Hey everyone, I'm Brandon Odo.
And I'm Brian Bulling.
And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling,
and expert guests to unpack how critical care is practiced in the real world.
All right, everybody, welcome back to the podcast.
Brian Bulling here with you and with me as always is Brandon Odo.
We have a special guest with us today.
I think, can we call you a friend of the podcast now?
This is your second time.
I think twice makes you a friend.
Yeah, absolutely.
The one and only Scott Weingart of the M-crit podcast, ED resuscitation est extraordinaire,
is going to join us and talk about some cool, cool stuff.
Brandon's got a good case for us.
I'm excited.
So let's just jump into it.
Yeah, we thought what we would tackle today is the idea of taking a patient in cardiac
arrest and sticking them on ECMO.
This is something that has been referred to as eCPR, eCLS.
It is a certain application of ECMO, which is not being done all that widely, even in
places that are using it for other things, such as the patient coming out of the cardiac
OR, the patient in respiratory failure who needs some VV ECMO.
And even the select patient, who seems like they would benefit from a period of going
on VA ECMO for other reasons, it's still a bridge from that to taking a patient who
actively has no pulse or is parry arrest and crashing them on to bypass.
But it is being done.
And Scott has done a lot of work in this area.
Scott, am I right in saying you developed a program for it, one of your jobs?
Well, we did, and I think even of greater significance is the course we run, the reanimate course
with three of my buddies, Joe Balazzo, Zach Shiner and Chris Ho, because what happened
over the past decade is we basically have had every person who is doing amazing work
in eCPR pass through the course, give their own benefit, the benefit of their own wisdom.
And so it's kept getting better.
So the protocol I'm most proud of is the one we have at reanimate.
Right.
And I did the course a couple of years ago.
I thought it was a huge shell, even though this is not something that we're doing.
It's just to see how things are being done.
So this is still kind of a niche or cutting edge area, but it's hard to work in this
field and not think that in some way this is part of the future.
So for those of you who could consider this, hopefully this is a call to arms, those of
you who are not there yet, I think at least will be interesting and you can get some pearls
from it.
But let's sort of explore it.
So Scott, you are sitting in your ER and you get a notification from EMS that they're
bringing in a patient who is in cardiac arrest.
He's 50 years old and he was witness to collapse at a mall in public.
People saw it happen and they actually started CPR right away, a couple of bystanders.
EMS got there.
He still had no pulse and they found him in VFib.
So they ran an ACLS code.
He ended up getting shocked three times and it was essentially an intractable VFib.
They got VT once for a little while, but back to VFib.
So he got some epi.
He got amiote, but he's still pulseless.
They were not able to get ROSC.
So they put a mechanical compression device in place.
They use the Lucas.
They packaged him up and they're bringing him to you.
So with their response time and the transport time, by the time he gets to you in a few
minutes, it'll be about 30 minutes total for the arrest.
All they could get was he's a healthy, yes, 50 year old.
He has hypertension.
He doesn't take any meds for that.
So this patient has ongoing chest compressions.
He's going to arrive in a few minutes.
In many places, they would just do ACLS.
If you're somewhere who would consider putting a patient on ECMO in arrest, which sorts of
patients are eligible?
Would this be one of them?
Yeah, it's going to vary depending on the center because the looser you make, your inclusion
criteria, the more patients you're going to treat and the lower your outcomes are going
to be.
So if you are a new program, you don't want to have dismal outcomes.
You want people to be excited.
You want patients to walk out of the hospital.
You have a parade and you have everyone's morale and spirit for this program go up.
So usually you'll start with very tight inclusion criteria.
And then as you become a more established center, people have seen the saves than you could
broaden out.
This guy would fit criteria in any place that has a ECPR program.
This is like the quintessentially perfect patient.
But in general, what you're going to find is there's usually an age cutoff and that should
be mitigated by physiological age.
So if your cutoff is 70, but the patient's 80, but they look 60, then you probably should
do them, I think, and most centers would agree.
So somewhere between 65 and 70, if there is an age cutoff.
Now, some places will restrict by rhythm.
And again, that just goes to trying to keep your cohort very potentially savable or wanting
to broaden your inclusion.
So if you stick with V-Fib, V-TAC, you will have much higher success rates.
But there are PEA patients that you can bring back.
Absolutely.
In fact, that's the rhythm.
Pulmonary embolism presents in much of the time and that's a salvageable patient.
Acystily, you really have to sell it to me.
Why?
This is a good idea.
Because a patient witnessed in front of you in acystily, well, that was their first rhythm.
Okay, that that pretends a very different prognosis than a patient in the field whose
acystily usually represents a long time without a perfusion to their heart.
So you have the rhythm and this patient fits that.
The lack of major comorbidities is absolutely key, both because their protoplasm is worse
and their outcomes are worse in general with major comorbidities like really advanced cancer,
advanced CHF, cirrhosis is a big one, serotics do not do well on ECMO, or any other weight
stage systemic disease.
They need a no flow time, meaning time without CPR to be very brief.
Some programs would say up to five minutes, but I really like to see the witnessed with
CPR being done right away.
Or you heard your dad fall in the other room, went over, he's on response immediately starts
CPR.
That's a good no flow time.
Going beyond about five minutes, it's going to be a real tough shot.
Now, the interesting one is the duration of the arrest itself, prior to ECMO implantation.
And that number keeps getting longer and longer.
In fact, the Annapolis study, which had into the 40% neurologically intact survival rate,
that was the, I don't remember if it was median or mean, but either way, it was 65 minutes,
meaning a bunch of patients were way longer than an hour in order to get that time.
So that, I have a very gray zone.
I think if you get me a reasonable patient in any amount of field time, it's probably
worth putting them on pump.
So if it was witnessed or a very short time without any resuscitation and it's a reasonable
patient, you might have a pretty long period of compressions and still have a good outcome.
If it was, I suppose, hopefully well done compressions and so on.
Yeah, absolutely can.
You could have patients at 80, 90 minutes walking out.
So let me ask this then, because I know a few years ago, this was a big deal in France,
in Paris, the guys there were doing field cannulation.
Does this sort of obviate the need for that even?
Because if you can do CPR for 60 minutes on somebody, it seems like it's better just
to scoop them up and get them to a hospital than to send a team out to do it in the subway.
It depends on your system.
If you can make field work, the sooner the better.
You know, just because you have that amount of time, in some patients, doesn't mean in
your individual patient that 20 minutes is going to be a vastly different scenario than
60 minutes for that individual patient.
