Teddy Hla Profile picture
Oct 25 18 tweets 12 min read
NEXT Speaker : VA ecmo for which patients?
Alain COMBES

Severe cardiogenic shock has different phenotypes
1. medical cardiogenic shock(AMI, end stage dilated CM, myocarditis, septic shock)
2. Post cardiotomy refractory CS (post CABG)
#LIVES2022
@ESICM #ecmo #resuscitation #ALS
@ESICM 2022 what do the guidelines say
- ESC recommends short term MCS should be considred in cardiogenic shock.
IABP may be considered but not routinely recommended in post MI
#LIVES2022
Image
What about in fulminant!myocarditis ? Mostly giant cell myocarditis #LIVES2022 Image
What about in cardiomyopathy patients?
- ECMO can be used as a bridge to heart transplant
- the other strategy is "bridge to bridge"
- 2 ecmo device for each L and R heart WOAHHHH!!
2 ecmo for 1 pt Image
ECMO has completely changed the way we manage heart transplant
- 20 years ago we dont have VA ECMO and not this rapidly
- e.g., RV failure post heart transplant.
- see below where ECMO pre Heart tx has almost as good outcome
Image
Next : what about in life-threatening PE?
this is a difficult area.
timing is very important
- as part of resuscitation OR to stabilise severe haemodynamics OR in case of failed sys thrombolytics or catheter directed therapies.

#pe #massivepe #ecmo #LIVES2022
Of course any #ecmo talk won’t be complete without talking ARREST trial. Really good outcome. Image
Contrast this with Prague OHCA
- non significant outcome.

(massive differences -- @drizopoulos has an ECMO bus that goes to scene, amongst many others) PRague - pt brought to centre.

- AGE and COLLAPSE to ECMO time - KEY

pubmed.ncbi.nlm.nih.gov/35191923/

#ecmo #ecpr #ALS #LIVES2022
@drizopoulos What about in "septic shock" - niche group

pubmed.ncbi.nlm.nih.gov/32828186/

ECMO patient has higher probability of survival . mortality dropped from 85 to 45%
Hazard ratio of 0.24.

Time window is "very narrow" here too to note.

#ecmo #septicshock #LIVES2022
Again Ecmo chat needs to reference @SCAI criteria of CS. #LIVES2022 Image
But class E may not be the right patient group. Multi organ failure is major risk factors for not surviving Ecmo. We need to find right patient group perhaps in scai C D groups. #LIVES2022 #ecmo #ECMO Image
A few more trials coming and more results likely to come out soon over next few months and years.

Another trial in France ongoing with a different primary end point.

#LIVES2022
#ECMO #als #resuscitation #mcs
Q: what about using ECMO earlier not as a final rescue device but more commonly?
A: clearly we have to move on to earlier in disease process but we do need to work on early identification of this patient groups for both ecmo and impella
#ecmo #LIVES2022
#ECMO
Q: drug toxicity cardiogenic shock?
A: again if started early could have good outcomes. WE SHOULD NOT hesitate to start ECMO in 2022 -- this is so 2010. :P #ECMO #als #MCS #LIVES2022
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More from @teddyhla

Oct 25
Carolyn Calfee Clinical and Biological phenotypes of ARDS
- what do they have in common?

ARDS : subgrouping since the begining
- sepsis vs. non sepsis
- hyper vs. hypoinflamm
- reactive vs uninflamed
#ventilation #ards #phenotypes #LIVES2022
Are clinical phenotypes biologically distinct?
looking at Trauma vs. Non trauma

ICAM-1 , SP-D, vWF, sTNFr-1 are different.
What about in "Direct" vs. "indirect"
or "Diffuse" vs "focal" -- sRAGE comes up again.

pubmed.ncbi.nlm.nih.gov/17944012/
#ventilation #ARDS #LIVES2022
Image
Read 13 tweets
Oct 25
Mariangela PELLEGRINI
Uppsala- Sweden
"Do we Need a biological definition of ARDS"

- Berlin definition has NO Diffuse alveolar damage .
- the Berlin defn does not capture well
Frohlich - different definitions specificity of 0.63, 0.42, 0.31 even!
#ventilation #ards #LIVES2022
academic.oup.com/bja/article/11…
The BJA article by Frohlich.
Fibrosis only starts after 7 days
Thille article : atsjournals.org/doi/full/10.11…
In essence, different disease processes are happening to the lung at different times in the "ARDS"
pubmed.ncbi.nlm.nih.gov/24429204/
Read 14 tweets
Oct 25
ARDS - new definition or phenotypes by @GicoBellani refreshing with Kigali definition of ARDS - useful not just low resource but during pandemic in supposedly high income settings and only draw back is no PEEp requirement #ards #ventilation #LIVES2022 @ESICM
@GicoBellani @ESICM Resolved versus confirmed ARDS
- prospectively applying Berlin definition did work but if ya wait 24 hrs and re-measure P/F ratio, you end up stratifying much better.
- Better separation of groups

pubmed.ncbi.nlm.nih.gov/29632996/
#ventilation #LIVES2022
@GicoBellani @ESICM Whichever definition - american european consensus or Berlin or Kigali -- all goes back to Ashbaugh original paper in 1967

thelancet.com/journals/lance…

Why are we so confused when it comes to ARDS definition ?

#ards #ventilation #LIVES2022 @ESICM
Read 12 tweets
Oct 25
Next : Mypinder SEKHON on cardiac arrest in COVID-19 era.

Works in Vancouver
COVID 19 era cardiac arrest ARE a lot less sexy with all the PPE. #als #covid19 #resuscitation #LIVES2022
@ESICM
@ESICM Let's look at epidemiology. Northern Italy, Manhattan - COVID hit hard and has impact on other diseases.

e.g., OHCA in Italy during COVID 19 massive spike.
Read 9 tweets
Oct 25
what about in refractory cardiac arrest?
ERC - ESICM guidelines 2021
- timing of CAG if no evidence ofr ST segment evaluation.

which means we will end up treating a lot of patients with stent and anticoagulation
TOMAHAWK trial : delayed or early invasive angiography -- no effec.

#LIVES2022
- immediate catheterisation for non ST elevationrr
Read 4 tweets
Oct 25
Updates on Advanced life supprot by Theresa OLASVEENGEN

Vasopressors and Drugs : recent trial outcomes.
#LIVES2022
@ESICM #als #resuscitation
@ESICM 2020 ILCOR consensus : strong recommendation to use "ADRENALINE" in cardiac arrest, if you dont have it "LIDOCAINE".

Adrenaline to placebo comparison is mainly 1 older trial with latest PARAMEDIC 2

pubmed.ncbi.nlm.nih.gov/30980877/
@ESICM PARAMEDIC 2 - big study
8007 pts, adrenaline 4000, placebo 3999
- a lot of discussion post trial
- need a nuanced interpretation.
- 19 "more good" survivors and 5 "more bad" survivors in adrenaline arm.

nejm.org/doi/full/10.10…
Read 19 tweets

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