to recovery, five days, they're out, then probably not.
Speaker: But that's rarely the case in really sick patients, right?
Speaker: So when they're there for two weeks, two and a half weeks,
Speaker: um ppi use definitely has been now that's that's a practice i don't know we really don't have any robust robust trials in the space now but the minute that they do have a gi bleed i think acting early from the icu standpoint especially discontinuing the anticoagulation coming up with the strategy hey
Speaker: For instance, if it is an impeller patient, like do we want to use the system, like, you know, remove the regular anticoagulation and just for the impeller system, do we want to use the purge or do we want to change that as well?
Speaker: Is the GI team ready to go and to actually diagnose?
Speaker: Do you have a robust interventional radiology team for backup?
Speaker: Yeah.
Speaker: I think the concept of GI shock team, so the ability for them to scope, I think is really important.
Speaker: Similarly, you need to have massive transfusion protocols in your ICU for MCS critical care patients to ensure that you're able to rescue these patients.
Speaker: Otherwise, the management of upper GI bleed and lower GI bleed is literally standard practice.
Speaker: I think it's just how soon you can intervene and rescue this patient that becomes important.
Speaker: Now, overall, then how do you put it together, right?
Speaker: Then, you know, I know you have a quality tool, whether it is lines, GI prophylaxis, DVT prophylaxis, therapeutic in terms of physical therapy, and the big time disposition and goals of care.
Speaker: So by taking a multi-system approach to MCS critical care, then I think you can make progress on these patients, right?
Speaker: to number one, having a strategy on how do you get them home.
Speaker: But really on a daily basis, patient assessment is their neurological status, their peripheral perfusion, and overall organ function assessment.
Speaker: I hope that was a broad overview, Sergio, before we go into troubleshooting.
Speaker: For sure.
Speaker: And one thing I wanted to ask you, I mean, I think that was a great comprehensive overview of kind of how you think about these patients on a daily basis.
Speaker: And before we go to troubleshooting, I think since we talked about a lot of the systems, I wanted just to ask you, Bindu, if you could tell us how you manage hematologic complications, bleeding, hemolysis, and thrombosis, just some general thoughts, and then we can definitely go into troubleshooting the different devices.
Speaker: Okay.
Speaker: So that's good that you mentioned that because now for under heme section, right, that's the...
Speaker: The key aspect is to look at it together, meaning, okay, you have a VA ECMO patient, you've been weaning the patient, you have not been able to do therapeutic anticoagulation for whatever reason, bleeding, brain bleed, etc.
Speaker: Now, you know these are pumps, and these pumps have increased shear stress and hemolysis.
Speaker: If the patient is making urine, something as simple as looking at the urine, getting a urine analysis is an important good start.
Speaker: And then you look at your total bilirubin.
Speaker: You can look at haptoglobin.
Speaker: We rarely do.
Speaker: We use plasma-free hemoglobin and LDH.
Speaker: One of the clinical pearls with that is if you have an acute shock patient and the ASD, ALT are in the thousands, then your LDH alone may not help you, but trends help you.
Speaker: Okay, that's number one.
Speaker: So using LDH to dictate, hey, I know we are on impella, but there's been ongoing hemolysis.
Speaker: We need to do something.
Speaker: Can we make sure that the device is working properly, the axial flow, for instance?
Speaker: Is there a change in the P in terms of the power, number two?
Speaker: And number three, how significant is the hemolysis would be the question.
Speaker: Now, the bleeding aspect is we use PT, PT.
Speaker: the question for you is twofold.
Speaker: Is it overall bleeding risk?
Speaker: Is it because of coagulopathy?
Speaker: Or is it a site-specific wound that just needs an extra suture or exploration?
Speaker: That's a key.
Speaker: Because if it is a site-specific and you're approaching it with this overall, then potentially you've contributed to thrombosis even because you're readjusting your anticoagulation when all it needed was a second look, a stitch, or exploration.
Speaker: Now, when you go into thrombosis, one of the things that you need to recognize is the longer you do the field at the bedside, you'll develop your own methods.
Speaker: But...
Speaker: Thrombosis is something that you need to recognize by multiple methods.
Speaker: One is LDH suddenly has gone up.