And if you can make a field program work, then that's obviously best.
There's been experimentation with that in New Mexico and in Minneapolis.
And in Minneapolis, they built basically a calf suite in a huge, you know, big ambulance.
And if you do that, then why bring them to the hospital?
You can just bring the calf lab to them.
So I think it all depends on the logistics of the system.
So it sounds like you're interested in who the patient is and their chance of a good outcome,
what the downtime and arrest was like.
And it sounds like maybe a little interested in the cause of arrest, but not as much as
these other factors.
Is that fair to say?
Yeah.
You know, the cause, we can figure that out later.
If you have a patient who has viable low flow perfusion, meaning that they had good CPR,
then if they have nothing else going on negative prognostically, then we're probably going to
want to put them on pump at most places.
And are you trying to make a final call on this before this patient turns up or you're
going to sort of put them on your radar, but decide once they get there and you have a
little more information?
Usually by what you get in the field, you have already made the determination this is
probably a case.
I don't think there's too much that if information wasn't changed, you know, sometimes you get
a story of, yeah, we had this patient and they were had CPR started immediately and
then the family gets there and they're like, no, no, we didn't start CPR.
We waited for the ambulance to come and it's been like 15 minutes between that.
Okay, well, you're going to stop.
But you know, the information you can get in the field when verified in person is pretty
much all you need.
You know, a lot of the time ECMO and other settings, they're really interested in if they're
going to be able to fix the underlying problem here.
And it sounds like you're saying it's just you're not going to be able to figure that
out in the short time you have.
So in a lot of cases, are these ECMO runs going to be almost a bridge to prognostication
and figuring out if it's going to be resolvable?
Yeah, that's a very good way to think about it.
And it's a bridge to diagnosis as well.
So you know, just as you alluded to, you're giving them the time to figure out a what
the hell is going on, b we could get some more information about prognosis.
So at the end, we should talk about the fact that the way to have a horrible ECMO program
is thinking you could prognosticate.
And I think that's a key point we have to talk about.
Okay.
All right.
So you've heard about this patient who sounds like a good candidate.
What sort of prep are you doing while this patient is, you know, a few minutes out?
What are you doing in the room and what are you planning to do as soon as they arrive?
Yeah, the most important thing is to split into two teams, if it's a potential ECMO candidate,
is the people who are working on cannulation cannot have any part in code management.
It becomes an absolute task focused activity.
In fact, you know, things will go into the room that are just crazy and later report to
me.
And that while I'm cannulating, I had no idea what's happening.
So, you know, like multiple gunshot wounds came in at the same time.
And everyone in the room is like trying to split up their stuff.
And I have no idea whatsoever.
And I'm sure you're both aware of this too.
When you get involved in a really, you know, life critical procedure, your task awareness
disappears.
There used to be two teams, one to run the code and one to actually handle ECMO cannulation.
You want to get, if you can, a second ultrasound machine because the ECMO cannulators really
need full access.
And then the people running the code generally going to want to use that for other stuff.
If you're going to be at a center where the ED is a spot where potential ECMO cannulation
or at least the access for eventual ECMO cannulation is happening, you want to have the right equipment
ready in a separate space or a space that you know is always going to be there.
You don't want to go looking.
You don't want to have to go through three rooms trying to find the equipment you need.
And I guess in a sec, we'll talk about what that equipment is.
But I prep my equipment.
I get an extra ultrasound machine.
I ask the nurses to get some heparin ready because sometimes that takes a while in the
midst of a code.
And that's pretty much the only medication I'm going to need at the very beginning.
And then I'm usually going to get sterile before the patient even arrives.
And then, you know, I've prepped someone to say, look, here's what I need from you.
You got to get the pants down and the underwear down and just prep my groin for me on both
sides and then I'm good to go.
You meaning the cannulator?
Exactly right.
Yeah.
Now, is the ECMO team larger than that one person?
You know, it can be done with one person.
All of us, you know, who teach at Randmate, we've all done solo ECMO.
And it's not that bad.
It is nice to have at least one assistant who does not need to be well-versed in anything
ECMO.
And you remember, Brandon, we had the, just not pejorative at all.
We had the dumb assistants and we had the smart assistants.
Was that not being a marker of intelligence would be a marker of ECMO cannulation familiarity.
But a dumb assistant, meaning they know nothing, their basic jobs is just to hold the back
of the wire.
They don't need to do anything else for me.
It can make it enormously more easy.
And it seems like the different models for doing this vary a lot in who is cannulating,
meaning by specialty.
So is this emergency physicians, cardiologists, cardiac surgeons, and, you know, within that
cohort, how many are there?
So if it's the ED docs, is it all of them?
Is there a select group of them?
So you're not diluting this.
What are their general thoughts on that?
All right.
So, you know, and I hope I don't piss off any of my brethren from other fields because,
you know, I have much love.
But here's the real arbiter.
Unless you're doing cut down cannulation, and that is what they're doing in Paris exclusively
is cut down for field cannulation of ECMO.
Everyone else, everyone else has gone the route of percutaneous ECMO cannulation.
And I really think that's the superior way.
Maybe you have the ability to do cut downs in your back pocket, but honestly, you know,
it doesn't happen very often.
If you're doing percutaneous, you got to have skill with ultrasound guided procedural use.
You just have to.
And most of my colleagues in CT surgery do not.
There's a very small handful that do, but you'll see the divergence.
Vascular has adopted ultrasound whole cloth.
I mean, vascular surgery loves ultrasound.
And so many of their procedures are percutaneous.
They very early on figured that future is percutaneous and they learned it better than, you
know, any other specialty out there of how to do these rapid procedures with ultrasound
guidance for needle placement and their masters at it, just like the cath lab folks are.
That's their gig.
This is their trade.
You know, who else is really good at that?
EM and critical care folks, you know, who's not for the most part, CT surgeons.
And yet in many places, the CT surgeons are the one who's cannulate and they're doing
blind cannulation.
And blind cannulation is fine for VA ECMO with a pulse.
But during cardiac arrest, there is no difference between venous and arterial blood in terms
of anything you can look for.
There is no way to do blind percutaneous cannulation.
We've had many cases of CT surgeons doing blind placement with AA placement or VV placement
during E-CPR.
Neither of those work very well for bringing this patient back.
So you got to use ultrasound.
So I don't care who's cannulating by service as long as they are savvy with needle placement
in the right vessel in one stick with ultrasound.
