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Crashing to ECMO with Mohsin Zaidi · Style Points

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Hello anesthesia enthusiasts and welcome to this month's episode of Style Points.
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Today we are going to talk about an essential but very intense aspect of critical care.
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It's the go-to when everything else has failed.
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That's right, we're talking about ECMO with one of our most experienced ECMO specialists,
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Dr. Mohsen Zedi.
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Before that, I'll turn it over to Nate Moore, who will introduce this month's RSI.
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Thank you, John.
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I'm excited to introduce Dr. Lauren Brown, one of our interns to the show.
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Lauren told me that one of her defining characteristics is that she loves sleep, which is perfect
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because she will be teaching us about obstructive sleep apnea.
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Welcome Lauren.
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Thanks Nate.
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Today I will be discussing obstructive sleep apnea, aka OSA, and its implications for anesthesia
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management.
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So first of all, what is OSA?
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Imagine trying to breathe through a straw that keeps collapsing every few seconds.
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That's what happens to patients with OSA during sleep.
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Their upper airway repeatedly obstructs, leading to interrupted breathing, oxygen desaturation,
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and increased cardiovascular strain.
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Let's talk about pathophysiology.
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OSA occurs when the negative airway pressure that develops during inspiration is greater
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than the muscular distending pressure, thereby causing airway collapse.
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Additionally, during sleep, laryngeal muscle tone is decreased and apnea can occur when
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the upper airway collapses.
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Obstruction can occur throughout the upper airway, whether above, below, or at the level
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of the uvula.
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Because there is an inverse relationship between obesity and pharyngeal area, the smaller size
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of the upper airway and pharyngeal area in the obese patient causes a more negative
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pressure to develop for the same inspiratory flow, increasing the risk of obstruction and
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apnea.
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OSA is increasingly common, especially with rising obesity rates.
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Nearly a third of U.S. adults aged 30 to 69 have some form of sleep-disordered breathing,
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with 15% having moderate to severe OSA.
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OSA is undiagnosed in an estimated 80% of patients.
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The gold standard for diagnosing OSA is polysomnography, better known as a sleep study, in which a
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patient's breathing is monitored for episodes of obstructive respiratory events.
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The three events we're looking for are apneas, hypopneas, and respiratory effort-related
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arousals.
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Apnea is defined as a complete cessation of breathing for 10 seconds or more.
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Hypopnea is a little bit more complicated.
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It's defined as a 30% or greater reduction in airflow for at least 10 seconds, combined
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with either a decrease in oxygen saturation by at least 3% or arousal from sleep.
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A respiratory effort-related arousal is simply any breathing-related awakening from sleep
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that doesn't meet the criteria for a hypopnea.
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If your sleep study shows at least 15 obstructive respiratory events per hour of sleep, you get
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a diagnosis of OSA.
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You can also receive the diagnosis with only 5 obstructive respiratory events per hour,
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but only if you have OSA symptoms, such as snoring or daytime sleepiness.
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Once someone has a diagnosis of OSA, it's helpful to be able to say how severe their
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OSA is.
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Severity is usually estimated using the Apnea-Hypopnea Index, or AHAI, which is calculated as the
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combined number of apneas and hypopneas observed during a sleep study, divided by the number
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of hours of sleep observed, giving a rate of events per hour.
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OSA is traditionally classified as being mild, moderate, or severe, depending on the AHAI.
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So mild would be anywhere from 5 to 14 events per hour, moderate would be 15 to 30 events
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per hour, and then severe would be greater than 30 events per hour.
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Treatment for OSA generally involves the use of positive airway pressure devices, such
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as a CPAP or BiPAP while sleeping.
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We'll leave the details to our sleep medicine colleagues, but just know that patients with
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an AHAI greater than 15 will generally be started on a CPAP or alternative PAP device.
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If the lack of detail starts keeping you up at night, then you may need to consider doing
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a sleep medicine fellowship.
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Anesthesiologists are eligible for it, or you may have OSA.
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Several OSA screening questionnaires exist.
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There's some controversy over their use, but suffice it to say they should only be used
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for patients with OSA symptoms.
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They are not effective as screening tools for asymptomatic patients.
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Perhaps the most popular OSA screening tool is the Stop Bang Questionnaire, where each
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of the eight letters in Stop Bang refers to a yes or no characteristic related to OSA.
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S is for snoring loudly.
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T is for tiredness during the day.
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O is for observed episodes of choking, gasping for air while sleeping.
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P is for pressure, that is high blood pressure.
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B is for a BMI greater than 35.
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A is for an age greater than 50.
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N is for neck size, typically greater than 16 inches.
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G is for gender of male.
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A score of three or higher indicates an intermediate to high risk of OSA, with higher scores indicating
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a higher risk of severe OSA.
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Now that we know who has OSA, let's talk about what we should do to take care of them
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perioperatively.
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OSA increases the risk of difficult airway management, post-operative respiratory depression,
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as well as cardiovascular instability.
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Preoperative evaluation aims to identify airway difficulties and potential cardiovascular
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complications from OSA.
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Chronic exposure to intermittent hypoxia and hypercarbic events while sleeping causes
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systemic hypertension and pulmonary hypertension.
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And the presence of pulmonary hypertension is particularly concerning, as it can lead
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to right-sided heart failure, which is difficult to treat as well as manage.
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It's reasonable to ask your patients about their level of adherence to their PAP therapy.
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If poorly adherent, they are likely at a higher risk of having cardiovascular comorbidities.
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Higher airway abnormalities and increased airway adiposity in patients with OSA predisposes
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them to be difficult to mass-ventilate after induction for general anesthesia, and oral
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and nasopharyngeal airways should be readily available.
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Excessive pharyngeal adipose tissue can make exposure of the glottic opening difficult
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during direct laryngoscopy or endotracheal intubation.
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OSA can be even more of a challenge when performing sedation or monitoring anesthesia care due
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to the combination of an unprotected airway with the potential for severe sedation-induced
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airway obstruction.
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Nasopharyngeal or even oropharyngeal airways may be the key to maintaining acceptable ventilation,
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in addition to upgrading the usual nasal cannula to a face mask or even high-flow nasal oxygen,
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depending on the severity of OSA and the specific facial anatomy of your patient.
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OSA patients are highly sensitive to respiratory depressants like benzos and opioids.
