Episode 9 - The rEVOLUTION of ECMO

What are the indications for ECMO beyond ARDS and refractory cardiogenic shock? In which patients should we consider eCPR and is this the new standard of care for patients sustaining out-of-hospital cardiac arrest? Finally, how do I work towards safely and efficiently weaning my patient from VV or VA ECMO?  These are just a few of the questions that we address on Rounds with our guest faculty member and Director of the UCLA Adult ECMO Program, Dr. Peyman Benharash. In this comprehensive review of ECMO we also explore the regionalization of ECMO care here in Los Angeles County, as well as the day-to-day considerations that you want to bear in mind when assessing and caring for your patients requiring extracorporeal life support. Learning Objectives

By the end of rounds you should be able to: 1. Understand the indications & contraindications to VV and VA ECMO support 2. Describe the basic components of an ECMO circuit 3. Describe the role of eCPR in the management of adult patients with out-of-hospital cardiac arrest 4. Discuss key management strategies to safely wean patients from ECMO 5. Describe common complications of ECMO and strategies to mitigate them Take Home PointsECMO is time-sensitive, therefore, early and safe cannulation is an important determinant of outcomeECMO is a bridge to therapyUse of scoring systems like the Murray Score may be useful to stratify the severity of ARDS among patients being considered for VV ECMO supportThe indications for ECMO are expanding to include technically challenging operative caseseCPR is a promising therapy for patients presenting to an ECMO center of excellence with refractory VF/VT cardiac arrest ECMO therapy, particularly VA ECMO, may affect virtually organ systemThe potential role of ECMO therapy during the current COVID-19 pandemic remains to be definedTime Stamps00:12 Introduction01:16 Overview of Rounds 02:13 The rise of ECMO 02:46 CESAR & EOLIA trials summarized 05:40 Venovenous (VV) vs. Venoarterial (VA) ECMO08:24 How to decide whether or not to place a patient on VA ECMO?   10:33 Timing & indications for ECMO support11:38 Murray Score explained12:24 Contraindications & patient selection for VV & VA ECMO13:56 Expanding indications for ECMO15:23 ECMO in the Setting of Trauma: Pneumonectomy & Retrohepatic IVC injuries17:45 Regionalization of ECMO in Los Angeles County21:52 Who should be cannulating?23:22 Approach to cannulation24:50 Distal perfusion catheters for VA ECMO26:10 Differences between VV & VA ECMO28:24 The W5H of eCPR34:26 Considerations for access for VV ECMO35:53 Avalon catheter 37:51 VV versus VA ECMO circuits/set-up explained43:30 Getting your patient off of ECMO & other key considerations48:56 Vasopressor & inotropic therapy during VA ECMO50:31 Virchow’s triad,  antithrombotic therapy & bleeding on ECMO54:30 AKI, end-organ dysfunction & the daily assessment of patients on ECMO57:22 ECMO 2.0 & the role of evolving technologies61:20 Role of ECMO during the COVID-19 pandemic 66:45 Take-home points68:38 Outro

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