Pediatric ECMO: Update Course 2018

The next talk is something that I asked uh Doctor Herschel to talk about because it's something that we've had questions about uh at our organization about um how is the best way to implement an ECMO program for the older patients. Uh, some people call it pediatric ECMO or older child ECMO. Um, um, so, uh, Doctor Herschel and his program, uh, in Michigan, uh, have really, uh, led the way and taught a lot of us about how we should be doing this. So I'm hoping he will teach us now again about pediatric ECMO. You talk about innovation, that was, uh, that was amazing. First off, this is Alejandro Brazalus, and I wanna thank her because she was incredibly helpful in putting together these slides. So everything you see in the slides is because she did it. I, uh, I helped her with the content, but she, she put it all together and actually made sure that I didn't do too many slides. OK, so you want to do the case presentation? OK. Uh, so we started, we wanted to start this topic with a case, and it's a pretty complex case, but we'll sort of go through it. It starts with a 14-year-old male, previously healthy. He had flu-like symptoms for like 24 hours, got increasingly lethargic and fatigued, and her parents brought him to the Emergency room with shortness of breath and fever. In the emergency room, he developed respiratory failure and had to be emergently intubated and subsequently developed hypotension, not responsive to fluids, so they initiated presser support. His X-ray looked something like this. He was transferred to Mt Children's on those ventilator parameters and those pressures that you see there, requiring intermittent bagging to keep PSAs in the low 80s with a PAO 2 of 50. Respiratory PCR came back positive for H1N1, and we as a group are consulted due to the lack of response to these escalation of therapies. OK, so we had a few things in here that we took out because, um, I just want to go back up for one second and, and note that these are really high vent settings and in fact, uh, there's something called the ARDS net which at the end of the 1990s, um, uh, informed us that in fact we ought to try to keep our peak inspiratory pressures less than 30 and our, our, um. Our, uh, volumes, uh, around 6 ccs per kilo and so we're way off that and they may have had to do this in order to keep him alive, but he needs to go on ECMO. Um, also, I was going to talk about the indications for ECMO, but in this 30 minutes I decided that we would instead, um, concentrate on some of the things, um, some of the technical aspects of ECMO and cannulation and so on. And one of the, I guess we can't do any, we can't do any polling, is that right? We can, we can't. OK, so the poll is this, uh, what components would you use for ECMO? Uh, membrane, lung, why don't here, you go ahead. OK, so we have membrane, lung and roller pump, membrane with centrifugal pump, or hollow fiber lung with those two combinations. We have some of the results coming in. What are they looking like? No, just turn around. It, it's not there. So what are the people here, uh, uh, what, what do you all think? What, what should we do? What would we, what would you use at your institution? Any thoughts? Uh, no, knowing it, somehow that one up, knowing absolutely nothing about ECMO, I think I read somewhere that there's a difference in hemolysis rates between the two types of pumps, and if I'm correct, the centrifugal one has a lower hemolysis rate. Is that correct, or am I the other way around? It's the other way around. It's the other way around, but it's a very, very, very good point. Um, so actually, actually, uh, there have been a lot of changes recently, and, and when I started doing ECMO, we did it with a roller pump, uh, which is occlusive. If you, if you clamp something on the out, outlet of the roller pump, it'll, it'll blow out. In fact, I've had that happen, um, and And if you, if you, um, uh, the, the, uh, membrane lung, uh, was, uh, just a sheet of membrane and, and, um, and now we have hollow fiber lungs. Used to be those hollow fiber lungs leaked after about 40 hours, not anymore. Uh, they have a coating on them which, which prevents leakage of, of plasma, and so we can use them now for long term support and the, and the, the, um, the pumps are now what's known as. Maglev pumps, they're magnetically levitated. So it used to be that the, the centrifugal pumps were on bearings, and they would heat up and they would cause hemolysis, but now they don't anymore. Actually, it may be, and some data suggests that still with these pumps and these hollow fibers that we have a little more hemolysis. But the bottom line is it used to be horrible and not anymore because they're magnetically levitated. There's no bearings, and so it's very little friction and very little heat. And because of that, we can now do use um these centrifugal pumps and hollow fiber um lungs for ECMO. They're very low resistance. They're non less, less, much less thrombogenic, and they're, they're much