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strategies to minimize complications include using regional or local anesthesia when possible,
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which may allow you to avoid sedatives entirely, extubating patients in a semi-upright position,
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using short active anesthetics such as SIVO and PROPE and multimodal non-opioid analgesia,
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avoiding nitrous oxide in patients with pulmonary hypertension, as nitrous can cause pulmonary
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vascular constriction, and then also employing supplemental oxygen and a small amount of
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PEEP post-extubation.
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Now that you've successfully gotten your patient through their anesthetic, it's time to think
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about their post-op care.
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OSA patients require close monitoring for post-anesthetic hypoxemia and respiratory
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complications.
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Best practices include positioning strategies to reduce apnea severity, shoving a pillow
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underneath the patient's shoulder blades can help relieve an obstruction by increasing
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their upper neck extension.
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Additionally, elevating a patient's head or even placing them in a side sleeping position
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may help with ventilation.
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The use of non-opioid adjuncts such as NSAIDs, acetaminophen, tramadol, or regional anesthesia
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can minimize opioid requirements, and then encouraging CPAP use post-operatively.
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While there's mixed evidence for routinely doing this, it's likely beneficial for patients
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with OSA diagnosis that are already adherent to their CPAP use at home.
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As you can see, there are numerous considerations when caring for patients with OSA.
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Identification of at-risk patients and tailoring anesthesia plans to their condition can significantly
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improve outcomes, and it's definitely a diagnosis you want to be aware of before you start an
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anesthetic.
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Mohsen Zeddy is an assistant, soon to be associate professor of anesthesiology at the University
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of Cincinnati.
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He did a fellowship in critical care.
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In addition to his many certifications and general expertise, he's been an invited speaker
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to discuss ECMO at the national ELSO meeting in 2024, and he's a faculty instructor who
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has taught multiple two-day courses in ECMO management around the country.
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Thanks for coming on the show.
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Thank you for having me.
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So Mohsen, what originally brought you to studying ECMO, learning more about ECMO?
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What's your journey been like for that?
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Well, my first introduction to ECMO was during residency at University of Michigan, and then
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subsequently into fellowship, and I found the technology to be very interesting from
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a scientific standpoint, and what it does.
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But really the implications of it and what it allows us to do for patients that was never
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allowed before really just intrigued me, and so I got more interested in it, would read
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more and more papers on it and literature, and spoke to experts, and really just it became
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one of my passions.
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And then when I got into practice, I joined the extracorporeal life support organization
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ELSO, which is the national or truly international body that comes up the guidelines for ECMO,
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does a lot of research for ECMO, maintains a registry of all patients who've ever been
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on ECMO, provided the hospitals submit that information, and I joined them to learn more
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about ECMO, and then as you mentioned, now actually instruct and teach other physicians,
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nurses, perfusionists, et cetera, on ECMO management.
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So how big of a part of your day is ECMO management?
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Is that something you do every day, every week?
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What kind of scenarios are you utilizing your skill set?
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So as you mentioned, I do both anesthesiology and critical care.
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So when I am up in the intensive care unit, our critical care team here manages cardiovascular
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ICU, which at UC is the primary location for all ECMO patients.
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We inevitably have one ECMO patient at least every time I'm on service on average.
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I would say one to three is pretty typical.
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We do go through some spurts where we don't have anyone on ECMO, which I suppose is a
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good thing that patients aren't needing it, but we are fairly, a relatively busy program
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and usually one to three.
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So when I am in the ICU, there's usually an ECMO patient on the circuit.
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So let me ask you, just backing up to one of my favorite get to know you questions,
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if you could invite anyone in the world over for dinner, it could be somebody from the
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past or from fiction, who are you going to have over?
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Now I remember you mentioned you'd have to think about this.
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So I'm curious what you've come up with.
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You know, I came up with an unorthodox answer and it's truly who I'd want to speak to.
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And that's my younger self.
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I would want to speak to them, to my younger self and just not necessarily change things
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because I'm not someone that tries to, you know, reshape the past or live with regret,
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mostly to remind me to enjoy some of the things that maybe I didn't enjoy as much when I was
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younger, knowing what I do now and, you know, this profession that we're all in or about
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to join, you know, it's a commitment and it takes a lot of time and sacrifice of, you
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know, time or of experiences.
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And you know, I don't regret any of that.
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But I would have, I would remind my younger self to make sure and enjoy some of the other
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things life has to offer before embarking on this journey.
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What age would you want to meet yourself or at what point in your life?
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I think I would say probably junior high or freshman year of high school.
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Oh, wow.
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Yeah.
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Yeah.
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That'd be very interesting.
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I have thought about this a lot myself.
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One of the lectures that I give to medical students is it's called What I Wish Somebody
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Would Have Told Me.
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So I have thought the same thing, that it would be really nice to go back and tell my
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younger self some of these things too.
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So I'm with you there.
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That's a really neat answer.
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I've been asking this question for many years and people, I've never gotten that answer
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before.
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So that's pretty cool.
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Thank you.
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So could you start by backing up and telling us a little bit more about ECMO?
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So what did you see the first time that you experienced ECMO and what got you so interested?
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Well, I remember seeing just someone on ECMO, you see these gigantic tubes of a patient's
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blood being removed from the body, spun through the circuit and through the specialized device
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that really is at the heart of the ECMO circuit, which is the oxygenator where gas exchange
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takes place and put back into a patient.
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I'd never quite seen anything like that.
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This was prior to doing even my cardiac anesthesia rotation where you at least see bypass.
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But ECMO is not strictly cardiac bypass.
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It's a modified version of that.
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And I think what really struck me was seeing an awake patient on ECMO because that was
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something I didn't even fathom as something possible that you can be wide awake on ECMO.
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And this was I think my intern year if I remember correctly because we did a lot of ICU rotations
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in our intern year in my residency.
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And that really just the cool factor.
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And yeah, that really just sold me on it.
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So what does ECMO do?
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Why would somebody be on ECMO?
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Tell me more about it.
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So in general, and I'll talk about the two types of ECMO in just a minute, but the essence
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of ECMO is you remove the patient's blood from their body.
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It's through a pump, usually a centrifugal pump, and it passes through a device called
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an oxygenator where oxygen is pumped in, it diffuses into the blood, carbon dioxide is
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removed from the blood by the same device, then the reoxygenated blood is put back into
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the patient.
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And that gets into the types of ECMO.
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There's ECMO for cardiac support and there's ECMO for strictly lung support or respiratory
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support.
