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Join critical care physician Jon Marinaro as we explore the transformative potential of extracorporeal cardiopulmonary resuscitation (ECPR) in revolutionizing cardiac arrest outcomes. Discover why traditional CPR’s limitations demand a paradigm shift and how ECPR offers hope for higher survival rates and better neurological outcomes. We discuss barriers to implementation, the importance of simplifying procedures, and the future of life-saving interventions.
Jon Marinaro is a critical care physician.
He discusses the KevinMD article, “The hidden flaws of traditional CPR: Why we need a new approach to save lives.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com slash podcast. Today, we welcome Jon Marinaro. He’s a critical care physician. Today’s KevinMD article is “The Hidden Flaws of Traditional CPR: Why We Need a New Approach to Save Lives.” Jon, welcome to the show.
Jon Marinaro: Ah, thank you very much. I really appreciate being invited to speak on what is a very large show.
Kevin Pho: All right, so before we start, just briefly share your story journey.
Jon Marinaro: Yeah, I’m Jon Marinaro. I’m a critical care physician from the University of New Mexico. I did the emergency medicine critical care pathway and did my residency in emergency medicine at the University of New Mexico, and then went to Shock Trauma in Baltimore and did a trauma critical care fellowship. I finished there, came back to the University of New Mexico, and I’ve been there since 2003 or 2005, actually, and have been the director of several ICUs here, and now the chief of critical care for the university health system, and the director of the adult ECMO program here.
Kevin Pho: All right, excellent. Let’s talk about your KevinMD article, “The Hidden Flaws of Traditional CPR: Why We Need a New Approach to Save Lives.” For those of you who get a chance to read your article, tell us what it’s about.
Jon Marinaro: Yeah, so, you know, it’s fascinating. In 1956 or so, Peter Safar came up with CPR, right? Pushing on the chest saves lives. And, you know, from 1956 till about 2000, that was the only thing we did for a person in cardiac arrest that was kind of generally pop that everybody in the world could do. Then, around 2000, Paul Pepe and Lance Becker published a paper about putting defibrillators in airports and how they really change the outcome of a lot of different patients. Their paper is a really great paper to read, and it talked about how if you can rapidly apply a defibrillator to a person immediately after cardiac arrest, the survival rates jump up enormously.
So right now, current out-of-hospital cardiac survival rates are about 8.5 percent of those people surviving neurologically intact. Other than that, 91.5 percent die or are neurologically devastated and die. With the addition of the defibrillator, if that defibrillator is applied early, you can actually save up to about 35 to 40 percent of people with neurologically intact survival. Outside of that, most people die if they have an out-of-hospital cardiac arrest.
What the paper is about is using ECMO, which is extracorporeal membrane oxygenation, applied emergently during CPR within an hour of the cardiac arrest to save more lives. What we have shown, the various centers around the nation that do this, is that if you apply this rapidly, you actually triple the survival rate. We’re getting around a 30 percent survival rate for cardiac arrest, up from the 8.5 percent. And these are all people that have failed the defibrillator. This is that subset of patients that never really had the chance. In the olden days, the person would get CPR, they’d get shocked, they don’t survive, and they die. As a matter of fact, in November of last year, the American Heart Association moved defibrillation ECMO to higher than amiodarone for refractory VTAC and VFIB cardiac arrest.
Kevin Pho: So those who aren’t familiar with ECMO, tell us about the device itself and the physiology behind it.
Jon Marinaro: Absolutely. So ECMO is essentially kind of like cardiac bypass, but it’s applied percutaneously in the emergency department or in the ICU, or for some of us who are doing this in the field. Basically, you put a cannula, which is like a large drainage tube, in the venous system—usually up into the intrahepatic IVC. You drain out, you go through a pump that pressurizes it, go through an oxygenator, which removes CO2, it adds oxygen, and then shoots it back into the left femoral artery, a common femoral artery, and provides perfusion to the organs.
