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ECMO In COVID - 19
13 Plays5 years ago
In today's episode of Critical Matters, we will discuss the use of Extracorporeal Life Support (ECLS) in the form of extracorporeal membrane oxygenation (ECMO) for the treatment of the sickest patients with COVID-19 induced ARDS.
Our guest is Dr. Jenelle Badulak. Dr. Badulak is an emergency physician and intensivist caring for patients in the Emergency Department, Cardiothoracic Intensive Care Unit, Medical Intensive Care Unit and Trauma Intensive Care Unit at the University of Washington Medical Center and Harborview Medical Center. She is a clinician-educator who specializes in curriculum development and assessment with a focus on graduate medical education and Extracorporeal Life Support/Extracorporeal Membrane Oxygenation (ECMO).
Additional Resources:
Extracorporeal Membrane Oxygenation Support in COVID-19: An International Cohort Study of the Extracorporeal Life Support Organization Registry: https://www.thelancet.com/article/S0140-6736(20)32008-0/fulltext
Extracorporeal Life Support Organization(ELSO) COVID-19 Dashboard and Website: https://www.elso.org/Registry/FullCOVID19RegistryDashboard.aspx
Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome Associated with COVID-19: A Retrospective Cohort Study: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30328-3/fulltext
Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: https://www.nejm.org/doi/full/10.1056/NEJMoa1800385
Books Mentioned in this Episode:
Extracorporeal Life Support: The ELSO Red Book: https://www.elso.org/Publications/RedBook5thEdition.aspx
Recommended
Transcript
Introduction to 'Critical Matters' Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
Speaker
And now your host, Dr. Sergio Zanotti.
Impact of COVID-19 on ICUs and Role of ECMO
00:00:33
Speaker
The first case of COVID-19 in the US was reported in January of 2020.
00:00:37
Speaker
By February, community transmission of SARS-CoV-2 in the United States was occurring.
00:00:42
Speaker
A year later, over 100 million patients have contracted COVID around the world and ICUs everywhere have been facing enormous strain from an unprecedented number of patients with respiratory failure.
00:00:54
Speaker
Today's episode of the podcast, we will explore the use of extracorporeal life support in the form of ECMO, extracorporeal membrane oxygenation,
00:01:02
Speaker
for the treatment of the sickest patients with COVID-19 induced ARDS.
00:01:06
Speaker
Our guest is Dr. Janelle Badulak.
00:01:08
Speaker
Dr. Badulak is an emergency physician and intensivist caring for patients in the emergency department, cardiothoracic intensive care unit, medical intensive care unit, and trauma intensive care unit at the University of Washington Medical Center and Harborview Medical Center.
Types and Applications of ECMO for COVID-19
00:01:23
Speaker
She's a clinician educator who specializes in curriculum development and assessment with a focus on graduate medical education and extracorporeal life support
00:01:32
Speaker
and extracorporeal membrane oxygenation.
00:01:35
Speaker
Dr. Badalak works closely with the Extracorporeal Life Support Organization, ELSO, on the ECMO Ed Task Force, contributing to development of an international standardized ECMO curriculum.
00:01:45
Speaker
She also serves as the Director of ECMO Education for the University of Washington and Harborview Medical Centers.
00:01:50
Speaker
Janelle, welcome to Critical Matters.
00:01:53
Speaker
Thank you very much for having me.
00:01:56
Speaker
Very excited to talk with you today about obviously a very
00:02:01
Speaker
important topic that I know you're very passionate about.
00:02:05
Speaker
And we were talking before we started recording about ECMO pre-COVID, but also what it means for COVID and what we've learned.
00:02:13
Speaker
So hopefully we can really address a lot of the clinical important points that are relevant to clinicians practicing at the bedside, both in places that do ECMO and places that may not.
00:02:28
Speaker
and identifying those patients and when they should be referred.
00:02:32
Speaker
So maybe we could start with a very basic definition or kind of explanation of the types of ECMO that have been utilized for COVID-19 and move into what we've learned with the ELSO registry on COVID-19 specifically.
00:02:49
Speaker
Yeah, sounds great.
00:02:50
Speaker
So the two main configurations for ECMO are VA or veno arterial and VV or veno venous.
00:02:58
Speaker
And overwhelmingly more than 90% of cases we've been using VV or venovenous ECMO for supporting patients with COVID with severe respiratory failure.
00:03:08
Speaker
So essentially just pulmonary bypass where we drain blood from the central venous system, pump it through a membrane lung, removing CO2 and oxygenating the blood, and then pumping it back into the central venous system, essentially placing a membrane lung in series with or before the native lung.
00:03:26
Speaker
There is a minority of, there are like a small number of patients who have COVID-19 that have cardiopulmonary failure.
00:03:35
Speaker
So they have some form of cardiogenic or obstructive shock.
00:03:39
Speaker
This seems to be patients with massive PE or potentially a stress cardiomyopathy or a frank myocarditis, potentially even
00:03:49
Speaker
Also, at acute coronary syndrome related to embolic phenomena or maybe hypercoagulability is still all fairly poorly understood.
00:03:57
Speaker
However, these patients can be supported on veno-arterial ECMO, where we're draining that blood from the central venous system and then pumping it back into the arterial system, bypassing both the heart and the lungs.
00:04:10
Speaker
So essentially creating dual circulations that are in parallel.
Evolution of ECMO Understanding and Outcomes
00:04:16
Speaker
Excellent.
00:04:17
Speaker
And it's very interesting that with ECMO, we've seen a similar evolution through the pandemic where early reports suggested that the mortality was exceedingly high and made people second think what we should be doing.
00:04:31
Speaker
Very similar to what happened with ICU, but as we really gained experience, understood what we were dealing with, and the numbers started increasing, it does seem that now we have a different perspective of what the real outcomes of these patients are.
00:04:47
Speaker
As far as I understand, ELSO has a registry for ECMO patients in COVID-19.
00:04:52
Speaker
And last I checked, over 3,000 patients have had ECMO runs with COVID-19 in the United States.
00:04:58
Speaker
Could you comment on that a little bit in terms of general findings to date with ECMO and COVID-19 specifically?
00:05:04
Speaker
Yeah, we've been really looking forward to this data that came out a couple of months ago published in The Lancet.
00:05:12
Speaker
to see what is the mortality for patients undergoing ECMO at experienced high volume ECMO centers and centers also that maybe aren't getting absolutely crushed with high volumes of COVID.
00:05:24
Speaker
I think that's part of the problem is initially mortality is quite high if centers that maybe don't have as many ECMO runs or are being totally overwhelmed with a totally unknown virus, it's hard for you to maintain the standard of care.
00:05:39
Speaker
when your volumes and your unknowns are unprecedented.
00:05:43
Speaker
So once we kind of, like you said, moved a little bit further into the disease and started to understand that, hey, it's kind of just another respiratory virus, potentially higher mortality, but treat it the same way that we know how to treat ARDS, then we started seeing that mortality for these patients is quite similar to pre-COVID ARDS mortality, or at least all comers for BBEcmo.
00:06:06
Speaker
So in general,
00:06:08
Speaker
The ELSO registry gathers data from all ELSO centers.
00:06:11
Speaker
So ECMO centers around the world who join ELSO then contribute their data.
00:06:17
Speaker
And they've been collecting data for decades.
00:06:21
Speaker
In general, VV ECMO survival, so for respiratory failure of all different types, not just ARDS, survival is about 65%.
00:06:29
Speaker
This is kind of like pre-pandemic historical survival.
00:06:36
Speaker
And then what we saw in the paper by Barrow in the Lancet was that survival was about the same, quite simpler.
00:06:43
Speaker
We also saw a nice multicenter French study that was just published just before the ELSO registry that showed about a similar mortality as well.
00:06:57
Speaker
And then we also have the ELSO or the Euro ELSO survey, which is,
00:07:03
Speaker
a group of, I think it's about a hundred and, well, no, many, a couple hundred, a couple hundred ECMO centers in Europe collecting data, looking at their mortality, which was just recently published as well.
00:07:18
Speaker
It seems like the mortality may be increasing with time.
00:07:22
Speaker
And I wonder, we all kind of speculate about this.
00:07:26
Speaker
Is it that people now who are on ECMO are sort of failing the other therapies that
00:07:31
Speaker
we didn't use before, like we didn't use high flow, we weren't using steroids.
00:07:35
Speaker
So now if patients are severe enough to require ECMO, they're just way sicker.
00:07:40
Speaker
But in general, like the big take home point is that yes, patients do have comparable survival to other causes of ARDS when they have COVID.
00:07:49
Speaker
So we should basically use probably the same selection criteria.
00:07:54
Speaker
Absolutely.
00:07:55
Speaker
And obviously the devil is always in the selecting the right patients, but the important lessons
00:08:00
Speaker
at least from what I've seen related to ECMO and COVID, relate to the mortality is not 100%.
00:08:07
Speaker
So there's actually a large number of patients, like you said, the majority of patients when selected appropriately that can survive.
00:08:14
Speaker
It also, I think, highlights that this data is based out of centers that are highly motivated, that do a lot of ECMO.
00:08:22
Speaker
So they're set up for ECMO.
