Is it better to rely on a few highly trained specialists—or an army of less experienced proceduralists? In this episode, Joe Bellezzo and Zack Shinar delve into the evolution of ECPR (Extracorporeal Cardiopulmonary Resuscitation), exploring the pros and cons of each cannulation model.
They examine how different cities face unique challenges and opportunities when implementing ECPR systems. San Diego’s approach, in particular, offers a replicable framework that may work for other urban centers. Joe and Zack break down the specific strategies that helped San Diego develop a successful and sustainable model.

Zack Shinar interviews Pranay Oza, an intensivist from Mumbai, and Simon Sin, an intensivist from Hong Kong, about the insights, necessities, and opportunities for ECPR in India and China.   Both of these physicians are leading the charge in places where ECPR is exploding.  Listen to this podcast to learn how they optimize their skills and resources to utilize this powerful tool.

 

Jon interviews Dr. Stephen Wall from NYU on the podcast where they discuss the need for organs and how ECPR inclusion criteria can significantly impact the problem.





Stephen P. Wall, MD MSHS MAEd, is Tenured Associate Professor in the Departments of
Emergency Medicine and Population Health, NYU Grossman School of Medicine. Dr Wall was
project manager and lead methodologist for the NYC uncontrolled donation after circulatory death
(uDCD) program that attempted to increase kidney donation opportunities by considering those who
die unexpectedly outside hospitals. Results showed the public was supportive of uDCD, so long as
permission is obtained prior to any invasive procedures being performed on the deceased. Lessons
learned from the Kidney uDCD program provided justification to attempt in-hospital Lung uDCD in
NYC, a project funded by NHLBI (R61/R33HL156890 – PIs Wall and Robert Montgomery, MD PhD).
These projects involve cross-disciplinary collaborations with bioethicists, clinical experts from
medicine, surgery, emergency medicine, and transplantation, both within and external to hospitals
and academic medical centers. Dr. Wall’s research was covered in news media including NPR,
NBC, and the Atlantic.


 

In our last episode, Trina Augustin discussed whether we should use a blender in ECPR patients citing the Blender Trial. This month we got the first author of the Blender Trial, Aidan Burrell, to give us insight into the use of blenders for not only ECPR patients but also thoughts on patients on VA for cardiogenic shock and VV patients. Jon Marinaro interviews Aidan for this wonderful addition to this complex decision.

 

Blender Trial - Burrell A, Ng S, Ottosen K, Bailey M, Buscher H, Fraser J, Udy A, Gattas D, Totaro R, Bellomo R, Forrest P, Martin E, Reid L, Ziegenfuss M, Eastwood G, Higgins A, Hodgson C, Litton E, Nair P, Orford N, Pellegrino V, Shekar K, Trapani T, Pilcher D. Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial: Study Protocol and Statistical Analysis Plan. Crit Care Resusc. 2023 Aug 4;25(3):118-125. doi: 10.1016/j.ccrj.2023.06.001. Erratum in: Crit Care Resusc. 2024 Feb 01;26(1):60. doi: 10.1016/j.ccrj.2024.01.003. PMID: 37876374; PMCID: PMC10581278.

 

Trina's editorial - Augustin K, Shinar ZM, Dos Reis Miranda D. Correspondence by Augustin et al. regarding the article "Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation". Intensive Care Med. 2025 Jan 21. doi: 10.1007/s00134-025-07791-7. Epub ahead of print. PMID: 39836262.

This seems like such a basic question and yet the answer is not an answer at all.  Rather it is an educated opinion.  Today we ask the question - Should we blend ECPR patients?

Here's the basic problem.  We think hyperoxemia in critically ill patients is bad (Remember hyperoxemia is high oxygen in blood, hyperoxia is high oxygen in the tissue).  We think that hypoxemia in critically ill patients is bad.  So if a patient gets put on ECMO and we can make the oxygen level coming out of the machine whatever level we want, what level should we set it at?

Well, today, Trina Augustin teaches how this seemingly simple problem is actually quite complex.  Trina is an ECMO superstar.  She practices at Mayo in Rochester as CV Intensivist with a background in CC/EM.  She teaches the most complex part of Reanimate - post pump critical care and yes she cannulates patients as well.  Listen to Zack and Trina banter over this complex topic specifically focusing on the release of the Blender Trial.

EMCRIT ECMO Podcast with Trina that is awesome! - CV-EMCrit - MCS Minute Series: Differential Gas Exchange on Peripheral Femoral VA ECMO with Trina

Bibliography:

Winiszewski H, Guinot PG, Schmidt M, Besch G, Piton G, Perrotti A, Lorusso R, Kimmoun A, Capellier G. Optimizing PO2 during peripheral veno-arterial ECMO: a narrative review. Crit Care. 2022 Jul 26;26(1):226. doi: 10.1186/s13054-022-04102-0. PMID: 35883117; PMCID: PMC9316319.