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And so if someone is in acute respiratory failure, refractory to all the normal things
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that we usually do like mechanical ventilation, other things that have been shown to help
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like proning a patient or paralyzing a patient, if none of these things help and you're on
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very, very dangerous settings on your mechanical ventilator, we're essentially causing more
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damage to the patient at that point than we're helping.
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And so ECMO will allow that patient to be on safer mechanical ventilation settings or
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even no mechanical ventilation, and it will take over the function of the lungs.
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And so in that case, this is called V-no-V-ness ECMO or V-V ECMO.
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You take blood out of a vein, usually the inferior vena cava, pump it through the oxygenator.
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It reoxygenates the blood, which the patient's lung is currently not doing because it's so
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sick.
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It removes carbon dioxide and then it pumps the blood back into the venous system.
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And the patient's native cardiac output distributes that reoxygenated blood everywhere.
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So the V-V ECMO then is the one for the patients whose heart is working just fine.
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Correct.
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Correct.
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Correct cardiac support is solely to take the function of the patient's native lung
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over.
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That makes sense.
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V-A ECMO, V-no-arterial ECMO is the one that supports the heart and by definition also
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supports the lung.
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So in this case, blood is drained out from the venous system just like in V-V ECMO, but
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after it passes through the oxygenator, it's reinjected into the aorta or some sort of
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major artery, like the femoral artery.
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And that allows complete bypass of the patient's native cardiac cycle and it takes over the
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function of the heart to an extent.
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And there's some nuances to that, but in general if your heart is very poor, whether your lungs
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work or not, you will be placed on V-A ECMO and it would take over the function of the
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heart temporarily.
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Okay.
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So V-V ECMO for lungs, V-A ECMO for heart.
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That's correct.
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Which one is harder to manage?
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That's a good question.
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It really is patient dependent.
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I would say V-A ECMO, if you're on V-A ECMO, you're generally sicker just by the definition
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that your heart's not working well and frequently that means the lungs aren't working at least
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for a while.
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So I would say if I had to pick between the two, in general V-A ECMO patients are harder
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to manage.
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There are some V-V ECMO patients who just were very, very sick and certainly COVID comes
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up when I think of that.
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If you ask me what some of my sickest patients were, they were COVID patients who were just
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on V-V ECMO whose hearts were actually working okay, but their lungs were so sick and other
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organs also were so sick that they were very, very difficult to manage because of how profoundly
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sick the COVID virus made them.
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So what makes it so hard in COVID for example?
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So in the COVID population what we found was it was very hard to support a patient's oxygen
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needs at the standard settings for ECMO, for V-V ECMO.
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And so the way ECMO works, there's a certain flow speed.
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And so with V-V ECMO, the blood that's directed into the circuit is a fraction of the patient's
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native venous return or the cardiac output, which are one in the same as far as volume
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and flow.
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So the more you flow into the ECMO circuit, the greater percentage of venous return is
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oxygenated.
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So you and me right now, we have normal lungs hopefully.
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And all our venous return goes through our lungs, it's oxygenated, the carbon dioxide
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diffuses out and it goes back, it goes into our heart, into our left side of our heart
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and out to the body.
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When you're on V-V ECMO and you assume that the native lungs are so sick that they're
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not contributing to gas exchange at all, the ECMO circuit is doing all the work.
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But you can't take the entire venous return out of the body at once to oxygenate it.
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So you get as close as you can.
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But there's technical considerations, you know, the pump itself can only pump so fast.
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And so what we found in the COVID patients is their oxygenation needs were so great,
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not only because their lungs weren't working, but also the COVID seemed to just cause a
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profound decrease in oxygen, sorry, increase in oxygen needs.
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We just couldn't meet those some patients and it was very, very tough to maintain oxygenation.
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Whereas in a non-COVID patient with acute respiratory distress syndrome, usually we
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don't have that problem.
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That makes sense.
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I remember dealing with a lot of ECMO patients during COVID.
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I remember being all geared up and gowned up and having the full respirator face mask
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and doing some of the COVID tricks that we did in the ICU for some of these patients
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that were on ECMO support.
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And that's a time that I remember very well, but not necessarily fondly.
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I 100% agree.
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It was a fraught time for a lot of critical care professionals everywhere.
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And particularly when there were more patients that needed ECMO or where ECMO could have
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helped patients and we just didn't have enough.
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When I say we, across the country, not just here.
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And that was a very fraught time for all of us, certainly emotionally.
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So COVID isn't the only thing that makes us put people on ECMO, certainly.
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I wonder if you could paint a scenario for VV in a standard patient and a scenario for
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VA in a standard patient.
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So yeah, VV, the most common use of VV ECMO is for ARDS or acute respiratory distress syndrome.
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Now there are many causes of ARDS.
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The most common is either a viral or a bacterial infection or pneumonia that leads to a profound
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inflammatory response in the body, particularly in the lungs.
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And the lungs become so inflamed, the alveoli fill with fluid, and gas exchange no longer
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occurs to a significant amount.
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And so we'll generally put those patients on mechanical ventilation, try to do what
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we can to support them and get them through that process.
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As you know, with viruses, you essentially have to let them run their course.
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We don't have too many antivirals.
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If you have a bacterial pneumonia, you treat it.
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But if that doesn't work and you're using, again, as I mentioned, dangerous levels of
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mechanical ventilation, then we'll consider a patient for ECMO.
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And that will allow us to support their oxygen, the oxygenation and ventilation while allowing
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us to decrease the ventilator settings that potentially is causing more damage.
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So causes of ARDS other than viral and bacterial pneumonia, trauma can do it.
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Even if there's not an injury to the lungs, just the massive inflammatory response of
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the body could affect just the lungs.
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Some burn patients have that effect, either from an inhalational injury or again, the
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massive inflammatory response.
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But by far and away, ARDS is usually from bacterial or viral pneumonia or some other
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infection that leads to it.
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What about for VA?
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So for VA ECMO, cardiogenic shock is the number one diagnosis for needing VA ECMO.
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Again, many reasons to have cardiogenic shock.
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There's ischemic cardiomyopathy where if you have a very large heart attack, very large
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area of the myocardium is infarcted, the heart muscle is just weak and it's so weak that
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it can't pump effectively.
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And then there's certainly non-ischemic cardiomyopathy where, for instance, a viral myocarditis might
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cause a profound decrease in the injection fraction.
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Normal 60 to 65%, it may drop to 5 to 10%, which in some patients is just not enough
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to perfuse their body.