safer because if you clamp the outlet of a centrifugal pump, it won't blow. And if you clamp the inlet, it doesn't suck very much, so it doesn't cause hemolysis. And, and in fact, that's why a number of places now are not having specialists, but in fact they're having the nurse do both the patient care and the ECMO care, and it's almost becoming like a respiratory therapist. There's one in the unit for all the patients on ECMO. And one of the things that I also was going to show you, which is very interesting, is that the number of cases of ECMO. Um, what, what do you think that the the greatest number of cases are? I'll ask the panel here, uh, newborns, pediatric, or adults? What do you think? What do you say? I take pediatric cardia. Pediatric cardia. It's adults by far. I, I don't know if it's two or threefold, um, and the reason is because of H1N1. And following H1N1, uh, the, this, this change in technology, so ECMO is being used in many more adults, um, and it's actually being used earlier. Uh, it's becoming a, a first, a, a almost a go to support system, uh, when you're failing on the ventilator. So, so actually neonatal and neonatal has cut down in about 5% because of nitric oxide. Peas has continued on, but adult has just burgeoned in terms of the numbers. OK, and this actually was one of the, uh, one of the questions which the PDC, uh, the Professional Development Committee wanted to, wanted to go over, and I, I took that on. So, so here you go. So for this patient that as we recall, had respiratory failure initially, that was his presentation, which ECMO modality would you use? vena venous or vena arterial? Yeah, and let's note that the patient is on pressors, on very high ventilators uh support, uh, has ARDS and, uh, and so, uh, you have a choice of going veno arterial or veno venous. I 80%. 0 good. OK, so, so yeah, so whoever put this patient on actually used veno arterial. I'm not saying that that was the right thing to do, but they were on a tremendous amount. One of the things that they may have done is they may have looked at it with an echo at their cardiac function. And in fact, after this specific patient went on ECMO, um, this patient had cardiac standstill. So in the end, actually, which. Sometimes it happens it's almost like the heart has been on so much in the way of pressors and, and has, has been working so hard that, that we think that, uh, uh, you know, the, the heart just basically tires out when you get on ECMO, there's some increased afterload when you're on to the heart when you're on uh VA and it goes into a standstill for a day or two and then start to actually. It's, it's function, it's not electrically, the, the heart still has, um, has waveforms, but it just doesn't eject and, um, and will, but it almost always will come back. So, um, however, um, you know, the use of this is just a clue you in here, VA is in red and VA is in blue and you can see on the left, the, the overall cumulative over the, the, uh, I guess it's close to 28 years or something. Um, maybe even more, um, 30-something years of the, of the registry, and, and you can see in the past year that the compared to overall that the, the number of VV in blue cases has increased substantially in pediatric ECMO compared to, uh, the, the early days and, uh, and, and overall over those, uh, all the years of the, of the registry and so in vino venous. Really provides some some advantages. Um, VA provides is, is advantageous in terms of human dynamics support. It offloads the right heart. Um, it actually increases the, um, after load of the left heart, but you don't have any recirculation, which is, which makes oxygen delivery much better. Um, uh, VV on the other hand. Um, gives you a normal left ventricular afterload and reduced risk for a systemic emboli coming out of the circuit because it goes into the venous side. And you don't have to cannulate an artery and therefore you don't have ischemia to a leg or stroke, uh, stroke because you cannulated the carotid or whichever it might be. So VV is, is markedly preferred. One of the comments that I would make is that this patient had, was on high ventilator settings and probably needed a lot of pressors, but once you took those ventilator settings off, those pressors may not be required. And so, ah, we tend to give the benefit of the doubt that that VV will work. In other words, that once you get onto ECMO with VV, you take the press, you, you take the, uh, ventilator settings down that, um, that they won't need as much in the way of, uh, of pressors. They still may need some. The oxygenation will not be as good. You'll be running SATs in the low 80s to mid 80s and the SVO2 will be hanging out at maybe 60 and sometimes even a little bit lower, a little bit above, but, but it's adequate and, and you see the advantages to VV and so that's why, um, really the, the, the, um, the, the best approach is to go VV unless you have specific reasons why you need to go VA. Any comments? Uh, just 21, I would disagree with you. I think this child