Interestingly enough, 75 to 78 percent of all cardiac arrests die because their brain doesn’t get saved. It’s not because their heart doesn’t come back. You can get the heart back, but you can’t save the brain. So the first five to 10 minutes of any cardiac arrest is about saving the heart so then you can save the brain. After about five to 10 minutes, when you’ve shocked that person two to three times, you really need to move into, like, how do we save the brain? And that is where ECMO really helps, because those that don’t respond to those first few shocks, the mortality just drops off substantially. Actually, I believe it is around—I might be wrong with this number—but I believe at 20 minutes, you have a 16 percent survival rate, I think is what it’s at.
Kevin Pho: So practically speaking, what does that look like? Let’s say someone in the ICU or in the emergency department comes in cardiac arrest or goes into cardiac arrest, CPR, defibrillator not responding, and then now you’re considering ECMO.
Jon Marinaro: Yeah, you know, so basically you have a witnessed cardiac arrest. We have five minutes for people to kind of stand around and look at the person and be like, what’s going on? Because a lot of people think people are seizing, or the patients are still gasping, because those are normal post-arrest things the body does—they look like they’re seizing, or they’re still gasping—and people have to jump on that patient and do CPR. So once the CPR starts, the clock starts ticking for 55 more minutes. You have a total of an hour. It’s kind of like the “final 60,” like there’s the golden hour for trauma, there’s the final 60 for this. And you have 55 more minutes to get the person from the place they arrested to the hospital where they could be cannulated for ECMO.
They basically prep the groins, put a needle in the common femoral vein, common femoral artery, put a wire up, dilate, put a cannula up, and turn the machine on. And you can do that. There are certain places around the world—Lyon, La Pitié-Salpêtrière in Paris with Alice Hutin—they do pre-hospital ECMO where they’re cannulating people on the floor of the Metro or in the Louvre. That’s the famous pictures that are out there. Dr. Yannopoulos, Dr. Bartos in Minneapolis have a mobile ECMO cannulation van; we actually have an ambulance that we’ve outfitted to do that. And so various places around the world are trying to bring ECMO to the patient. Then there’s a lot of places that just do it in the hospital, in the ER is where they’re doing it. Actually, in the Netherlands, Dennis Miranda has a helicopter-based pre-hospital ECMO service where they’re flying a helicopter and they’ve shortened their time from arrest to time being on ECMO to 40 minutes, from the moment of arrest to the moment of being on flow.
Kevin Pho: So in the United States, how available is extracorporeal CPR?
Jon Marinaro: Yeah, it’s growing. You know, 10 years ago, this was like, what are you doing? You’re crazy. This isn’t going anywhere. Now, across the U.S., most major centers are offering ECMO, like academic centers such as us. In San Diego, Sharp Memorial with Zach Shinar, Joe Bellezzo, those guys are actually—they’ve trained 150 ER doctors up across the Sharp Memorial system. It is the standard of care if you arrest in that Sharp Memorial area—you get on ECMO. The people in Los Angeles have a growing ECMO program, Salt Lake City, Utah, and Seattle, and all the way across the U.S. I’m obviously on the west part of the country, so I know those folks a lot better, but across the country, most major academic centers are offering some form of eCPR, and more and more smaller places.
Jason Bowman at Ephraim McDowell Regional Medical Center in Kentucky actually offers it, and that’s a smaller place. Chandler Regional Medical Center in Arizona, a smaller place, they’re offering it, too.
Kevin Pho: Now, does it require specialized training on the physician standpoint? What are some of the barriers preventing a spread?
