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: After a short break during January, we are back recording new podcast episodes.
Speaker: I hope everybody had a good start to 2026.
Speaker: I am certainly looking forward to a year with great conversations on a wide range of topics relevant to the practice of critical care medicine.
Speaker: Extracorporeal membrane oxygenation, ECMO, is an increasingly important therapeutic option for critically ill patients with circulatory and or respiratory failure.
Speaker: In today's episode, we will discuss a structured approach to ECMO emergencies, focusing on recognizing cardiac arrest, organizing the team response, and early ECMO troubleshooting to support key life-saving interventions.
Speaker: Our guest is Dr. Wakas Akhtar, a consultant at Guy's and St.
Speaker: Thomas NHS Foundation Trust in the United Kingdom.
Speaker: Dr. Akhtar completed full postgraduate certification in cardiology, intensive care, and general internal medicine with a particular interest in cardiogenic shock, heart transplantation, and mechanical circulatory support.
Speaker: He has received multiple recognitions from the NHS for program development and training in critical care medicine.
Speaker: Dr. Akhtar is the lead author of the recently published British Society's guideline on the management of emergencies in patients on extracorporeal membrane oxygenation.
Speaker: Wachos, welcome to Critical Matters.
Speaker: Thank you very much for having me.
Speaker: So I would like to start with a broad question.
Speaker: Why should intensivists care about this topic of ECMO emergencies?
Speaker: Yeah, no, perfect.
Speaker: I mean, ECMO has been growing in the last decade or two, along with many other forms of mechanical circulatory support.
Speaker: So obviously it started in pediatrics and with the pandemic in 2010-11 in the UK, it really picked up in terms of vena venous ECMO for a severe respiratory failure.
Speaker: They actually demonstrated quite good outcomes for these patients.
Speaker: And there have been a number of trials in the respiratory field.
Speaker: And the cardiac element has lagged behind a little bit.
Speaker: But in more recent years, in particular in relation to myocarditis, there's been observational data showing that actually there's pretty good outcomes for these patients if you catch them early.
Speaker: And many places don't really feel there's much equipoise in those groups of patients.
Speaker: However, there is a larger question around cardiogenic shock.
Speaker: So overall, the use of ECMO and other mechanical circulation support has been growing.
Speaker: And I think that's why it's become an increasingly important part of critical care medicine in the UK for the management of these patients.
Speaker: And I think it's really essential because of their unique physiology and the device patient interaction that we really provide some sort of framework for our frontline staff who are having to look after these patients.
Speaker: I mentioned in the introduction that you were the lead author of a recently published guideline from several British societies.
Speaker: Could you provide a general overview of this guideline on the management of emergencies in patients on ECMO?
Speaker: Yeah, of course.
Speaker: So the guideline was intended for people who are working with patients who are supported with ECMO, and it's intended to assist staff in those first couple of minutes when there's a significant deterioration in the patient on support.
Speaker: And it's meant to provide a framework for you to follow in the overall areas around recognition of cardiac arrest and when to start CPR, when not to start CPR.
Speaker: And then around the initial interventions you can make in the first one or two minutes, which can be life saving for a patient who's deteriorated on support.
Speaker: And then at the end to provide the structure by which you can think about what the next steps might be in more advanced management of these patients.
Speaker: So that structure should hopefully follow what people are familiar to in other advanced life support protocols, which come out in adults and children and trauma and pre-hospital areas to provide that structure in a really time critical situation where you can get
Speaker: a large amount of cognitive overload with the amount of information and the stress of a situation.
Speaker: What does this guideline add to the literature from your perspective?
Speaker: What is unique about it?
Speaker: Yeah, so there isn't a lot of information around this topic.
Speaker: So certainly there's an even more limited amount of information in terms of randomized controlled trials to even look at when you should be using mechanical circulation support, certainly a lack of those that have been positive.
Speaker: But then even smaller areas around this area when you've actually already got a patient on mechanical support and then they then deteriorate.
Speaker: So it was meant to fill a gap based on the experience of multiple people across different institutions who've had to deal with these situations and try and distill that clinical acumen and knowledge that you can only really gain by looking after these patients into a framework that is able to be utilised by people who are looking after these patients day by day.
Speaker: In terms of ECMO emergencies per se, what are some of the main complications and emergencies that we should be thinking about before we dive into specifically the discussion of the guidelines?
Speaker: Yeah, of course.
Speaker: So there's, they can be roughly grouped into issues that you have with the patient and issues that you can have with ECMO itself.
Speaker: And so there are a whole host of different complications, in particular in relation to bleeding with a device, which is very common.
Speaker: And that's partly due to the anticoagulation need.
Speaker: to manage these patients.
Speaker: They can also issues that arise due to the hemodynamics.