had very high ventilator settings and lung injuries, so it has very high pulmonary vascular resistance. It would probably benefit from VA, so I don't wanna bypass the lungs for a while. But, um, uh. The, the second question, cause that's sort of a, how do you convert from VV to VA? And the third question to just throw it out there, why not a sternotomy and cannulate right into the aorta and avoid all these peripheral vascular injuries? Well, central cannulation or going right into the aorta has, has issues with two big issues. One is that you end up having bleeding problems, and, uh, the second thing is, you have an open chest and the patient that, uh, this patient, uh, may be on eCO for months. Um, and so, uh, doing it through the chest has it, you can do it, but it has their issues and, uh, mediastinitis and, uh, having an open chest, and, and so we prefer to do peripheral cannulation for those reasons. Um, converting from VV to VA, it depends what your, what your VV cannulation strategy is. If it's a double lumen, uh, cannula, then, then, uh, we simply cannulate the, uh, the, the artery that we're going to cannulate. We'll talk about that in a second, but, uh, and, and. Um, can then drain from both the, the, um, uh, venous, uh, uh, limbs, um, and the same thing is true if it's, uh, if it's, uh, let's say you used a femoral and jugular, um, venous cannulas, um, you can do the same thing. So you can drain from both of them and then, and put a cannula into the carotid or femoral, whichever you're gonna do. So that's, that's how it would convert. A real good question is when do you convert, and that requires a lot of judgment. There's. There's a tendency to, to, um, worry. I'll put it that way, especially when you're on a veno Venus and the sats are a little, are sagging and the, and the venous, and the mixed venous saturation, oxygen saturation is sagging and. And you know, should we put them on a lot of hand wringing, um, I would say especially in the first day or two that, um, uh, sort of, sort of biding your time and, um, and, and letting things settle out and letting some of the physiology improve a little bit often will, will give you the right direction. Other comments? Question is, do you use, uh, uh, so you use echocardiograms for your decision making early on? Well, I think it helps you. I mean, if you really see that there's a, a heart that where the function is poor, then, then that will direct you. Um, I think that, uh, and you see a heart that's really functioning pretty well, then that also, you know, uh, gives you some direction. I have one more question because you're an expert and I don't know the answer to this one. heparin, well, heparin is sort of a nightmare because you can never, you're always over anticoagulated or under anticoagulated, and you, I don't know if follow ACTs or heparin levels and it's a disaster, but how about by Val Rudin? I mean, it seems like it's a great solution. So there have been a lot of, a lot of, uh, centers now that have gone over to Balerudin, and some of them have used it in hundreds of, of patients, and some centers have used it in specific, uh, areas when you have, uh, heparin induced thrombocytopenia is one, but another one is, is, uh, in diaphragmatic hernia. Um, the, the data on, on that are mixed. Some have found that for instance, in, in diaphragmatic hernia that have been operated on, the bleeding's less, and others have said no, it's. It's the same, but, but it's much easier to control by Valeruddin, um, and, um, and, uh, it's, it appears to be overall anec I'll say anecdotally, it appears to be a, an, a safer mechanism or safer means of providing anticoagulation, and a lot of centers are, are have, are switching or thinking about switching. I will tell you in Michigan that we're getting uh the best way to put it is we're talking about it and we're making plans and um and we think we're going to um probably move over it's a lot of education it's a big change um but uh but it's it's easier to manage and and um appears that it may have some advantages over Heparin. Age wise, any, I, I, I don't think that, yeah, across, across the board, the, the big experience really there are centers um that have, have, um, have used in adult patients have used by Valerudin as their as their first line anticoagulation in hundreds of patients. And, and so there's a, there's there's a fair amount of experience, but it's uh it's, it's in pockets, so it's in some centers that are using it and they've had had pretty significant levels of experience but not broadly. OK. So, what is your preferred cannulation site for VA ECMO? And we have carotid, uh, carotid IJ combination, femoral versus, uh, with femoral IJ subclavian and IJ or femoral, and then femoral IJ. And let's see how the pole's doing. I'm just gonna pick the whatever, so we can see the results. for this child who's 14. Yeah, let's see, let's do a, yeah, um, let's do an older child, yes, 14 years old, exactly. Uh, anybody have thoughts on what you would do? Uh, I'm, I know