Neuro Resus

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Coordinating an ECMO service with retrieval Sep 25, 2018

Show notes

Since the H1N1 influenza pandemic of 2009 there has been a dramatic increase in the number of patients receiving ECMO and in the number of hospitals that provide it. Data from the Extracorporeal Life Support Organisation (ELSO) suggests that over the last decade the number of adult patients receiving ECMO for respiratory support has increased at least 12-fold and the number of centres submitting data to the ELSO registry has tripled.

The approach to the provision of ECMO in NZ and Australia has been very different, with Australia seeing a huge increase in the number of ECMO centres since 2009 (there are now at least 17 centres in Australia) whilst NZ has continued to have a single national service based in Auckland.

Multiple studies suggest a significant outcome benefit for patients treated at high-volume ECMO centres (defined as those with >30cases per year) compared with "occasional" users and guidelines from the UK, NZ and elsewhere recommend that its use be restricted to expert centres that integrate ECMO within a specialist service providing care for patients with severe acute lung disease that have the capacity to transport these patients safely on ECMO if required.

This session will discuss the evidence for the perceived "volume effect" and the challenges of providing a comprehensive retrieval service.

Optimising support Sep 25, 2018

Show notes

Optimising support by Dr Susanna Price

Extracorporeal Membrane Oxygenation (ECMO) for all? Sep 24, 2018

Show notes

I will consider this question in two parts;

Should ECMO be considered for all patients?

Should ECMO services be provided in all ICUs?

From a patient perspective, ECMO is a highly invasive intervention and like every other intervention that we consider, the benefits it provides must outweigh its risks for it to be worthwhile.

Clearly, veno-venous and veno-arterial ECMO supports are very different beasts – the patient profile, physiology, complications and outcomes differ considerably. At the extreme of the VA-ECMO spectrum is ECMO-CPR (e-CPR).

Whilst ECMO centres nationally and internationally have published indications and contraindications (which will be discussed), to make decisions around an individual case it is helpful to understand the burden that ECMO support imposes.

For patients this is the physiological burden of being placed on ECMO. This includes frequently the need for ongoing sedation and lack of mobility, the non-physiological cardiorespiratory effects conferred by ECMO, the complications at insertion and during support that patients are exposed to and the uncertain long-term outcomes. These will be discussed further.

The next question is whether all ICUs should be providing this service. The demand for this technology appears to be growing steadily, as is the expectation by other specialties within the hospital for an in-house ECMO service.

Again considering burdens imposed, housing an ECMO programme impacts workload and flow by utilising significant bed-days at the expense of other services that need to be provided, education and credentialing requirements for staff and a financial cost for these resource-intensive patients. These will be discussed individually.

Lastly, the patient outcome implications of centre volume for this highly specialised service will be debated.

VAD & transplanted patient with non-cardiac critical illness Sep 19, 2018

Show notes

Use of Ventricular Assist Devices (VAD) and heart transplantation (HT) for end stage cardiac failure have increased significantly in recent decades. These support strategies hold inherently different risks in the face on non-cardiac critical illness, and require multidisciplinary team management.

According to INTERMACS, more than 2500 VADs/year are implanted the USA. Most implanted devices are continuous flow left-VADs (75%) which deliver systemic cardiac output directly related to pump speed and inversely related to pressure gradient across the pump. Improved survivorship has resulted in increasing outpatient management, however 12-month mortality is 12%, and <30% of patients are major-event free for 1-year. Critical illness may be device related, including cerebrovascular accidents, gastrointestinal bleeding, infection or multi-organ system dysfunction. Alternatively, presenting complaints may be unrelated to the device, with 23-27% of VAD patients undergoing non-cardiac surgery during support. Regardless of etiology, patient management is inherently linked to optimizing device function. Maintaining Left-VAD flow depends on adequate preload, supported right ventricular contractility and afterload reduction whilst managing systemic vascular resistance. Attention to associated coagulopathy, anti-inflammatory therapy and early institution of anti-microbial agents should be considered.

HT is established therapy for end-stage heart failure, with more than 5000 HT reported to ISHLT in 2015. Complexity has increased due to comorbidities and recipient age. Etiologies of critical illness for HT patients include post-transplant complications such as acute rejection, graft failure and cardiac allograft vasculopathy. Acute rejection episodes affect >1/4 of patients within 1-year post-transplant. Systemic illnesses may also be associated with chronic immunosuppression, for example malignancy and unusual presentations of infectious disease; as well as medication toxicity where the post-transplant medication cocktail exacerbates underlying renal insufficiency and multi-organ dysfunction. Therapeutic interventions must also take into consideration potential drug-interactions. Recognizing and managing critical illness in the post-transplant population is exacerbated by vagal denervation blunting normal heart rate response, obscuring illness severity and limiting augmentation of cardiac output.

Transplant or durable mechanical support Sep 19, 2018

Show notes

Both cardiac transplantation and durable mechanical support with ventricular assist devices (VADs) have a parallel history – poor results to begin with followed by progressively improving results with more targeted immunosuppression, better recipient selection, improved diagnosis and treatment of rejection and opportunistic infections (cardiac transplantation) and a major step forward with replacement of pulsatile pumps by continuous flow devices (VADs).

Heart transplantation continues to be regarded as the gold standard therapy for end stage heart disease and that is why there is a rather artificial VAD indication classification – bridge to decision, bridge to transplantation and destination therapy. It is the dynamic nature of heart failure and its treatment that may mean a VAD patient may move in and out of these designations. This would argue for a single designation – indication for a VAD.