Speaker: So depending if you're on VV ECMO, if you've got high cardiac output that can affect the ability of the device to deliver sufficient oxygen.
Speaker: And then in VA ECMO, that can affect the oxygen that's arriving to your brain and the need to manage that if your lungs are not working.
Speaker: So there's quite complex interplay, but
Speaker: Roughly, you can split them into patient issues to do with the hemazomatics and the heart and bleeding and infection, and then issues to do with the machine, which could probably be focused around mechanical issues, thrombotic issues, and whether the device itself is offering sufficient support for the condition that the patient has.
Speaker: Are there important differences between VA ECMO and VV ECMO from an emergency or a complication perspective?
Speaker: Yes, absolutely.
Speaker: And there's lots of different combinations you can get.
Speaker: So not just VV and VA, but you can have combination modes between the two.
Speaker: You can have central and peripheral configurations, and you can have support which has either an oxygenator within it or just a pump.
Speaker: And the problem is there's so many iterations of the different types of devices along with other mechanical circulation support devices, such as balloon pumps or impellers or LVADs or BIVADs, that what we try to do in this guideline is try to group together the ECMO, both VV, VA and VVA into a single guideline.
Speaker: So it didn't require three separate guidelines.
Speaker: But obviously there's critical differences.
Speaker: For example, VV is purely respiratory support.
Speaker: So if something happens to your heart,
Speaker: And effectively, that patient you would manage as a normal patient you would do with a cardiac arrest, whereas VA ECMO, obviously very different.
Speaker: And you can often lack some of the core features you'd expect to find in a patient who would otherwise be...
Speaker: otherwise be alive so that be for example feeling a pulse or having vf and lack of a pulse and vf and the normal patient would likely indicate cardiac arrest but in an echo patient on va would definitely would not always be the case so um there are very important differences between the two but for the purposes of this which we can go into a bit more detail later we've separated them we've combined them into one algorithm perfect
Speaker: Obviously, the guidelines, as you mentioned earlier, arose because of the need of really trying to codify and create a framework for responding to these emergencies.
Speaker: And because there's some subtle differences when you have a patient on ECMO compared to a patient that's being supported in the intensive care unit without ECMO, what are some of these differences in cardiac arrest on patients in ECMO?
Speaker: Yep.
Speaker: So the first thing is actually the recognition of cardiac arrest.
Speaker: So most advanced life support protocols will look at someone who is not breathing normally or who doesn't have a pulse.
Speaker: Now, ECMA patients may well be sedated and ventilated, although increasingly many are managed to wake.
Speaker: And so that's not necessarily a helpful criteria for you to decide.
Speaker: The second is if they have a pulse.
Speaker: So VV ECMO, yes, they will have a pulse, but in VA ECMO, there will likely be continuous flow.
Speaker: And if they've got a second device in, like an impeller in acapella therapy, they may have no pulse that you can detect because it's continuous flow from both devices.
Speaker: And that's a really core criteria that people would use to detect whether someone's gone into cardiac arrest.
Speaker: that would make it very difficult for people to recognize.
Speaker: In intensive care, you're going to be invasively monitored.
Speaker: So all patients who have ventilated should have N-tidal carbon dioxide measurements.
Speaker: But then again, because of the presence of the oxygenator, this will affect your carbon dioxide detected on your N-tidal.
Speaker: So that might actually be reading low because of the device itself clearing carbon dioxide rather than the fact that the patient has a really poor circulation.
Speaker: And so it can be very difficult to actually recognize sometimes, especially if you've got a sedated patient, whether they've actually gone into a cardiac arrest or ECMO or not.
Speaker: We'll definitely talk more about that as we dive into the emergency algorithm.
Speaker: So the heart really of these guidelines is the adult ECMO emergency algorithm, which I believe is a wonderful tool for all clinicians.
Speaker: And there's some very interesting aspects of this that I would like to discuss in more detail as we go through the different recommendations that
Speaker: that the task force, the panel have proposed.
Speaker: But I would like to start with core principles.
Speaker: And there was something that really caught my eye in terms of a very important distinction and emphasis, maybe is that better word and distinction, on having two teams respond to these emergencies.
Speaker: Could you talk about that core principle?
Speaker: Yeah, of course.
Speaker: So it's something that's familiar to lots of different emergency situations where you separate out into teams that have skills to deal with different airways.
Speaker: For example, in advanced life support, you'll have someone focusing on the airway, someone focusing on CPR, someone focusing on delivering the defibrillation.
Speaker: And they have their responsibilities and you have a team leader that oversees this.
Speaker: So this is a much more wider approach, splitting the teams at the start into two different groups.
Speaker: So one focus on the patient very much following those advanced life support principles.
Speaker: And we want to make sure that when we're delivering that, we're delivering exactly what has been codified in the evidence base, which is the core bits of resuscitation.