Speaker: Suddenly, for the same speed, you're not getting flow.
Speaker: And then the third thing is, you know, most importantly, remember prediction and prevention.
Speaker: So if you have this thrombosis, the chance of stroke can go up.
Speaker: Then you can look at your coagulation panel.
Speaker: And I want you to also pay attention to D-dimer.
Speaker: Trends in D-dimer matter.
Speaker: Single D-dimer value could be useless.
Speaker: Trends can help you.
Speaker: So when you then look at the patient together, then you can optimize managing and balancing that bleeding risk with the hemolysis, with the thrombosis.
Speaker: And I think we can talk about it a little bit more with each device, but I think that's the overall way I look at those three issues.
Speaker: Perfect.
Speaker: Let's talk about troubleshooting like the different devices.
Speaker: And I know that there may be a long list of complications or troubleshooting situations, but I wanted just to focus on maybe one or two relevant situations that are common with the different devices.
Speaker: So maybe we can start with the impella and just tell us, I mean, what are some of the things that as an intensivist we have to be aware of for potentially troubleshooting?
Speaker: So first with the impeller, you want to know, is it a left-sided or the right-sided device?
Speaker: And then the next one is to figure out, is it the impeller CP system?
Speaker: That's the femoral.
Speaker: Or is it the impeller 5-5 system?
Speaker: That's the axillary.
Speaker: And to briefly overview from the first talk, it essentially is a pigtail catheter that is venting the left ventricle and releasing the vented blood right over the aortic valve.
Speaker: So the signs of migration could include like, you know, you have a sudden drop in device flow, your changes in hemodynamics,
Speaker: And the impeller, the AIC is pretty smart.
Speaker: It will tell you if there's small position, but at the end of the day, it's a machine, right?
Speaker: So you want to be able to interact with it in a meaningful way.
Speaker: The way when I go to the bedside, the way I look for device migration is not when it is migrating.
Speaker: In the morning, what did we look for to see if it is working properly?
Speaker: Step one for me, I look at the motor current, which is the green line.
Speaker: As long as it has a nice pulse at all, like that signal, you know that there is a pressure difference in two chambers.
Speaker: And my test tube method of teaching is it's suctioning blood from the LV and putting it in the aorta, right?
Speaker: So the second step then is how much is it doing that?
Speaker: And that's the P value.
Speaker: If it is a P7, then it is a higher amount of suctioning that is coming from the LV.
Speaker: Then I look for the flow.
Speaker: Okay, with that P7, how much flow am I getting at baseline in the morning, let's say, and it says 3.8.
Speaker: You know, like, okay, that's good.
Speaker: Now I want to look at the two other waveforms, which is the white one, which is the LV signal, and the red flow, that is the aorta signal.
Speaker: Now remember, the LV signal, which is the
Speaker: is less than P4, not because it doesn't see it, it's just it's not as accurate, okay?
Speaker: But if it is more than P4, it's actually going to give you what is going on in the LD at the bottom, which is the diastolic pressures, okay?
Speaker: And if it has a nice waveform and then you have the aorta, then you know that, hey, at P7, I'm getting this much flow and my LVEDP has been okay and I'm not getting any diastolic suctions.
Speaker: And my aorta waveform is showing you what my pressure there is.
Speaker: So things are going well.
Speaker: Now, if you suddenly have a sign of migration, it could be that both the red and the white are over each other.
Speaker: For instance, if the red waveform starts looking like the LV waveform, then you know that the device is too far in and it needs to be pulled back.
Speaker: Conversely, if you lose the LV waveform and suddenly it's over the aortic valve, you know that the cannula has been moved too far out, right?
Speaker: your inability to support the patient because there is a sudden drop in flow because that's how he's being supported.
Speaker: There is a native aortic valve in there, and this kind of an axial flow pump moving in and out, which rarely happens, is beyond just, oh, it's a small position, it needs to be corrected.
Speaker: It could cause injury.
Speaker: So it's an urgency, okay?
Speaker: Okay.
Speaker: Like you never leave a patient with aortic insufficiency, right?
Speaker: Because that patient is a surgical severe AI, is the surgical emergency.
Speaker: It's the same thing.