It's really the only way it could get done.
And in most places, that means that even when there is a CT surgeon available, that that
initial placement of what we call access lines should really be done by someone who is
ultrasound capable.
Okay.
So in your case, that's going to be the emergency physician.
Yeah.
Well, at my old center, it was a select group of ED critical care or CT surgery.
But we asked, you know, we started telling the ED folks, I don't care if CT surgery is
going to come.
I want you placing the arterial line and the venous line, regular arterial and venous lines,
even though CT surgery is going to do the actual cannulation.
And that's a very good hybrid approach because now you get the benefit of all worlds where
the ED, because oftentimes the CT surgeon is not available right away.
It's going to be a while.
If the ED or the critical care folks get properly placed, properly located, arterial and venous
lines, and then CT surgery comes, first of all, that patient will definitely be able
to be put on pump because that's the main decision, the main arbiter of whether you're
going to successfully cannulate or not is can you get in arterial and venous lines.
Everything past that point is pretty doable for every patient.
And then CT surgery could come and work from those lines that are already there.
But it really behooves then the ED or critical care folks to know how to place these lines
properly, which they don't learn in regular training.
It's a different experience as you remember, Brandon, we teach people that you never learn
to put in an arterial line until you take an ECMO course because oftentimes they're placed
in the superficial femoral artery and you get away with it with a 20 gauge arterial line.
You never know that you've placed that in the wrong place for where an arterial line
should be placed.
So if we could teach that, and I don't know, you guys might want to talk about this a little
bit more, if you could teach that, then that's the best.
Just let the ED or critical care place those access lines and then they could be the ones
who are cannulating or it could be some other service cannulating.
But now you've taken out the major failure point of ECMO cannulation.
Okay.
So the kind of team on the ground there could do the entire cannulation or they can start
with getting access as a bridge to somebody else coming in and doing the big dilation
and things.
Do you think this workflow is any different in a patient who, let's say was in the ED
and arrested there or is not in the ED?
They're in the ICU or on the floor in the hospital and you're trying to make things
happen there?
No, a good ECMO program, a CPR program, said I should say, is location agnostic.
And because as Brian alluded to, they could do this in the field.
We could certainly do it in a hospital bed on some random floor.
It's just a matter of logistic pre-planning.
And at my old center, the ECMO cart would come and it would be the one they'd use in
the OR for bypass cases.
And it had thousands of cannuli and everything.
And it's like, yeah, well, at some point the paralysis of choice becomes really annoying
and finding the stuff becomes really annoying.
And I much prefer centers that have gone as if the ED is the field, as if the ICU is the
field.
But I'm going to bring everything I need, but not one thing more in a very organized fashion
with minimal amount of equipment because it's so much easier when you have that as you are
way.
And if you build that and there's carts online on our site, you can check them out.
If you build this and that shows up, you're pretty much good to go.
You don't need anything else to be supplied by the actual place you're at.
Hey, everyone.
Future Brandon cutting in here.
They'd intended to ask Scott at the time about this and forgot, but I followed up later.
You might wonder if you're dealing with an in-hospital arrest like in the ICU or even someone who
arrests maybe in the ER after arrival.
You don't have that lead time of the pre-hospital code to kind of set them up as being a refractory
arrest.
So at what point for those cases would you consider going on ECMO?
Obviously, it's not going to be immediately when they code.
I asked Scott that and he essentially said for a PEA arrest, which he says tends to have
a pretty narrow window for a successful run of eCPR, you know, he would start putting
in those arterial and venous catheters right away and would pretty much progress to cannulating
for ECMO if they seem like a good candidate by the time, you know, he was ready to place
a large catheters.
For a patient with shockable rhythms like V-fib or V-TAC, again, start right away getting
that venous and arterial access.
And then if you get to about three shocks and they still haven't had Rosk, that's when
he would start proceeding to ECMO.
Obviously there can be some case-by-case variation here, but that's the kind of general approach
he suggested.
All right, back to the case.
Okay.
All right.
You're in your resuscitation room, you've gotten sterile, you have some equipment ready,
and your goal is for this patient to turn up.
The team who's going to run the arrest is going to essentially do a normal ACLS code.
And meanwhile, you're asking someone to, you said, expose the femoral area and you're
going to prep a site and start getting access to veins and arteries.
Yeah, I actually like them to prep for me, but if they can't, I'll do it, but it's just
easier for them to not break my sterility to just let them prep the grind for me.
And assuming that everyone listening has some familiarity with central and arterial lines
and other contexts, what are you doing now that's different from that?
Okay.
So the, and I should say one more difference before we get to this point is if mechanical
CPR is available in that ED or critical care unit, that's what should be used because it
keeps the growing so much more stable.
And it just makes everything easier.
So that, even if you don't like it, if it's there, it's really good for the CPR case,
the E CPR cases, if it's going to be hands CPR, then I need a person assigned.
They don't need to have any skill to hold a pelvis stable for me.
And that breaks the connection of the vibration of that body between the chest and the pelvis.
If someone's just holding and pushing down on that pelvis for me.
So the difference between standard femoral vascular access is a few things.
The, as CPR goes on and the code continues, the artery shrinks and the vein gets bigger
and bigger and bigger.
So depending on the duration of CPR is how difficult that arterial access is going to
be.
The vein is always easy to get.
It gets enormous during cardiac arrest.
You have to hit that artery between the ligament and the branch point.
You want to be between that happy landing zone, which isn't that big.
It's like four or five centimeters.
So you really have to find, be sure, definitive.
This is artery, right?
Because you really need to know which vessels, which otherwise you're going to get AA or
VV placement.
And then you want to go down on that femoral artery until it splits to the SFA and the
perfundis and then come back up a few centimeters.
Now that's the spot your needle has to hit.
That's not where you're going to enter the skin.
So it really relies on a lot of trigonometry and a lot of experience with vascular access
under ultrasound because you really need the needle to be under your probe face at a very
small landing area because if you're too close to the junction, you could blow it out
and that's a disaster.
If you're above the ligament, then you actually could wind up with retroparotenial bleeding
if you actually back wall it, which is a bad show.
So you're looking for a really small landing zone and then you need to put something in
that artery that will take ECMO wires.
And ECMO wires are standard vascular access wires.
So their .035 is what you're looking for.
And now what does this translate to?
You're like, oh, what does that mean, Scott?
I'm not an interventional radiologist.
It means you can't place a 20 gauge art line, which is the most common art lines out there
because a 20 gauge art line will not take ECMO wires.
