This month we are honored to have Neville Vlok on the show.  Neville has been one of the key physicians pushing for ECPR in South Africa.  In this episode, we explore what medicine and resuscitation looks like in South Africa, how ECMO has been utilized, and whether ECMO even makes sense in developing countries. 

Vlok N, Hedding KA, Van Dyk MA. Saved by the pump: Two successful resuscitations utilising emergency department-initiated extracorporeal cardiopulmonary resuscitation in South Africa. S Afr Med J. 2021 Mar 2;111(3):208-210. doi: 10.7196/SAMJ.2021.v111i3.15366. PMID: 33944740.

Using ECMO for traumatic patients has had some promising papers through the years, but the data overall is still poor.  Justyna Swol has teamed up with ELSO to improve this deficiency by making a trauma carve out of the ELSO registry.  In this episode, Zack discusses with Justyna the many facets of ECMO in trauma.  A few pearls and references are below:

Anticoagulation in ECMO is not mandatory.  A reasonable strategy is heparinized circuit with a titrating dose of systemic heparin as necessary in the trauma patient.  This includes everyone from isolated pulmonary contusions to intracranial hemorrhage.

VV-ECMO similar to ARDS in medical causes can be used and likely offers survival benefit to those patients with post traumatic lung injury.  Initiating early (maybe PaO2 of 80 on 100% FiO2) is likely best.

ECPR can be done in the traumatic arrest.  Best when done in parallel to the other resuscitative needs of the patient.  Data is promising in case series.  Need for bigger data sets is clear.

The Netherlands has undertaken a monumental task: provide ECPR to 100% of their country.  Dinis Reis Miranda and his team have put in place an unbelievably organized and robust project to improve the survival from cardiac arrest for their entire country.  Listen to Dinis explain about the project, their struggles, and this world changing experiment going on right now in Netherlands.

Here is their projects website and some of its content - https://onscenetrial.com/

In this short episode, Zack makes two points.  One, it was tough to get to where we are with ECMO acceptance.  Two, cardiac arrest patients in PEA should be considered for ECPR.  Below is the full editorial Zack and Alice did recently in the Journal of Resuscitation on the topic.  It was born out of a fantastic German article centered looking at registry outcomes for PE and ECMO.

Full Free Link to Editorial (until January 2022) - https://authors.elsevier.com/a/1eAXK_6ryqqpRd

Article link - https://www.resuscitationjournal.com/article/S0300-9572(21)00403-2/fulltext

Have you ever pondered whether all the work over ECPR was worth it?  Even if you did save a few patients, does this really make sense from a societal standpoint?  Am I giving up my life on a project where my efforts could be better elsewhere?  Then this episode is for you (and me).  This month I talk with Melissa Barnes and Ryan Coute about the economics of cardiac arrest and specifically ECPR.  Ryan has just published a great paper in Resuscitation on the costs on OHCA.  We will talk with Ryan and Melissa Barnes, ECMO manager at Sharp Memorial Hospital about benefits and costs to society of OHCA and ECMO.  I learned several pearls from Ryan's paper as well as a paper by Grosse that Ryan references.  Below are the links to both papers with a couple graphs to try to wrap your head around.

Here is the conclusion for the interview of Jan Belohlavek and his Hyperinvasive Trial

Wait...ECPR works?

To the believers, this has been a foregone conclusion.  To the rest of the world, the question of whether ECPR improves cardiac arrest survivorship has been in question. Jan Belohlavek and his Prague colleagues just presented their 8 year data showing better outcomes in cardiac arrest patients that got a grouped therapy of early transport, prehospital hypothermia, mechanical chest compressions, and ECMO over those who got a traditional resuscitation.  This study is key and contrasts to the Oslo study that we reviewed just a few months earlier.  Jan speaks with Zack about the details of the results and what were the keys to their success.

Hyperinvasive trial study proposal - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492121/

Jan's slides on Hyperinvasive Results

Heparin has been the mainstay of anticoagulation for ECMO patients for years.  In recent years, this has been challenged.  Bivalirudin has b

ecome a potential better anticoagulant.  Troy Seelhammer in EDECMO episode 55 gave us some insight into this.  This month Ryan Rivosecchi and his crew at UPitt have released their findings in Critical Care Medicine.  This retrospective study suggests great improvement in major bleeding in patients who received Bivalirudin compare to Heparin (40.7% vs 11.7%, p < 0.001).  Listen to Ryan and Zack discuss anticoagulant use in ECMO patients in this month's episode.

Rivosecchi RM, Arakelians AR, Ryan J, Murray H, Padmanabhan R, Gomez H, Phillips D, Sciortino C, Arlia P, Freeman D, Sappington PL, Sanchez PG. Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin. Crit Care Med. 2021 Mar 15. doi: 10.1097/CCM.0000000000004944. Epub ahead of print. PMID: 33711003.

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In this episode, we dive into the abyss of resource allocation.  Much of the world is saying that the limited number of ECMO circuits should be used for COVID induced lung injury.  This means that ECPR initiatives have been shut down or severely limited.  Is this the right thing to do?  What does the data say?  What strategy gives the most benefit to the most people?  Zack invited Brian Grunau to discuss these topics as well as a recent ECPR paper out of Norway and study dealing with signs of life during CPR.

In this episode Joe Bellezzo talks with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) expert Zaf Qasim about NON-TRAUMA applications of aortic compression for control of non-compressible non-trauma torso hemorrhage.