Jon Marinaro: Well, yeah, it’s a great question. So does it require specialized training? Well, for most ER docs and critical care docs, putting in central lines is regular training, and all we’re doing is putting in bigger central lines. Now, when you start saying most people who go out and practice in the community may, after a few years, stop putting in central lines, they do a lot of stuff through peripheral lines, and they let the specialist—maybe the surgeon or the critical care doc or whatever—put in the larger central lines. But these are really, it’s a 15. I’m actually just about to hopefully publish a paper about a 13 French ECMO cannula, which is the arterial return, and a dialysis catheter is 13 French. So if you’ve ever put in dialysis catheters, it’s about the same as that on the arterial side. The venous cannula is about the size of my index finger, so that’s usually like a 25 French. And that’s really the special training: who do you put on, can you put in these big cannulas?
Then you typically just need an ECMO specialist, which almost every hospital has, who has a perfusionist team, and they turn, they hand you the tubes, you turn on a machine, and it goes. But the machines are getting simpler and simpler—you actually don’t need a super highly perfusionist-trained person. We use ECMO specialists, which are nurses and respiratory therapists who’ve just been through extra training, and they’re super well qualified. But it’s not quite the same as going to perfusionist school.
My entire career goal is to make ECMO available to the masses, because you’re not going to save people just being near University of New Mexico or near the University of Minnesota in Minneapolis—you need to make this more widespread. Really, the goal of all of us should be to simplify this so that we can save more people, much like Lance Becker and Paul Pepe did with the defibrillator on the wall in the airport.
Kevin Pho: So just so I’m clear in terms of the outcome data, we’re talking about a benefit, not only in overall survival rate, but also in terms of intact neurological function after cardiac arrest?
Jon Marinaro: Yeah, basically, the national data is you have a 30 percent neurologically intact survival rate with using ECMO CPR, eCPR. And again, that is people who are typically getting on between 30 and 60 minutes after their cardiac arrest, which if you look without that, the survival rates are in the single percentages. We say it triples survival, but a lot of that tripling is because you’re taking the 8.5 percent, which is all different levels of survival. This is like people who would have, years ago, we would have just stopped, but now we’re continuing. And, you know, I’ve put on people at an hour and 16 minutes, and they’ve survived, and we’ve actually had hypothermic arrests—one person that was at three hours of CPR, and they walked, they were neurologically intact, and left the hospital. And there are a number of stories. That’s not some random story; at these centers that do this, this is a common thing.
Kevin Pho: So you mentioned one of your goals is to bring ECMO and eCPR to the masses, like in Paris, for instance. What’s preventing your vision from happening? What are some of the immediate obstacles that prevent that?
Jon Marinaro: Yeah, you know, some of the immediate obstacles are technological. The pumps are expensive, right? So, like, if you look at the Cardiohelp pump, it’s something like 000, probably depending on how many you buy for your hospital, and the disposables are 14,000 to 15,000. When you start making products that—it’s a wonderful product, the Cardiohelp ECMO pump is a great product—but it’s kind of complex. There are a lot of buttons and a lot of things, and you’ve got to zero stuff and all this other stuff. When you start making devices that are kind of complex like that, it scares people off, and they’re like, oh, now I have to have an ECMO specialist, and now I have to—this stuff.
What we did initially in Albuquerque for our pre-hospital is when the mechanical pump goes down, you have a hand crank that powers the motor. And so in the back of our ambulance for the first couple of years we did this, we had just the hand crank that’s not powered, and we had a firefighter just hand crank, and the only thing you needed to do is connect the tubes and have him crank, and you could get flow. It works perfectly; it works just fine. We’ve now moved, because we have enough machines and we have enough bodies, that we could actually have an ECMO specialist in the back of the ambulance. But the whole point of the thing is, you just need to beat CPR, and you’re going to save more lives. So if you can simplify the process—smaller cannulas, easier setup, devices that are just a single squeeze or just something simple, as opposed to all this other stuff—you’re going to simplify the technology and make it something like an intubation, right?