Speaker: You could have a surgical emergency on your hand if you ignore these warnings.
Speaker: So immediately, the way you manage is I want to confirm the position.
Speaker: Let me get my pocus.
Speaker: Let me get my x-ray.
Speaker: Let me get the team ready and whoever it is.
Speaker: Now, each team may work independently, but you need to be able to, for instance, if it's a surgeon, hey, this is what I'm seeing.
Speaker: These are the waveforms.
Speaker: Here is the transthoracic view.
Speaker: We have everything ready and then we will probably need to either pull it in or pull it out.
Speaker: Number two, remember again that if you're at P7 and all of this is happening, you may need to drop the impeccable flow, right?
Speaker: P, because otherwise your pump would be harmful.
Speaker: Number two,
Speaker: you need to be ready to take over for the hemodynamics because you have had the privilege of this patient being supported on the pump you have not needed to use inotropes and you know your uh you know your pressures so if there is sudden decompensation sudden flash pulmonary edema sudden inability to support the patient then you need to go back and have everything ready whether it is access to a central line that you have removed
Speaker: or whether it is having the ventilation be on standby.
Speaker: Very rarely do you need it.
Speaker: I mean, you can easily take over, put some, if things are that bad, use some BiPAP support, but it's the ability to rescue that defines MCS critical care, right?
Speaker: So that's how I would look at it for the impeller in terms of device migration for the left side device.
Speaker: What about the right-sided devices as the RP Flex is in the market, RP Impella?
Speaker: You know, the RP Flex and the RP Impella, and I think that's something that should come even more naturally to MCS critical care physicians because it's essentially you just have a SWAN, right?
Speaker: And the SWAN is a Theranostic device.
Speaker: It's giving you therapeutic, in this case, with the RP Flex, and it's giving you true diagnostic measures, right?
Speaker: So similarly, you're looking at the same thing is that if you have sudden drop in device flow, did it migrate down?
Speaker: Does it need to be repositioned?
Speaker: And always get comfortable with the alarm overview on the console because the console has built in the ability to kind of help.
Speaker: Hey, you know, you'll need to push it back, pull it in and kind of navigate along with that.
Speaker: That's for the Impelda, Sergio.
Speaker: And now when you go into Vino-Arterial ECMO, I think VA ECMO, we already talked about it in the first part of the conversation about Harlequin syndrome.
Speaker: Really, in terms of things to look out for are, do you have an oxygenator failure?
Speaker: Do you have cannula problems?
Speaker: And managing it is where is your cannula?
Speaker: Do you have like, you know, IBC appropriate drainage?
Speaker: Does it need to be readjusted?
Speaker: And the best time to readjust cannulas for VA ECMO, especially with the venous limb is at the time of cannulation, right?
Speaker: The arterial really gives you issues.
Speaker: I mean, it's a small cannula.
Speaker: The 17th French, it stays there.
Speaker: But, and you can manage the complications of bleeding and ischemia.
Speaker: The number one thing for VA ECMO is the leg.
Speaker: Right?
Speaker: That catheter that, you know, some places, because, you know, it's a very short run, it doesn't need an anti-grade, so you need to watch the leg.
Speaker: Some of the best practices have been you could use NEARS, you know, tissue oximetry to pick it up earlier, or you do the anti-grade and every single day you go touch the leg and you make sure that the compartment pressures are okay.
Speaker: It's scary that when you can save a patient from AMI, cardiogenic shock with VAF more, and then you lose the legs for more reasons than one, right?
Speaker: Because it could have been a potentially preventable condition.
Speaker: You look for signs for poor flow, hematomas, a sudden drop in blood pressures in veno arterial, like more remember you have anticoagulated patient.
Speaker: that have been recently intervened on.
Speaker: So RP hematomas are not going to show up on your bedside POCUS.
Speaker: So you do need to have imaging and access to, hey, let me see what the hemoglobin is.
Speaker: Let me see if I need to quickly go down and see, make sure that he's not bleeding.
Speaker: So those are the for the cannula and RP bleed.
Speaker: Oxygenator failures, you need to look for increasing transmembrane pressure gradients and decreasing oxygenation and obviously divisible clots.