They won't take any vascular access wires.
And it's a pain in the ass.
We got to switch that out.
So if you could put something in 18 gauge or above or four French and above, then we're
good to go.
So it means if your shop has 18 gauge A lines, gorgeous, just place the A line, if you don't,
if you have 20 gauge A lines, then what you want to place in there is a four French cordis,
which is commonly available in every hospital, but it's just not commonly available in the
ED or critical care unit.
We have the nine French cordis, the 8.5s, but we don't have the four French.
So that's something you want to stock in your little ECMO box so that you know you have something
that the ED could place in the femoral artery to actually allow that transition to ECMO calculation.
The vein's easy.
Again, you just want to be at that same level, pass the junction, but honestly, it doesn't
matter as much of the vein.
We get away with it.
It's not as crucial, but you could stick anything in there.
You could put a triple lumen in.
You could put in a cordis, you could put in a single lumen, whatever you have.
There's nothing you're putting in a femoral vein that's not 18 gauge and above.
So I mean outside the pediatric range, which I don't talk about.
I don't know anything about pediatric ECPR, but for adults, anything you're going to stick
in the femoral vein will work fine.
So your goal at this stage is not to immediately progress into dilating up to ECMO canula.
It's to get some kind of placeholder devices into these vessels.
Yeah.
Well, I'm giving you the way it'll work in any situation.
If I'm there and I'm the one cannulating, I'm going to do the same thing, but what my
temporary access device is going to be is one of my dilators.
There's no reason to go through the rigameral of actually putting in a triple lumen when
I could just put in the smallest dilator.
And then the reason we still have this transition, and this is inside baseball type stuff,
but people should understand is when I'm first accessing these vessels, I use very floppy
wires, the kind of wires you'd get in your central line kit or your art line kits.
But then very quickly, we want to transition to what we call super stiff wires.
That's actually what they're called, is super stiff.
It's like a Viagra commercial.
And these wires are very, it's not difficult at all to puncture a vessel with them.
You really have to be sure you're in and not in the wall of an artery.
You can really destroy that vessel.
So I really love putting in a needle, putting in a floppy wire, taking the needle out, putting
in a dilator, taking out the floppy wire, and then putting in my super stiff ECMO wire,
taking the dilator out and then progressing from there.
So we teach at the course some form of bridge access, no matter what.
That bridge access could be, like I said, an art line and a central line, or it could
be the smallest dilator of your kit.
But I don't like to do what Unopolis, who's probably the best in the world that this does,
he's a cath lab guy and has the best ECMO CPR, save rates worldwide at the current point.
He goes needle right into super stiff wire.
We try to advocate to not think that our skill level is that of Unopolis.
So we want to stay a little safer, make sure that you're actually in the best.
You know if you run a dilator up smoothly to the hilt over your floppy wire that you're
probably good to go and then you can transition out to the super stiff wires.
Okay and if in the middle of this you've got a pulse back or someone realizes patient's
not a good ECMO can, you can just use your sheaths for arterial and venous access.
Yeah, you know this is the transition point.
This is when you know you got to really make a decision, it's right at this moment.
You know if I've put in a small dilator, I'm probably going to be able to back out and
just switch it for lines but in the artery, you know even in eight French dilation, it's
kind of dicey to just pull and hold.
You could get away with it especially if you could borrow from the cath lab, you know one
of their femme stop devices.
But anything bigger than that, you know anything bigger than a seven or eight French in the
artery, you're probably now committed to taking them to the OR for vascular repair.
Most of the time at that point if we dilated anything beyond, you know like I said for
the artery most of the time I'm putting in a four French device, that's fine, you just
pull that.
But anytime you go beyond that, you really have to ask yourself, wouldn't it be safer
to just put them on pump?
Even if they had a pulse back because most of the time in cardiac arrest, they get a
pulse back and they lose it again.
And even if they don't lose it again, the magic of E CPR is not even getting them out
of the initial arrest.
It does that wonderfully but that's not the magic.
When you ask yourself, why could patients with E CPR survive a 90 minute low flow time,
90 minutes of CPR, when a patient who you get back at 90 minutes, if you even got them
back, never lives.
Like why is that?
And it's not a matter of the ECMO during the initial cannulation.
It's the fact that over the next three to five days with these long down times, the
body can't maintain itself.
It can't do it.
The massive SIRS response, the massive cardiac stunning of that long arrest leads these
patients to not be able to make it through the next three to five days.
You know, the way I could demonstrate this, I can't actually do this study but you can
do a mental projection of it is if I can you ate it a patient, got them back and they're
doing okay with a 60 minute downtime and then I just withdrew ECMO.
That patient would die.
I would argue 100% of the time that patient would die even though we got them back, even
though they cleared all their metabolic milieu of evil and their lactate cleared and all
that, they would die anyway.
You cannot make it through the post arrest syndrome.
I believe the biggest number in the literature, I saw, it's 46 minutes of low flow time.
That's the cutoff.
Past that, you're not going to make it through the next three to five days with that ECMO.
So even if that patient got a pulse back, if they had a 60 minute downtime, I think you
still put them on pump and I think if you've dilated the artery to any significant amount,
you just put them on pump because it's going to be the same amount of withdrawal, pain
in the butt, whether you put them on pump or just leave a huge cannula, like let's say
you decide to put a nine French courtis in the artery to hold it to keep it from bleeding
and then we'll take it out later, that patient's still going to have to take a trip to the
video or I think you just put them on pump because that patient's chance of survival
dramatically increased if they have that as their bridge through the next three to five
days of post arrest syndrome.
Okay.
Now, you talked about the difficulty identifying your vessels.
So what's the trick here?
You said you're using ultrasound 100% of the time.
Are you just identifying artery versus vein by their anatomic location?
They're not possible.
Oh, you were so close to me being happy.
Or identifying based on anatomy, not their location.
The location is completely variable.
It depends on the leg positioning, whatever.
You can't go with the vein medial to the artery as a consistent marker, but you could
always consistently see the wall thickness and size and shape and that's what we go with.
If you want a pearl, here's the pearl, buy a high resolution ultrasound machine and keep
it from the hands of the barbarians.
Am I saying we should have dedicated ultrasound machines just for ECMO?
I don't know.
Would the butterfly probes getting better or what?
I'm not I'm brand agnostic on this would be personalized.
Take it home in your pocket probes getting better and better resolution.