Speaker: good quality CPR, early defibrillation, all those aspects that are taught on intermediate and advanced life support courses across the world and reinforced by resuscitation training.
Speaker: The second group is focusing particularly on the machine.
Speaker: which not everyone may have expertise on, but also needs to be managed in its own right and requires a different level of expertise.
Speaker: And that's why we separated those two teams because then they can focus on those two different bits, much like how you would focus on the airway and doing CPR.
Speaker: It's two different people doing two different things and they don't necessarily need to be focused on the other person's activity, making sure they're delivering their bit the best that they can.
Speaker: And so because of that,
Speaker: complexity within the mechanical support and to make sure also that people don't just prioritize the machine, although that is really important to troubleshoot, always having a patient focus as well.
Speaker: So that's why we split into those two teams and then overseen by a single team leader, because you do need to have interaction between the two teams to really troubleshoot some of these difficult situations.
Speaker: Do you think, Vakas, that this could be a concept that should be extended to non-ECMO mechanical support?
Speaker: We're seeing a rapid increase in impellas, the use, again, of introdic balloon pumps that are much more common, at least in the ICUs that I practice, than ECMO these days.
Speaker: Would the same approach make sense?
Speaker: Yes, absolutely.
Speaker: So actually, we've just produced two other guidelines also in relation to impeller exactly as you said, and durable LVAD therapy.
Speaker: So three of the most common devices that we have in the UK in terms of mechanical circulatory support.
Speaker: And exactly like you said, it's important to form a structure for the management of these devices, because actually the teams are not entirely interchangeable.
Speaker: Of course, it'd be great if one person can manage all these devices, but they all require a different level of expertise.
Speaker: And for example, you bring up impeller, which actually requires quite a significant knowledge of echocardiography is pretty key, particularly the impeller MCP, which can be relatively mobile.
Speaker: And you really do need to have an ability to perform echocardiography to troubleshoot that adequately.
Speaker: and actually the people who might have expertise for example cardiologists may tend to be the people who will be able to intervene a just position for you for the impeller whereas ecma for example in the uk is predominantly managed by intensivists and then durable lvads for example are managed by our transplant surgeons so it's a real um difference in perhaps the skill set that you need for the management of the devices and that's why we've also produced those guidelines for those other those three most common devices that we use in the uk
Speaker: Excellent.
Speaker: In terms of the initial response, what triggers an ECMO emergency response in this protocol?
Speaker: Yeah, so we tried to make a core entry point that was familiar to people because part of the process was to follow the design of other advanced life support principles.
Speaker: So at the start, we've got an unresponsive or a patient who's not breathing normally.
Speaker: So that's the same terminology that's used for advanced life support and other similar algorithms in the UK.
Speaker: Obviously, that's not enough because there may well be a patient who is sedated and paralyzed, so they won't be responsive or breathing normally.
Speaker: But clearly, if someone is, then that doesn't then require entry into this algorithm.
Speaker: And the second factor is that you require a confirmed mean arterial pressure less than 30 millimeters of mercury.
Speaker: So,
Speaker: Obviously, there's no clear evidence, interestingly, even with a significant period of time, about what MAP actually constitutes sufficient adequate circulation.
Speaker: Actually, this is quite an interesting question in terms of cardiac arrest.
Speaker: Also, some people get better outcomes than others and whether they were actually maintaining some level of perfusion with a low MAP during cardiac arrest versus no MAP at all.
Speaker: And so we reached an expert consensus around the map reading where we felt below 30 was in an adult, unlikely to be compatible with the life-sustaining circulation.
Speaker: And we placed the terminology of confirmed previously because obviously you need to make sure that your transducer and your arterial line is working and it's appropriately zeroed.
Speaker: Now, obviously, there might be times where the arterial line is not functioning properly, and that'd be a bit unfortunate if that happened at the same time as a cardiac arrest, but obviously that can be the case.
Speaker: And so we have got additional criteria which are not required, but can help you indicate whether there might be a problem with adequacy of circulation.
Speaker: So one is a
Speaker: a sudden unexpected drop in your end tidal co2 now we talked about the end tidal being often low anyway because of the oxygenator within the circuit but if you have a sudden drop from when you've been running a level that can indicate whether there has been uh reduction in your circulation and clearly also having no ecmo flow and a patient who should be supported with ecmo is obviously a good indicator that actually something might be wrong uh if that's not intentional
Speaker: And this is important also for people who might not be as familiar or initially with ECMO is that our usual starting point for a lot of our responses to cardiac arrest is no pulse, right?
Speaker: No pulse.
Speaker: Yes.
Speaker: And here really you're thinking of three very important aspects, which are
Speaker: The blood pressure being a map below 30, because like you said, a lot of these patients might not be pulsatile or have a pulse.
Speaker: Number two, a drop in the end tidal CO2.