Bureau C, Schmidt M, Chommeloux J, Rivals I, Similowski T, Hékimian G, Luyt CE, Niérat MC, Dangers L, Dres M, Combes A, Morélot-Panzini C, Demoule A. Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study. Anesthesiology. 2024 Jul 1;141(1):87-99. doi: 10.1097/ALN.0000000000004962. PMID: 38436930.

Burrell A, Ng S, Ottosen K, Bailey M, Buscher H, Fraser J, Udy A, Gattas D, Totaro R, Bellomo R, Forrest P, Martin E, Reid L, Ziegenfuss M, Eastwood G, Higgins A, Hodgson C, Litton E, Nair P, Orford N, Pellegrino V, Shekar K, Trapani T, Pilcher D. Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial: Study Protocol and Statistical Analysis Plan. Crit Care Resusc. 2023 Aug 4;25(3):118-125. doi: 10.1016/j.ccrj.2023.06.001. Erratum in: Crit Care Resusc. 2024 Feb 01;26(1):60. doi: 10.1016/j.ccrj.2024.01.003. PMID: 37876374; PMCID: PMC10581278.

 



EDECMO episode 92 features Dr. Mark Dennis, a cardiologist from Sydney, who has published extensively in the field of ECPR.  Zack and Mark talk about so many subjects including pre-hospital considerations, algorithmic management of post ECMO initiation cardiac arrest patients, ventilation management of ECPR patients and much more.

Prof Dennis would like to thank all the ambulance paramedics, ED docs, intensive care specialists, surgeons, radiologists, nurses and cardiologists across Sydney. Without their support none of the work would be possible.

Also very special thanks to Natalie Kruit and Brian Burns for their immense efforts to bring ECPR to Sydney.



Blender Trial - Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation | Intensive Care Medicine

CO2 Drop in VA ECMO - ELSO Registry - Critical Care Medicine

 

Should we keep cardiac arrest patients on the scene when we have the ability to put them on ECMO in the hospital?  That is the question we tackle this month on EDECMO.  Brian Grunau and the great crew from Prague published a study looking at the Hyperinvasive trial data.  They make some profound observations about the benefits of ECPR and some data supporting transporting patients early in functional ECPR systems. Saul Levine and Jonathan Goldstone from the SDRC join the podcast this month to give their insight into the formation of ECPR receiving centers as well as the paper.



 

Grunau's Paper  

*
The time-dependent yield of invasive vs. standard resuscitation strategies: A secondary analysis of the Prague out-of-hospital cardiac arrest study
Grunau, Brian et al.
Resuscitation, Volume 0, Issue 0, 110347

Editorial

Shock, Shock, Go

 

In this episode of the ED ECMO Podcast, hosts Zack Shinar and Jon Marinaro interview Dr. Powell & Dr. O'Connor from Baltimore Shock Trauma, exploring ECMO's critical role in trauma care and its impact on patient outcomes. They discuss patient selection criteria for ECMO, managing hemorrhage and anticoagulation considerations, choosing between veno-arterial and veno-venous ECMO, practical insights on vascular access, and strategies for team coordination during ECMO emergencies. This discussion is essential for trauma surgeons, emergency physicians, critical care teams, perfusionists, and anyone involved in trauma care or ECMO deployment.

With the growing prevalence of ECPR, it is now more important than ever for all individuals in the medical community to understand what ECMO is, not just those providers who are directly involved with its use. In this new podcast series, Zack Shinar and Jon Marinaro help Nathaniel Dennis-Benford, a first-year medical student, explore what a medical student should know about ECMO and ECPR. In this first episode of the series, we start from the basics: what is "cardiac arrest", how is it traditionally managed, and finally what even is ECMO?

 

AHA recommendations for ECPR at 2A - see article here

Free link for Zack and Dinis editorial on Lactate use here

If you are running or starting a US ECMO program, this episode is a must listen.  John Mehall from Innovative ECMO Concepts goes through the financial aspects of ECMO care.  He covers everything from hospital charges to physician reimbursement to areas where hospitals commonly fail.  We all know that you cannot have a successful ECMO program unless you have sufficient funding to keep it going.  Jon Marinaro, Zack Shinar, and an entire audience of Reanimate 9 attendees join the episode to ask questions and give their own insight.

Web Pricer (cms.gov) - your hospital weight.  Times it by DRG to get your hospital ECMO compensation.

This month Zack gives some pearls from his travels to Prague for Jan Behlolavek's ECPR school, Poland to meet with Marek Dabrowski, and ELSO with the entire crew.  Zack also interviews Saul Levine for the first of what may be a recurring conversation about the San Diego Resuscitation Consortium.  His efforts along with Kristi Koenig, Shawn Evans, Todd Baumbacher, and many others have paved the way for an OHCA ECPR protocol that may change more than just San Diego cardiac care.  Listen to Saul explain how the first 3 months of this process has expanded the minds of what cardiac arrest care can look like.