00:08:24
Speaker
And like you said, probably speaks to the nature of a high resource intensive
00:08:31
Speaker
in therapy like ECMO is not something that you might be able to do when your ICU capacity is exceeded with a surge of patients or you haven't done it before in terms of having the
Guidelines and Future of ECMO Resource Allocation
00:08:43
Speaker
right resources.
00:08:43
Speaker
So that also, I believe is an important aspect of ECMO and COVID during a pandemic, right?
00:08:50
Speaker
Right, and this is something that, you know, we actually coming shortly, hopefully within the next week or two have some updated
00:09:00
Speaker
guidelines for COVID coming from ELSO and kind of navigating this, like who should, where's the best, how is it, what's the best method to take care of our patients?
00:09:11
Speaker
How do we get the most people to survive with the resources that we have and how do we work together to do that?
00:09:17
Speaker
We do know that there probably is an economy of scale and a volume outcomes relationship.
00:09:25
Speaker
where if you have a higher volume, so more than 30 ECMO runs a year, your outcomes seem like they are better.
00:09:33
Speaker
And so COVID would be no exception to that.
00:09:36
Speaker
So trying to concentrate ECMO volumes at ECMO centers, just to try to concentrate that expertise, it makes sense, right?
00:09:45
Speaker
And so figuring out how to create hub and spoke networks where referring facilities know who to call and kind of when to send their patients to an ECMO center seems like the best way for all of us to work together to try to save as many lives as we can.
Development and Technology Evolution of ECMO Centers
00:10:02
Speaker
In some areas, they have created newer ECMO centers to meet the need of more patients that are ECMO candidates.
00:10:14
Speaker
However, they've done this in a really deliberate fashion with close mentorship from an established ECMO center.
00:10:21
Speaker
So it's not creating from the ground up a brand new center.
00:10:26
Speaker
It's essentially a branch of a big center that's mentoring a new physical location.
00:10:33
Speaker
And that seems like they've had some success.
00:10:36
Speaker
There've been a couple of different programs in the Middle East who've done this and exemplify that if you're going to create a new ECMO center, it really
00:10:44
Speaker
it just doesn't make sense in the middle of a pandemic or any time just to sprout a new program, because there's the learning curve is too steep and it doesn't really make sense to reinvent the wheel.
00:10:53
Speaker
So do it with another established program to help make sure that you hit the ground running with really good outcomes and that patients don't suffer in the meantime while you're just trying to figure things out.
00:11:04
Speaker
A great point that was done by one of our previous guests was that if you don't do it in peacetime,
00:11:10
Speaker
don't start doing it in the middle of the war, right?
00:11:12
Speaker
I mean, it's just not the right time to start something that's so complex.
00:11:16
Speaker
On the other hand, Janelle, I think that we are seeing that the technology and the ability of us to provide ECMO continues to evolve rapidly.
00:11:26
Speaker
So also I would imagine that even though a hub and spoke model makes a lot of sense now, as we move forward, those hubs will probably increase in size, right?
00:11:36
Speaker
There'll be more and more of them.
00:11:37
Speaker
Probably.
00:11:38
Speaker
And it, you know, it also really depends on what is the future of ECMO?
00:11:42
Speaker
What is the role of ECMO in critical care?
00:11:45
Speaker
When do we use it?
00:11:46
Speaker
And right now it's kind of this, for better or worse, a bit of a salvage technology or rescue.
00:11:54
Speaker
We need to learn more about the technology and again, think about our approach to ARDS.
00:11:59
Speaker
always thinking of how can we make things better for patients and where does ECMO fit into the ARDS algorithm?
00:12:06
Speaker
We really don't know.
00:12:08
Speaker
There's a lot of opportunity for research, and that is definitely one of the challenges of spending a lot of time caring for ECMO patients while we have technology and research trying to catch up to technology and to sort out when and whom should we use this.
00:12:24
Speaker
And if our research tells us that maybe this should be more widespread,
00:12:28
Speaker
then it makes sense for this to kind of gradually move into more intensive care units if it's a useful technology and also if we're able to sort of scale up its use.
00:12:38
Speaker
Right now, it's fairly resource intensive and it is fairly expensive.
ECMO Timing and Patient Selection
00:12:43
Speaker
And there are still some risks, mostly around bleeding and complications in the hematologic inflammatory system.
00:12:50
Speaker
So I think once we kind of learn more about getting over some of the hurdles like that have already been really a lot of incredible strides have been made from the 70s and 80s with membrane like silicone membrane lung oxygenators to now our polymethyl pentane oxygenators that work really, really well and that we're able to have like, you know, bio line and phosphorylcholine and heparin line circuits that we don't need to use as much endicoagulation essentially
00:13:20
Speaker
Lots of different moves forward have been made in technology.
00:13:25
Speaker
And then once we can basically figure out how to use this technology, how to do it really, really well, then study it and figure out what the role of ECMO is, I wonder if it will start to become a really central role in intensive care.
00:13:40
Speaker
And then we would expect it after that, of course, to spread more widely.
00:13:44
Speaker
but hopefully we do it in a really deliberate fashion.
00:13:48
Speaker
Cause the worst thing that could happen is we have a new sort of disruptive technology that spreads too quickly and we hurt people because we don't know how best to, when we should use it or shouldn't.
00:14:01
Speaker
I agree.
00:14:02
Speaker
And obviously one of the most difficult aspects of ECMO, even though it's been around for decades has been to really study it in a rigorous way for many challenges.
00:14:14
Speaker
and figure out really what the right patient, what the right timing is.
00:14:18
Speaker
But without going into that rabbit hole, why don't we talk initially about what are the commonly accepted indications for ECMO and COVID-19 and contraindications and start with indications probably.
00:14:34
Speaker
Yeah, so indications should be the same for pretty much any patient.
00:14:39
Speaker
when you're considering for ECMO.
00:14:40
Speaker
So we've really recognized that you don't want to necessarily wait longer or have a patient in more extremis before considering ECMO because you're sort of a self-fulfilling prophecy that outcomes will be worse.
00:15:00
Speaker
What we think of are generally like evolving criteria for VV ECMO selection, or we'll focus mostly on VV ECMO since this is most relevant for COVID-19, are seeming to be more and more similar to the EOLIA criteria.
00:15:16
Speaker
So the RCT based in France looking at early use of ECMO for ARDS essentially
00:15:25
Speaker
Should we be using ECMO as a way sort of to mitigate some lung injury if we are unable to safely ventilate people without avoiding volutrauma and barotrauma and high mechanical power with the mechanical ventilator versus not offering ECMO?
00:15:45
Speaker
but it's very hard to study ECMO when many people consider it to be unethical to withhold.
00:15:52
Speaker
So there's a ton of crossover, as many of you guys know, in that study.
00:15:57
Speaker
So the criteria for eolia are fairly widely being adapted, but again, we don't know if these are the right criteria and we still have a lot of work to do to really fine tune this.
00:16:09
Speaker
But at this point, it seems like
00:16:10
Speaker
Patients should go on ECMO if they have a low P to F despite traditional less invasive therapies for hypoxemia.
00:16:19
Speaker
So P to F probably calling for a referral with a P to F less than 100 to put the patient on an ECMO center's radar.
00:16:28
Speaker
And then we're generally cannulating patients if they have a P to F of less than 80 for more than like six hours, so sustained, or maybe less than 50 for more than three hours,
00:16:38
Speaker
So patients who are just frankly hypoxemic that were unable to tune up and sort of rescue.
00:16:44
Speaker
Proning seems to be probably the most important intervention that we really don't cannulate anyone unless they've failed a trial of proning.
00:16:52
Speaker
Because patients can respond really beautifully to proning, and that is kind of a no-lose situation to prone someone.
00:16:59
Speaker
And the role for neuromuscular blockade is a little bit hard to understand at this point.
00:17:05
Speaker
Some trials saying do it, some no.
00:17:09
Speaker
And then of course inhaled pulmonary artery vasodilators are a bit of a band-aid, so they may help you transport a patient or get them through a cannulation, but I'm not sure that layering that on to make a patient's P to F ratio look better is necessarily the right thing to do.
00:17:24
Speaker
As we know, inhaled pulmonary artery vasodilators don't seem to improve mortality, just the numbers.
00:17:31
Speaker
And then, so that's the P to F ratio.
00:17:33
Speaker
And then tightly linked with that would be your ability to ventilate the patient.
00:17:38
Speaker
So ARDSnet recommendations, keeping the plateau pressure less than 32, and maybe considering ECMO if you're unable to maintain a pH above 7.25.
00:17:49
Speaker
So I think one of the biggest pitfalls that people run into is that they are liberating the tidal volumes and accepting a higher plateau pressure as the original
00:18:01
Speaker
ARDSnet recommendations from over 20 years ago recommended.
00:18:05
Speaker
And ECMO centers would say, hey, let's not, for lack of a better word, trash the lungs with the mechanical ventilator because if we try to do ECMO after that and the lungs are damaged with COVID and ventilator-induced lung injury, even buying time on ECMO won't save them.
00:18:24
Speaker
Excellent.