Speaker: So again, it's not the value, but the trend that really can alarm you.
Speaker: And then obviously the lack of ECMO flow, which should prompt all emergency bells going on.
Speaker: Yeah, exactly.
Speaker: So in terms of recommendations, you talked about the areas that we should focus on.
Speaker: But as you start CPR and responding to this emergency, now you break off into the ECMO team and the patient team.
Speaker: So could you talk about the initial and secondary response and how these teams will be focusing this and what's different for the patient team regarding a normal ACLS or ALS response?
Speaker: Yeah, absolutely.
Speaker: So, um, once you've reached that defined criteria for cardiac arrest, the expectation is that you place, uh, um, uh, uh, a cardiac arrest call, whatever the activation system is in your institution.
Speaker: So on intensive care, you never mind that, might that.
Speaker: involve pulling the emergency buzzer or in some hospitals it might involve dialing an emergency number and in the UK where these guidelines were actually developed in cooperation with all 14 ECMO centres in the UK we've got a standardised emergency call number which is 2222 so that will alert marissa statistician teams anywhere in the UK
Speaker: to a cardiac arrest.
Speaker: So once that's activated, the priority for the patient team is to perform standard advanced life support.
Speaker: So that's this initiate CPR.
Speaker: And they should very much follow the algorithm with shockable versus non-shockable rhythms, assess the patient for reversible causes of cardiac arrest because, as you said, the causes for cardiac arrest can be both a machine or patient.
Speaker: And then if there's things in the patient, for example, a tension pneumothorax or a tamponade, that needs to be rectified and identified early by the patient team, as you would do normally in a resuscitation.
Speaker: The only bit where we discussed...
Speaker: quite a lot of detail about deviation from advanced life support algorithms was the use of adrenaline.
Speaker: Now, obviously there's been a number of trials looking at the use of adrenaline, because some in the UK, that's a paramedic trial, which showed that actually adrenaline can improve survival, but that does happen at the cost of more significant neurological injury.
Speaker: And some people thought there was a bit of equipoise there about the utilisation of adrenaline, although it is a core part of our algorithm.
Speaker: But in the context of ECMO, adrenaline can pose a number of difficult issues.
Speaker: So if you've got something that you're going to be able to immediately rectify within the circuit, that might have happened.
Speaker: For example, you've got a kink and you can release that.
Speaker: to then have given the patient a milligram of adrenaline, particularly for example if they're on VA ECMO, can be very troublesome with then maintaining appropriate flow from the device and can actually cause harm to the patient.
Speaker: So at that consideration, we thought that adrenaline should only be utilised by an expert in that situation, so someone who understands the ECMO device and is overseeing the overall situation.
Speaker: So you can make a quick judge after the initial
Speaker: machine assessment and the patient assessment to see whether it's appropriate to give adrenaline if it is a PA or a systolic arrest.
Speaker: So that is the only deviation.
Speaker: And it is interesting because there are other suggestions in the resuscitation literature about, you know, whether perhaps adrenaline
Speaker: as a continuous infusion rather than bolus might be better.
Speaker: In eCPR, there's been consideration about whether we should be giving lower overall doses of adrenaline because it can cause issues also with being able to get access to vessels.
Speaker: But that's the main deviation for the patient team.
Speaker: For the ECMO team,
Speaker: Their first job is to fully expose the patient and inspect the circuit so there isn't something really basic to fix, like, you know, the wheel of the bed has gone over the tube or something that shouldn't have happened.
Speaker: And that's called a kink in the circuit and make sure that the cannula hasn't migrated out, obviously, or been malpositioned in any way.
Speaker: So those are the initial bits that both teams need to focus on.
Speaker: And I think that the concept of the ECMO team being very protocolized and assessing all these potential problems that can be resolved immediately is very important because it's well documented from a human factors perspective that in emergencies we can be either losing situational awareness or we can...
Speaker: be embedded in a tax fixation and working on the CPR, working on something.
Speaker: And like you mentioned, a great example, somebody is overlooking that a tube is being compressed by a wheel right now, and that's all that needed to be addressed.
Speaker: So the idea of uncovering the patient and going in a methodical way over the tubing and the hookup by the ECMO team is extremely important.
Speaker: Yeah, absolutely.
Speaker: And it's a, you know, it applies to the bit we were just talking about before with the confirmed map on the arterial line.
Speaker: You know, how many times have you been to a patient who looks like they're deteriorating on ICU, but actually it was a problem with the transducer and everything else and the patient numbers looks okay, but the map was reading ridiculously low.
Speaker: So I think it's always making sure that the information that you're getting is accurate.
Speaker: So that does involve the basics, checking the patient, all the tubing, the connections.
Speaker: Perfect.
Speaker: In terms of assessing the ECMO blood flow or the ECMO troubleshooting, could you expand on what the recommendations are and provide us some useful tips?