 

This episode is a follow up to last month's episode with Nichole Bosson.  Zack interviews Vadim Gudzenko about the in-patient aspects and critical care doctor perspective on the Los Angeles OHCA ECPR program.  A few take homes are that EMS is critical to any OHCA ECPR program.  Nurses need support for these intense patients with high mortality.  And emergency physicians need to buy in to the idea of ECMO for cardiac arrest to make a successful program.

 

Upcoming Events

Sept - ELSO - Summary - 34th Annual ELSO Conference (cvent.com)

Oct - Prague ECPR School - https://www.ecprprague.com/

Nov - Reanimate Reanimateconference.com

 

Zack and Jon's Editorial about Sakuraya PE trial

https://authors.elsevier.com/a/1hlr514RWGNg8s

 

One of the biggest questions in ECPR right now is how do we organize our system to provide ECPR in an effective and streamlined approach?  Nichole Bosson, Dave Shavelle and the army of L.A. ECPR enthusiasts have successfully implemented a multi-hospital ECPR receiving center program in Los Angeles.  In this episode, Zack talks with Dr. Bosson about how they started, what they learned, and where they are going.

 

A little about Dr. Bosson

* She is the Assistant Medical Director at the Los Angeles County EMS Agency. She is an Associate Clinical Professor at David Geffen School of Medicine at UCLA and faculty and EMS fellowship director in the Department of Emergency Medicine at Harbor-UCLA.

 

* Here is the link to her paper

Bosson N, Kazan C, Sanko S, Abramson T, Eckstein M, Eisner D, Geiderman J, Ghurabi W, Gudzenko V, Mehra A, Torbati S, Uner A, Gausche-Hill M, Shavelle D. Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest. Resuscitation. 2023 Jun;187:109711. doi: 10.1016/j.resuscitation.2023.109711. Epub 2023 Jan 30. PMID: 36720300.

 

* And here is Jason Bartos' editorial

Bartos JA, Yannopoulos D. Starting an Extracorporeal cardiopulmonary resuscitation Program: Success is in the details. Resuscitation. 2023 Jun;187:109792. doi: 10.1016/j.resuscitation.2023.109792. Epub 2023 Apr 10. PMID: 37044354.

 

 

Jon Marinaro takes EDECMO through another great podcast.  This time he interviews Christine Stead, the CEO of ELSO.  She talks about how ELSO is setting up standards for ECMO programs to try to make ECMO care at all hospitals safer.  She talks about how she works also with the device industry.  This involves working with the FDA for future innovations and CMS for reimbursement issues.  She talks about the website and how to get your program certified.  Christine as a person is amazing.  She and her 5 person team runs an organization that has its hands in so many different areas.  Also, she is avid runner having completed 12 Boston Marathons!

 

ELSO website - www.elso.org

Annual ELSO conference in Seattle



Reanimate 9 is nearly sold out.  November 2023.  Check it out here

In this episode Jon Marinaro joins the ED ECMO team and interviews his colleague Sundeep Guliani, MD about the use of an ECMO first strategy for Massive Pulmonary Embolism. Jon and Sundeep review the data and processes from their institution and from other institutions in the United States.  Could it be that ECLS could move the survival needle on this high mortality disease? Listen and find out!

Hobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP,
Gori T, Münzel T, Konstantinides S, Keller K. Clinical use and outcome of
extracorporeal membrane oxygenation in patients with pulmonary embolism.
Resuscitation. 2022 Jan;170:285-292. doi: 10.1016/j.resuscitation.2021.10.007.
Epub 2021 Oct 12. PMID: 34653550.

Shinar Z, Hutin A. Pulmonary ECMO-ism: Let's add PEA to ECPR indications.
Resuscitation. 2022 Jan;170:293-294. doi: 10.1016/j.resuscitation.2021.11.004.
Epub 2021 Nov 10. PMID: 34774708.

Pudil J, Rob D, Smalcova J, Smid O, Huptych M, Vesela M, Kovarnik T,
Belohlavek J. Pulmonary embolism related refractory out-of-hospital cardiac
arrest and extracorporeal cardiopulmonary resuscitation: Prague OHCA study post-
hoc analysis. Eur Heart J Acute Cardiovasc Care. 2023 May 12:zuad052. doi:
10.1093/ehjacc/zuad052. Epub ahead of print. PMID: 37172033.

Karami M, Mandigers L, Miranda DDR, Rietdijk WJR, Binnekade JM, Knijn DCM,
Lagrand WK, den Uil CA, Henriques JPS, Vlaar APJ; DUTCH ECLS Study Group.
Survival of patients with acute pulmonary embolism treated with venoarterial
extracorporeal membrane oxygenation: A systematic review and meta-analysis. J
Crit Care. 2021 Aug;64:245-254. doi: 10.1016/j.jcrc.2021.03.006. Epub 2021 Mar
24. PMID: 34049258.

