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EMCrit Wee - Controlled Automated Reperfusion of the Whole Body (CARL) ECPR / ECLS Yields Amazing Results

EMCrit Wee - Controlled Automated Reperfusion of the Whole Body (CARL) ECPR / ECLS Yields Amazing Results

Update: 2024-06-03
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This episode of M-Crit "We" delves into the Carl system, a novel approach to ECPR (Extracorporeal Life Support) that goes beyond standard VA ECMO. The Carl system, developed by Dr. Friedhelm Byersdorf, utilizes a multi-organ repair strategy, adjusting 14 key parameters in the blood to mitigate reperfusion injury. This includes a protective profusate, pulsatile flow, high flow and pressure, immediate hypothermia, and comprehensive monitoring. The system is also portable, allowing for pre-hospital use. Dr. Byersdorf discusses the rationale behind these components, emphasizing the importance of pulsatility for organ preservation and the need for a multi-faceted approach to address the complex challenges of cardiac arrest. The episode highlights the Carl system's impressive results, particularly in patients with traditionally poor survival rates, such as those with pulseless electrical activity (PEA) and asystole. While the Carl system is not yet an RCT, its results compared to historical controls are compelling. The episode concludes with a discussion of the potential for adapting elements of the Carl strategy to existing ECPR programs, emphasizing the importance of distal limb perfusion and the need for further research to determine the optimal implementation of the Carl system.

Outlines

00:00:00
Introduction

This Chapter introduces the topic of the episode, which is a new modality of ECPR called ECMO CPR, also known as Extracorporeal Life Support. The episode is sparked by a paper titled "Treatment of Refractory Cardiac RS" by Controlled Reprefusion of the Whole Body, a multi-centre-perspective observational study. The senior author of the paper, Friedhelm Byersdorf, is interviewed to discuss the results of the study, which were quite impressive.

00:03:30
Dr. Byersdorf's Background and the Carl System

This Chapter delves into Dr. Byersdorf's background and his work on the Carl system. He explains that he has been working on tissue repair and avoiding reperfusion injury for most of his career. He discusses the limitations of standard ECPR and how the Carl system addresses these limitations. The Carl system utilizes a multi-organ repair strategy that involves adjusting 14 key parameters in the blood to mitigate reperfusion injury. Dr. Byersdorf explains the rationale behind these adjustments and how they are implemented through a combination of priming the circuit and online monitoring.

00:15:31
Summary of the Carl System and its Components

This Chapter summarizes the six primary differences between the Carl system and standard ECPR. These differences include the use of a protective profusate, pulsatile flow, multi-organ repair, high flow and pressure, immediate hypothermia, and comprehensive monitoring. The chapter also discusses the potential for adapting these components to existing ECPR programs.

00:22:53
Pulsatile Flow and its Importance

This Chapter focuses on the pulsatile flow component of the Carl system. Dr. Byersdorf explains that the system uses two pumps to achieve a true pulsatile flow, which is not available on any other ECMO circuits. He discusses the potential benefits of pulsatile flow for organ preservation, particularly in the brain and kidneys. He also explains the rationale behind the development of the Carl system as the first pulsatile ECMO circuit.

00:26:48
The Carl System's All-Comers Approach and its Implications

This Chapter discusses the Carl system's all-comers approach, which includes patients with all rhythms, including PEA and asystole. Dr. Byersdorf explains that this approach was based on promising results in animal studies and early clinical trials. He highlights the impressive neurologically intact survival rates observed in the Carl study, despite the inclusion of patients with traditionally poor survival rates. The chapter also discusses the challenges of conducting randomized controlled trials in cardiac arrest patients.

00:32:26
Cannulation and Bleeding Rates

This Chapter addresses the cannulation and bleeding rates associated with the Carl system. Dr. Byersdorf explains that the study did not specify a particular cannula size, allowing centers to use their standard ECPR practices. He discusses the rationale behind using smaller cannulas in ECPR and the lack of data on whether smaller cannulas can achieve the same flow, pressure, and pulsatility as larger cannulas. He also addresses the bleeding rates observed in the study, noting that they were not significantly higher than those seen in standard ECPR patients.

00:34:00
Piecemeal Adoption of the Carl System

This Chapter explores the possibility of adopting elements of the Carl system piecemeal. Dr. Byersdorf acknowledges that centers may not have access to the full Carl system but could potentially implement some of its components, such as the protective profusate. He cautions that the results of adopting only certain components are unknown and that the Carl system's multi-faceted approach is likely crucial to its success.

Keywords

ECPR
ECPR stands for Extracorporeal Cardiopulmonary Resuscitation. It is a life-saving technique used in cases of cardiac arrest where the heart and lungs are unable to function effectively. ECPR involves using a machine to circulate and oxygenate the blood, taking over the functions of the heart and lungs. This allows for more time to treat the underlying cause of the cardiac arrest and potentially improve the chances of survival.

ECMO
ECMO stands for Extracorporeal Membrane Oxygenation. It is a type of life support that provides both respiratory and circulatory support to patients whose heart and lungs are unable to function adequately. ECMO works by circulating the patient's blood through an artificial lung, where it is oxygenated and then returned to the body. ECMO is often used in cases of severe respiratory failure, cardiac arrest, or other critical conditions.