00:18:25
Speaker
So before we go into the contraindications, I think it's worth kind of
00:18:30
Speaker
re-emphasizing a couple of points that you made that I think are critical for our listeners.
00:18:36
Speaker
First is that obviously this is for severe ARDS.
00:18:39
Speaker
So if the P to F ratio is not below 150, ECMO is probably not right now, at least in your conversation initially.
00:18:49
Speaker
But when it goes below 100, after optimization, especially, or as you're trying to optimize somebody, getting in contact with the ECMO team, where it's at your institution,
00:18:58
Speaker
or an outside institution is probably the right thing to at least start.
00:19:04
Speaker
And the things that you would do to optimize it, everybody agrees on would be prone positioning.
00:19:10
Speaker
And some things that people probably go back and forth would be neuromuscular blockage, higher PEEP strategies.
00:19:16
Speaker
And like you said, some people would recommend that you consider inhaled pulmonary vasodilators, but those obviously are not usually associated with improved mortality and might be more of a bridge as you get them cannulated or you get them to ECMO.
00:19:28
Speaker
And for the criteria that you mentioned, really there's three important criteria that I think people can remember, which are a P to F ratio below 80 for six hours or more, a P to F ratio below 50 for three hours or more, and for the ventilation aspect, when your pH is below 7.25 with the PCO2 equal or greater than 60 for six hours,
00:19:54
Speaker
all of these after you've optimized your ARDS net and lung protective strategies, correct?
00:20:00
Speaker
Correct.
00:20:00
Speaker
And I think the last point is probably one of the most important is to not liberate tidal volumes and to not accept a higher plateau pressure in order to keep the pH and the hemodynamically stable high enough first to avoid terrible shock and RV failure, myocardial dysfunction.
00:20:20
Speaker
because that's when we get the, I think the most common like too late referrals would be a patient who's been exposed to injurious mechanical ventilator settings and those patients do pretty terribly.
00:20:31
Speaker
Excellent.
00:20:32
Speaker
Now, more difficult in terms of having precise criteria, but I think obviously still very relevant to discuss are the contraindications for ECMO.
00:20:41
Speaker
Could you talk to those, especially specifically for COVID?
00:20:45
Speaker
Yeah, so this is a really tough area.
00:20:48
Speaker
And
00:20:50
Speaker
I've learned a lot from our ethicists as we engage them in all of these discussions for when we have a limited resource that we've never really had to decline patients because we didn't have capacity before, how do we do that?
00:21:08
Speaker
So if we, you know, like many places have had to ask this question for things that come before ECMO, like ICU space because of a limitation of a physical space or
00:21:19
Speaker
nurse or respiratory therapist or maybe mechanical ventilators or at least the good kind the ones that are actually icu mechanical ventilators so um the ecmo community is no different and this is really tricky for us to sort through what are the contraindications and in general when you're thinking about contraindications you want to try to select patients that are most likely to survive and are
00:21:45
Speaker
like if they're likely to make it through an ECMO run, so they have to have the physical fitness to be able to do that.
00:21:52
Speaker
And the COVID ECMO runs are longer than the pre-COVID runs.
00:21:55
Speaker
So on average, or median and mean seem to be somewhere between 11 and 30 days for COVID, where pre-COVID is somewhere more around seven to 11 days.
00:22:08
Speaker
So significantly longer time, meaning that patients who may have been able to survive a shorter ECMO run without COVID, I'm not sure they'll be able to survive an ECMO run with COVID.
00:22:19
Speaker
But again, most all of our data are observational, which leads to significant limitations.
00:22:26
Speaker
So we really don't know who we should exclude, but what we try to do is use data from some of the like mortality prediction tools to just get a general idea of maybe which patients are less likely to survive and then restrict ECMO use when we're running out of ECMO capacity just to the patients that maybe lack some of those comorbidities.
00:22:51
Speaker
In general though, the only real contraindication to a patient going on ECMO
00:22:56
Speaker
is that you don't have an exit strategy, right?
00:23:00
Speaker
So a patient that you're putting them on VV ECMO or VA ECMO and you don't anticipate recovery and the patient is not a transplant or durable device candidate.
00:23:10
Speaker
That's a clear contraindication because ECMO can't be a bridge to nowhere or ideally not.
00:23:17
Speaker
Yeah.
00:23:18
Speaker
And it seems that when you look at the Lancet data from the registry, some of the independent risk factors with higher mortality were obviously higher age,
00:23:27
Speaker
So in some places that might be a consideration, immunocompromised state, people like you said who had chronic respiratory disease at baseline, which probably leads to that exit strategy implications.
00:23:39
Speaker
And also, I mean, other organ failures obviously contributed to that.
00:23:43
Speaker
So those are all things that people should consider.
00:23:45
Speaker
And it seems like the hard part is that you're trying to find patients who are sick enough that without ECMO they won't survive.
00:23:55
Speaker
but that have a chance to survive, right?
00:23:58
Speaker
So you have to find them at the right spot.
00:24:01
Speaker
And that has been, I think, kind of like the Holy Grail in terms of identifying the right population.
00:24:08
Speaker
Yeah, it really is the biggest challenge because you'll look at a patient and, you know, I run into this all the time, way more often than I wish that I did, but you look at a patient and you see her trajectory is headed in the wrong direction.
00:24:23
Speaker
But she hasn't been intubated for a very long time.
00:24:26
Speaker
One of the things we should probably talk about is duration of mechanical ventilation.
00:24:29
Speaker
Don't let me forget about that because that's an important one.
00:24:32
Speaker
But anyway, patient is not doing very well.
00:24:35
Speaker
She hasn't been mechanically ventilated for that long.
00:24:38
Speaker
And you're trying to sort of wish you had a crystal ball to figure out which direction is she going to go.
00:24:43
Speaker
If you put her on ECMO now, you run the risk of giving her an ECMO run that she didn't need.
00:24:50
Speaker
Well, what's the risk benefit ratio for that?
00:24:53
Speaker
She could potentially get hurt from ECMO.
00:24:55
Speaker
But if I wait longer and keep her on mechanical ventilation, she continues to decline, and I wait too long, then maybe she's been exposed to mechanical ventilation for too long.
00:25:04
Speaker
We think there seems to be some kind of dose-harm relationship with time on mechanical ventilation because patients just don't survive ECMO if they've been exposed to a mechanical ventilator for a prolonged period of time, like more than seven to 10 days.
00:25:19
Speaker
so you know i what drives us kind of crazy is just trying to predict the future to say which direction is this patient going to go because it's very hard when then you're on day 10 or 12 and the patient you know you thought that they were going to get better and then all of a sudden she significantly declines and then you you really regret having not put her on ecmo um when you sort of had the chance earlier
00:25:43
Speaker
So I think that's what's so tricky about patient selection is putting these patients on an ECMO program's radar early is really helpful to understand a patient's trajectory because we don't know what the right thing to do is, but potentially it may make sense to put someone on if their trajectory is really concerning with knowing that you may expose them to an ECMO run they didn't need, but that may be the lesser of the two evils.
00:26:09
Speaker
Yeah.
00:26:10
Speaker
obviously in places that do ECMO very well, or if you have the capacity to do that, depending on what's going on, obviously with the number of patients, which we've seen with these surges can be quite a challenge.
00:26:22
Speaker
Let me give you two numbers, Janelle, that I want you to react to.
00:26:25
Speaker
These are numbers that kind of I have just from what I've learned, I mean, kind of kept in mind.
00:26:31
Speaker
One is that it seems that the median time for initiation of ECMO and the ELSO COVID registry
00:26:39
Speaker
for patients is four days after initiation of mechanical ventilation.
00:26:44
Speaker
On the other hand, the other number I want to give you is seven.
00:26:47
Speaker
And it seems that when people are really over seven days of mechanical ventilation, the odds of us being out of the window increase significantly.
00:26:56
Speaker
Are those, do you think, reference points that can be useful for clinicians?
00:27:00
Speaker
Yeah, I think so.
00:27:02
Speaker
I think that, you know,
00:27:04
Speaker
Often what will, as we all know, in intensive care, when you intubate a patient, when they are failing high flow, for example, with ARDS, and they decompensate and they're quite hypoxemic at the beginning, we don't know which direction they're going to go.
00:27:20
Speaker
Then we quickly get them in the prone position, neuromuscular blockade, and then we kind of sit on them and try to sort out which direction are you going to go as we optimize PEEP as well, of course.
00:27:28
Speaker
um and then um you know i think at that point kind of once you get an idea of where is this person going to settle out and if they're really starting to improve um then you can um
00:27:43
Speaker
If they're really starting to improve, then kind of wait a little bit and figure out which direction they're going to go.
00:27:49
Speaker
But if they're really not improving, yeah, I think like within the first couple of days, referring them to an ECMO center makes sense.
00:27:58
Speaker
And I can speak for our ECMO centers that
00:28:01
Speaker
We always appreciate early phone calls.
00:28:04
Speaker
I think in general calling after, we sometimes get calls for patients who are on high flow pre-intubation, which is probably not as like, we just don't know what direction they're going to go.
00:28:16
Speaker
In general, most centers, maybe with few exceptions, are really requesting that a patient fails invasive mechanical ventilation before utilizing ECMO.
