Arterial and Intraosseous Lines, Intra-

Aortic Balloon Pumps, and

Extracorporeal Life Support

(ECMO)

Arterial and Intraosseous Lines, Intra-

Aortic Balloon Pumps, and

Extracorporeal Life Support

(ECMO)

Sergey M. Motov, MD, FAAEM

Brooklyn, NY USA

FINANCIAL DISCLOSUREFINANCIAL DISCLOSURE

LEARNING OBJECTIVESLEARNING OBJECTIVES

Upon completion of this presentation the audience will be able to:

• Describe indications and techniques for placement of intra-arterial and intra-osseous devices

• Identify procedural complications of these devices

• Review current literature supporting their use in the ED

DEVICESDEVICES

• Arterial Line • Intraosseous Line• Intra-Aortic Balloon Pump• Extra-Corporeal Membrane

Oxygenation

CASE 1CASE 1• A 61 year old man is brought in with

shortness of breath • He has been unwell for the past 48 hours

with a productive cough, lethargy, and fever• BP 70/40, HR 130, T 40.2°C, O2 sat 90% on

15l/min• 2L NS given, still hypotensive, central line

placed• Vasopressors started and …you reach for

arterial line

Emerg Med J2005;22:17-21

INTRA-ARTERIAL LINESINTRA-ARTERIAL LINES

INTRA-ARTERIAL LINES-OVERVIEWINTRA-ARTERIAL LINES-OVERVIEW

• Important invasive device in the treatment of critically ill patients

• Assist in continuous BP monitoring in patients with hemodynamic instability requiring inotropic or vasopressor support

• Important skill for ED physicians to master

INTRA-ARTERIAL LINES-INDICATIONS/CONTRAINDICATIONSINTRA-ARTERIAL LINES-INDICATIONS/CONTRAINDICATIONS

• Consistent and continuous monitoring of BP of critically ill patients

• Facilitation of reliable titration of vasoactive medications

• Reliable access for measurement of arterial oxygenation and frequent blood sampling

• Known deficiencies in collateral circulation:

• Raynaud’s phenomenon

• Thromboangiitis obliterans

• Brachial artery insufficiency

• Infection of the site• Trauma to the

proposed site• Excessive

anticoagulation

INTRA-ARTERIAL LINES-PROCEDUREINTRA-ARTERIAL LINES-PROCEDURESite

• Radial Artery• Femoral Artery• Axillary• Brachial

Technique• “over the wire”

• “over the needle”

http://emedicine.medscape.com/article/80412-overview#a16

INTRA-ARTERIAL LINES-PROCEDUREINTRA-ARTERIAL LINES-PROCEDURE

INTRA-ARTERIAL LINES-COMPLICATIONSINTRA-ARTERIAL LINES-COMPLICATIONS

-Review of the literature-1978 to 2001-19,617 radial, 3899 femoral and 1989 axillary artery catheterizations-Major complications -fewer than1% of the cases: Temporary occlusion, Pseudoaneurism, Sepsis and local Infections, Bleeding, Hematoma ,Ischemic Limb

KEY POINTSKEY POINTS

• The radial artery is preferred site for cannulation to provide continuous BP monitoring and arterial blood sampling

• The catheter-over-needle technique is preferred procedure

• The complications rate less than 1%• Sterile technique and limited attempts of

cannulation decrease risk of severe complications

INTRAOSSEOUS LINESINTRAOSSEOUS LINES

http://emedicine.medscape.com/article/908610-overview#a30

CASE 2CASE 2

• A 28 year-old male is brought in by EMS actively seizing

• Seizures have continued for 35 minutes despite 15mg of Midazolam IM

• No IV access, vascular access is urgently needed

• Central line ???• …You reach for intraosseous catheter

INTRAOSSEOUS (IO) ACCESS-OVERVIEWINTRAOSSEOUS (IO) ACCESS-OVERVIEW

• Recommended for resuscitation in all age groups

• Rapid and efficient access• AHA recommends IO over ETT for drug

delivery • IO access provides delivery of medications

(pressors), crystalloids, colloids, and blood products

• Used for blood samples: CBC, T&S (T&C), chemistries, VBG

N Engl J Med 2011;364:e14

INTRAOSSEOUS ACCESS-INDICATIONS/CONTRAINDICATIONSINTRAOSSEOUS ACCESS-INDICATIONS/CONTRAINDICATIONS

• Critically ill- shock, sepsis, acute hemorrhage

• Respiratory or Cardiac arrest

• Immediate need for fluids/medications

• Need for rapid sedation/intubation (Psycho- behavioral emergencies)

• Pre-hospital, mass casualties, disaster situations, combat

• Fracture near or proximal to insertion site

• Previous unsuccessful IO attempts

• Indwelling hardware• Infection in the skin

or soft tissue overlying the insertion site

• Osteogenesis imperfecta or osteopenia

• OsteopetrosisN Engl J Med 2011;364:e14

INTRAOSSEOUS ACCESS- PROCEDUREINTRAOSSEOUS ACCESS- PROCEDURE

SITE• Proximal tibia• Proximal humerus• Distal femur• Sternum and distal

radius (adults)

EQUIPMENT• Manual needles

(Large-bore spinal and butterfly needles)

• Power-assisted devices:

• spring-loaded device• drill-assisted devices

INTRAOSSEOUS ACCESS- PLACEMENTINTRAOSSEOUS ACCESS- PLACEMENT

INTRAOSSEOUS ACCESS- PLACEMENTINTRAOSSEOUS ACCESS- PLACEMENT

• Needle should stand on its own

• Aspiration of bone marrow contents

• Absence of local swelling at the insertion site

• Fluoroscopy and ultrasonography (not routinely used)