I'm the disruptor, but I would go central. I think it's just safer. You're not gonna stroke anybody out. You're not gonna have any ischemic legs, and you have excellent circulation. So, I think it'd be safer. Well, I'm actually pretty excited about this, uh, this talk for just this reason, because, uh, growing up and, uh, and cannulating femoral artery and, and, uh, the internal jugular vein, which was sort of our go to, um, uh, is painful and has a lot of problems associated with it, but we were all, all taught and largely by the Michigan group to, uh, uh, don't tie off those carotids, uh, after about 2 years of age, or maybe you can push it to 4 years of age, and now you've taught us differently. OK, so how do I, how do I see my, so we got 72% carotid IJ leading. OK, so, so, um, first off, I just want to talk about VAV. So, this is a, a, a different kind of, uh, so this is one of the problems with doing femoral, uh, vein drainage to femoral artery. OK, one of them is ischemia of the leg, the other is that what's called North-South syndrome. So, um, how do I, can I point? Well, let me just say, if you, if you look up at the, at the purple arrow up in the heart, the blood coming out of the heart is ischemic. It's, it's or it's hypoxic, and it's feeding the head and it's feeding the heart, you know, the coronaries and it's feeding the upper arms and so on, whereas the blood that's coming out of the eCO circuit, that's the bright red, um, arrow, is, is well oxygenated. So the legs and the lower body are really well oxygenated and the things that we want to be well oxygenated like the head and the heart and the, you know, and, and, and so on are, are poorly oxygenated and so we call that north-south. Syndrome. So one of the ways that we've gotten around that is to put another cannula into the internal jugular vein, and then what you can do is you can, you can direct blood from the emo circuit into the right atrium, and, and that's pretty well oxygenated blood, and that blood then goes through the native um uh cardiopulmonary system and comes out of the left ventricle and therefore the, the upper body is, is much better oxygenated and you can put a. Hoffman clamp on the, the blood that's coming out of the cir circuit that goes into the femoral artery and the and you can see it up there it's actually on on the one that goes into the into the uh uh uh internal jugular in the right atrium and so you can actually adjust how much blood goes into the right atrium how much goes. Into the into the femoral artery. The femoral artery really is has reinfusion for blood pressure support, and the one that goes into the right atrium is for oxygenation of the upper body. And so you can adjust them. It's not easy to do, you know, it's not ECMO 101. It's about ECMO 510. Um, so it's, it's, it's, but what it does is it allows you to cannulate the femoral artery and vein, and we'll talk in a little bit about, about the ischemia part. But the other thing that I just want to point out is this is from Samir Gattapali. He took the 30,000 patients in the registry, and he looked at the stroke rate. And in the red, what you see is the stroke rate when you don't cannulate the carotid and in the blue when you do cannulate the carotid at a variety of different ages, right? All the way up to, you know, neonate up to 18 years of age, and the stroke rate is about 5%. Um, if you cannulate the carotid, but look, the stroke rate, if you don't cannulate the carotid is only about 1% less. So we tend to go, Oh boy, we have a 5% stroke rate if you cannulate the carotid. But actually some of that is endemic to the, you know, the physiology and disease and so on and so forth. So, Kaling the crowded is not like, it's not the, it's not the end of the world. I just want to say that. And I, and, and what I really want to make as a point is, is if you have someone who's really sick, OK, don't mess around because you can sit there messing around. Trying to knock came at the carotid when the best thing for them is to get on VA bypass and get them stabilized. So, you know, we all have seen patients that are, you know, that are, you know, they're a little hypoxic and that you have time and those that are really compromised and need to get on good support. You know, uh, Ron, two things about it that, that, uh, obviously, what we want to do is deliver our oxygenated blood to the heart and the brain, the most vital rather than the legs. And so that's appealing in terms of your carotid cannulation. I wanted to ask you a little bit about your, your combined, uh, or your inflow via the, the right atrium. And my question there is, some of us have struggled with getting adequate venous drainage through that, uh, through that femoral vein catheter to support ECMO. Has that been a problem for you or are there tricks that you can give to us? Well, especially, let's talk about this, patient, you know, who's older. Um, we, we in general put around. In older, uh, teenagers, you know, we'll put something like a 23 French, it's a 23 