Speaker: Yeah, of course.
Speaker: So to start with, it's very similar to what we were just talking about in terms of the readings that you're getting, that you want to make sure that the flow sensor on the ECMO is actually working as a position and orientated correctly.
Speaker: Because if you don't have that on, you're not going to be getting an accurate reading of ECMO blood flow.
Speaker: And we use that as our initial criteria for the ECMO team to in order to direct their troubleshooting.
Speaker: For an adult, if you've got over two litres, we thought that would be sufficient flow in most cases.
Speaker: That would mean that would be unlikely that that would be the explanation for the cardiac arrest, although obviously there can be situations where that occurs.
Speaker: The next bit down is that we have a low flow.
Speaker: to less than two litres per minute with the ECMO.
Speaker: And in this situation, the plan should be to try and address what the most likely cause here, which is suction.
Speaker: So the first step and the easiest step you can do is reduce the RPMs on the ECMO.
Speaker: And you can either come down slowly or you can go down rapidly and then bring back up
Speaker: the rpms depending on the degree of suction and flow that you're experiencing and then in the interim someone can prepare a fluid bolus and deliver that and we've said two and a half mils per kilo but 250 500 mils per patient who's got significant suction is fine and then obviously you want to look for what's causing the suction and as we talked about anticoagulation from post bleeding are important issues in patients with mechanical support so
Speaker: Always look to see if there is bleeding.
Speaker: Common sites, for example, if you've got an impeller in, sometimes the positioning of the impeller can affect bleeding in the groin.
Speaker: And these patients have been anticoagulated unwell.
Speaker: So GI bleeding is another thing to consider as well as hemolysis.
Speaker: There's things that you might need to have a look at in terms of giving blood products or reversing anticoagulation.
Speaker: And a lot of devices are very good now.
Speaker: So you can manage
Speaker: without anticoagulation for a period of time.
Speaker: Even some of the longer term devices like the HeartMate-3 are extremely good for leaving without anticoagulation.
Speaker: But those are the things to assess in low flow.
Speaker: And then the severest category is if you've got no flow on the ECMO.
Speaker: And so the most important thing here is to prevent any harm to the patient.
Speaker: So you want to clamp the return line.
Speaker: That's to prevent any air embolus or any other entry of
Speaker: material into the patient from the return cannula.
Speaker: And then in this category, there are a number of device specific interventions you will need to make.
Speaker: So the common causes that
Speaker: you may get no flow.
Speaker: One, obviously you check that you've got no interventions active on the ECMO.
Speaker: So some ECMOs have bubble alarms and they'll seize the pump if that happens.
Speaker: So make sure that you've dealt with that and you've reset the intervention.
Speaker: But obviously you've got an air embolus, you need to get the air out.
Speaker: If you've got a motor failure, you will need to change the pump.
Speaker: If you've decannulated, then you're going to have to think about whether you're going to be able to get another device in.
Speaker: And obviously, a circuit rupture you'll need to change.
Speaker: So those are all dependent on the device that you specifically use.
Speaker: So they weren't listed in detail within the algorithm because that will need to be judged based on the multiple different types of air commut machines you can get.
Speaker: And at the end, to make sure once you've done that, is to reset your pump interventions again to make sure you get flow.
Speaker: So that is how we broadly categorize the initial intervention based on the ECMO blood flow.
Speaker: And obviously, we've addressed a lot of flow issues, but also important to check your gas line and make sure that's connected to an oxygenator and that you have good gas flow present because a lot of these patients might be having respiratory issues to begin with.
Speaker: Yeah, absolutely.
Speaker: And actually, out of all the incidents in our hospital, actually, we've got three hospitals on our site, and it's occurred at every single one of them is that the oxygen flow to the oxygenator has stopped.
Speaker: And particularly with certain ECMO machines, there isn't a sensor to detect an alarm if there's a lack of oxygen flow to the oxygenator.
Speaker: And often this happens when a patient's gone to CT on a canister and come back, or perhaps they've been moved to theatre and been left on the canister and it depletes.
Speaker: And actually, it's quite tricky for people to pick up.
Speaker: Before we'd published this guideline, we'd done a local study where actually we put our staff through a simulation where we...
Speaker: disconnected the oxygen flow to the oxygenator.
Speaker: And actually a third of our staff who are super experienced to be doing this for decades didn't detect that within the five minutes that we ran the scenario.
Speaker: In fact, we all got bored of waiting for people to pick up that that was actually what happened.
Speaker: So it just shows you that even experienced people can not spot things in emergencies.
Speaker: And that's why much like the aviation industry and other places, you need to have checklists in place to make sure people run through all the possible scenarios.
Speaker: And as you mentioned earlier, with this particular technology or therapeutic intervention, making sure that we train our teams to divide the task and to make sure that we always have the expertise on site to troubleshoot the machine.