The automatic assumption that patients who have a VAD implanted should proceed with listing for cardiac transplantation (in the absence of transplant contraindications) is now coming into question. Comparing the survival of cardiac transplantation versus that of VADs is a difficult statistical problem but there is now evidence that for a subset of patients who have undergone a VAD implant that over the short term their survival may be equivalent to that of a patient receiving a heart transplant. Of course that does not say anything about quality of life and long term survival but at least there is evidence that in the short term there may be equivalent survival which makes decision making both easier and harder. The decision becomes easier in that equivalent survival means that some VAD patients don't automatically have to be considered for transplantation but harder in the sense that it is unclear which VAD patients may be better keeping their device rather than proceeding to transplantation. That is one of our current challenges.

A new heart – who gets one and what next? Sep 19, 2018

Show notes

This talk with discuss the indications for, contraindications to, and expected outcomes after heart transplant with a focus on the New Zealand and Australian experience. I will discuss the transplant assessment process and listing criteria. Perioperative and long term management of heart transplant patients will be covered. Post heart transplant outcomes (morbidity and mortality) will be discussed.

I will discuss organ donation with a focus on the donor heart, covering what criteria we use to determine if a heart with be suitable for transplant.

At the end of the talk attendees will have an understanding of which patients are likely to benefit from heart transplantation and the short and long term outcomes after transplant.

ECLS in adults – where are we now? Sep 19, 2018

Show notes

Talk will discuss the use of ECMO as advanced cardio-pulmonary resuscitation in the setting of refractory cardiac arrest.

The aim will be to provide useful information for those already experienced in ECPR as well as those with no experience but an interest in establishing an ECPR in their adult centre.

Topics covered will include the rationale for the use of ECPR , the evidence base and current Australasian practice.

Practical issues re patient selection , cannulation , post cannulation management of haemodynamics , monitoring and ongoing management of the ECPR patient will be covered.

Potential future directions for ECPR will conclude the talk.

ECLS – where are we now? Young ones Sep 19, 2018

Show notes

Extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (ECPR) is an effective therapy to improve outcomes for children who experience cardiopulmonary arrest. Survival after ECLS varies between 60% and 75%. For ECPR survival is lower, with 40% to 50% of children surviving ECPR. After ECPR good neurological outcomes are seen in 40% to 60% of children. This contrasts with adult patients where neurological outcomes after ECPR are poor. Given these findings the American Heart Association has included ECPR in their 2015 guidelines for children who experience an in hospital cardiac arrest (IHCA).

Several modifiable and non-modifiable factors have been identified as influencing outcomes after ECPR. Location (in-hospital versus out-of-hospital[OHCA]) of cardiac arrest as well as pre ECLS CPR duration impact survival. For children, OHCA is generally viewed as a contraindication. However patients who achieve intermittent output during their OHCA may still qualify for ECPR, particularly if they show signs of good cerebral perfusion during the CPR event. Whether the duration of pre ECLS CPR impacts survival is debated, with studies showing conflicting evidence for and against an observable effect. Duration of in-hospital CPR should therefore not serve as a decision making guide whether ECLS is offered to patients or not.

Post resuscitation care equally raises challenges: targeting normothermia has become a clinical standard, but what oxygenation (which can be independently selected via ECLS) should be aimed for remains unclear.

The organisational structure of a hospital-based ECPR program influences patient survival and must be tailored to the respective institution's ECLS experience. ECPR eligibility should be anticipated, possibly for any patient entering the hospital. There must be clear agreements for inclusion and exclusion criteria, the latter including severe cerebral injury (hypoxic, metabolic or haemorrhagic), end stage terminal illness or uncontrollable haemorragic disease.

ECPR confers a clear survival benefit for children, but due to logistic requirements remains challenging to implement.

We have ROSC. What next? Sep 19, 2018

Show notes

Patients admitted to the ICU after cardiac arrest have, by definition, achieved ROSC. In such patients the major issues remain those of ongoing support hemodynamic and cardiorespiratory support, cerebral protection, aetiological diagnosis, and rapid intervention to deal with the underlying trigger (coronary angiography and stenting of coronary artery disease or CT pulmonary angiography and anticoagulation/thrombolysis for PE). Once the aetiological diagnosis has been made and its cases addresses and cardiovascular stability has been achieved, the priority of care is directed toward cerebral protection. Previous randomized controlled trials had suggested that hypothermia would deliver superior neurological outcomes compared to usual care. However, methodological concerns led to a further large trial of strict normothermia (TTM-1) which found strict normothermia to be equivalent to hypothermia in terms of neurological outcomes. Such findings have led to the design and randomization of patients with out of hospital cardiac arrest (OOHCA) to normothermia vs. avoidance of fever (TTM-2). At the same time preliminary work has demonstrated the potential of hypercapnia to act as a cerebral protector in patients with OOHCA. His has now led to a large trail called TAME, which currently also recruiting patients worldwide and in ANZ. These two trials will provide important information on the outcome of OOHCA patients and may identify new ways of achieving cerebral protection in this setting.

Resuscitation update Sep 19, 2018

Show notes

The good news in resuscitation is that there have not been any new advances that mandate a change in practice since the 2016 ANZCOR Guidelines. The bad news is that despite our best intent, the ever-increasing research appears unable to demonstrate improved outcomes with any particular approach. Two of the most exciting areas (eCPR and post-resuscitation care) are being covered in detail at separate talks at this meeting. This presentation will focus on updating the audience on the more continuous approach to evidence evaluation, and the key recent publications that have made us at least re-evaluate our practices in BLS (including ventilation), ALS (including anti-arrhythmics) and peri-resuscitation care.

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