ECMO has been around since the 1970s. this image shows a successful ECMO run! however, ecmo in the 1970s wasn't generally awesome.
- @iceman_ex at #HRreloaded
- current ECMO: portable, may be started in the field.
- remainder of talk will focus on venovenous ECMO.
- @iceman_ex at #HRreloaded
does ECMO work?
- CESAR trial: transport to ECMO center improved survival. Controversial b/c many patients didn't actually get ECMO.
- EOLIA trial: stopped early, but bayesian re-analysis suggested may be positive after all ?!?
- @iceman_ex at #HRreloaded
UK - at baseline, 5 referral centers with 30 ECMO beds (currently more due to COVID).
- @iceman_ex at #HRreloaded
cameo appearance by @DGlaucomflecken !
how much peep? ALL THE PEEP
(although maybe that's not fantastic for the right ventricle)
- @iceman_ex at #HRreloaded
hemodialysis used to be restricted to a few centers, but now it's widely available everywhere.
- @iceman_ex at #HRreloaded
evidence-based division between high- vs low-volume center might be as low as 6 cases per year, per ELSO
- @iceman_ex at #HRreloaded
lack of proven benefit for ECMO?
There is no proven benefit for much of what we do in the ICU !
- @iceman_ex at #HRreloaded
expense? ECMO appears to be more cost-effective than hemodialysis.
- @iceman_ex at #HRreloaded
lack of a destination can be a problem, but this is often our fault if we cannulate the wrong patients.
- @iceman_ex at #HRreloaded
selection of appropriate candidates up front can be tricky. which patients would do OK without ECMO?
- @iceman_ex at #HRreloaded
evolution of ECMO - might we reach a point where we could move directly to awake ECMO to minimize ventilator-induced injury?
- @iceman_ex at #HRreloaded
outcomes from ECMO at Segun's center (2 deaths from ICH, 2 from refractory organ failure, most survived!)
- @iceman_ex at #HRreloaded
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)