00:28:27
Speaker
So after patients have been intubated, after they've really settled out in the ICU, just figure out which direction they're going to go.
00:28:33
Speaker
If it's really still concerning with a P to F less than 100, then I'd put that patient on ECMO center's radar.
00:28:39
Speaker
And the seven-day mark, while that was kind of the, that came up quite a bit for maybe the outcomes are really pretty terrible after seven to 10 days.
00:28:49
Speaker
And this is of course pre-COVID data.
00:28:51
Speaker
The inflection point for, well, I shouldn't say inflection point,
00:28:55
Speaker
the signal for harm really starts around day three to four, where patients have worse outcomes.
00:29:02
Speaker
So of course, patients always have better outcomes if they're placed on ECMO earlier, but we don't really know why that is, right?
00:29:08
Speaker
Because it could be that we're exposing a lot of patients to ECMO runs that they didn't need because they were just less sick.
00:29:14
Speaker
Or is it because these patients are having, they're having better survival because they have a lower dose of basically mechanical power from positive pressure ventilation?
00:29:25
Speaker
Nobody knows, but it is something certainly worth considering.
00:29:30
Speaker
So a take-home message would be that prior to optimizing what we know we can do for ARDS, including prone positioning, plus-minus neuromuscular blockers, plus-minus increasing P, plus-minus inhaled basal dilators, we really shouldn't be thinking of ECMO.
00:29:48
Speaker
So let's do that as soon as possible.
00:29:51
Speaker
And on the other hand, if somebody's been in the vent for a long period of time or
00:29:55
Speaker
when you start to go after a week of mechanical ventilation, probably the window is too late, especially in the current circumstances where we are strained for resources and trying to make the best decisions, right?
00:30:07
Speaker
Right.
00:30:08
Speaker
And that's the thing with ECMO is that we are strained for resources, but we want to select patients at the right time because if we wait too long, it doesn't make sense.
00:30:17
Speaker
Our outcomes are going to be worse.
00:30:19
Speaker
So we want to try to find those
00:30:22
Speaker
especially the very young, previously totally healthy, otherwise pretty physically fit that can make it through a really long ECMO run when they have a bad trajectory to get them to an ECMO center or just consult over the phone.
00:30:35
Speaker
And often we'll follow them for a while over the phone together and stay updated.
00:30:40
Speaker
And then we can also plan the ideal time to retrieve or transport the patient.
00:30:44
Speaker
So let's dive into a little bit more of the management and especially talk about some important aspects
00:30:52
Speaker
dealing with a patient who now, who you're going to start ECMO, always on ECMO.
00:30:57
Speaker
And maybe we can start with the initiation and very briefly at a high level, just any conulation comments or any specific issues that you've learned with COVID-19 in this aspect.
00:31:11
Speaker
Yeah.
00:31:11
Speaker
So I think that
00:31:13
Speaker
Probably the biggest thing that we've all learned is to stick to the standard of care.
00:31:18
Speaker
So whether that is how you cannulate your patient, how you manage your ARDS, what your nursing cares are, how you run ECMO, just do it the same way you've always done it.
00:31:30
Speaker
And kind of at the beginning, maybe we would tweak it a little bit because we had a very unknown virus and didn't know how to stay safe.
00:31:38
Speaker
But it's really important that we do critical care is, you know, outcomes are a conglomeration of a ton of things.
00:31:45
Speaker
And ECMO is just one little technology piece.
00:31:49
Speaker
So if your physical therapy and OT and skin care are, you know, and nursing cares aren't up to par, your ECMO outcomes will significantly suffer.
00:31:58
Speaker
So just wanted to start off with that, that we really stick with the standard of care because we know how to keep our healthcare workers safe now, especially if you have
00:32:07
Speaker
force adequate PPE.
00:32:09
Speaker
So a reason I started thinking about that is because we think about, okay, well, how did we start cannulating these patients?
00:32:15
Speaker
And in general, we do most of our BB cannulations at the bedside, which makes perfect sense.
00:32:19
Speaker
The patients are quite unstable.
00:32:21
Speaker
We have access to whatever we need for imaging.
00:32:24
Speaker
And for the most part, most patients can be cannulated quite easily with a surface echo or potentially fluoroscopy.
00:32:32
Speaker
Rarely really needing TEE.
00:32:35
Speaker
It's another tool that you can definitely use.
00:32:38
Speaker
It just depends also on what your configuration is.
00:32:40
Speaker
Initially, we thought maybe these patients should only be supported with two cannulas to enable really high flow.
00:32:46
Speaker
But it seems like, and I've had a couple of patients supported with dual lumen single cannulas and they do just fine.
00:32:52
Speaker
Potentially needing TEE for positioning of the return flow through the red atrium.
00:32:59
Speaker
But also this can be accomplished pretty effectively with fluoroscopy as well.
00:33:06
Speaker
And then, of course, we also have a cohort of patients that were outcomes published from Chicago using the Protech Duo, which is drainage in the right atrium and return across the pulmonary valve so that you also have an RVAD, which is really very interesting to me.
00:33:24
Speaker
They have the lowest mortality of any cohort internationally.
00:33:28
Speaker
Interesting.
00:33:29
Speaker
And in terms of initial goals for the ECMO, in terms of oxygenation and ventilation, could you give us some general targets, just an overview?
00:33:37
Speaker
Yeah, so in general, thinking of oxygenation, striving for greater than 88% at the beginning, certainly not wanting to sacrifice the lungs for that.
00:33:48
Speaker
So using lung protective ventilation or ultra lung protective ventilation, I kind of dislike this word lung protective ventilation because I think that's kind of an oxymoron.
00:33:57
Speaker
I don't think positive pressure is ever okay for the lungs.
00:34:01
Speaker
But anyway, trying not to damage the lungs while we buy more time.
00:34:06
Speaker
And so many patients can, you can get them above 88% with optimizing your blood flow.
00:34:13
Speaker
So increasing blood flow to the point of not causing high level hemolysis and shear stress and not having a higher circulation fraction if you're dealing with a two cannula configuration.
00:34:25
Speaker
And then if they are not able to achieve an 88% goal, of course, you don't want high FIO2, high pressures, high volumes with positive pressure ventilation.
00:34:35
Speaker
Then kind of backing off on your oxygen saturation goal, and it seems like permissive hypoxemia is fairly well tolerated.
00:34:42
Speaker
At least we have some nice observational data that our colleagues in Sweden have published looking at permissive hyper
00:34:49
Speaker
Hypo, excuse me, hypoxemia and neurocognitive outcomes at a year, it seems like patients are unaffected.
00:34:57
Speaker
But this was also a pretty young cohort.
00:34:59
Speaker
I think that their mean age is in the 30s.
00:35:02
Speaker
So anyway, but looking at end organ function in particular, lactate or maybe troponin, because of course the coronary sinus saturation will be quite low.
00:35:11
Speaker
And if a patient's hypoxemic and your drainage saturation is very low, making sure that we don't then end up with
00:35:17
Speaker
a higher risk of RV failure, which a lot of these patients are going to be facing with high PBR with the ARDS.
00:35:23
Speaker
So taking saturation goal down to 85% is often tolerated, potentially down to 80%.
00:35:28
Speaker
It really just sort of depends on the patient, their age, their atherosclerotic disease, and how their organs are able to function and whether or not you feel the need to transfuse up to a higher hemoglobin.
00:35:42
Speaker
although we don't really know how useful that is.
00:35:45
Speaker
And it should be noted that most critical care literature looking at DO2 to VO2 goals for blood transfusion in critical care, we don't seem to see improved outcomes with that goal-directed therapy.
00:35:58
Speaker
So it's something to note and think about.
00:36:02
Speaker
Yeah, absolutely.
00:36:03
Speaker
And I just want to poke on a couple of things for more clarification for our listeners.
00:36:07
Speaker
So
00:36:08
Speaker
you talked about percent and when an intensivist hears 88 percent they're thinking pulse ox and really what you're talking about is the percent you're following in the serial abgs right or as long as your pulse oximetry is working so um the you know if you there you know i think it's always important to verify that your pulse oximeter is working especially with your patients who are with people of color because we've seen with a recent publication that
00:36:36
Speaker
pulse oximeters may be under-recognizing hypoxemia.
00:36:40
Speaker
And so I don't think that necessarily we need to send blood every two hours.
00:36:45
Speaker
We can rely on the pulse oximeter for sure, but as long as it is actually tracking with the patient's S-A-R-O-2 or the arterial oxygen saturation.
00:36:55
Speaker
Excellent.
00:36:56
Speaker
And can you give us a little bit more color or explanation on recirculation, something that I often hear people get confused about?
00:37:05
Speaker
Yeah, so recirculation is a phenomenon where you essentially have a garden hose return and a vacuum cleaner drainage, right?
00:37:14
Speaker
So if you either have a single cannula that has two lumens in it that provide both drainage and return, or if you have two different cannulas,
00:37:26
Speaker
Most commonly, the drainage cannula is in the femoral vein that goes up to the IBC and right atrium, and the return cannula is either in the contralateral femoral vein returning to the right atrium or in the internal jugular vein.