French shorter cannula that we put in the groin and the same thing that we'll put in the, in the internal jugular, and that's plenty of drainage. Um, I'm gonna show you some data. We're going to ask a question in a minute about which way should you drain from the femoral or drain from the, the right atrial, um, but, uh, but so we'll talk about that then. So I have a little bit of an odd question. Which, where does the hemispheric stroke or, or carotid stroke occur on the side you ligated or on the other side? Because I've seen both. Yes. Yeah, and it can occur on both. And then actually the, you know, the, the, um, uh, it depends whether it's an embolic or whether it's an ischemic, and, and it happens in, in both. And, uh, and, uh, um, so, um, and that's one of the reasons why you end up with such a high rate also of the non- carotid, um, cannulated, uh, group as well. Ron, I was wondering if you can comment, you know, we've all seen the ischemic leg after you put the femoral cannula in, and I know you guys, you guys taught us to take, you know, this little, put an angio cath in the posterior to. Maybe, maybe you'll address that. OK, OK, great. That's, that's, I think that might be the next, next question, but yeah, of course. I think the graph that you show is interesting, but I thought the real concern was not stroke at 18 years, but stroke at 68 years when you have atherosclerosis in your other carotid. Yeah, so that's a, that's another question about whether or not you should repair the, um, the carotid after you decanulate and, uh, you know, since we have 30 minutes, I think I'm just gonna have to say this much about it, and that is that people also worry that having repairing a carotid artery that could have. Clot in it that could be abnormal, that could have atherosclerosis in and of itself. You could, you could debate both sides of that argument very effectively, let's put it that way. And um there are there are centers that repair it and centers that don't, and they both give very good reasons as to why they choose one or the other. OK. And this, this just, at UFM just uh as a, you know, to give you what we do in VA for child less than 35 kg, we do carotid IJ. You get over 35 kg because you were saying in, in an older patient, yes. And um, we might go the, the groin and then, uh, or, or the carotid and IJ as I discussed, just depends on, on, uh, uh, but, but again, remember, we, we would really try to go VV. OK, so. Yes, so what they were saying over there, would you do anything to prevent uh leg ischemia in an older child when cannulating the femoral artery? So your options are you can use a small cannula, you can cannulate distally, you can cannulate the posterior tibial or nothing different. Todd, how much time do I have? OK. Right, no problem. Right, I got it. Yeah, I think I had it up on a slide too, so, but it's been mentioned. OK, so, so yes, uh, we, we think that, um, that, uh, there's some data from, uh, Charlie Stoller's group, which looked at femoral artic cannulation from 2 to 22 years of age. And 50% of them had ischemia. Some of them, now they, they did not can't the posterior tibial. They cannulated retrograde down the femoral artery. So that's a little bit different. In fact, in one of those, they had a compartment syndrome because of, I think because of blood flow down or some, something happened. I don't quite know what. But the bottom line is, even with a distal profusion cannula, they ended up in 9 of 11 having ischemia. Um, in two of them, uh, that didn't have a profusion cannula, they at least in one of them, they ended up with a, with a, uh, below the knee amputation. And almost every femoral cannulation store, you know, uh, uh, series has, has a, uh, um, Uh, so it's changed some. Um, every cannulation series has, has a, uh, a, a below the knee amputation, um. So, OK, can I go to the, can I go to the other, let me. So, we would, we actually in older patients will do um a posterior tibial artery and we do it routinely. You can see toward the bottom there that 58% that were less than 6 hours, got a posterior tibial artery cannula, um, had no problems, and 42% greater than 6 hours had some problems. So we always, we always do it, uh, just routinely now. regret. Um, somewhat, some, sometimes what we'll do is sew a gortex graft to the side of the femoral artery, then you don't have to do all this stuff. You just can, you cannulate the cortex like that, like that. So yeah, so there's some other creative things. I mean, you know, you're a place that does a lot of ECO, so, you know, I mean, and, and so, um, putting a, a, a side cortex onto the femoral artery also onto the subclavian artery. So, a lot of adult practitioners use that routinely. That is a subclavian access, and that way you're not dealing with the leg, arm tolerates things a lot better. So, we call it a stovepipe uh cannulation, and uh it's pretty, pretty, uh, pretty effective. I just want to mention here that, that um this is a really good paper if you're interested in the technique, like