Speaker: I don't know how it's in the UK, here in the United States.
Speaker: My feeling is that there's three buckets of ICUs.
Speaker: ICUs that are very experienced with ECMO.
Speaker: ICUs that are starting to do ECMO or don't do as many cases.
Speaker: They have the capability, but perhaps have not reached the expertise of the other centers.
Speaker: And then there's places who don't do ECMO, but they might still have to deal with one of these patients if the patient gets cannulated to be transferred.
Speaker: So,
Speaker: So having this knowledge and training our teams is very, very important.
Speaker: And it sounds like you at your institution, Vacas, are doing like simulation and definitely going through these exercises to make sure that people get used to this protocol.
Speaker: Yeah, I couldn't agree more.
Speaker: And actually, that was one of the core bits of this guideline, the first statement was around training.
Speaker: And actually, even we struggle to deliver training sometimes to all our staff because you have a natural turnover, especially with resident doctors who rotate, but also nursing staff and keeping everyone trained and up to date because these emergencies are not common.
Speaker: And therefore, you need to drill and be familiar with them to be able to deal with them well.
Speaker: And actually,
Speaker: I think that's probably the biggest issue.
Speaker: I'm totally not protectionist around ECMO.
Speaker: I actually think in order to provide more equity for the population, which is a really core principle for the NHS in the UK, we actually do need to have more services able to provide ECMO, particularly if we're talking about ECPR, we need to have much better coverage for the UK because at the moment it's very much focused in a couple of cities.
Speaker: But in order for it to actually...
Speaker: We spread across the UK, you need to have enough experience for these places to do it.
Speaker: And there's a question about what's the minimum number you need to do in a year.
Speaker: But then it's not just the number, it's about the actual training of the staff, which is often neglected, you introduce it, but you don't have a system in place by which to reinforce this learning.
Speaker: And all this stuff is very much focused on the non exciting bit for many doctors, which is about putting
Speaker: the device in and the indications for it but actually this is all about the aftercare and you'll have a huge number of expert people right at the start but then everyone goes home and at night time it's a person left to deal with the device who may have not had training from both the doctor and nursing perspective
Speaker: And actually, that's a point where you're going to have the issue with that patient inevitably.
Speaker: And so therefore, to really provide good care for these patients, I think if you're going to set up a service and deliver ECMO, you need to have a comprehensive training program.
Speaker: And that needs to be invested in.
Speaker: And you need to have staff who've allocated time to be able to deliver that training in a regular fashion so people can keep up to date.
Speaker: Perfect.
Speaker: Like in any ALS or ACLS effort, at one point you have to pause CPR and reassess for adequate circulation.
Speaker: How do we deal with determination of adequate circulation in these situations?
Speaker: Yeah, so at this point, we would pause CPR and use as the initial criteria.
Speaker: So using MAP to see whether you have adequate circulation or no, but also you will have your ECMO flow and saturation is also important, particularly for being a venous ECMO.
Speaker: So at this point, if you fill the same criteria you did at the start of the algorithm where your MAP is under 30 and you've got no ECMO flow and no saturation, then you need to restart CPR.
Speaker: In a particular situation, we use a fair amount of ECMO postcardiotomy.
Speaker: You need to think about this point, you want to open the chest, which is important to do to resolve anything that may be causing deterioration such as a tamponade.
Speaker: In the intermediate category, so if things are not great, but in between, so you've got a map between 30 and 55, we've still got low flow and suction on the ECMO.
Speaker: If you've got low saturations, particularly on VV ECMO.
Speaker: The first thing you probably ought to do is have a look, see if you need to change a circuit so that you might have had indicators before the patient had arrested that this was something that was going to cause a problem.
Speaker: So you could have had rising transmembrane resistance on the oxygenator or your post-oxy might have been falling over that prior time.
Speaker: So you think about whether you need to make an emergency circuit change.
Speaker: And then echo is very key.
Speaker: At this point, to not only rule out other reversible causes, such as the tamponade, but also to assess your kind of position, especially if there might be migration or movement of the device.
Speaker: And then it becomes a little bit more complex here also if you've got other mechanical support in situ.
Speaker: So many places use ECMO and impeller in combination.
Speaker: And it may be that you can utilize the impeller to improve flow to the patient.
Speaker: So if often they're set on a very low setting on ECMO on P1 or P2 to just unload the left ventricle.
Speaker: But actually in this situation, you might want to ramp that up if your ECMO is not functioning to provide sufficient circulation.
Speaker: And then if you're on VV ECMO, as we talked about, it's only respiratory support.
Speaker: So if you've got a cardiac arrest that's ongoing, then you think about whether you want to put an arterial return.
Speaker: So effectively, that would be eCPR.
Speaker: but that would be switching it to a VVA combination.