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And so they'll come into the hospital and we'll see that and they are diagnosed with
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cardiogenic shock, meaning a shock state caused by the decrease in function of the heart itself
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as opposed to septic shock or other types of distributive shock or hypovolemic shock.
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In that case, there are medications you can put them on like inotropes to try to kick
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start the heart and make it pump a little harder.
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But those have their side effects and sometimes they just don't work well enough.
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And so we would put a patient on ECMO to support their heart, take over the function of their
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heart.
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The other kind of a subset of VA ECMO that we do here, not every place that does VA ECMO
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does this, but there's the idea of eCPR or extracorporeal cardiopulmonary resuscitation.
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And that is a patient who is actually arresting.
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So I mean, there's cardiogenic shock, but the heart's still beating.
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And then there's pure cardiac arrest, you know, a V-fib or a V-tach arrest.
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And they've been, you know, ACLS is initiated.
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We're doing CPR.
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We're giving epinephrine.
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We're giving all the, you know, we're trying to shock them out of it.
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And if it's refractory, which is generally in the literature defined as about 10 minutes,
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we might put them on ECMO emergently and essentially have ECMO take over the function of their
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heart while we're trying to restart the native cardiac function.
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I have been on a few of those crash under ECMO cases and eCPR.
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It's usually pretty exciting.
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It is exciting.
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And this is certainly one word to describe it.
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You know, as you know, John, codes are often controlled chaos and eCPR is no different.
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But it's very nice that we have that program here because it's different than just having
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a quote unquote plain old VA ECMO program.
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It takes more infrastructure.
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The way eCPR works here and in many other cities is if somebody were to have an out
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of hospital arrest, we actually liaise with the city or the local EMS or the fire department.
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In this case, Cincinnati Fire Department, you know, liaises with us and we have given
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them criteria saying if they respond to a cardiac arrest in the community around our
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hospital and certain criteria are met and those criteria include the type of rhythm
24:47
like a VTAC or VFib, age of the patient, etc.
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They are to get them to the hospital as quickly as possible, not just do ACLS in the field,
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just to get them on into the ambulance, put a mechanical device that will do CPR for them
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and bring them here as quickly as possible so that we can potentially put them on ECMO
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as quickly as possible.
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And time is of the essence as with any cardiac arrest.
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So we've we've said put them on ECMO a bunch of times.
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You've gotten the call.
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You need to go put someone at ECMO.
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What does that look like?
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How do you what are the steps?
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How does that happen?
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So to put someone on ECMO is the term we use is cannulation.
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And so they will come into usually the hybrid room or the cath lab, some sort of operating
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suite or procedures suite that has imaging, in this case, fluoroscopy to help the cannulators
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put the large devices in where they should go.
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And so the first generally in the case of let's say VA ECMO or and or ECPR will go in
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the groin and cannulate the femoral vein on one side and the femoral artery on the other.
25:59
And that's pretty typical.
26:01
And in VV ECMO, you could do that as well.
26:03
But with both veins, VV ECMO can also be the drainage cannula in the groin and the return
26:10
cannula in the internal jugular.
26:13
There's different cannulation strategies.
26:15
But in general, we'll talk about fem fem.
26:17
So for VA ECMO, they will clean off the sterilized groin with, you know, chlorhexidine.
26:24
They'll stick a needle in selling their technique like what we use all the time for central
26:29
lines, they will access the artery usually under ultrasound guidance, they'll access
26:34
the vein on the other side.
26:36
Once they get a wire in there, then it's a series of dilations similar to what we do
26:40
for a triple lumen or a maccortis or a trialysis line or similar device.
26:45
However, these devices are much bigger.
26:48
So your standard maccortis is about nine French, your trialysis line for temporary hematology
26:53
is 13 French.
26:55
An arterial cannula for an adult is usually 17 to 21 French, sometimes even larger.
27:01
And a venous cannula for ECMO in an adult is anywhere from 23 to 32 French.
27:08
So these are gigantic cannulas, you know, not much larger than the standard stuff we
27:13
put in.
27:14
And so once they access as a wires in, you dilate up to these massive sizes, and then
27:19
you put the cannula in.
27:20
And then under fluoroscopy guidance, or you can also use transesophageal echo, if that's
27:26
available instead, the cannula, the tip of the cannulas are inserted up to a certain
27:32
point and you know, depending on what kind of cannula and what we're using, usually the
27:37
venous cannula gets up to the cavoatrial junction, the arterial cannula will be put in the femoral
27:42
and usually, we just want to make sure it's, you know, flowing into the aorta right.
27:48
And then once those are in, you will then hook them up to the circuit, start drawing
27:52
blood out the venous and you're on ECMO at that point once you're on full flow.
27:57
The circuit is usually primed with saline.
28:01
In children, we might prime it with blood, but we generally don't do that with adults.
28:05
And then, you know, obviously heparin is given prior to putting in these large cannulas because
28:11
you don't want the circuit to clot.
28:13
Less doses, or a smaller dose than what we give for cardiopulmonary bypass, but usually
28:18
about 10,000 units IV heparin is usually given just prior.
28:23
So why would the blood clot?
28:25
Well, you know, anytime blood is in contact with a non-organic surface, there's a risk
28:30
of clotting.
28:31
So I can tell you the modern ECMO circuit is such that the tubing and most of the components
28:38
are coated with an anticoagulant proprietary coating to help prevent this.
28:44
That being said, if clot were to form, particularly within the circuit, it could cause obstruction
28:49
of the circuit.
28:50
And just like an obstructive shock in the body, if your circuit is obstructed by a thrombus,
28:55
it will not work and you won't be able to flow adequately and it would be as if you're
28:58
not on ECMO.
28:59
So in the worst case scenarios, it stops the circuit completely and you just can't flow
29:02
at all, which is a true emergency.
29:05
So I've got to ask, what do you do in the case where it's not a PE, it's not a heart
29:11
attack, but your ECMO machine is becoming infarcted?
29:14
What kinds of steps do you take there?
29:16
So that's an emergency.
29:19
And if we see if it's a catastrophic obstruction from clot, we actually have to switch out
29:24
the ECMO circuit.
29:26
And the way we do that, we leave the cannulas in because switching those out is not really
29:30
practical, particularly when speed is of the essence.
29:34
And so we will clamp off the circuit on both sides of the circuit, whether you're VV or
29:39
you're VA, we'll then cut the tubing and bring in a new circuit that's primed and reconnect
29:45
them with special connectors.