Speaker: And the management is, you know, it's a multidisciplinary effort to just replacing the oxygenator as soon as possible.
Speaker: The third device that I wanted to talk about was, I think, and Sergio put down for Tandem Heart.
Speaker: Now, Tandem, made by Levanova, is no longer on the market.
Speaker: But you want to know about this because there may be some patients that you may use the cannulas in the Tandem configuration.
Speaker: So a left-sided Tandem Heart is a cannula that is deployed in the femoral vein
Speaker: and it is transversing that into right atrium, across the pre-F4, into the left atrium, suctioning blood, oxygenated blood, taking it back to a centrifugal pump outside the body, so pericorporeal, and then giving it in the aorta.
Speaker: So this is a centrifugal pump.
Speaker: Compared to an axial venting device, right, that's the impeller, that's an axial pump intracorporeal.
Speaker: This is a pericorporeal device.
Speaker: So let's say that the patient has severe mitral stenosis and severe pulmonary hypertension, and you want to decompress before you take them for the MVR.
Speaker: An impella is not going to work because, you know, it's mitral stenosis.
Speaker: The blood didn't even make it into the ventricle.
Speaker: So with this device, our team, Dr. Carr, is our lead and basically has shown that you could actually decompress the left atrium.
Speaker: And you don't need an oxygenator because these patients already have the oxygenated blood being removed, right?
Speaker: So what are some issues that can happen?
Speaker: Remember, there's no suture holding this cannula in.
Speaker: So when the patients move, literally the cannula can get dislodged.
Speaker: So typically these patients are bed bound.
Speaker: We don't ambulate them.
Speaker: We used to intubate.
Speaker: We keep them all extubated mostly now.
Speaker: The second group of patients this could help is your ventricular septal defect patients.
Speaker: We published on that.
Speaker: And the issues for you to monitor are
Speaker: Basically making sure that the cannula has not migrated.
Speaker: And it's very easy for you to see that because the blood that was very bright red.
Speaker: Now, if it is in the right atrium, it's going to become very dark and the patient will become immediately hypoxemic, right?
Speaker: Because now you're giving...
Speaker: deoxygenated blood straight into the aorta.
Speaker: So if that happens, you need to go down on the pump flow immediately.
Speaker: And one way to rescue them if they need the support, obviously, is you can splice an oxygenator in and convert that into a veno arterial ECMO.
Speaker: Okay.
Speaker: What about balloon pump?
Speaker: Now, balloon pump is one of our counterpulsation devices.
Speaker: It will be here for a long time.
Speaker: Sudden loss of augmentation and alarms, I think a lot of you know about it.
Speaker: Very rare to have balloon rupture, but signs could include blood in the catheter, loss of augmentation and not working properly.
Speaker: So you want to remove the balloon pump and just consider alternative support.
Speaker: And in terms of improper timing, there's multiple cheat sheets online for teaching you guys signs of early inflation, signs of late inflation, early deflation and late deflation so that you can synchronize them with the cardiac cycle.
Speaker: And the best way to learn more about the balloon is when you go to the bedside
Speaker: looking at it and then with you know if there's any alarms actively managing those alarms that's that's for those four devices in terms of how do we look at it at the bedside Sergio perfect and we'll try to include some links to online and resources for the improper timing of the intra-aortic balloon pump and another obviously other references but thanks for
Speaker: for going over those because I think that for many intensivists who are not as used to working with these patients, the alarms and these problems can be quite daunting.
Speaker: And even though obviously it requires a team effort, just understanding what is happening to our patients and who we need to call can be very, very helpful.
Speaker: So I really appreciate you going over those in detail.
Speaker: The next topic as we close, I wanted to talk about is kind of how do you move forward with the care of these patients on MCS?
Speaker: We talked about in part one, a little bit about, and you alluded to it a little bit when we were talking about management, about instances when we might need to upgrade the amount of support.
Speaker: So if they're on an intracuric balloon pump and go to another type of device, or if they're an impella,
Speaker: upgrade to an Impala 5 or to a VA ECMO.
Speaker: But what I wanted to talk a little bit more and hear from you in more detail, Bindu, was about weaning versus withdrawal.
Speaker: And first, maybe talk about weaning a patient from temporary mechanical support.