00:37:41
Speaker
And if the return flow gets sucked into the drainage cannula, then you'll basically be sort of excluding the patient from the ECMO-affected blood, right?
00:37:56
Speaker
So the blood that's been oxygenated and CO2's been removed.
ECMO Integration with Other Therapies and Techniques
00:38:00
Speaker
So essentially, then the circuit is just recirculating with itself.
00:38:04
Speaker
and you're draining and returning to the central venous system and you're not allowing any of that blood to be entrained into the native heart and thus increasing the oxygen content of the pulmonary artery which is how vv ecmo works um and things a number of things that can increase recirculation are going to be cannula position so if you have two cannulas if they're too close together
00:38:29
Speaker
so that the drainage and return ports are quite close to one another, that increases recirculation fraction.
00:38:35
Speaker
Also, if you have a malpositioned dual lumen cannula and the return port is not facing across the tricuspid valve,
00:38:45
Speaker
Then it can lead to essentially just sort of a hot tub kind of effect where return and drainage are happening in the same enclosed space in the cava.
00:38:55
Speaker
And then at higher speeds, you'll have a much more negative drainage pressure.
00:38:59
Speaker
So that will increase the tendency for the return blood to be directed into the drainage cannula.
00:39:09
Speaker
If you think about it, if you had like a garden hose and it's on a trickle and it's 10 centimeters away from a vacuum cleaner, not a lot of it's gonna get sucked into the vacuum cleaner, but you crank the hose up and it starts to, the fluid dynamics, the trajectory of that jet of blood is gonna get shot directly into the vacuum cleaner.
00:39:26
Speaker
That would be why with increasing flow or circulation fraction increases.
00:39:31
Speaker
There's a couple of other smaller things that contribute to it, but those are the two main things.
00:39:36
Speaker
And what would be, Janelle, the finding at the bedside that the clinician would say, hmm, I probably should check for recirculation?
00:39:45
Speaker
Yeah, so there's always going to be some degree of recirculation because we're draining and returning from the same space, the central venous system.
00:39:54
Speaker
But if you have a patient with pathologic recirculation, that's the scenario where the patient is becoming more hypoxemic in the setting of a rising drainage saturation.
00:40:05
Speaker
So this can be manifest as some of the circuits have continuous oximetry on the drainage cannula, and you might see the drainage, the venous drainage saturation or the pre-oxygenator O2 saturation going up.
00:40:24
Speaker
And it's concerning if the patient's peripheral oxygen saturation is going down.
00:40:29
Speaker
Also, both of the tubes will be bright red if you have pretty significant recirculation because all of that return blood that's quite oxygenated is also being drained out instead of the deoxygenated venous blood.
00:40:43
Speaker
And then, so I think that when you're evaluating your amount of recirculation, it really just depends on whether or not it's leading to pathology, so unacceptable patient hypoxemia.
00:40:58
Speaker
Excellent.
00:40:59
Speaker
What do we do with a ventilator while somebody's on ECMO?
00:41:03
Speaker
That is such a good question.
00:41:04
Speaker
And if I could answer that question, I would be so happy.
00:41:07
Speaker
That's a big question mark, right?
00:41:11
Speaker
So let me rephrase it.
00:41:13
Speaker
What do you do with a ventilator when somebody's on ECMO?
00:41:16
Speaker
It's so hard.
00:41:17
Speaker
I feel very conflicted.
00:41:18
Speaker
There are two kind of different schools of thought.
00:41:20
Speaker
Both seem to have
00:41:22
Speaker
fairly similar outcomes.
00:41:23
Speaker
One would be ultra, ultra low tidal volume, low pressure, where there's almost apneic oxygenation happening, and you're relying on ECMO with pulmonary bypass to do almost all the gas exchange.
00:41:39
Speaker
You're going to have to accept some permissive hypoxemia for this because it's hard to fully
00:41:45
Speaker
support someone on peripheral VA ECMO or VV ECMO for total lung bypass.
00:41:52
Speaker
It's quite hard to do, especially because most of these patients have quite high cardiac output.
00:41:56
Speaker
And the idea behind increasing oxygenation with flow is that you're trying to keep up with the patient's cardiac output and try to make sure that the blood that's being entrained into the heart happens to be conditioned by the ECMO membrane lung, oxygenated, CO2 has been removed.
00:42:15
Speaker
So other school of thought would be, okay, well, you know, we all agree that positive pressure is probably bad, more is bad.
00:42:22
Speaker
Every piece of data that we have for 20 years is telling us that, but maybe we shouldn't go all the way down the ventilator.
00:42:31
Speaker
Maybe there's some benefit to maintaining some recruitment.
00:42:34
Speaker
Maybe that would help us shorten the ECMO run and maybe the risks of the ECMO run outweigh the risks of ventilator-induced lung injury.
00:42:43
Speaker
I don't know.
00:42:44
Speaker
So other strategies might be to pursue a more of an open lung ventilation strategy like APRV or inverse ratio ventilation, again, with really narrow driving pressures because we, you know, more and more observational data tell us that perhaps that actually tracks with mortality even better than a plateau pressure.
00:43:04
Speaker
But suffice it to say, nobody knows.
00:43:07
Speaker
And there's some exciting research looking at the ideal mechanical ventilation strategy.
00:43:15
Speaker
What we use is moderate PEEP, so PEEP somewhere between 10 to 15, ideally set prior to going on ECMO, where looking at compliance curves and looking at optimized PEEP to narrow driving pressure.
00:43:31
Speaker
and sticking with that PEEP if it's not excessive once we get cannulated, and then just narrowing the driving pressure.
00:43:37
Speaker
And so we tend to use pressure control ventilation and use a driving pressure of about 10 to maintain some tidal volumes and a very low respiratory rate and try to prevent significant interaction with the ventilator, causing significant transpulmonary pressures when the patient
00:43:56
Speaker
takes really forceful breaths in.
00:44:00
Speaker
We don't know, of course, we, the community about patient induced lung injury on positive pressure, but I suspect we will find that that is not good.
00:44:14
Speaker
Excellent.
00:44:15
Speaker
What about anticoagulation during ECMO runs?
00:44:18
Speaker
Obviously, you mentioned at the beginning of the podcast, the whole issue of anticoagulation and COVID-19 has been quite a,
00:44:26
Speaker
an area of interest and a lot of emerging data.
00:44:30
Speaker
But even from the get-go, it was really felt that people on life support, such as ECMO, probably should be in anticoagulation for many reasons.
00:44:37
Speaker
Could you comment on that?
00:44:40
Speaker
Yeah, so that's another big question, Mark.
00:44:43
Speaker
With more and more time, we've been able to demonstrate the safety of VV ECMO runs with smaller and smaller amounts of anticoagulation because, again, a lot of the
00:44:53
Speaker
The complications that we would have were related to bleeding.
00:44:57
Speaker
And a lot of our, almost all the circuits are coated with something that's anticoagulant.
00:45:06
Speaker
So,
00:45:06
Speaker
You know, with COVID, the question comes up, do these patients have a proclivity for clotting?
00:45:13
Speaker
Are these patients with RV failure having RV failure because of a PE?
00:45:17
Speaker
Or is this from like more of a microvascular problem that we see on histology and some autopsies?
00:45:26
Speaker
You know, it's really hard to know what the best anticoagulation strategy is.
00:45:31
Speaker
In general, we've kind of taken the approach that we've tried for everything with intensive care is don't throw the baby out with the bathwater and do what you know how to do, and then collect data and don't make changes without informed.
00:45:45
Speaker
Like if something's squarely within the research realm, don't just experiment on your patients.
00:45:49
Speaker
So we actually use the same anticoagulation strategy that we did pre-COVID, which is a 10A, anti-10A of 0.1 to 0.3, or a PTT of somewhere around 40 to 60.
00:46:00
Speaker
So not fully anticoagulated.
00:46:04
Speaker
One of the factors, Janelle, that has been associated with increased mortality in these COVID-19 patients that go on ECMO and has also been a common issue in ECMO is renal failure.
00:46:15
Speaker
Yet obviously, a lot of patients who ended up on ECMO are going to receive renal replacement therapy.
00:46:21
Speaker
Could you talk a little bit more about that?
00:46:24
Speaker
Yeah.
00:46:24
Speaker
So the nice thing about RRT and ECMO is that we can easily
00:46:30
Speaker
dialyze on the circuit.
00:46:32
Speaker
So kind of once you're on ECMO, dialysis isn't really that big of a deal.
00:46:37
Speaker
And it seems like many patients have AKI, whether that's a pre-renal ideology related to their sepsis or septic ATN, or a cardiorenal problem with RV failure would be the most concerning one.
00:46:53
Speaker
for prognosis, but it doesn't really kind of affect our decision-making that much unless the patient has like pretty severe multi-organ failure and maybe has some other premorbid or excuse me, like other comorbidities in advanced age, but otherwise it doesn't really factor into our decision-making.
00:47:12
Speaker
And just from a practical standpoint, these patients usually will have their cannulation catheters for ECMO and we will just
00:47:20
Speaker
do the CRRT hooked up to the ECMO circuit, right?