In this episode, Jon Marinaro and Zack Shinar go through the hot off the press Inception trial.  The trial was touted as a negative ECPR study though many reasons make this trial different then the ARREST trial.  They go through several important take home points for practitioners starting or running an ECPR/ECMO program.

 

Inception Trial

https://www.nejm.org/doi/full/10.1056/NEJMoa2204511

In this podcast, Joe Tonna tells us how to approach hypothermia with ECPR patients.  He also goes through his paper RESCUE-IHCA giving us an immediate way to prognosticate in patients to use of ECMO or not.


Hypothermia - Resuscitation

Nakashima T, Ogata S, Noguchi T, Nishimura K, Hsu CH, Sefa N, Haas NL, Bĕlohlávek J, Pellegrino V, Tonna JE, Haft J, Neumar RW. Association of intentional cooling, achieved temperature and hypothermia duration with in-hospital mortality in patients treated with extracorporeal cardiopulmonary resuscitation: An analysis of the ELSO registry. Resuscitation. 2022 Aug;177:43-51. doi: 10.1016/j.resuscitation.2022.06.022. Epub 2022 Jul 3. PMID: 35788020.

Hypothermia Meta-Analysis

Duan J, Ma Q, Zhu C, Shi Y, Duan B. eCPR Combined With Therapeutic Hypothermia Could Improve Survival and Neurologic Outcomes for Patients With Cardiac Arrest: A Meta-Analysis. Front Cardiovasc Med. 2021 Aug 13;8:703567. doi: 10.3389/fcvm.2021.703567. PMID: 34485403; PMCID: PMC8414549.

In Hospital Cardiac Arrest and ECPR Inclusion

Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, Zhang C, Rycus P, Keenan HT; American Heart Association Get With the Guidelines–Resuscitation Investigators. Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation. JACC Cardiovasc Interv. 2022 Feb 14;15(3):237-247. doi: 10.1016/j.jcin.2021.09.032. Epub 2022 Jan 12. PMID: 35033471; PMCID: PMC8837656.

In this episode,  Zack interviews Florian Schmitzberger who just published a fantastic study that incorporates fourteen leaders within the ECPR community to hash out the specific procedural steps associated with ECPR.

 

INCLUSION
• Age <75 years
• Witnessed arrest
• Initial rhythm is shockable rhythm (VF / VT)
• ECPR can be initiated within 60 minutes of the arrest, though a longer interval may be considered circumstantially (e.g. hypothermic arrest)
• Aggressive ICU care consistent with patient wishes
• No prolonged downtime without CPR
• End-tidal CO2 ≥ 10 mmHg (unless pulmonary embolism is suspected)
• Treating physician/surgeon agreement to proceed
EXCLUSION
• Contraindication to anticoagulation
• Cannot perform activities of daily living at baseline
• Advanced comorbidities / known irreversible organ failure
• Advanced COPD or other pulmonary comorbidities
• Metastatic malignancy
• Major stroke or neurologic impairment
• Do-not-resuscitate / Do-not-intubate status

 

The Paper

Schmitzberger FF, Haas NL, Coute RA, Bartos J, Hackmann A, Haft JW, Hsu CH, Hutin A, Lamhaut L, Marinaro J, Nagao K, Nakashima T, Neumar R, Pellegrino V, Shinar Z, Whitmore SP, Yannopoulos D, Peterson WJ. ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation. Resuscitation. 2022 Oct;179:214-220. doi: 10.1016/j.resuscitation.2022.07.003. Epub 2022 Jul 8. PMID: 35817270.

This month Zack gives a few pearls from the recent Reanimate courses and annual ELSO meeting in Boston before he interviews Gowry Mork from Aarhus University about her fantastic recent paper.



* Pearl #1 is about hand placement in cannulation.  Hold the ultrasound in your left an
d needle in right.  Once in the vessel, drop the US probe and take your left hand and gently hold the needle. With your right hand grab the wire far enough up to be to insert into the vessel in one push.
*
* Gowry's paper has many interesting points.  Probably the biggest is the reasonable survivorship for prolonger arrests.  This is tied to equality of care for patient who live far from the closest ECMO center.

 

 

Gowry's paper - 

Mørk SR, Bøtker MT, Christensen S, Tang M, Terkelsen CJ. Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support. Resusc Plus. 2022 Apr 6;10:100230. doi: 10.1016/j.resplu.2022.100230. PMID: 35434669; PMCID: PMC9010695.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9010695/

Gowry's Twitter

@MSivagowry -  https://mobile.twitter.com/msivagowry

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

 

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