Speaker: And then in VA ECMO, if you hadn't done already, you want to try and maximize flows to make sure that you are able to give as much support from the device as possible if it's functioning to try and restore an adequate circulation.
Speaker: And then if everything looks fine, then you should go ahead and do your normal A2E assessment and make sure you've thoroughly assessed to see if there's anything else that's happened in the interim or other explanations for the patient's deterioration.
Speaker: In most cases, obviously, we are hoping for successful restoration of circulation and you continue with the care you're providing.
Speaker: Like you mentioned, a lot of times when things are not going the way we hoped,
Speaker: we might escalate the level of intervention.
Speaker: I wanted to ask you a little bit about when things don't go the way that we were hoping for this patient.
Speaker: Would it be fair to say that in ideal situations, ECMO support should be stopped after a discussion and more in control circumstances than in these emergencies?
Speaker: And how do you think about the holistic aspects of caring for these patients, which obviously are quite ill and by definition have a poor prognosis?
Speaker: That's what we're trying to revert.
Speaker: Yeah, so I think it's becoming increasingly tricky, actually, in mechanical support, because sometimes the more difficult situations, you end up with someone who's awake and dependent on support, but there's no clear exit strategy.
Speaker: And it's what you do in those circumstances, because the devices can't be maintained indefinitely on intensive care.
Speaker: And those discussions are extremely difficult and very tricky to manage.
Speaker: And I don't think anyone in the world has
Speaker: a good answer for that at the moment um we actually have very close links with our palliative care team and i think as many places whenever a patient ends up going on ecmo on mechanical support we involve them quite early on obviously we're hoping for the best and we do have relatively matched outcomes in terms of survival from ecmo compared to international registries but even so you're going to have almost half of your patients are not going to be able to make it so i think engaging quite early
Speaker: with palliative care with the family and obviously the patient if they're awake and able to have those discussions about what happens if things deteriorate and what they would prefer to do.
Speaker: And I think in acute situations where you're doing active resuscitation, it's always been important aspects in the UK is about involving the family so they can come and witness the resuscitation if that's something that they wish to do.
Speaker: And effort should be made to support that so they can see that everything's been done for their loved one.
Speaker: Of course, if they don't want to, that's not something that has to happen.
Speaker: And I think trying to avoid a situation where you even ended up doing CPR on these patients is really key.
Speaker: So as you said, making those treatment escalation plans early on and
Speaker: Many of the issues that arise on mechanical support can be predicted to a degree.
Speaker: So you may have started detecting thrombosis or hemolysis or complications, which might indicate something may happen in the future.
Speaker: And to try to make those plans before, say if the patient is going to pass away, it's a dignified death and we're not having to do lots of emergency intervention than CPR, if that also is unlikely to be successful.
Speaker: So, yeah, very much a proponent of early involvement, palliative care, of treatment escalation plans and decision making in collaboration with the patient and the family.
Speaker: As we close our discussion for a summary, could you share, walk us with us, some pearls for success and also some pitfalls to avoid for our listeners?
Speaker: Yeah, so I think in relation to setting up and running a mechanical circulation supports service, I think it's really key to appreciate this is going to be MDT multi-disciplinary team approach.
Speaker: There's no one person that can really do all of this.
Speaker: There's often a couple of people who are super keen and drive the effort, but really it's a whole team effort.
Speaker: And I think that's been demonstrated in studies as well.
Speaker: If you look at some of the ECPR
Speaker: literature, particularly the centres that have been very successful.
Speaker: It's been a system wide approach that really produces good outcomes for patients.
Speaker: So before the hospital, in hospital, as well as involvement, all the different teams.
Speaker: So I think
Speaker: if you're setting up a service or you want to look after these patients that's probably the most important thing is to accept that you need to have really good buy-in from all your services in cardiology intensive care your allied healthcare professionals and make sure people are invested from the start because it's all the little bits that come together to actually make it a success and i think sometimes
Speaker: you do need to push ahead and try and set up a new service.
Speaker: But you need to take the time to think about things that perhaps are going to be quite time consuming and perhaps not as fun, which is writing all the SOPs and repeatedly running all these training sessions.
Speaker: But actually it reaps rewards because then all your staff are properly supported.
Speaker: It's not only good for the patients, but it's also good for your staff because there's a lot of moral injury
Speaker: involved if people don't feel like they've been adequately trained and supported to look after these patients, especially when things go wrong.
Speaker: What areas or future areas of ECMO care are you most excited about at this time?
Speaker: Yeah, so I'm particularly interested in ECPR, so extracorporeal cardiopulmonary resuscitation.
Speaker: I think actually it's really great that we finally have a positive RCT, plus or minus another one, in the use of VA ECMO in these cardiocris patients.