00:47:25
Speaker
Yeah, you can do that.
00:47:27
Speaker
And then with the, like the Prisma Flex sends to hook up pretty nicely to most circuits.
00:47:32
Speaker
You just have to make sure that the pressure going to the circuit or to your CRRT machine doesn't exceed its upper pressure limit.
00:47:42
Speaker
And there's a couple of hacks that, that,
00:47:46
Speaker
that you need to look into to get a software update and stuff like that.
00:47:49
Speaker
But in general, dialyzing on the circuit is totally fine.
00:47:53
Speaker
If you have any trouble, then inserting a separate dialysis line in the patient works.
00:47:58
Speaker
Excellent.
00:47:59
Speaker
And regarding patients with COVID-19 who are in ECMO, have any of these been proned?
00:48:06
Speaker
Is that something that people have even tried?
00:48:08
Speaker
Is there any point of doing?
00:48:10
Speaker
Obviously, the logistics might be complicated, but is that something that's even on the radar right now?
00:48:16
Speaker
Ah, yes, and there's going to be some interesting data coming, so stay tuned, that I've just heard whispers of that I'm very excited to see.
00:48:26
Speaker
We have a lot of abs, not a lot, I should say, I think there's like four or five observational studies pre-COVID looking at proning while on ECMO and seeing a mortality benefit signal.
00:48:40
Speaker
And so that's, well, I guess, certainly
00:48:43
Speaker
studies showing feasibility and safety and low rates of complications, some showing a mortality signal benefit, some not.
00:48:53
Speaker
It also really just depends on how people are using proning.
00:48:58
Speaker
And we don't really know how to use it goal-directed.
00:49:01
Speaker
So we've actually created a proning protocol for ECMO.
00:49:06
Speaker
And we're thinking of using it if patients proning maybe everybody at least once, and then if their compliance improves and continuing to dose with proning.
00:49:16
Speaker
The thing that can be confusing for us is that patients, quote, failed proning to even get on ECMO in the first place.
00:49:23
Speaker
but it seems like some patients can still derive benefit, but maybe they're just still too sick, but they're better in the prone position.
00:49:30
Speaker
And we see this a lot with patients, so they just can't tolerate being supine.
00:49:34
Speaker
So we kind of supinate them, cannulate them while they're satting 60 or 70%, and then you wish you could prone them again because it seems like their compliance gets better, gas exchange is better, it's not going to hurt anything.
00:49:46
Speaker
And pronings, we have, you know, our data tend to tell us that early and often proning
00:49:51
Speaker
probably improve mortality, so we don't want to stop that because we put them on ECMO.
00:49:56
Speaker
So it's a big unknown.
00:49:58
Speaker
Nobody knows, to be very clear, but I'm pretty optimistic about proning on ECMO.
00:50:03
Speaker
And I think it also speaks to the way we think of proning.
00:50:07
Speaker
For most clinicians, it's a PaO2, FiO2, or oxygenation issue, but really, perhaps the benefits really are derived from how they protect the lung or minimize the amount of injury that we are causing on that ARDS lung.
00:50:20
Speaker
And that might be the beauty of it.
00:50:22
Speaker
So it's intriguing for sure.
00:50:24
Speaker
And we'll stay tuned for more information as it comes out.
00:50:31
Speaker
I would like to talk a little bit about weaning from ECMO.
00:50:33
Speaker
So you did mention, Janelle, that on average, the patients that have been placed on ECMO for respiratory failure from COVID will stay on the ventilator longer or on the ECMO longer and have longer ECMO runs.
00:50:47
Speaker
But how do you think about, okay, it's time to start weaning
00:50:50
Speaker
those who are responding and how is this different or not in COVID-19 patients and then we can talk about what do you do when they're not responding but let's start with weaning those who seem to be responding
00:51:03
Speaker
Yeah, so the general approach that I take to weaning that most centers do is once you have a patient who has either if you're like improved enough compliance that you can safely execute six cc per kilo with a plateau pressure less than 30 without a super high minute ventilation, so maybe something less than 15.
00:51:28
Speaker
and that you can maintain a PaO2 of greater than 80 and maybe your oxygen support is not super high on the vents, so PEEP is probably 10 or less and the FiO2 is somewhere like 50% or less, then those are patients that are looking like, hmm, maybe they're going to be headed towards weaning.
00:51:53
Speaker
So in general, these patients are going to be satting 100%
00:51:56
Speaker
because they're on bypass and their lungs have recovered, and then they have good compliance.
00:52:01
Speaker
When you're seeing that, then working on weaning the sweep down to transition that ventilatory load from the membrane lung to the native lungs, and then getting an idea of, okay, what is my minute ventilation if I'm relying on the native lungs?
00:52:17
Speaker
And this COVID is no different than any other kind of ARDS, that dead space is the last thing to recover.
00:52:23
Speaker
And sometimes I need an extra week or two on ECMO just waiting for dead space to recover, just for, excuse me, to recover, whether that's like capillary microthrombosis or capillary destruction with DAD and ARDS.
00:52:41
Speaker
we all suspect it's kind of the same mechanism.
00:52:43
Speaker
It's just, it's pretty severe with COVID and creates for like, the oxygenation will recover, but we need some more time for dead space.
00:52:51
Speaker
And this isn't something that's evidence-based.
00:52:52
Speaker
This is something that the ECMO community has been kind of talking about, and I'd love to see something published here.
00:52:58
Speaker
But anyway, weaning the sweep down until the sweep is around 0.5 liters per minute.
00:53:02
Speaker
And then you know that you've transitioned almost the entire ventilatory load of CO2 onto the native lungs.
00:53:09
Speaker
and then reducing the blood flow a little bit just to see how the patient tolerates that because you're currently still on 100% oxygen support pretty much.
00:53:19
Speaker
If you have any, if the memory lung isn't apneic, it's probably completely oxygenating the blood.
00:53:24
Speaker
And then if that looks okay, then maybe turn your FiO2 up on the ventilator to 100% just to kind of help with VQ matching in the native lungs and then disconnect the sweep gas.
00:53:39
Speaker
And then make sure that you're not running low blood flows on VV ECMO for no reason, kind of hitting that sweet spot of not causing high blood stress or shear stress and hemolysis, but not clotting off your circuit.
00:53:51
Speaker
So I tend to run them around three liters per minute while we're, quote, off ECMO or off sweep gas.
00:53:57
Speaker
and wait for the lines to become both very dark and then wean down your FiO2 pretty quickly and see how your patient does.
00:54:04
Speaker
And again, if they meet those parameters that I mentioned at the beginning, then they're probably gonna be ready for decannulation.
00:54:11
Speaker
I think it's quite important to be patient with decannulation and make sure that your patient can appropriately ventilate because we've had a couple of patients where they look great for the first six hour blood gas and then tomorrow morning while we've kept them off sweep,
00:54:26
Speaker
you know, their hypercarbic respiratory failure is actually pretty bad and they can't keep up.
00:54:30
Speaker
So that's just, you know, a testament to how long it can take for dead space to recover and they need to go back on ECMO until they can handle the CO2 load.
00:54:41
Speaker
What about tracheostomies in these patients with COVID-19?
00:54:45
Speaker
Are you doing trachs in these patients?
00:54:47
Speaker
It's hard to know what to do.
00:54:48
Speaker
So there's kind of a couple of different strategies and like how much do we utilize awake ECMO?
00:54:54
Speaker
So, you know, there's a lot of different thoughts.
00:54:57
Speaker
Some places basically they get a package of you get cannulated and tricked.
00:55:02
Speaker
Some places say, well, I'm going to have you cannulated.
00:55:05
Speaker
And if it looks like you're not going to have a shorter ECMO run like a week or so, then I'm going to just go ahead and trick you then.
00:55:13
Speaker
So about a week or seven days into the run, if it looks like the trajectory is going to be a long run than trach.
00:55:18
Speaker
Other centers have been working more towards extubation on ECMO.
00:55:24
Speaker
And this is highlighted, I think, really nicely with the Chicago cohort that published in JAMA, where they use the PROTEC duo.
00:55:32
Speaker
And then they, so they, their patients were cannulated and intubated, I think for about like a week or week and a half, then they extubated, then they did another week
00:55:42
Speaker
or like two weeks on ECMO.
00:55:44
Speaker
So they're like finished out the run using the membrane lung instead of the native lungs to finish out the recovery.
00:55:56
Speaker
And this enables you to ambulate the patient and move them around more.
00:56:00
Speaker
Granted, this is much easier to do with a cannula that's not going to have problems with suction or recirculation or malposition when it's in the heart.
00:56:11
Speaker
But it's purely preliminary data.
00:56:13
Speaker
I don't want to advocate that we all just jump and run and do this, but it is interesting to look at the different approaches.
00:56:20
Speaker
Currently what we do, and it's no better or worse than what anybody else does, is to look and see if the patient looks like they're going to have a longer run than we trach the patient, probably around a week or so.
00:56:34
Speaker
And if it looks like they're actually improving, it's going to be a short run, then we don't.
00:56:37
Speaker
We work towards extubation.
00:56:38
Speaker
We've had a number of patients do just fine extubated.