Yeah, I think it's probably eventually going to be worth the investment of the $2,000 to
keep a probe just for these kinds of situations because what happens is they have their sonoside.
It's been beaten up over three years and it just grays out.
And yeah, vessel anatomy becomes really difficult to see.
And then you get that one week of the new machine that just came in before the little
goblins start getting to it and dropping the probe on the floor a few times and you're
like, oh my God, it's like putting on glasses for the first time being nearsighted and realizing
like you thought the world was one way and all of a sudden it's this entirely beautifully
crystalline world.
Well, that's what it's like with a good versus bad ultrasound probe and like all of the problems
of like I couldn't identify which one was which is because yeah, it's just a great mess on
that screen.
Okay, so the artery should be thicker walled and smaller in diameter in a patient and
arrest, but you can't decide from where it is.
Yeah, I can't imagine a situation where the artery is going to be bigger in a significant
downtime arrest.
Okay.
And once once you have wires in, you're not doing anything else to confirm that you're
in because you're taking another step by placing something else before you do any big
dilation.
Well, it depends, you know, it depends on your center and who's there.
Like for instance, we'll throw a TE probe down on every patient during arrest at my
old shop where I had my ECPR program because we had people to do it.
You know, there was always 20 people available for every arrest and we have TE and we have
a very, you know, prolific ultrasound fellowship.
And so they were able to show me a bicable view and I could watch my wire go from inferior
vena cava, katren, first RA into the SVC in real time.
Now you absolutely could do that with external ultrasound as well.
And you could absolutely see IBC on a subcostal view and I see your wire pass.
So yeah, it just depends on who's around to help you.
Can I do this without that?
Yes, we could do a blind placement as long as we've identified the vessels in the groin.
I'm not going to wait for confirmation, but it's a lot nicer when you can watch on ultrasound
your wires progressing.
Maybe not getting too lost in details here, but just to give an overview for people who
have never cannulated, you have some kind of access to the vessels.
You're going to start dilating up and getting your bigger cannula in.
What does this process basically look like?
What sorts of wires and dilators and catheters are you using?
And again, how does it maybe differ from other dilation and catheter placement people
are used to?
Yeah, look, if anyone's placed the percutaneous pigtails, you know, like the Wayne Kits or
it have you, that's 14 French.
That's not too far off from what we're doing for ECMO these days for ECPR.
So you kind of have the experience at that point.
It's the bigger the dilators get, the more force you have to use, but then you have to
learn what is appropriate force and what isn't.
And you get away with poor vector and angling on your tiny, you know, your seven French
triple lumen.
You're like, okay, well, dilation's easy.
I just go, eh, but you know, as the dilators get bigger, if you go, eh, at the wrong angle,
you blow out a vessel.
So it's really a matter of keeping a consistent angle, whatever angle the needle entered.
That's the angle that your dilators have to enter.
And then understanding what is the appropriate amount of tissue resistance and what is not
feeling right.
And but again, if you get to, you know, do it, if you place a dialysis catheter, you know,
that's also, that's a big line, right?
You understand and you start getting familiar with it.
Now, in ECPR, we've gone much smaller than we might do for a post cabbage disaster VA ECMO.
So we're talking, you know, at our shop, it was 17 French for women, 19 French for men
at, in the Alfred, you know, where we always have buddies come and teach with us.
They're placing 17s in everyone and some patients, the small females are getting 15s.
Well, now you're pretty much talking the same size for all intents and purposes of
the dialysis catheter for your arterial.
And then they're placing their venous at 19.
I like 21.
In fact, I'll even go 23 for a big man, but they get away with like 15 and 19 without
a problem.
That, the smaller you go on these ECMO cannula, the easier it becomes to do the dilation and
cannulation.
And so you really can get it in a situation where you don't need training on massive,
you know, there's this cut off world we all talk about when we were doing our ECMO training
and especially for VV.
But like once you start going above 25 French, it's a different world.
It's really hard and really takes a lot of skill.
As you start shrinking away from that number, it's not that tough compared to a dialysis
catheter.
Now, I know there's some ED docs out there, they don't place dialysis catheters.
So this might be a jump.
But if you're placing dialysis catheters, you're placing Wayne or whatever pigtail kit you want,
you're kind of already developing the skill set and it doesn't take much.
And in fact, we train people for two days at our course and then inevitably every course
we've had someone in the next two weeks after the course have to cannulate for the first
time ever and they get it done safely without blowing out vessels.
So I think it's well within the purview of your intensivists and your ED docs.
Okay.
So similar process for artery and vein, you're just dilating up through the steps that you
have to whatever you think is the right size.
You're using, you said an amplat super stiff wire with a soft but straight tip.
Is that right?
Yeah, some people like the J's.
I like the soft and flappies.
It doesn't have to be amplats.
That's the one I prefer but the other manufacturers make their own versions of super stiff wires.
But that has been the money is non floppy wire cannulation.
You know, on the cases that have time because they have a pulse, then you want to be as safe
as possible.
Like I said, these stiff wires could blow out vessels if you're not careful.
So you go with the flappies because you have time.
But if you're going to get this done as quickly as possible and what we're shooting for,
the ideal is less than five minutes on pump from the time you actually make your first
needle stick, assuming it's a continuous cannulation and not the access happening and then a break.
So you know, but if a continuous cannulation, we're looking for five minutes or less.
The best way to get that done is with a super stiff wire.
As you get better, you skip dilator steps.
You don't have to go in a progressive, you know, bomb, bomb, bomb.
You could go basically two dilators per cannula.
The cannula themselves, you know, everyone has their preference for which ones they like.
I really wish they would build them so they lock their dilator in to the cannula because,
you know, it's a situation just like a cordis or an introduce or where there's an inner
dilator and some of the brands, it's like, who designed this?
Because the, as you're pushing in on the echmocannula, the dilators just pop out the
back and now again, you need an assistant to really help you.
You can't do it yourself.
So I prefer cannula that the dilator is really going to stay in there until you pull it out
really hard.
All right, and so now we have the ideal situation would be the arterial cannula just sits anywhere
in the iliac.
It doesn't matter.
Maybe it hits the aorta.
Maybe it doesn't.
It doesn't matter.
It's really, it's irrelevant.
The Venus though, in an ideal world, will actually transverse the RA into the SVC and
that's a big change from the standard CT surgery placement of this.
They're always staying in the IVC.