Speaker: If you could share with us some pearls and pitfalls.
Speaker: So...
Speaker: One of the things that I look at the, I mean, the pearls and fitfalls are, I think the more you do, the better you get.
Speaker: There's no question.
Speaker: But looking at it as a process, you have supported the patient, you have rescued the patient.
Speaker: It's similar to a ventilator, right?
Speaker: You intubate a patient, you leave them at 100%.
Speaker: You never leave them at 100%.
Speaker: You go just enough support.
Speaker: Some people may go to 50 or 60%.
Speaker: So gradually reducing support while monitoring hemodynamics and managing the clinical status is a daily, multiple times a day, ongoing process.
Speaker: That's the best pearl I can give you.
Speaker: You don't walk in the room, make a plan, and leave the room and assume that it will take care of itself.
Speaker: It's a daily thing.
Speaker: And always be prepared for, obviously, rapid re-escalation as you do it.
Speaker: And then, but to get there, we need to know what are the criteria for weaning.
Speaker: So each device is dependent upon what is the etiology on the patient.
Speaker: The patient, for instance, that had a RP flex placed because the patient has an RCA infarct is a whole different strategy for when you would wean.
Speaker: Maybe that patient had already been taken to the cath lab and we are just waiting for the RV function, the native function to improve, the pulsatility to improve before you take that RV ad out.
Speaker: Similarly, a balloon patient, you know, we typically go down in support and then if their native hemodynamics are good, great.
Speaker: The Impella, the console will give you as you're coming down on the p-value, what's happening to the cardiac output.
Speaker: Once if you have the swan and you know that, you know, if your VO2, the oxygen delivery is fine, then, you know, you can start weaning.
Speaker: The best pearl is end organ function.
Speaker: As you are weaning this support, remember the first time we talked about how you can have a hemodynamic problem to go to a hemometabolic problem, then that hemometabolic problem, are you worsening?
Speaker: Are you getting it better?
Speaker: So if your AST, ALT are getting worse, if your AST, ALT are getting worse,
Speaker: then you know that you have a hemo metabolic problem that you have not rescued and now you wanna DC the device and that's gonna get worse.
Speaker: let's say because of decompression.
Speaker: Let's say you were AKI, and now that AKI is progressing.
Speaker: So there's another hitting age that there may be endorgan dysfunction.
Speaker: So I think on a daily basis, the best pearl I can give you is by assessing with hemodynamics plus echocardiogram with adequate endorgan perfusion,
Speaker: then you know that the patient is ready to wean, provided you're going back into the room multiple times to ensure that process that you have in your mind, you're able to quickly rescue for rapid re-escalation.
Speaker: So what are some of the indications that you need to go upgrade immediately?
Speaker: If you are inadequate support with the current device, progression of the disease and the complications that you can't manage with the current support, then you have to.
Speaker: And for instance, you have a balloon and the balloon may be upgraded to an impeller and you put in a 5.5 or an impeller and the RV is taking a hit.
Speaker: And then you may need to add a right-sided device or the patient is in Sky E extremis, PEA about to happen, Udobe ECMO, and then you de-escalate the same way.
Speaker: So escalation and de-escalation, I think, are always this highway that you're going back and forth on.
Speaker: And that's the reason that I think as an intensivist that has a good eye on things with cardiology and CV surgery, navigating those waters becomes very important.
Speaker: And so as in terms of, you know, looking at these patients, the best pearl I can give you is the sense of urgency.
Speaker: Because urgency for us is a lot more clearer than urgency for other fields.
Speaker: So I think it's helpful to be a pain sometimes.
Speaker: What are your plans?
Speaker: When are we taking the patient to the OR?
Speaker: And in our team, it's the other way around too, because I joke with that, everyone is an intensivist, our CV surgeons, our heart failure docs.
Speaker: So it's really nice to witness that growth, because if you grow
Speaker: If you literally grow older together in your MCS critical care units and you have this team, then you have cross trained each other.
Speaker: Right.
Speaker: They they have trained you and you've trained them.
Speaker: So that's those are the best pearls I can give you guys.
Speaker: Perfect.