00:56:42
Speaker
Excellent.
00:56:42
Speaker
Extubate after decannulation.
00:56:44
Speaker
We haven't really been extubating on ECMO.
00:56:46
Speaker
Okay.
00:56:47
Speaker
And that's something that obviously might be also related to the nature of the respiratory disease versus somebody who may be on VA ECMO for cardiopulmonary collapse, which I've seen people extubated and talking while on ECMO, which is a different situation.
00:57:02
Speaker
Yeah.
00:57:03
Speaker
I know that I've been talking mostly about VEV for COVID, but almost every single one of my VA patients is extubated.
00:57:10
Speaker
What about stopping ECMO for futility in COVID patients?
00:57:14
Speaker
So at what point do you say, well, this is really not getting better?
00:57:18
Speaker
And how does that really happen?
00:57:20
Speaker
And just your thoughts.
00:57:22
Speaker
Yeah, this is really hard.
00:57:24
Speaker
So whereas in the past, we used to think that fibrotic changes on CT portend a terrible prognosis and it was time to move for comfort measures only.
00:57:36
Speaker
incredible places like michigan said let's see what happens if we leave you on ecma for a really long time and the regenerative capabilities of the lung are very poorly understood and it's surprising that lungs can actually recover um so we really don't have a great test of any kind to know when is it completely futile but i mean it's also it's a really it's tough i mean this is not a comfortable way to live
00:58:05
Speaker
A lot of the time with these patients, they go through a lot and you're trying to figure out, okay, what is the likelihood that there's light at the other end of this tunnel?
00:58:12
Speaker
What is the likelihood that I'm actually going to be able to send you back to a quality of life that you find acceptable?
00:58:19
Speaker
And when I feel like that is becoming vanishingly a small opportunity to get you there, then maybe that's time to talk about switching to comfort measures only.
00:58:31
Speaker
I really think with ECMO, it's important to either be a hundred percent in or don't do it.
00:58:37
Speaker
I think it's really not a great place to be in the middle because then you have a self-fulfilling prophecy of a poor outcome, right?
00:58:45
Speaker
And then you're just utilizing resources and there's emotional stress as you basically kind of run a patient with maybe non-escalation, you know, kind of stuff.
00:58:56
Speaker
Like I'm not gonna escalate the pressers, we're not gonna start dialysis, but we're gonna keep them on ECMO.
00:59:00
Speaker
It doesn't really make a lot of sense to me, because you gotta either be all in with ECMO or switch to comfort care only.
00:59:10
Speaker
I think it makes the most sense.
00:59:11
Speaker
And it's really, really important that we communicate clearly with our families at the beginning of the ECMO run, what ECMO can do, and more importantly, what it can't do.
00:59:20
Speaker
And really at regular intervals, reassess the progress that the patient is making.
00:59:26
Speaker
or lack thereof, and when we think that we've met a point of probably no return, then being honest with ourselves about that.
00:59:33
Speaker
Yeah, and I think it's very important, obviously, like you mentioned, the ongoing conversations and being very clear with family in terms of goals and what's possible and what's not.
00:59:45
Speaker
It's also interesting to me that when I review the registry data, that the vast majority of patients who die on ECMO seem to die off ECMO.
00:59:54
Speaker
So in terms of
00:59:56
Speaker
A lot of patients seem to die after ECMO is stopped.
01:00:01
Speaker
And obviously those I presume are the cases you're talking about where they really don't think that there's much more to offer.
01:00:06
Speaker
Is that correct?
01:00:07
Speaker
Or they're dying, I guess, on ECMO so that they aren't being weaned and then die later.
01:00:13
Speaker
It's that they die because we transitioned to comfort care on ECMO.
01:00:18
Speaker
So either the patient has terrible multi-organ failure and is refractory spiraling shock,
01:00:24
Speaker
you can't rescue and this isn't a cardiogenic shock that's rescuable with a vav configuration for example um that's probably that probably makes sense a devastating central neurologic uh injury like a really bad bleed with a bad neurologic prognosis that's another probably reason to stop um and then a patient who say has a really really long run um is not a lung transplant candidate and is so severely deconditioned
01:00:53
Speaker
and there's no hope for enough native lung recovery to be able to aid in some, like you just can't get them, they have to stay paralyzed and sedated.
01:01:02
Speaker
That's really not a sustainable solution.
01:01:04
Speaker
And it's, you know, even then, even if you could wait out a long time with months on ECMO, this person's not gonna have an acceptable quality of life if they want any degree of independence, if they have to stay paralyzed and sedated for weeks, that's just not reasonable.
01:01:20
Speaker
Excellent.
01:01:22
Speaker
I would like to talk a little bit, if you could, Janelle, on complications related to ECMO, but are there any specific complications that you think are most relevant for the COVID-19 patients and just maybe some advice on them before we move on to the closing parts of the podcast?
01:01:38
Speaker
Yeah.
01:01:38
Speaker
I mean, I think that the complications that we see with ECMO in general tend to be around bleeding and clotting, and that's what makes ECMO different than the mechanical ventilator.
01:01:48
Speaker
So I think it's hard to know what to do.
01:01:51
Speaker
Some centers would really pretty strongly advocate for full anticoagulation.
01:01:55
Speaker
Other centers have seen really devastating intracranial hemorrhage or retroperitoneal bleed with massive transfusion.
01:02:01
Speaker
I've seen all of these.
01:02:03
Speaker
And so it's hard to know what the risk-benefit ratio is.
01:02:07
Speaker
But I think it's important for each center to collect their own data, whether it's QI or to submit to a registry so that we can sort out what the best practice is.
01:02:15
Speaker
Another one that we see is ventilator-associated pneumonia.
01:02:19
Speaker
Actually, pretty decently high co-infection or super-infection rates and something that we've all known about influenza and maybe you're learning more that COVID will have a bacterial infection.
Monitoring and Coordination for Optimal ECMO Treatment
01:02:32
Speaker
And I also kind of wonder, and this is also me just being speculative, if the patients who end up requiring ECMO are the ones with a bacterial infection.
01:02:40
Speaker
That's why they end up getting so severe.
01:02:42
Speaker
I don't know.
01:02:44
Speaker
but remaining very vigilant for that and also knowing that the pulmonary toilet is often subpar when you have a deeply sedated patient.
01:02:52
Speaker
And we don't know the role of toilet bronchoscopy.
01:02:54
Speaker
We don't have great data for that in the medical intensive care patients in general, but maybe we should be encouraging more cough and secretion clearance.
01:03:06
Speaker
We really, we just don't know.
01:03:10
Speaker
Excellent.
01:03:11
Speaker
Like we were talking before we started recording and throughout the podcast, the vast majority of intensivists who listen to the podcast probably are not doing ECMO for COVID-19 in their facilities, but obviously have had cases where they're thinking, should this patient be referred to an ECMO center?
01:03:28
Speaker
We talked about the indications.
01:03:29
Speaker
We talked about some of the timing issues.
01:03:32
Speaker
But I think this is a topic that is so important for our listeners that I would like to kind of revisit and emphasize.
01:03:39
Speaker
And maybe if you could just give us, from your perspective, Janelle, some advice for non-ECMO centers on how to interact and engage with a patient who might benefit from ECMO with an ECMO center.
01:03:51
Speaker
What are some of the things that you recommend highly?
01:03:54
Speaker
Wonderful.
01:03:54
Speaker
Yeah, I think the main thing is to not accept injurious ventilator settings.
01:04:00
Speaker
So if you're unable to maintain a, you know, like if you're using esophageal balloon, a transpulmonary pressure less than 25 or 20 or a plateau pressure less than 30, I would definitely reach out because I think that's the number one thing that we see is a patient's had a plateau pressure of 45 for a couple of days.
01:04:22
Speaker
And then that outcome is probably going to be significantly worse.
01:04:27
Speaker
And calling early, I think makes sense.
01:04:29
Speaker
When the patient's intubated and they're not doing well, call your ECMO center and put them on the radar and say, hey, you know, I just want this person on your radar, curious about your capacity, see if you're the right destination, because we've also, you know, a lot of ECMO centers are working together to try to help referring centers, not have to shop their patient around or call a bunch of places.
01:04:49
Speaker
We're trying really hard to coordinate that for everyone.
01:04:53
Speaker
But the earlier that we have someone on the radar, then we know, or at least collectively, for example, in the Pacific Northwest, we have an ECMO collaborative and we know where the patients are at other centers.
01:05:04
Speaker
And we're getting an idea of where are they going to go next?
01:05:06
Speaker
Where's the next patient going to go and know about the really good candidates that are quite sick?
01:05:11
Speaker
And then we can also plan extraction at the right time.
01:05:14
Speaker
We don't want to, I mean, transport is a really high risk time for a patient and you don't want to unnecessarily transport a patient if they can be managed really well where they are.
01:05:23
Speaker
And then also reaching out to an ECMO center just to, you know, we can talk about the strategy for ARDS management together.
01:05:31
Speaker
I think it's always really nice just to like talk through things together and, you know,
01:05:36
Speaker
and have like a nice plan and then think through the what ifs and the if thens and then the criteria for pulling the trigger on ECMO I think is really quite helpful.