29:47
So it's essentially an entire change out of the circuit except for the cannulas.
29:51
And while that sounds very complicated, and it truly is, it's actually the fastest way
29:56
to get someone back on the circuit rather than try to clean out the clot or certainly
30:01
to replace the cannulas.
30:04
So that sounds really scary and dangerous, obviously.
30:08
What are some other things that can go wrong with ECMO that you have to watch out for?
30:13
Well, so I mentioned heparin or some similar anticoagulant is used during cannulation.
30:19
Part of care is still to also run some sort of anticoagulant while you're on ECMO, again,
30:25
to prevent this clotting phenomenon.
30:28
And so anytime you're on a blood thinner, whether it's heparin or bivalorutin, et cetera,
30:33
you are on the risk of bleeding.
30:34
And so other than clotting, bleeding is the other most common complication on ECMO.
30:39
And bleeding doesn't have to happen where you put the ECMO cannulas in, although that
30:43
certainly does occur.
30:45
Sometimes you just start having gastrointestinal bleeding or whether it's upper or lower or
30:51
uterine bleeding or just oozing from other sites of the other equipment, like central
30:57
lines, et cetera.
30:58
And that's a problem.
30:59
And then it becomes even more of an issue if the patient needs some sort of surgery
31:04
or procedure done while on ECMO, which does occur.
31:09
And that's where we really run into problems with bleeding.
31:12
And so we may have to pause anticoagulation at that point.
31:15
There are some centers that have started running patients on ECMO without any anticoagulation
31:21
after the initial bolus.
31:23
And while that's currently not standard of care, more and more emerging research suggests
31:28
that that may be safe to do.
31:31
Since they're using some of that proprietary coding to prevent the clotting.
31:35
That's correct.
31:36
Yes.
31:37
The ECMO circuits back in the 90s and before did not have this proprietary coding or it
31:45
certainly wasn't as good back then.
31:47
And a lot of the early data on ECMO was very negative.
31:51
And it was mostly because of bleeding complications.
31:54
And that thankfully, through innovation on the biotech side, they've really gotten these
32:00
circuits to the point where they don't clot off like they used to.
32:04
And therefore, you can get away with running lesser amounts of systemic anticoagulation
32:09
or as I mentioned, some places particularly for VV ECMO don't run anticoagulation as standard.
32:15
So let's say for an anesthesia resident who hasn't managed one of these patients before,
32:22
you learn maybe the day before that you are going to be doing some sort of procedure on
32:27
one of these ECMO patients.
32:29
What kind of advice would you give them?
32:31
What would you tell them to keep in mind for these ECMO patients?
32:35
What to do?
32:36
How to manage it?
32:37
What comes to your mind?
32:40
So the first thing you want to figure out is what type of ECMO support they're on.
32:45
And because you're going to manage the patient differently.
32:47
So if they're on VV ECMO and their heart's otherwise working okay, that gives you some
32:52
good information on what you're going to have to manage versus if they're on VA ECMO and
32:57
essentially the ECMO circuit is taking over their heart and lung function at that point.
33:02
So once you figure that out, you need to, you know, as with any ICU patient, see what
33:07
drips they're on, your sedatives, etc.
33:09
You know, if they're still intubated, which they normally are, but there are going to
33:14
be some patients that are extubated who are on ECMO.
33:16
But assuming they're intubated, you can still, you know, quote unquote plug and play and
33:21
bring them when you bring them down, plan to hook them up to your anesthesia machine.
33:25
You can still deliver anesthetic agents and inhaled agents through the tube and it will
33:30
still anesthetize them even if some of that is diverted through the circuit.
33:33
It doesn't, it doesn't affect, you know, it's a, it's a clinical effect.
33:38
So when you're talking about the actual sedation plan, that should still be the case.
33:42
If they're on IV sedation, that's also okay, which is what we use in the ICU.
33:46
You know, if they're on propofol, etc.
33:48
All that's okay to use.
33:49
There's really no restrictions on that.
33:50
When you're talking about management.
33:52
So if they're on any kind of ECMO, as I said, their, their oxygenation ventilation is being
33:57
taken care of by the ECMO circuit, whether that's VV or VA.
34:01
And so I think it's important to realize a couple of things that you'll see when you
34:05
hook up a patient to our, to your anesthesia machine who's on ECMO.
34:09
The first thing you'll notice is because they're not using, we're not using their lungs, we're
34:12
using the ECMO oxygenator to be their lungs.
34:17
You'll notice their end title CO2 is very low and so low that if it were, if it were
34:21
that low on a normal patient, you should be calling for help.
34:24
We're talking about, you know, it might even be 10, but don't be alarmed because that's,
34:30
that's normal in a patient on any sort of ECMO where the circuit is doing the lung work
34:34
for them.
34:35
So the circuit is removing the carbon dioxide.
34:38
So there's less of the native lungs, less for the native lungs to breathe out.
34:41
So that's why you see a lower end title CO2.
34:45
If you run into hemodynamic issues, you know, and you're on VA ECMO, you have to realize
34:50
that while you can still give some medications, you know, like vasoconstrictors, because that,
34:55
you can still be vasodilated on ECMO and that could still cause hypotension.
34:58
You also have to communicate with the person running your ECMO circuit, which is usually
35:02
an ECMO specialist or perfusionist or nurse, and communicate with them that, hey, you know,
35:08
we're running into perhaps hypotension.
35:10
Can you, is there anything you can do on the ECMO circuit to help?
35:13
So it's going to, it's going to be a lot more communication because you have somebody else
35:16
managing the patient.
35:17
It's not just all you like we're used to.
35:19
Yeah, that makes a lot of sense.
35:21
It's tough taking things out of our hands, I suppose, we're kind of control freaks in
35:25
anesthesia.
35:26
Yes, very, very much so.
35:28
And it really is important to communicate with not just the perfusionist or whoever
35:34
is running your ECMO circuit, with your ICU team, with your surgeon about what might be
35:39
happening, certainly bleeding during surgery, you know, oftentimes, we will pause the anticoagulation,
35:47
as I mentioned previously, for bleeding or to prevent bleeding.
35:50
So let's say you need to have, you know, a section of bowel removed while on ECMO, which
35:54
has happened, you know, we'll usually hold the anticoagulation so that there's not a
35:59
ton of bleeding during surgery.