Speaker: And obviously, you talked about urgency, but some patients, we might have put them with a bridge to decision, and the decision might be that there is no other therapy and they're not progressing.
Speaker: Any comments on considerations for the intensivist on when withdrawal of a mechanical device is in place, recognizing that the patient is likely to die?
Speaker: So...
Speaker: Out of everything that we've talked about between this talk and the previous, I think this is the best role for the intensivist is recognizing and coming to a conclusion with the team.
Speaker: What we are doing is not working.
Speaker: AMI cardiogenic shock continues to have a high mortality rate.
Speaker: We need to develop these devices to rescue patients, but we owe it to the technology for MCS so that you don't use the device on a patient that it doesn't work on.
Speaker: And when that state is reached, we owe it to the patient that we give them a good death.
Speaker: I think...
Speaker: my mentors of the past, I've noticed it's not what they do at the bedside with utmost competence.
Speaker: I'm like inspired and in awe of, but it's the commitment to the patient to see that they're not suffering that makes them a wholesome physician.
Speaker: And I think we are really aptly suited to kind of navigate those waters
Speaker: and ensure that we communicate because when you're in the forest it's very difficult to see the big picture inside but hey we have had him on maximal support for x number of days i've talked to the family just as you have but they may not be telling you but they don't want to proceed with this and i think ensuring palliative care involvement and actually as we're about to
Speaker: published in terms of how few of patients actually have palliative care involvement in cardiogenic shock.
Speaker: And I think that's because the ownership, the ICU teams do it themselves.
Speaker: But I think sometimes it's good to share your mental bandwidth with other colleagues because you're only one person and you may go into the room for 40 minutes and discuss this, but the other team may have 40 minutes to just discuss that single point.
Speaker: So we do get palliative care involved.
Speaker: In fact, we have it as a dashboard.
Speaker: How many times have we called palliative care on ECMO patients, on WAD patients?
Speaker: And we try to engage with our colleagues on that.
Speaker: Because it's not about palliative care.
Speaker: It's not just utilization, right?
Speaker: Because we can't measure if we have taken time out as a huddle and ensured that somebody...
Speaker: has had their goals of care discussed in a meaningful way, but at the end of the day, we owe it to the patient and their family that their passing is as painless as possible and with the team at the bedside.
Speaker: So I think that's the withdrawal pearl that I want to share.
Speaker: Perfect.
Speaker: And I think that we had a very, I think, comprehensive discussion of many, many aspects of MCS management in the ICU.
Speaker: And you're already a pro on the podcast, Bindu, and you know we would like to finish on a note that really digs into your wisdom as a whole, as a whole physician, not only as an expert, obviously, in critical care and MCS,
Speaker: So would it be okay if we ask some questions not related to the clinical topic?
Speaker: Yes, yes, yes.
Speaker: So last time we spoke, we talked about books and that I want to ask you now about music.
Speaker: So, and I'm old school, Bindu, I still play vinyl.
Speaker: So I think of music and albums.
Speaker: But if you were stranded on an island or you were isolated for some sort of new infection like COVID, God forbid, what music, album or artist would you want to have with you?
Speaker: Um, so I came here when I was about 15.
Speaker: So I think somehow the music of my teenage years, you know, coming of age in India really calms me.
Speaker: And that's, um, this, I mean, he sings now, but A.R.
Speaker: Rahman is a musician, a director, a
Speaker: And he has thoroughly, like, I think, between when I was like 10 and 15, changed the way Indian Bollywood music.
Speaker: And Tollywood is the place in India that I'm from, which is Andhra Pradesh.
Speaker: And he has changed that.
Speaker: So...
Speaker: If I was stuck on an island, I think I would probably just ping Rahman and say, hey, dude, you know, what are you doing?
Speaker: Bring your team over.
Speaker: We have an intensivist group here.
Speaker: Perfect.
Speaker: And he can play the music for us.
Speaker: Beautiful.
Speaker: And one of the reasons why I love to ask these questions is because it's a way of learning about new things.
Speaker: And I have not been exposed to this music, but we put a link in the show notes and I definitely will check it out.
Speaker: So thanks for sharing that, Bindu.
Speaker: The second question is, could you share something that you have changed your mind about over the last couple of years?