01:05:47
Speaker
So I think the early calls, not accepting injurious ventilator settings and like
01:05:55
Speaker
I think you can also, if you're not sure if a patient has a contraindication, just call.
01:06:00
Speaker
Because I think sometimes people think that, oh, this person's maybe too sick or too old or too whatever, but just give us a call and then we can sort through and like whether or not that patient is a good candidate.
01:06:12
Speaker
And also I will say that, you know, exclusion criteria are the things that are going to widen and narrow based on capacity in general.
01:06:21
Speaker
The inclusion criteria won't change, but if we only have one circuit left, we're going to try to pick the patients who are most likely to survive.
01:06:28
Speaker
So maybe if a patient was excluded for comorbidities or age three weeks ago, maybe our circuits opened up and now we're going to take a patient with those characteristics.
01:06:39
Speaker
So I think always calling.
01:06:40
Speaker
really helps erring on the side of calling and not feeling bad if you call and it's a person that isn't a candidate.
01:06:46
Speaker
It's always, I think every ECMO center really is happy to hear about who's out there.
01:06:52
Speaker
Absolutely.
01:06:53
Speaker
And I think like in many other issues in life, when in doubt, call and ask.
01:07:00
Speaker
And early is better than late, it sounds like would be the summary, right?
01:07:03
Speaker
Yeah, that sounds good.
01:07:06
Speaker
So last question on ECMO.
01:07:08
Speaker
I know you're passionate about education.
01:07:11
Speaker
any resources that you want to share and we can link them on the, on the podcast notes for ECMO education in general.
01:07:18
Speaker
Yeah.
01:07:19
Speaker
So I can talk about some upcoming things.
01:07:22
Speaker
So with ELSO we have adult courses that are virtual.
01:07:27
Speaker
So those, there's a couple of them coming up for mobile ECMO and for adult management and we have a neonatal and peds course.
01:07:34
Speaker
So if you go to the ELSO website, you can see how to register for those courses.
01:07:40
Speaker
We're also in the middle of creating our online curriculum for ELSO.
01:07:49
Speaker
And our idea in the future is for this to be an asynchronous curriculum that you have access to.
01:07:54
Speaker
And then having ELSO endorsed courses at various ECMO centers or ELSO centers for the in-person component once we can get back to safely doing that.
01:08:07
Speaker
And then I think
01:08:08
Speaker
The other thing that there's also an ECMO 101, which is a kind of a introductory ECMO course on the ELSO website to just to go through.
01:08:22
Speaker
It's actually not just an introductory course.
01:08:25
Speaker
It's actually in a bit of great detail, but that's something that's free and open access and available to you at any time.
01:08:33
Speaker
And then, so I think that as our ECMO community tries to get back together, in the meantime, virtual conferences.
01:08:41
Speaker
So Euro ELSO is coming up in May, and then the ELSO conference in September.
01:08:47
Speaker
There's a lot of really incredible lectures, and we all really look forward to exchanging ideas for what's next with ECMO and how to stay current in a field that's rapidly changing.
01:08:59
Speaker
Excellent.
01:09:00
Speaker
So Janelle, really enjoy the conversation on ECMO and COVID-19.
01:09:05
Speaker
There's a lot more I'm sure that we can dissect in the future and a lot to come, which is exciting.
01:09:10
Speaker
We'd like to close the podcast with some questions that are unrelated to the clinical topic.
01:09:15
Speaker
Would that be okay?
01:09:16
Speaker
Sure.
01:09:18
Speaker
So the first question relates to books and what book or books have influenced you the most or what book have you gifted most often to others?
01:09:26
Speaker
You know, and this is something that I wish that I feel like I end up reading so much about ECMO and that's probably like the lamest answer ever.
01:09:35
Speaker
But whenever I do get a chance to read is, is, is, is it's pretty few and far between.
01:09:44
Speaker
But I think that for me personally, like,
01:09:48
Speaker
Being able to read something that's like sort of just fun and escapism and to think about something that has to do with magic or fantasy or something like that is really nice to sort of escape our world and to think about things that are, I don't know, wondrous.
01:10:09
Speaker
So I don't know, I feel like I don't even remember the names of the books that I read.
01:10:13
Speaker
It's just something to be able to mindlessly think about that's nice.
01:10:17
Speaker
And I don't tend to read a lot of nonfiction unless it has to do with ECMO, to be totally honest, to confess.
01:10:23
Speaker
Fair enough.
01:10:25
Speaker
And there is always an ELSO, a textbook that's updated regularly that for people who want to learn more is available and also very, very interesting, correct?
01:10:35
Speaker
The ELSO Redbook is a really wonderful textbook.
01:10:38
Speaker
And then also coming soon, we are publishing an eCPR book under the leadership of Zach Shiner from San Diego.
01:10:48
Speaker
So that's going to be really useful for resuscitative ECMO.
01:10:51
Speaker
Well, it's not just eCPR, but any emergent deployment of ECMO.
01:10:55
Speaker
Excellent.
01:10:56
Speaker
Second question relates to beliefs.
01:10:59
Speaker
What do you believe to be true in medicine or life that most other people don't believe or at least don't act like they believe it?
01:11:06
Speaker
Um, I mean, a truth in medicine or life, I think sometimes we don't recognize how grass, how green the grass is right where we're standing.
01:11:19
Speaker
And I think it's really important, especially in a time of so much stress, um, to be able to think about the things that are going well and the things that we're thankful for.
01:11:30
Speaker
and just take those little moments every day as we work through this marathon and it's really hard for us in intensive care, I think.
01:11:39
Speaker
But to just take a moment and be thankful and reflect on what we have that's working and whether that's the little victories for your patients at work or your personal victories at home, but to really enable yourself to celebrate them when it's hard to celebrate too many things right now.
01:11:56
Speaker
And I think that's a great, a great
01:11:59
Speaker
insight and I love it how you said it that the grass being green where you are as opposed to the usual framing of the grass is not greener on the other side, which is something that I've seen a lot throughout ICUs around the country right now.
01:12:14
Speaker
People leaving or some of our colleagues in nursing and RT becoming traveler nurses and really thinking it's going to be better elsewhere.
01:12:22
Speaker
and then they go and find that actually there's a lot of green where they were before.
01:12:27
Speaker
But I think that also in terms of focusing on what's around us, what's good around us, and what we should be grateful for, super important with this pandemic, but I think true for no matter what's going on in our lives.
01:12:39
Speaker
And I think that's a great insight, Janelle.
01:12:42
Speaker
Thanks.
01:12:43
Speaker
The last question is, what would you want every intensivist who's listening to us to know?
01:12:49
Speaker
Yeah.
01:12:50
Speaker
I think the main, the thing, um, it's totally un-ECMO, not ECMO related, but has to do with what we were just talking about is probably the most important thing I think is to make your working environment inspiring and fun.
01:13:06
Speaker
It's, it can be so tiring and, um, making everyone really recognize the impact that they have.
01:13:13
Speaker
So they understand, oh, this is why we do what we do.
01:13:17
Speaker
And this is why we sacrifice so much.
01:13:20
Speaker
When we get to see our patients get better and see them go home and recognize the good saves and to inspire the people on our team, I think that that really, really helps us to prevent burnout.
01:13:34
Speaker
And burnout is probably one of the biggest problems that we face in healthcare.
01:13:39
Speaker
And so I think that, I just think of that as the intensivist, we have that unique opportunity to lead our team
01:13:46
Speaker
and to find little ways to make work fun and to make everyone on the team feel really appreciated, I think goes so much farther than we ever really realize.
01:13:56
Speaker
And I agree 100%.
01:13:56
Speaker
And it's very interesting because a lot of the things you mentioned are deliberate practices that can make a difference, right?
01:14:03
Speaker
So finding joy in what we do on a daily basis, but also reconnecting with purpose.
01:14:08
Speaker
And a lot of people have studied this outside of medicine, but it really seems that when you think of your job, not in terms of
01:14:15
Speaker
the tasks you do on a daily basis, but the people's life that you change on a daily basis, whether that be our patients, the people we teach, the people that we help be their best selves at work in our team, it really transforms the way you feel about your job.
01:14:30
Speaker
And I think that is very, very important since we spend so much time working and so much time trying to get where we are today.
01:14:36
Speaker
Yeah, it makes the hard work worth it.
01:14:38
Speaker
We can change the world one patient at a time, maybe.
01:14:42
Speaker
Excellent.
01:14:43
Speaker
Janelle, it was a true pleasure to talk with you today.
01:14:46
Speaker
I definitely hope that we can see each other in person soon and definitely will keep you on the radar as these new exciting data come up, maybe post-COVID.
01:14:56
Speaker
We'll have a lot more to talk about ECMO and other aspects of critical care.
01:15:00
Speaker
Thank you.
01:15:00
Speaker
Thank you very much.
01:15:01
Speaker
Thank you so much for having me.
01:15:03
Speaker
Appreciate it.
01:15:04
Speaker
Take care.
01:15:06
Speaker
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01:15:11
Speaker
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01:15:17
Speaker
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01:15:22
Speaker
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