Carl System
The Carl system is a new modality of ECPR that involves a multi-organ repair strategy and a portable device. It was developed by Dr. Friedhelm Byersdorf and has shown promising results in both in-hospital and out-of-hospital cardiac arrest patients. The Carl system utilizes a protective profusate, pulsatile flow, high flow and pressure, immediate hypothermia, and comprehensive monitoring to improve survival rates and neurological outcomes.

Pulsatile Flow
Pulsatile flow refers to the rhythmic flow of blood that mimics the natural pulsation of the heart. In the context of ECPR, pulsatile flow is believed to be beneficial for organ preservation, particularly in the brain and kidneys. The Carl system is the first ECMO circuit to provide pulsatile flow, which is achieved through the use of two pumps.

Multi-Organ Repair
The Carl system's multi-organ repair strategy involves adjusting 14 key parameters in the blood to mitigate reperfusion injury. This includes adjusting calcium levels, pH, and other factors that can damage organs after ischemia and hypoxia. The Carl system's multi-faceted approach aims to address the complex challenges of cardiac arrest and improve overall patient outcomes.

Reperfusion Injury
Reperfusion injury occurs when blood flow is restored to an organ after a period of ischemia (lack of blood flow). This can lead to further damage to the organ, as the sudden influx of oxygen and other substances can overwhelm the cells and cause inflammation and cell death. The Carl system's multi-organ repair strategy aims to minimize reperfusion injury by adjusting key parameters in the blood.

Controlled Reprefusion of the Whole Body
Controlled Reprefusion of the Whole Body (CRWB) is a strategy used in the Carl system to optimize blood flow and oxygenation to all organs after cardiac arrest. This involves adjusting various parameters in the blood, such as calcium levels, pH, and temperature, to minimize reperfusion injury and improve organ function.

Distal Limb Perfusion
Distal limb perfusion is a technique used in ECPR to ensure adequate blood flow to the extremities, particularly the legs. This is important to prevent ischemic limb complications, which can be devastating and even fatal. The Carl system emphasizes the importance of distal limb perfusion as a key component of its strategy.

Reanimate Conference
The Reanimate Conference is an annual conference focused on resuscitative ECMO. It brings together experts in the field to share knowledge, discuss best practices, and advance the use of ECMO in critical care. The conference provides valuable training and education for healthcare professionals involved in the care of patients with cardiac arrest and other critical conditions.

Q&A

  • What are the key differences between the Carl system and standard ECPR?

    The Carl system differs from standard ECPR in several ways, including the use of a protective profusate, pulsatile flow, multi-organ repair, high flow and pressure, immediate hypothermia, and comprehensive monitoring. It also features a portable device, allowing for pre-hospital use.

  • Why is pulsatility important in ECPR?

    Pulsatile flow mimics the natural pulsation of the heart and is believed to be beneficial for organ preservation, particularly in the brain and kidneys. It helps to improve blood flow and oxygenation to these organs, reducing the risk of damage from ischemia and hypoxia.

  • What is the rationale behind the Carl system's multi-organ repair strategy?

    The Carl system's multi-organ repair strategy aims to address the complex challenges of cardiac arrest by adjusting 14 key parameters in the blood to mitigate reperfusion injury. This includes adjusting calcium levels, pH, and other factors that can damage organs after ischemia and hypoxia.

  • What are the potential benefits of the Carl system's portable design?

    The Carl system's portability allows for pre-hospital use, which can be crucial in cases of out-of-hospital cardiac arrest. This can help to reduce the time to initiation of ECPR and potentially improve survival rates.

  • What are the implications of the Carl system's all-comers approach?

    The Carl system's all-comers approach, which includes patients with all rhythms, including PEA and asystole, has shown promising results in terms of neurologically intact survival rates. This suggests that the Carl system may be effective in a wider range of cardiac arrest patients than traditional ECPR methods.

  • What are the potential challenges of adopting the Carl system piecemeal?

    While it may be possible to adopt certain components of the Carl system piecemeal, the results of doing so are unknown. The Carl system's multi-faceted approach is likely crucial to its success, and adopting only certain components may not yield the same benefits.

  • What are the potential risks associated with the Carl system?

    The Carl system, like all ECPR methods, carries certain risks, including bleeding complications. However, the study did not find that bleeding rates were significantly higher than those seen in standard ECPR patients. The Carl system also emphasizes the importance of distal limb perfusion to prevent ischemic limb complications.

  • What are the next steps for research on the Carl system?

    Further research is needed to determine the optimal implementation of the Carl system and to compare its effectiveness to standard ECPR methods in a randomized controlled trial. The Reanimate Conference provides a platform for experts in the field to share knowledge and advance the use of ECMO in critical care.

Show Notes

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EMCrit Wee - Controlled Automated Reperfusion of the Whole Body (CARL) ECPR / ECLS Yields Amazing Results

EMCrit Wee - Controlled Automated Reperfusion of the Whole Body (CARL) ECPR / ECLS Yields Amazing Results

Scott D. Weingart, MD FCCM