the specifics of how do I, how, what do I put in like a 6 or 8 French cannula or an angioath and, and then how do I hook it up to my ECMO circuit. Um, this gives you a lot of, uh, a lot of information on those specifics because a lot of people haven't done this. The one picture you showed had artery on one side and vein on the other. How often do you boo? How often do you do both groin? The one, didn't that have the venous on the arterial on one groin and the venous on the other groin? No, that one, it's got a venous, and I, I just never, I thought one leg, I, I thought one leg at risk was sufficient for each patient. one-legged wrist. Yeah, I don't know. This was done. This is a picture in their, in their, um, paper, but, uh, I mean, it's, there's nothing wrong with it. You can choose to, one of the things I think is prob probably is when you start putting distal profusion cannulas retrograde, is you use up a lot of real estate. And so there's not a lot of room for that venous cannula, but, you know. What's your preferred uh technique for gaining access to the posterior tibia? Do you cut down on it? Do you use ultrasound? Do you have IR help? What's your strategy for that? Yeah, we cut down on it, cut down on it. Um, you make about a few centimeter, um, incision, just cut right down on it. There's a retinaculum there. You go through an artery sitting right there and then you just tie it off and then, uh, distally and cannulate it. OK. So, uh, VV VVACM modality what you use, and we have VV with, uh, draining from the femoral and reinfusing into the IJ, draining from the IJ and reinfusing into the femolar, femoral or using a double lumen cannula. Uh, I think we've ended up in most of these older kids, at least at some point in time with a, a drain in the neck and a drain in the femoral, both. Yeah, the, the, uh, notion of a, uh, a double lumen cannula certainly, certainly appealing in terms of the simplicity of, of putting that in. It means, uh, that you have to have an adequate size and you have to position it in such a way so as not to injure, uh, during your positioning. Yeah. So we, we, we're doing a double lumin Avalon cannula, um, but, you know, the, uh, the other, the other thing you don't have up there is, I know before we did that, and when we don't have the Avalon available for some reason, we'll do, we'll do IJ femoral, but then we'll put a cephalide IJ cannula as well. And that, or, or sometimes sometimes even in the big kids, we'll do a cephalite just to get it because you're right there, the veins there, you know, and there's a lot of blood coming down from the brain. It's, it's, and there's actually, and I've even done both percutaneously with a double stick, one up, one down. So there, there's room for that. You can do that too. Great. So, so yeah, so, so this is a study that we did a number of years ago. And, um, and, um, of course, anything in Michigan is called the M. So it was the M bridge. Actually, it's because it's, you can see the M in there somehow, right? And, but, but what it allowed us to do was we could do femoral, atrial or atrial femoral, right? We had cannulas in the femoral and cannulas in the IJ and one cannula in the femoral, and one can vein, and one cannula in the IJ. And then what we did was we either drained from the IJ and went back into the femoral or drained from the femoral, went back into the IJ and we could do it by clamping, you know, various ends, sides, ends of the, of that bridge. And the bottom line is what you see in the graph is that when you went femoral, atrial, that you got the best that, so, so, drain femoral, infuse in atrial, and that's because you don't recirculate. OK. So, if you, if you drain from the femoral and or drain from the atrial and reinfuse in the femoral, it goes back up to the atrial and you recirculate. And so, and actually we got to your question, we got pretty good, we got great femoral drainage and then reinfusion into the atrial, and so that would be our preferred, but actually this is the, you know, across the country and even the world now, the Avalon is the, is the preferred access. Uh, the, the problem with it is that the, that you have to place the distal tip into the inferior vena cava, that's not easy to do. Um, we're very fortunate that Marcus Jarboau is a, is, was, is IR trained in our institution. So, you know, with our comfy catheters and our, our wires and so on, he's taught us enough that we're able to actually make this something that's, that's, that's pretty easy to do. But you got to get in, you got to get a wire down into the femoral, into the inferior vena cava. And, and, but it's a single cannula. Patients, you know, I mean, it's, it's well tolerated, um, and it allows more mobility, which will be another question we might get to. So anybody have any comments on that? Do you need, uh, fluoroscopic guidance in terms of placement? OK, we're gonna get to that in just 11 minute. Thank you for that lead in. OK, so now what about if this were a neonate though? We, we're