36:01
That being said, if the surgeon runs into bleeding, that is going to affect your ECMO
36:05
circuit just like it would have affected your patient if they had their native cardiac output
36:09
running.
36:11
And that's something to keep in mind that, you know, volume management is still something
36:15
to keep in mind on ECMO.
36:16
You still have to do volume management.
36:18
If you lose volume, you have to give it back because the pump will only pump what it's
36:22
given.
36:23
So if it's given less, it's going to pump less.
36:25
And so at a given volume, you have a certain flow rate, let's say four liters a minute.
36:30
If you have 500 of blood loss all of a sudden, that flow rate at the same speed of the pump
36:37
is going to go down.
36:38
And that means less support.
36:39
That's as if your patient's cardiac output is decreased.
36:42
So it's going to be less support for the patient.
36:44
That is still up to you, the anesthesia provider, to fix.
36:48
Yeah, that makes sense.
36:51
One thing that I used to have questions about before I finished my anesthesia residency
36:56
is I would see a patient on ECMO and I would wonder about just some of the general monitors
37:03
I would need.
37:04
Does every ECMO patient need an arterial line or does a blood pressure cuff work sometimes?
37:10
Can you help elucidate some of that for us?
37:12
For VV ECMO, as long as their heart's working okay, you technically don't need an arterial
37:18
line for hemodynamic monitoring.
37:20
I think most of us would feel better with one.
37:22
I think no one would fault you for having one.
37:25
But there are certainly places that run VV ECMO without an arterial line.
37:30
And that's not uncommon or to give someone a break from an arterial line, especially
37:34
if you're on VV ECMO for a long time.
37:37
Honestly for VV ECMO, the arterial line is less for hemodynamics and more to easily draw
37:42
arterial blood gases without having to sick the patient each time.
37:47
Now for VA ECMO, personally I can't imagine a scenario where I wouldn't have an arterial
37:52
line in such a patient.
37:54
And that's because an arterial line gives you a lot of information.
37:57
It gives you your real-time measurement of your mean arterial pressure, which is what
38:04
you generally titrate your ECMO flows to, again, on VA ECMO.
38:08
The other thing it does is it shows you pulsatility.
38:11
So the point of ECMO is to allow the native organ function to return.
38:17
It's to buy time.
38:18
It is not a cure.
38:19
Being on ECMO doesn't cure the lungs.
38:21
It buys time for the lungs to recover.
38:23
Being on ECMO, if your heart's not working well, buys time for your heart to recover.
38:28
Now the other side of that coin is it could also buy time for a transplant if you're a
38:34
candidate.
38:35
But that's a more fraught decision and there's a lot of criteria that has to be met.
38:38
But in general, ECMO is to buy time.
38:40
And so for an arterial line or the other purpose of an arterial line in VA ECMO is to see if
38:47
the heart is recovering.
38:48
And what you'll see is you might initially, when the heart's sick and not working very
38:53
well, you might see a relatively flat A-line tracing or maybe a very small deflection with
38:58
cardiac output.
38:59
As the heart gets stronger, while on ECMO, you'll start to see pulsatility come back
39:04
on your arterial line tracing.
39:05
And that's usually our first sign as the ECMO team that, oh, maybe the heart's starting
39:10
to recover from whatever insult caused the problem in the first place.
39:14
So it's very helpful for that.
39:15
Now for a procedure, going down into the OR or to a procedural suite, as an anesthesiologist,
39:21
I definitely want an arterial line for VA ECMO.
39:24
For VV, I think it would depend on the procedure.
39:26
I'd still feel better with one.
39:28
But just realize that an arterial line on VV ECMO, you're still measuring the cardiac
39:32
output of the native cardiac output.
39:35
So we talked about reasons why to put somebody on VA or VV, the heart's not working, the
39:41
lungs aren't working.
39:42
How do you make the decision to try to turn the ECMO off?
39:47
How does that work?
39:50
That's a very difficult decision sometimes.
39:53
Certainly if we see evidence of lung function or heart function return, we'll do trials
39:59
off ECMO.
40:00
And when I say off ECMO, it differs for VV versus VA.
40:04
So for VV ECMO, we will just stop the gas flow to the ECMO machine so that while the
40:12
blood still goes through the machine, nothing's actually happening.
40:16
No gas exchange is actually happening.
40:17
We're relying on the patient's lungs to do the work.
40:20
So we will turn off the gas flow to the ECMO circuit on VV ECMO but allow blood to still
40:26
come out and go back in, which doesn't actually affect much.
40:29
And we'll see how the patient does.
40:30
We'll see what their pulse ox shows, what arterial blood gas shows.
40:33
And we want to see if oxygenation and ventilation has returned to normal or close enough to
40:38
normal that we would feel comfortable coming off ECMO.
40:41
And so there's not too strict criteria.
40:44
There's some kind of algorithms we use to see if a patient's ready to come off VV ECMO.
40:50
With VA ECMO, it's a little tougher.
40:53
I mentioned earlier that even though it's for heart support, a lot of times a patient's
40:58
lungs aren't great either when they're in cardiogenic shock because as you know, with
41:01
cardiogenic shock, you can get pulmonary edema and a backup of fluid into the lungs.
41:07
And it's not uncommon for the heart to recover before the lungs do when that happens.
41:11
So with VA ECMO, we need to make sure the lungs are working and the heart's working.
41:16
And sometimes we'll do a trial where we turn down the flows on VA ECMO.
41:24
So therefore, less support is being offered by the circuit and more blood is returning
41:28
to the patient's heart.
41:29
And we'll see how the heart does.
41:30
Then we'll look at the arterial line and the map.
41:33
Does the map go up?
41:34
The mean arterial pressure.
41:36
If they have a Swan Gans catheter, we'll see if those numbers look good.
41:42
Often we'll do it under echo guidance, either a transthoracic echo or a transesophageal
41:46
echo and just look directly at the heart and just see how its function handles getting
41:49
more blood back to it rather than it going through the ECMO circuit.
41:54
And if you pass that criteria, you're decannulated.
41:57
In VV ECMO, they pull the cannulas out of the veins and hold pressure for a long time.
42:01
They usually do that at the bedside.
42:03
For VA ECMO, often the arterial cannula when it comes out needs to be, the artery needs
42:09
to be primarily repaired.
42:10
However, that's not always the case.
42:14
In the situations where a patient has been on ECMO for a while and you don't see evidence
42:19
of recovery, that gets really tricky.
42:23
You have to then think about, okay, is this patient a transplant candidate, whether it's
42:29
heart or lung?