But everyone in the ECPR world agrees, if you saw your wire on ultrasound or fluoro, but
we don't have fluoro, but you know, the folks in the cath lab do, if you saw your wire
transverse the RA into the SVC, then you're just going to place your cannula pretty much
all the way to the hub because you would get so much better flow and we could steal so
much of the patient's systemic Venus return if we have ports both in the SVC, the RA and
the IVC.
That's the ideal situation.
Now if I had to do it blind, then I'm just going to measure externally on the body and
it's going to sit in the IVC in the ideal world right at the junction of the IVC and
the RA.
We measure that just externally by going from the groin to the right nipple.
It's a lot better, like I say, if I could hub that bad boy.
Are you doing any kind of confirmation for those positions after they're placed?
Are you just getting started on pump?
Yeah, we'll get started on pump and confirm.
The dirty secret is we can move that cannula around at this point even after they're on
pump if we have to.
My brethren in the CTICU, oftentimes if we'll place a IVC, Venus cannula, they will actually
push that up into the SVC on their own.
Now here's what you got to understand.
If you're a CT surgeon, you could do all sorts of stuff and if there's a disaster, then
you just blame it on bad luck in the patient.
But if you're a non CT surgeon doing ECMO, anything bad that happens, you get blamed.
I'm going to be much more conservative on the stuff I will do than what my CT surgeon
brethren will do.
They absolutely will just get an X-ray, push the cannula up into the SVC and they get another
X-ray.
If something bad happens, they're going to take the patient to the OR themselves and
patch up that RA.
I can't patch up that RA and they get really pissed when there's any mistakes.
I'm going to be much more conservative, so I'm going to always go with the safest stuff
and that's what we teach in our course.
Okay.
And we should have said earlier, are you always doing these in the FEM?
Are you doing them both in the same leg or one on Venus, one arterial?
Okay, well, if it's a cut down, they're both going to go in the same leg because you're
not going to want to do cut downs on two legs.
In an ideal world for purcutaneous, we will separate the cannula between legs because you're
not going to have the Venus cannula pushing up against that artery potentially causing
even more Venus, sorry, arterial insufficiency, which is one of the big problems of ECMO is
trying to keep that leg perfusion distal to the cannula.
So we'll go on either side.
If we have to do one leg, it just, you know, they blew out the vessels on the other side
or it's just not good vascular anatomy, yeah, we'll absolutely just place them in the same
leg if need be.
All right.
So you've got your catheters in and this is, again, getting a little esoteric, but you're
going to hook up to the pump.
Is the pump something that you've had already set up?
Is it in any way pre-setup between these cases or if not, are you prepping it prior
to arrival or what's your process?
In an ECPR center, what should be the case is that you have a pump already primed and
ready to go.
And, you know, depending on the manufacturer, they could just sit there for 30 to 60 days
ready to go and sitting there.
And the machines, you know, the ECPR has made a big evolution.
It was considered disastrous, you know, even 15 years ago.
It just didn't have the right stuff.
The cannula weren't.
Heparin bonded.
The machines were complicated and not good pumps and they, you know, had all sorts of,
you know, issues with cavities.
It was just a disaster.
Now, the stuff has gotten to the point where if you can run a D-fib, you can run an acnopump.
So, you know, if you wanted to put a patient on 15 years ago, there would have had to
be a profusionist at the bedside, you know, the same person that does bypass cases, you
know, someone who's specially trained for this.
Now it really could just be done by a bedside nurse who's had a little additional ECMO training,
at least for the initial just getting them on pump or, you know, all of us because of
the way we teach our course.
If they bring the prime pump to me, I could get them set up myself.
Now, do I want to have to do that all myself?
No, but we can because it's gotten to the point of ease and pre-setup that you're pretty
much capable of doing it all on your own.
You know, I just basically would have to point at something and say, hand me that onto my
sterile field and we'd be able to get them on to pump.
So yeah, it's nice to have, you know, a really experienced person there, but it's not absolutely
necessary.
I mean, it's basically at the initial stage, one dial.
You know, that's, we're talking like one dial and a oxygen flow meter.
That's the extent of how much we have to really set at the initial attachment to the
pump.
And I talked about who's cannulating.
The people who are managing the pump could be perfusionist, but it could just be your
bedside nurses if you give them a little training on that.
Or even in extremis, you can just kind of direct people and essentially get these initial
things done and then maybe somebody can take over for the longer term care.
Yeah.
You know, by the 15-minute mark, you really need someone there.
But that someone, depending on center, is either going to be a perfusionist or it's
going to be what's called an ECMO specialist, which is an RT who has done specific ECMO
training, or it could be a bedside nurse from the whichever unit takes these patients who
also has had training on ECMO.
And any of those three models will work.
All right.
You got your cannula in, you're hyperinizing these patients.
At what step are you giving them, Heparin?
Once we start actually dilating for the big cannula is when we'll heparinize them.
Okay.
I think not obvious to everyone.
It seems like a really bad time to anticoagulate a patient is when you're putting giant garden
hoses into them.
But if you don't, they're going to clot them off, right?
Well, yeah, even beyond that, we'll take patients who have gotten TPA for their pulmonary
embolism and it hasn't worked.
They're still crashing and we'll cannulate them.
The point at which it's a pain in the ass to have anticoagulation or thrombolytics is during
the access step because that's when if you stick and don't get it, it's going to be a
real pain in the ass.
Their leg's going to blow up.
You're going to lose your vessel.
Once you actually have a conduit for your wires, then it's not really a problem to have
heparin or even thrombolytics on board.
Once people are on pump, do you like to get like pan CT scans?
Look for bleeding and these patients who are now going to be anticoagulated.
This is the major takeaway for the people that are listening to this that may not have
eCPR at their shop is one of the things that came out of the eCPR studies where they were
doing consistent CT scans on these patients is the just number of unrecognized injuries
you find from just CPR itself.
Horrible liverlax and all the stuff that you won't find if you don't look.
Because of their milieu of post arrest disaster, a lot of times these patients may be bleeding
and it just gets attributed to post arrest syndrome and they die and it was a reversible
cause.
My take on CPR now is regardless of whether they're an ECMO candidate on pump or a regular
CPR player, they all get a pan scan in my world at this stage of the game.
It has the ability to diagnose CPR injuries.
It also has the ability to diagnose what caused the arrest.
I'm at the point now where for post arrest patients who the cath lab doesn't want them,
I actually think we should be doing a CT coronary vasculature as well for these patients.
As the machines have gotten better, it's really easy to do even on patients who aren't braided
cardic and most of these post arrest patients are braided cardic because they get cold from
the environment.