gonna get, go out of our, would, would you use the Avalon double lumen cannula? Avalon, uh, IJ femoral or an origin cannula. We're running out of time, so we're gonna have to stop doing polls soon, but let's see what this looks like. OK. Haven't they stopped making origins? Uh, no, uh, the origins actually had some issues with, uh, with their, I'll say their quality control. And, uh, and so, but, but actually now the number of, of the breadth of the origins of cannulas and in terms of size has actually increased. The difference is the origin cannula only goes into the right atrium. The Avalon goes into the distal, um, uh, into the, um, IVC so. OK, so this is data uh back in 2012 from, um, from Texas Children's where they had a series of neonates, uh, they did, they did cut down and they found that, uh, 9 neonates they did pretty well with the with an Avalon cannula. There's a presentation at, at APS I don't know whether it's been published, which showed that atrial perforation with an Avalon increased from 0.1 to 3.2% and from, um, uh. From Leicester, um, uh, Giles Peake and his group in Leicester in England, where they had a 6.9% right atrial perforation rate. OK. Yeah. And, and not only that, repositioning this thing, the problem is that the distal part of the cannula has to stay in the IVC and it's very short. And if there's any kind of movement, it flips out. And once it does, In order to get it back in, you have to, we, we, we developed some tricks to doing that. I don't have time to go into it, but you have to, uh, essentially come off bypass in order to get a wire down and get it back in. So it's, so it's, it's treacherous when it does. Um, the origin cannula does stay, does not, as you can see here, um, in the upper right corner, the origin is in the right atrium instead. And, um, and so, um, it, it is easier to place than, uh, than the Avalon. And because of this issue of perforation, um, we, uh, no longer use an Avalon less than 19 French. So if you have to use an Avalon less than 19 French, we'll, we'll do VA or we'll do an origin or we'll do something else. Um, and that's because of this issue of the cannula needing to, to, um. Engage in the IVC and when it flips out, boy, it's a problem and then also this issue of perforation. Do you have a problem with the Avalon occluding the hepatic veins if it's gonna be in the IVC? It can go down into the hepatic veins, um, but we usually can identify that when we're putting, when we're putting them on by, by our imaging, but, um, but I haven't had a problem with occluding it. OK. And um I'm just gonna move through this then. Uh, this is which technique do you use for cannulation uh during with the Avalon double luin cannula, your question, correct? And, and that is that we believe, we take all of our, if we're gonna do an Avalon, we, we, we actually now have the ability to do fluoro up in the intensive care unit, but we will not put an Avalon in. Without fluoro, and the reason is because the, we, we use both echo and fluoro and go ahead this, and this just shows what you see when you, you know, in terms of the, the echo and you can see the cannula and where it's loced see the flow, flow out of the cannula and into the right atrium and so you know you've got it in good position, you know it's not in the hepatic veins and then we also inject contrast when we're doing fluoro. Um, and, uh, and so we can see it go nicely into the, into the right atrium, the right ventricle, and up into the pulmonary artery. But the problem is that if you, even just using echo, the wire can go into the right atrium, into the, um, right ventricle and come back out. And when you're, you're pushing that cannula in where you are at that point, then, you don't. No. And um we've seen and heard of enough perforations that we are uncomfortable without having imaging that allows us to see the wire, to place the wire, see the wire, and therefore to be able to put the cannula safely into the inferior vena cava. So if we're going to use this cannula, we will only do it in um in uh um uh in the OR. Yeah, so, so we're in a time crunch, but we have a question from Doctor David Rothstein from Buffalo. So he wants to know your opinion on ECPR. Oh, OK. So good question. So we did, I have to tell you, I was involved in ECPR for many years, running in from home and, and, uh, you know, around the hospital. We did ECRPR for many years and, and, um, and we got about somewhere between a 30 and 40% survival, which is not, not bad. I would say that those patients that if everybody's there and they're in arrest and especially with the cardiac patients which seem to have some correctable problems that it's reasonable to put them on. On the other hand, we don't do it blanket as in somebody arrested, we're going to put them on we're going to put them on ECPR. That being said, there is a A big push in the United States and Japan and some other parts of the world to do ECPR from out of hospital arrest. So in other words, patients come into the emergency room, they still