42:31
And unfortunately, a lot of times they're not.
42:33
And that's because they get sick, just as part of their illness, other organs go bad,
42:38
particularly the kidneys.
42:40
And those things could preclude them from getting a transplant, at least at that time.
42:44
And again, ECMO is supposed to be temporary.
42:47
It's not meant to be long term.
42:48
The longer you're on ECMO, the more complications you accumulate.
42:52
And so at some point, we have to have very difficult conversations with a patient's family
42:57
or sometimes even the patient when they're awake, wide awake with it, extubated on VA
43:03
ECMO, let's say, and able to make their own decisions.
43:07
And thankfully, that's not super common, but it's very, very difficult to have those conversations
43:13
saying we don't feel there's any meaningful recovery that's going to happen.
43:20
Your loved one or you, the patient is not a transplant candidate, and we can't keep
43:25
you on ECMO forever because you're accumulating complications that are going to be detrimental.
43:31
And there are instances where we have to withdraw care from it, you know, and turn off the ECMO
43:36
machine and that will result in the patient's death, usually quite quickly or within a few
43:42
days.
43:44
How do you start to approach those conversations with the patient?
43:50
What kinds of things do you have in mind?
43:51
What's going through your head?
43:53
My personal approach is to be very pragmatic with them and discuss their care.
43:58
I give them, you know, particularly it's usually with the family, but if it's the patient and
44:02
they're with it, they often know how sick they are, but sometimes they don't.
44:05
And I paint the picture of, you know, go down every organ system and say where it's good
44:11
and where it's bad.
44:12
And I tell them both, like, all right, this organ system is working, but this one is not.
44:15
You know, your liver is working okay, but your kidneys are shot and they're on dialysis.
44:19
And I don't know when you'll come off or if you'll come off dialysis.
44:22
Your heart is just not recovering.
44:24
And if we were to take you off ECMO right now, you would pass away immediately.
44:28
Your lungs are not recovering.
44:30
We don't anticipate they're going to recover anymore and they're not working well enough
44:34
that you can be off ECMO.
44:35
I'd be very, almost blunt with them on that because I don't want to give a sense of any
44:42
kind of false hope, but I also don't want to, you know, be cruel.
44:45
And so I try to balance that and it's a hard thing to do.
44:49
And I talk to them about that.
44:51
I paint that picture and then I say, here are the options.
44:53
We could keep on ECMO.
44:55
We could wait longer for recovery or transplant.
44:58
And then I go through the risks and benefits of those.
45:03
In some situations, I don't offer to keep them on ECMO because of the various issues
45:08
that they're having.
45:10
And usually I can, and I'll usually have the palliative care team or, you know, other
45:17
specialties that can help me paint this picture.
45:19
So if we're worried about neurologic status, have neuro critical care or neurology come
45:23
talk.
45:24
If it's the patient's not a transplant candidate, maybe have cardiothoracic surgery, come talk
45:28
and explain why they're not a candidate.
45:31
And that, I've found that approach and that multidisciplinary approach really helps families
45:36
understand.
45:37
And the biggest thing is I try to give them time.
45:39
I try to start that conversation early when we suspect that this is not going to go well,
45:43
that the outcome is not going to be ideal for this patient.
45:47
Now, from my understanding, ECMO is something that is complicated.
45:53
It's hard to do.
45:54
It takes a lot of specialists.
45:55
It takes an expensive machine.
45:57
What are some of the financial resource implications for using an ECMO machine?
46:02
What kind of cost to the healthcare system does an ECMO machine cost?
46:10
That's a good question.
46:11
I don't, and I don't have specific numbers as far as cost, just because, you know, with
46:15
every patient it's different.
46:17
But ECMO is very expensive from a technological standpoint.
46:22
You know, the pumps are expensive.
46:24
The tubing is expensive.
46:25
The oxygenator is expensive.
46:27
And then from a manpower standpoint, we have, it's a true team that takes care of an ECMO
46:34
patient.
46:35
You have physicians.
46:36
You have nurses.
46:37
You have advanced practice providers.
46:39
You have perfusionists or ECMO specialists.
46:42
You have respiratory therapists.
46:44
And then, you know, you still need nutritionists, et cetera, all the things that come with a
46:47
critically ill patient.
46:50
But the addition of some of these other specialists are expensive.
46:54
And you know, you also need to have as a hospital system enough of those people to take care
47:01
of ECMO patients and, you know, other patients that they have to attend to.
47:05
So it's a very, very expensive from a, you know, personnel and from equipment standpoint
47:13
for a hospital system to have an ECMO program.
47:16
And so some hospital systems only do one type of ECMO.
47:19
Some hospital systems have the ability to cannulate for ECMO but then ship the patient
47:23
to a center like ours to manage the patient long term.
47:27
And that's very common around our region here where a lot of hospitals can cannulate for
47:31
ECMO, particularly VA ECMO, but then they'll transfer the patient here for long term management.
47:38
And that's just because of the costs involved.
47:41
It really is resource intensive.
47:43
It takes specialized training.
47:44
You know, you have to, if you aren't in a critical care fellowship where you had ECMO
47:50
patients, you really need to seek out other training.
47:53
Most, I would say, but not certainly not all, but most critical care anesthesiology fellowships
47:59
are at centers that do have some ECMO.
48:02
But I'm sure certainly not all of them do.
48:06
So ECMO, despite all the costs, despite all the complications and the ethical things that
48:11
can come up, can work too.
48:14
I remember specifically one ECMO patient that I took care of when I was in my intern year.
48:21
They had somebody who had been found down for an unknown period of time and she had
48:29
unfortunately gotten very cold and she was in cardiac arrest.
48:37
And they brought her to the ICU and hooked up the ECMO cannulas at bedside and started
48:43
it up.
48:44
And I remember ending my shift that day, close to the time where a lot of that was going
48:51
on and I was sent home.
48:52
I needed to come in the next morning.
48:55
And I felt conflicted about it because I remembered feeling, wow, I don't know what benefit this
49:03
is going to have because I feel like this patient is, for all intents and purposes,
49:09
is dead and I'm not sure what we're doing here.
49:11
This is a really dramatic intervention that I'm not sure what could happen here.
49:17
And so I went home.
49:20
I thought about it.
49:21
I came in the next morning and got report and I was waiting to hear back that the ECMO
49:29
patient had passed away, of course.
