ECMO has great potential, as shown in numerous studies. Still, there are the nay-sayers. The pessimists and the #ResusWankers. It’s useful to have a balanced debate, but to denouce the life-saving potential of ECMO is not useful. Once you’ve seen a low-flow/cardiac arrest patient put on VA ECMO, seen the color return to the skin, the blood gases normalising and all parameters like circulation, blood pressure, saturation and tissue oxygenation return to normal values – it is very hard not to be optimistic for many of its uses.
One group is within the invasive cardiologist group. The most conservative among them. The ones that had their peak in the 90s. When the invasive cardiologist was king, and held all focus in cutting edge cardiac arrest resuscitation: When shocks and CPR were not enough, some frontier souls would take these arrest patients to the cath lab. And in the best versions of this history, the cardiologist would have the main role and all focus at opening the closed LAD, where-after the heart would jump start with strong contractions. That’s a glorious moment in an invasive cardiologists life. And rightly so.
But they seem to forget the actual goal for the patient. In the 90s, the goal was to get the heart started – but only because we had no other way to get good circulation – because circulation is what we really wanted. Restarting the heart was just the only realistic way to get that done. Then came small and light ECMO machines with simplified set-ups. All of a sudden, we could get the circulation going without having to depend on a coronary artery that might or might not open within the next minutes, and a heart that might or might not start within the next minutes.
Restart the circulation – especially to the brain, and to the coronaries. Then you’ll have more time and better working conditions, to reopen the blocked vessel. Of course, myocardium is dying by the minute, but so are neurons.
To maximise success in selected patients, the new cardiac arrest approach around ECMO centers should be the standard early CPR and shock. If not successful within three rounds of CPR, ECMO is the next option. Angio and coronary intervention comes after circualtion is re-established.
You need a good system all the way from pre-hospital and in. The ambulance teams must be drilled in contacting the ECMO center early, to have the ECMO team ready, and the ambulance team must prepare for early and quick transport if normal CPR isn’t getting ROSC.
Many ECMO centers battle bad set-ups and slow cannulation times and slow ECMO initiation times. But Minnesota has shown what is possible: 6 mins. With a pre-primed ECMO circuit available in the room where you’d want to cannulate, and experienced cannulators with ultrasound training will get you up and running quickly. It is important that the cannulators have extensive experience with the Seldinger technique, also in emergency settings. It will differ from country to country and center to center which specialty should handle the cannulation. The important part is not to make it a specialty turf war – but to look at the best for your patient, and how to best set up such a service in your hospital.
In Minnesota, it is actually the cardiologists. They cannulate femoral artery and veins all the time. And in Minnesota they are dedicated to CPR ECMO. And they have learned ultrasound cannulation. So it works well there. In other centers, it could be the cardiothoracic surgeon, the anaesthesiologist or the emergency physician. And who-ever is doing it currently, might not be your best option when you really look at the set-up and how to minimise time and maximise success at your center.