I think you should do an arrest on everyone.
But yeah, definitely we'll do a at some point a CT scan on these patients.
Sometimes it's pretty obvious that it's a coronary cause.
They're going to go to the lab first and then we'll swing by CT after.
Sometimes we don't know the cause.
It doesn't seem classic for a myocardial infarction, in which case the first stop before we go
to ICU is going to be the CT scanner.
Okay.
Now for those who have some experience with ECMO and the settings on it but not necessarily
kind of inducing a patient, especially post arrest or intra arrest, what are your initial
settings looking like and what's kind of your process for that?
All right.
So this is going to be my personal opinion and the opinion of folks from our course because
we don't have great evidence for this.
But oftentimes you'll see patients get crashed onto ECMO and they'll be on 100% FiO2 or to
be precise so people don't yell at me.
It's FDO2 because they're not inspiring it, right?
So it's fraction of delivered oxygen.
So they'll be on 100% FDO2.
They'll have their sweet gas up.
We used to say, oh, you just match your ECMO flow.
So you're on five liters.
We'll give you five liters of sweep.
What you'll and sweet gas is how much gas we're sending passing through the artificial
lung for these patients and it determines what the patient's CO2 is.
And we have really minute control of the patient's CO2 using a sweep gas setting.
And what will happen is these patients have been in the cardiac arrest milieu of their
blood where their CO2 was through the roof, they're acidotic and they're in a ischemic
state and then all of a sudden you crash them onto ECMO at 100% FDO2.
They're hyperoxic and you lower them from their acidosis state to alkalotic.
That is, in my opinion, horrible for the brain.
Horrible, horrible for the brain.
And there's some literature to support that.
So I like to go low and slow.
I'll put a very low sweep gas, which will keep their CO2 high, which is fine.
High CO2 is fine right now and will gradually bring them down.
I want them to be on a low FDO2 so I'm not flooding their brain with hyperoxia.
We have evidence of the deleterious effects of hyperoxia and post arrest patients.
And then for blood flow, pump flow, which is in essence cardiac output, in the post-cabbage
VA ECMO disasters, these patients get started very high.
In the ECPR world, we generally will go lower.
We want their native heart to come online and beat.
We want to have their native circulation doing some of the work and it eliminates the necessity
in many cases if we could keep them low on our pump flows to then need augmentation
of the left ventricular with a support device.
These patients a lot of times are getting an impella in addition to their ECMO because
the amount of afterload the ECMO causes, actually their heart can't pump against it
and their LV starts filling up, their LA starts filling up, they could get pulmonary
edema, they need ventricular offloading.
But I have found in my own practice that if you keep the ECMO flow low, and remember,
these patients are comatose, they're not using much energy.
Oftentimes we're doing some form of targeted temperature management, so we're lowering
their metabolism even more.
They don't need a lot of blood flow as long as we could look at the indices that show us
that their cells are getting enough oxygen.
Keeping that ECMO pump flow low, actually I think saves a lot of problems down the line.
Alright, so presumably at this point, the patient kind of just turns into a more typical
VA ECMO patient, they go off to whatever unit at your hospital can manage that sort of
a patient.
But it seems like one of the big differences here is that most other VA ECMO patients
were going to be more carefully screened for their prognosis and don't have nearly the
same risk no matter how you try to select for having a catastrophic neurologic injury,
which you're not going to know until some time is passed.
So what is the approach to managing this in these patients?
You just have to decide that after X amount of time in whatever neuro-prognostication
tools you care to use, they're not waking up, then you're just going to take them off
the pump and that's just a policy you all agree on?
Or, I mean, because you could always end up with a patient who is never going to wake
up and also never going to get off the pump, right?
Yeah, so here's the deal.
The major difference between E-CPR and standard VA ECMO that gets missed at most centers is
that you put a patient on VA ECMO post-cabbage and you know looking at their heart in the
next few days how this is going to go most of the time.
A patient who's had the insult of cardiac arrest could have no heart function at all
for the first 72 hours or even longer depending on how long the stun lasts.
And there's cardiac prognostication going on by the CT surgeons or whoever, whichever
unit these patients are in, they look at the ejection fraction, they're like, this patient's
not coming back and they're not a candidate for any form of transplantation or LVAD.
Let's just take them off pump.
That can't happen.
You cannot prognosticate the patient's heart function early on in a post- arrest patient.
You cannot make that determination.
I've seen cases get pulled, perfectly good cannulations with viable down times and they're
like, ah, at the two day mark, there's no chance this patient's coming back and they'll
just tell the family, I don't think it's going to work and they'll get the shared decision
making of we could just pull back from the ECMO.
That is a horrible mistake.
You should not be doing any form of cardiac prognostication for the first five, seven days.
These patients will come back online and the Annapolis study, why was this rate so good?
These are patients, like I said, greater than 65 minutes, downtime, I believe 44% neurologically
in tax survival with the ones who got ECPR.
Why?
It wasn't just because of their exomes of cannulation though they are excellent.
It's because they didn't let people get early prognostication and therefore get pulled from
the ECMO.
In fact, every center that gets very high rates of neurologically in tax survival with
ECPR not only owns the cannulation but owns their ICU course and has to say you are not
allowed to pull on my patient.
You're not allowed to.
You're not allowed to.
You have to be willing to work with these patients for a few weeks.
Now they're not going to be on ECMO for a few weeks.
The beauty of ECPR is a few things that allude to your earlier comment, Brendan.
First of all, they're short run times for the most part.
A VA cabbage patient, we want to leave them for 29 days, 30 days to make it past that
goal line.
It costs the hospital a lot of money.
ECMO reimbursement is very good up front and horrible as time goes on.
It's why VV is such a hard sell economically for a hospital.
ECPR is not like that.
They're runs average five, six days and then they're off.
When I say keep them for three weeks, it doesn't mean keep them on ECMO for three weeks.
It means own them even when they get off ECMO so that people don't pull back because they
need to have the dedication of three weeks of care in order to get out of the hospital
neurologically intact and they need good care for that.
Then you mentioned, well, are we going to have patients with neurologically devastating
neurologically, neurologic devastation on pump?
Oftentimes, no.
No, dichotomize is very nicely.
When you look at the literature really nicely, like better than any other disease state you
could find, they dichotomize to brain death or obvious poor neurologic prognostic signs
with an actual algorithm.
You could say they're not going to make it or they are going to be neurologically intact.