Thirty, or maybe not 30—like 60 years ago, people probably were like, only an anesthesiologist could intubate a person, and now paramedics intubate. And, you know, 50, 60 years ago, surgeons were probably like, you have to be a surgeon to put a chest tube in. Now anybody can put a chest tube in. We just have to keep simplifying the technology and simplifying the processes, and we’ll be able to bring this to the masses. Because it’s unfortunate that so many people are going to die between 10 years ago and 10 years from now—between the early adopters and the laggards who decide to adopt this because, oh, it’s too hard to do this. And there are just going to be a lot of body bags that do not need to be filled.
I can tell you the most important thing is Peter Safar’s 1955 CPR. You cannot save a person 60 minutes into their cardiac arrest with ECMO unless they have had really good CPR for 55 minutes. So the public education is that when you see a person suddenly collapse, and even if they look like they’re breathing or they look like they’re seizing, they very easily could be a cardiac arrest, and you should start CPR, activate 911. There’s more and more technology out there that’s on your iWatch or your Apple Watch or all these things that says, hey, you’ve collapsed, and it can alert stuff. But that rapid CPR—because if your low-flow or your no-flow time, which is no CPR, is greater than five minutes, you’re not a good candidate, and you have to have good CPR for 55 minutes now within starting ECMO and within starting the bypass.
What I think is really important is that, you know, I want to say it’s like Jan Belohlavek from Europe and Demetri Yannopoulos were really very responsible for making ECMO be a 2A indication under American Heart Association. That really helped a lot with getting more people to say, hey, we should be offering eCPR at our institution because now American Heart Association is saying what everybody has been doing is not the number one indication. If you have the ability to do ECMO, you should do ECMO, not amiodarone for VTAC, VFIB arrest, refractory VTAC, VFIB arrest. And so the ability for some of the really big powerhouses around the nation to move American Heart Association to say, hey, should we raise these levels to even higher? And then once those levels are higher, hospital administration will say, yes, now we need to have this at X hospital or Y hospital, because it’s the standard of care for managing things.
You know, the other thing I was amazed by is massive pulmonary embolism. A massive pulmonary embolism kills a lot of people. In 2016 at our institution, we had an 80 percent mortality rate. Since 2017, if you’re not in cardiac arrest, you do not die at the University of New Mexico from a massive PE. We put 100 percent of our massive pulmonary embolism patients on ECMO if they’re candidates—they’re not older, too old, or have too many comorbidities or whatever, that kind of stuff. But if they’re a candidate for ECMO, we put them on, and then they get their clot sucked out. You know, that’s not quite eCPR, but it’s another example of how good ECMO is at saving people who previously died.
Kevin Pho: We’re talking to Jon Marinaro. He’s a critical care physician. Today’s KevinMD article is “The Hidden Flaws of Traditional CPR: Why We Need a New Approach to Save Lives.” Jon, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Jon Marinaro: Yeah, I mean, I would just say the take-home message is if you’re a physician, if you’re a critical care physician, emergency physician—actually, the other great group would probably be trauma physicians, because they’re in the hospital 24 hours a day, kind of people who are always at the hospital. You can’t have a call-in, like, hey, I’ll be there in 20, 30, 40 minutes. You’ve got to have the people who live at the hospital. And again, it’s, you know, if you’re a shift-working trauma surgeon, shift-working critical care doc, shift-working ER doc, you or somebody is in the hospital 24 hours a day who can then apply this technology quickly. So if you’re one of those docs, take the time, go to an ECMO class, learn how to be an ECMO cannulator. It’s not hard. It’s just getting over a little hump. Then work with your institution to create the infrastructure so that you have a robust cardiac resuscitation program with your nurses running your CPR and your ACLS, and with your physicians cannulating and getting these people on, and you will save lives.
And it’s a great opportunity for the medical community to hinge on what Peter Safar did in 1955, and what Lance Becker and Paul Pepe did in 2000, to finally move the needle further forward on cardiac arrest survival.
Kevin Pho: Jon, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Jon Marinaro: Thank you so much. I appreciate the time.