49:32
And I came in for a report and the overnight person said, well, the ECMO patient is actually
49:38
complaining of such and so.
49:41
And I don't even remember what she was complaining about, but it stopped me sort of dead in my
49:46
tracks.
49:47
I was like, what, she's complaining?
49:52
That means so much.
49:53
I mean, wow.
49:55
And she actually walked out of the hospital.
49:58
So it's an intervention that is complicated and is fraught with all sorts of financial,
50:06
ethical issues.
50:08
But it really can work in some of these cases.
50:11
Absolutely.
50:13
And that's why we keep doing it and that's why it's becoming a little more common to
50:17
see even in smaller centers.
50:20
For a while it was only in large academic centers or tertiary medical centers.
50:25
And now you're starting to see it out in the community because it has a good success rate.
50:31
So also the organization keeps a live database and all of the, with the exception of ECPR,
50:40
which is kind of a separate entity, VA, VA, and VV, ECMO patients and adults have a, you
50:46
know, over 50% success rate.
50:48
And these are patients who otherwise had very high mortality, predicted mortality with their
50:54
initial issue.
50:57
It really is, I have countless stories of where patients who absolutely should have
51:03
died or should be dead are alive and neurologically intact.
51:07
And that's another big one is there's being alive and there's also being alive and functional.
51:11
And that's looked at a little more now with the ECMO research and we're still seeing good
51:15
results that you're not just alive, you're walking out or you can still lead a meaningful
51:21
life after being on ECMO.
51:25
And you know, it's certainly dramatic with ECPR.
51:27
I'll actually be lecturing at the Society of Critical Care Medicine's annual congress
51:31
coming up next month about this.
51:34
ECPR, you know, most out of hospital arrest, at most 10% survival rate with standard ACLS.
51:43
With ECMO, with ECPR specifically at a center that knows what they're doing, 30%, which,
51:49
you know, it's still not great, but sure beats 10%.
51:53
You know, and it's only going to get, hopefully only going to get more.
51:56
Now at some point, you know, other factors come into play, but it has absolutely saved
52:02
lives.
52:03
There are several patients that I can think of off the top of my head that I just, I couldn't
52:09
have the same reaction as you is I couldn't believe that that person's alive.
52:14
One quick anecdote, so I remember in my CA three year, I believe it was, no, no, I'm
52:19
sorry, I was a CA two.
52:20
It was a Saturday morning and the labor and delivery area was in the Children's Hospital
52:29
at Michigan.
52:30
So it's Mott Children's Hospital.
52:31
It's called the Women's and Children's Hospital.
52:32
Two floors are labor and delivery.
52:34
The rest is all peds.
52:36
And it was completely resident run at the time.
52:39
And it was two of us there with an attending who was a peds attending, but kind of moonlit
52:46
on the weekends covering the OB service.
52:49
And we come in in the morning and there was a patient who was septic, unfortunately had
52:54
an intrauterine fetal demise, but had gotten septic overnight.
52:56
They were planning to do the dilation and evacuation that morning.
53:02
She was inpatient, obviously.
53:03
And while we were in our 7am sign out, and mind you on a weekend, like I'm sure at most
53:07
places where we got skeleton crew, you know, just the bare minimum to get through the day.
53:13
And the code alarm goes off and we run there.
53:17
She's not actually coding, but she's profoundly hypotensive.
53:20
She's gray.
53:21
She's clearly not oxygenating well.
53:23
So we rush her to the OR, you know, intubate her.
53:26
They pull out the products of conception which were grossly infected and she codes.
53:35
And we call for help.
53:38
There was not a lot of help to be had.
53:41
The pediatric anesthesia team happened to be between cases downstairs.
53:44
So they came to help us.
53:46
We called over to the adult side.
53:47
They were all busy.
53:48
Though I think one person called, I called to the surgical ICU and see if the, which
53:53
was in the adult hospital and said, hey, can you send the fellow over at least to help?
53:58
We could not get her back.
54:00
We assumed it might have been an amniotic fluid embolism, but combined with septic shock.
54:06
We could not get her back.
54:07
She was otherwise a completely healthy 38 or 37 year old.
54:11
And we made the decision to ask, the surgical ICU fellow came over and said, would this
54:16
be an ECMO candidate?
54:17
And we said, yeah, we can't think of any contraindication.
54:21
And so long story short, they essentially was an ECPR case.
54:24
The cardiac surgeon who cannulated happened to be in house doing residency interviews.
54:31
That's the only reason he was close by.
54:34
And he came over, cannulated, and she came to the CVICU.
54:39
We took care of her.
54:40
She was decannulated about a week later.
54:42
And I remember seeing her on her day of discharge to rehab.
54:45
She was completely neurologically intact.
54:47
And actually, I asked her for permission to present her case at ASA, which I did that
54:51
year.
54:53
But she was completely intact.
54:54
She thankfully didn't remember any of it, which it's always a surprise in the critical
54:59
care world that a lot of patients even without any sedation just don't remember those things,
55:03
which is good.
55:04
But I mean, that's just one of countless stories I have that this technology saved a life when
55:10
it otherwise would have gone the other way.
55:13
That's really cool.
55:14
And I appreciate you sharing that with us.
55:17
So lastly, sort of to wrap up, I wonder what style points you can share with us, points
55:22
of personal preference, things that have gotten you further in your career or that you just
55:27
think are really good pieces of advice for people?
55:32
For me personally, I think being practical when talking with patients, when talking with
55:38
colleagues, sometimes being blunt, just so people see you as genuine and see you as somebody
55:48
that tells it like it is.
55:49
And sometimes you have to have those hard conversations and it may not always endear
55:53
you to people.
55:54
But I found for me personally that that has helped with my career, helped me talk to patients,
56:01
helped me deal with colleagues, particularly difficult colleagues.
56:05
We're all going to have interactions with folks in the future that don't always go well.
56:11
And you have to handle that professionally.
56:14
But at the same time, stay kind of true to yourself and really make sure that you respect
56:19
yourself in those situations.
56:21
And I find that I have gotten more better outcomes out of those situations being assertive,
56:29
but not mean, not unprofessional.
56:31
And sometimes that's a hard, particularly in the operating room environment, that can
56:35
be tough.
56:36
And that's a skill that you have to perfect over time.
56:40
And it's never too early to start working on that.
56:44
Wilson, thank you so much for joining us.
56:47
Thank you, John.
56:49
Thanks for joining us for this month's episode of Style Points.
56:53
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