have they still have fibrillation or whatever. The cardiac rhythm may be and they're emergently cannulated and put on ECMO, often taken straight to the cath lab and can and put on ECMO and so that's a there's a big push around that. It's been shown to increase the survival compared to standard. Survival from at home or out of hospital arrest, which is dire, very poor, and so there's a lot of work being done in that area, and I think it just remains to be seen, but you know how it works, but I do think that there's going to be a role for ECPR in that circumstance. M you comment on your choice for cannulation. In those circumstances, is it, is that when you go right to the neck? Yeah, usually, actually, most, mostly it's, it's femoral, so it's femoral artery, femoral vein, um, easy access, um, easily identified by ultrasound, um, you know, it's away from where people are working and doing, doing CPR and, um, and then, and you get femoral and arterial and you can deal with the other consequences. So I, I will just say one last thing, and that is, um, in terms of when you have a small pneumothorax and patient is not being affected by it. Um, I would not hurry to put a patient on ECMO. Um, so, as it says, sit on your hands, don't put lines, don't put chest tubes unless you have to. If they're physiologically compromised or you really think that it's, it's compromising their gas exchange or their ability to come off ECMO and so on, fine, but we've had plenty of chest tubes we place. You put a chest tube in, I would say about half the time you're going to end up doing a thoracotomy because of bleeding and, um, and. Uh, you know, that ends up with doing a thoracotomy, packing the chest, um, leaving it open, and so on and so forth. So the bottom line is, um, is think, think about that before you put the chest tube in. If, if you need to put it, you should go ahead and do it. Um, but on the other hand, um, don't, uh, don't, uh, don't do it unless there's a good reason. So Ron, um, are we, are we going, Ted? Are we live? All right. Uh, go ahead in the chat and tell us if you guys can see and hear us, uh, cause that's how we know. You guys tell us you see it. Um, why don't you do me a favor, Ron? Can you in? 30 seconds to 60 seconds summarize every major key point, yep, because that's what I, I, that's what would be a great thing to post is to show people the key points that you made. So, uh, ECMO has changed. We mostly use hollow fiber lungs and, and, and roller pumps. Try to do VV whenever you can. Avoid VA, but use it when there's, there's, uh, uh, uh, hemodynamic compromise that. I'm sorry, did I say it? I'm sorry. You want to use membrane lung, sorry, I'll start again. You wanna use mem you wanna use hollow fiber lungs and centrifugal pumps, um, uh, whenever you can because their, their tech the technology is so much better, uh, for performing ECMO. Um, the, you want, you would like to use VV whenever possible. Uh, if you need hemodynamic support, uh, then using VM. No arterial is reasonable, but in most cases you should be able to use veno venous even when hemodynamics are compromised before going on ECMO. Your preferred site of cannulation for VA in younger children is the carotid artery. In those greater than 35 kg, it's going to be the femoral artery and femoral vein. Perhaps adding in a cannula to the IJ vein, uh, or if they're really, really physiologic compromised and sick, um, uh, go straight to uh carotid and, uh, and, uh, internal jugular. Um, if you do use the, uh, femoral artery, uh, uh, cannulate soon after with a posterior tibial artery, uh, prophylactically, uh, don't wait for ischemia to set in. Um, in general, veno venous, uh, uh, should be by a double lumin cannula. Um, if you are going to use an internal jugular and femoral cannula, uh, uh, use the approach which is, uh, uh, draining from the femoral and reinfusing into the atrial. Um, In neonates, we don't recommend using the Avalon cannula in those that require a size less than a 19 French cannula because of perforation and, and, uh, uh, positioning issues. If you're going to place an Avalon double lumen cannula, uh, use, uh, fluoroscopy, uh, preferably both fluoroscopy and, and echo to do so, uh, and do it, um, uh, we like to do it in the operating room. And finally, uh, if you have a, uh, small pneumothorax, um, don't be in a hurry to press, to put in a chest tube. That was awesome. All right, so, uh, for all of you watching, um, the way this is gonna go is we're gonna, um, edit all of these, but we're gonna create these 12 or 3-minute video clips that summarize the key points made. And that's gonna be a video that I'm gonna show our team, uh, what was, what, what Ron just said there at the end is a great summary of everything. And, uh, so you'll look forward to seeing those in about a week or so. And we'll be posting those on social media as well. So I think, uh, Ron, that was awesome. Thank you for doing that talk. I think all of us need that. Uh, Alex, nice job putting those together. Thank you. Uh,