Speaker: So we're able to actually demonstrate that
Speaker: an improvement in survival, which is quite significant that we haven't really seen resuscitation medicine for decades and to improve particularly for refractory cardiac arrest, which near universally has extremely poor outcomes to a 30 to 40% survival to discharge home.
Speaker: I think it's quite revolutionary.
Speaker: We've created a whole entire new cohort of patients that didn't exist before with the utilisation of this technology.
Speaker: And actually, it's bridged so many interesting areas around how do you provide really high complex interventional procedures to a population rapidly.
Speaker: How do you provide that service equitably to the entire population?
Speaker: And, you know, I suppose in the US also it's relevant in terms of whether you have health insurance or not, and you're probably not going to have time to assess that when someone's having CPR or might need to go into ECMO.
Speaker: It also raises a lot of interesting ethical questions, particularly around
Speaker: organ donation.
Speaker: So you, of course, have the 30 to 40% that you will save, but a large proportion will not be saved, even with the utilisation of the device.
Speaker: But the device actually then allows you to go on and give the gift of life to many other patients through organ donation, particularly those
Speaker: who have been put on eCPR.
Speaker: And in some countries, in Europe and Spain, it's extremely common to use normal thermic region perfusions, essentially ECMO circuit, but with a balloon and the descending aorta to prevent blood flow to the brain to actually facilitate uncontrolled donation in cardiac arrest.
Speaker: And actually that has saved subsequently huge numbers of lives through renal and liver transplantation.
Speaker: So there's huge potential here that bridges quite a lot of different areas.
Speaker: And if you're purely looking at it from a health economic perspective,
Speaker: that donation element in particular could pay for entire services because of the savings you make in renal replacement therapy dialysis costs for the longer term.
Speaker: So I think it's really interesting system-wide design, high complex intervention, ethical aspects, and I think ECPR bridges all of those.
Speaker: So it'd be very interesting to see how different countries deal with that challenge.
Speaker: And obviously with the wider picture about
Speaker: what can a country afford for their population, especially in financially constrained times.
Speaker: ECMO often gets the hard line about being something that's too expensive for a population and not the right thing to do.
Speaker: But actually, I think in combination even with prevention and other therapies, I think that's probably going to be one of the most interesting areas to see develop in this field.
Speaker: And like any other therapy, it's about finding the appropriate patients, right?
Speaker: But like you said, ECPR is really opening new doors, not only for the patients who suffer the refractory cardiac arrest, but also, like you mentioned, with transplantation and being able to impact the life of many others.
Speaker: So clearly, it's something to stay tuned into.
Speaker: Vakas, we'd like to close the podcast with a couple of questions that are unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: Yeah, of course.
Speaker: So the first question relates to books.
Speaker: Is there a book or books that have influenced you significantly or a book that you have often gifted to other people?
Speaker: I quite like fantasy and sci-fi, so I've always really liked Philip Pullman's His Dark Materials, and I think it's always an escape for everyday life.
Speaker: I've read those quite a few times and showed them to quite a lot of people.
Speaker: But yeah, anything fantasy or sci-fi related, I'm more than interested in.
Speaker: Is there one particular book that comes to mind?
Speaker: Yeah, I think, to be honest, it was probably the first book in the series, I think was the best to get into the series.
Speaker: And actually, I think it's just really well written and you don't know what exactly to expect.
Speaker: And I think, yeah, I definitely would recommend that.
Speaker: Perfect.
Speaker: The second question, could you share something you changed your mind about over the last few years?
Speaker: Yes, I think...
Speaker: It's an interesting question because I was reflecting on that recently and I think there's a lot within healthcare that we feel as doctors we can't necessarily influence because it's outside of our control and a lot of it's to do with politics and with finance.
Speaker: But actually I think the more time is spent is actually people don't really realise the influence and power that they have in themselves.
Speaker: And I think...
Speaker: You know, being a frontline clinician managing patients, I think gives you intense insight and actually power to try and improve the situation for both your colleagues and for patients.
Speaker: And actually, I think if more clinicians recognise that and the power that they do have to affect change, I think that's one thing that I've tried to take through with everything that I'm doing.
Speaker: Yeah.
Speaker: Perfect.
Speaker: And to close, is there something you would want every listener to know?
Speaker: Yeah, so I think following along with that theme, one of my favorite quotes is from Margaret Mead, where it's never doubt that a small group of thoughtful committed citizens can change a world, because indeed, it's the only thing that ever has.
Speaker: I think that's a perfect place to stop, especially these days.
Speaker: And I guess I really want to thank you for first putting out a wonderful guideline that addresses a very important aspect of our practice that is evolving very rapidly and fills a very important gap, obviously.
Speaker: And also, we just want to thank you for sharing your time, your expertise with us and hope to have you back on the podcast soon.
Speaker: Thank you so much for having me.
Speaker: Very grateful.
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.