If you put a bunch of patients on, they're not going to wind up in a vegetative state
having to deal with family that says we can't take them off pump.
They declare themselves one way or another in almost every case.
Are you saying that cardiac prognostication lines up with neuro-prognostication?
If they're going to do well from a cardiac standpoint, they're going to be neurologically
intact, most likely?
No, I don't know if I could say that.
I'm saying you cannot do cardiac prognostication at all early on.
Neurologically, they will either go in one of the two directions to clear this patient's
not viable based on objective criteria, not based on gestalt or neurologically intact
survival.
Okay.
So you think early on typically they're going to declare and if it looks like poor neurologic
outcome, you can have that conversation while they're still on ECMO and we can just have
to sort of withdraw from.
Yep, yep.
And you know, it's not uncommon to have a patient on day two.
You've seen the CT and it is a devastating injury and then you start testing for brain
death and they actually are viable.
Organ donor candidates at that point and then that's another beautiful reason to place
these patients on eCPR.
Now, because of a whole bunch of ethical regulatory stuff, it's tougher in this country.
But when you look at a country like Spain, their eCPR leads to an enormous number of
viable organs.
You might be like, well, who would want to post the rest?
Orga?
No, many of these organs are just fine post the rest.
And it's another beautiful thing the family could offer that, you know, in this horrible
circumstance, some good comes out of it.
Well, that's really nice because I know a lot of times we run in with these situations
post arrest where, you know, we go along and I'll go on along and then we get them to a
point where we can liberate them from the ventilator.
We can, you know, they're going to survive from a cardiac standpoint, but they're going
to be neurologically devastated.
And at that point, there's really nothing to do except accept the fact that your family
over is now, you know, neurologically devastated, but there's nothing to stop, you know?
So it's nice that you can have that early prognostication to know before we go down
the road too far.
Well, to your point, Brian, because I think it is a valuable point, even though I say
most of the time they'd economize nicely, you know, there will be ones that don't.
Sure.
So what has to happen for a viable ECPR program is that the family must be aware early on that
we're going to continue aggressive care at their behest if they want, but we will not
continue ECMO at their behest.
It is not a long-term therapy.
And we could tell them that this is not built for long-term.
So at some point, depending on how we see the care going is when we will determine we're
going to take the patient off ECMO, that doesn't mean we will stop aggressive critical care.
But if you enter in a situation where, you know, maybe the hospital administration has
said, no, no, we don't want to a lawsuit, just listen to the family with whatever they
want, then your ECPR program is going to close down because you cannot have an ECPR program
where the family is determining how long you're on pump.
It's just too many resources to ever have a situation where the patient's going to be
on for weeks in a not neurologically devastated state, but in a neurologically bad state,
you can't have that kind of situation happening.
Yeah, that's a good point.
For all the people listening to this saying, this sounds pretty cool, but we're not doing
this and it's hard to imagine.
Where are we at in 2023 as far as the feasibility of setting up an ECPR program?
How logistically and financially challenging is it?
And I guess the flip side is how many people should be setting them up?
Should every large and small hospital in an ideal world be doing this or is it more
amenable to some kind of a referral system?
Oh, this is where I'm going to get myself in trouble, but you know me, I'm just going
to have to speak my mind.
I don't think cardiac arrest should be going to small centers.
I think what we will see in the future is first off, there will be cardiac arrest centers
that are level one cardiac arrest centers that offer ECMO or an ECPR.
And it's not a tough field triage determination, right?
We told you the criteria, paramedics are well within their purview to make these calls of
like, okay, well, this is an 85 year old with, you know, acystily, okay, we can take them
to any center if they're not going to just declare on the field.
But if they're going to take that patient, they could go to any center versus this is
the 50 year old with V-FIB and a witness to rest, that patient should just go to an ECPR
center.
There's no reason for them, even if it means, because I told you we have some time on the
low flow time, it's so much more viable to just go and, you know, drive an extra five
minutes and wind up at an ECPR center.
Now, let's say you're in a row environment, this is the only hospital, you know, for like
a 90 minute transport time.
Yeah, that hospital should have ECMO.
And it doesn't mean that their ICU needs to be ECMO capable.
That's the hard part.
But like I told you, the actual cannulation actually could be done by, I could train you
in two days if you have good ultrasound and central line skills, I could train you in
two days and you'll be ready to go at that rural center.
And maybe they should have a group of five docs who are available.
They have a, you know, the big ECMO center has bought them a pump because the big ECMO
center will want to because their referrals will pay for that pump in one case.
In one case, it will pay for the pump to leave at the rural center.
And then that patient could be an ECMO transport.
So you don't need to have a CTICU with CT surgeons, you just need to have a pump at
the center and then an ability to transport them to the actual hub.
And I think that's what the future will show is that there needs to be a geographically
located, you know, viable ECMO option for the right patients everywhere.
And I think that's where we're going to be in 10 years.
Well, this has been a great look at this topic.
Brian, what else should we say about this?
I don't know.
I think this is really, it's really interesting.
I mean, obviously those of us who have done some ECMO, I think it's cool and it's lots
of potential for good.
But I think this really makes a lot of sense.
Like you were saying, you know, I mean, we have a similar model, I think, in our place
with relationships with smaller hospitals who can you let people and then our team goes
and gets them.
And yeah, like you said, putting somebody on pump is pretty straightforward.
It's just the care afterwards.
And you know, if you want to learn more, I do endorse the reanimate course.
Scott, one of the next dates.
Oh, we finally have our dates there in November.
I want to say November 8th or 9th, but don't quote me on that.
It's at the beginning of November in San Diego.
And if you want to check that out, go to reanimateconference.com and you'll find the
actual dates that my senile brain can't remember.
But I believe it's 11, 8, 11, 9 of 2023.
All right.
Final thoughts on this topic?
If it was me, look, I'm going to hit 50 this year.
If I had a cardiac arrest, I'd want to have someone do ECPR and it would be a real loss
if I wound up at a hospital or just like, oh, we'll run the code for 30 minutes and then
call it a day when I could have survived at a center that had ECPR.
It's just not fair, I think, to not offer this to our patients.
So I really am happy with the direction we're going where it's becoming more and more viable
to do at pretty much any center that wants to.
Awesome.
Well, thank you so much for joining us.
And thank you all for listening.
Remember, these are just our personal views, not those of our institutions.
And I hope you're not considering this.
Any personal medical advice is just some educational content.
We'll talk to you guys next time.
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