Speaker: I think I have changed my mind about the importance of work-life balance.
Speaker: I truly, because my dad was a physician, I really believed that relentless dedication and long hours were the keys to success and like true, true professional satisfaction.
Speaker: And I still believe it because Dr. Carr, Dr. Baila Patel, these people that work day and night like to really do what they do.
Speaker: But I've also noticed that they do take some time and they just do their rest in different ways.
Speaker: But that it is incumbent upon me and a team to pursue our own hobbies and pursue our own time with loved ones if we were to last in that hallway.
Speaker: And I say that metaphorically.
Speaker: Like really, truly, because I look at this hallway that I've been in in 11 years, MCS hallway, right?
Speaker: If I need to exist in that hallway with my infinite energy and love for patients, for colleagues, and I keep wanting to give this energy back.
Speaker: What charges me is, yes, these are patients that do better.
Speaker: That charges me.
Speaker: But so do my roses.
Speaker: So do my travel.
Speaker: So do meeting new people through teaching avenues, such as I'm doing here when I go to conferences.
Speaker: I think sustained productivity and creativity will only come with balance.
Speaker: And I think after COVID, I think I speak with all of you, for all of you,
Speaker: that there has never been a better time to focus on our own mental and physical health so that we lead like truly fulfilling professional lives to create that mastery in our brain of whatever niche you want to create.
Speaker: Like Sergio, like you have this handle on everything I see you.
Speaker: But to love it and to give that energy, I think you need to have a creative outlet.
Speaker: And it may be different for you guys, but that's, I love gardening, travel, spending time with my children and mentoring and like young minds.
Speaker: I love being surrounded by youthful idealism.
Speaker: There are kids around us that are like, just want to change the world.
Speaker: And I love being inspired by them.
Speaker: They teach me every day, including the fact that you cannot give hard exams that you did not teach in class.
Speaker: So I teach med school.
Speaker: So I've been taught that.
Speaker: So I've become a better teacher.
Speaker: But that's that's my that's what I think is that I've definitely changed my mind about that.
Speaker: Awesome.
Speaker: Thanks for sharing that, Bindu.
Speaker: And I think very pointed and you're right.
Speaker: I'm a big student of philosophy and there is a Latin phrase that says memento mori.
Speaker: which really means remember you will die.
Speaker: And the point being in terms of balance is that if you knew you were going to die tomorrow, what are the things that you want to make sure you do today?
Speaker: Right?
Speaker: Yes.
Speaker: Part of that is professional for sure.
Speaker: It's our impact and how we grow, but there are so many other dimensions in our lives.
Speaker: And I think it's different for each person, but to find the time and create the space to enjoy that for each person, I think is very important.
Speaker: So that's a great, a great message.
Speaker: The final question to end Bindu would be, what would you want every intensivist listening today to know?
Speaker: Could be a quote, a fact, or just a thought.
Speaker: I think I just got back from SIO that was in DC and I stayed in Gettysburg with my children because we went camping for a day or hiking in Cattoptic Mountains.
Speaker: And I think Abraham Lincoln, there was a quote in one of the museums and it said, you know, in the end, it's not the years in your life that count.
Speaker: It's the life in your years.
Speaker: And I think as intensivists of a particular generation that has gone through COVID, I think we are living our lives a thousand times over.
Speaker: I tell people that I'm in my bonus round of life.
Speaker: Right.
Speaker: We've been called to duty.
Speaker: We have delivered that care.
Speaker: And now we are in the bonus round.
Speaker: I think we can make a profound difference with our skill set, with our competence and the compassionate dialogue.
Speaker: And there's no question it's stressful and uncertain environments in the ICU.
Speaker: But I think if every day we wake up and go, you know, I'm just going to do the very best job today.
Speaker: And tomorrow may not happen or it's not promised.
Speaker: But for today, I can look at myself in the mirror and go, okay, decent job.
Speaker: Good job.
Speaker: Perfect.
Speaker: I think that's a great place to stop, Bindu.
Speaker: I want to thank you again for sharing your expertise with us, for sharing your precious time with us.
Speaker: And I look forward to having you back on the podcast soon.
Speaker: Thank you so much, Sergio.
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: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