N Engl J Med 2011;364:e14

CONFIRMATION

INTRAOSSEOUS ACCESS INTRAOSSEOUS ACCESS

• Extravasation ( muscle necrosis)

• Compartment syndrome• Infection at the insertion

site• Fractures• Growth-plate injuries

(physis insertion)• Local Hematoma

COMPLICATIONS

INTRAOSSEOUS ACCESS-EVIDENCE INTRAOSSEOUS ACCESS-EVIDENCE

INTRAOSSEOUS ACCESS-EVIDENCE INTRAOSSEOUS ACCESS-EVIDENCE

35 IO insertions: 24 tibial and 11 humeral; 20 seconds to insert, 98% first success rate; 88.6% - easier than intravenous cannulations

32 IO needles inserted- 97% effectiveNo complication of infection was noted

JR Army Med Corps 153(4): 314-316

INTRAOSSEOUS ACCESS-EVIDENCE INTRAOSSEOUS ACCESS-EVIDENCE

129 patients: younger (1—6 years), more severely injured, higher mortality (Int. J. Care Injured (2005) 36, 1034—1038)

Tibial intraosseous access:-highest first-attempt success for vascular access-91%-most rapid time to vascular access -4.6 minutes

Ann Emerg Med. 2011;58:509-516.

KEY POINTSKEY POINTS• Emergent vascular access in both

children and adults• The use of the IO’s provides fast, easy

and reliable alternative mode of venous access

• Flow rates may be improved by the use of pressure bags

• Short learning curve• Great first attempt success

Intra-Aortic Balloon PumpsIntra-Aortic Balloon Pumps

CASE 3CASE 3• A 47 year old female presented to the ED with a

four hour history of severe central chest pain • ECG showed atrial fibrillation and broad QRS

complexes with a sine wave appearance• Patient was thrombolysed with alteplase for

presumed myocardial infarction• Ten minutes later-BP 60/40, pt is lethargic• Dobutamine and subsequently Norepinephrine

started,• Pt still hypotensive , bedside ECHO showed severely

impaired left ventricular function• You consider intra-aortic balloon pump

Intra-Aortic Balloon Pumps-OverviewIntra-Aortic Balloon Pumps-Overview• Most widely used circulatory assist device in

critically ill patients with cardiac disease• The National Centre of Health Statistics

estimated that IABP was used in 42 000 patients in the USA in 2002.

• Percutaneous insertion, sheathless insertion techniques, and enhanced automation permitt use of IABP in a variety of settings with greater efficacy and safety ( including ED)

Intra-Aortic Balloon Pumps-PrincipalIntra-Aortic Balloon Pumps-Principal• Counterpulsation is a term that

describes balloon inflation in diastole and deflation in early systole

• Balloon inflation causes “volume displacement” of blood within the aorta, both proximally and distally

• This leads to a potential increase in coronary blood flow and potential improvements in systemic perfusion

Intra-Aortic Balloon Pumps-PrincipalIntra-Aortic Balloon Pumps-Principal

Intra-Aortic Balloon Pumps-Goals and Effects

Intra-Aortic Balloon Pumps-Goals and Effects

Intra-Aortic Balloon Pumps-IndicationsIntra-Aortic Balloon Pumps-Indications

Intra-Aortic Balloon Pumps-Contraindications

Intra-Aortic Balloon Pumps-Contraindications

Intra-Aortic Balloon Pumps-ComplicationsIntra-Aortic Balloon Pumps-Complications

• Ischemia from balloon inflations

• Aortic dissections• Abrupt vessel

closure • Malignant

arrhythmias• No-reflow

phenomenon• Renal emboli • Thrombocytopenia

• Hemorrhage• Femoral artery

laceration• Infections• Hemolysis• Trombosis• Systemic Embolism

Intra-Aortic Balloon Pumps-EVIDENCEIntra-Aortic Balloon Pumps-EVIDENCE

-884 patients with CS due to predominant left ventricular (LV) failure-Patients treated with IABP in conjunction with TT had lowest in-hospital mortality rate (47%)-Intra-aortic balloon pump use associated with a lower mortality rate than no IABP (50% vs. 72%, p <0.0001)

Intra-Aortic Balloon Pumps-EVIDENCEIntra-Aortic Balloon Pumps-EVIDENCE

-IABP should be reserved for patients with severe hemodynamic compromise and in CS-Class IB recommendation in the current American Collegeof Cardiology (ACC)/American Heart Association

Eur Heart J. 2009;30:459–68

88 Patients in CS treated with IABP; 38% survived

KEY POINTSKEY POINTS

• IABP is indicated for patients with STEMI complicated by Cardiogenic Shock, Acute Heart Failure

• IABP is a bridging therapy to definite emergency revascularization, heart transplantation and acute valvular repair

EXTRACORPOREAL LIFE SUPPORT (ECMO)EXTRACORPOREAL LIFE SUPPORT (ECMO)

ECMO system. (Courtesy of O. Ayad, MD, Columbus, OH)

CASE 4CASE 4• 24 yom presents to the ED with 4 days of

cough, malaise and fever• Pt is tachypneic, tachycardic and hypoxic• IV fluids, O2, Monitor, CXR showed Left

Lower Lobe infiltrate• Pt is more tachypneic, started on CPAP• 4h later- pt is intubated and started on

pressors• Admitted to ICU- 4h later ECMO initiated

EXTRACORPOREAL LIFE SUPPORT-OVERVIEWEXTRACORPOREAL LIFE SUPPORT-OVERVIEW• Used in acute severe cardiac or respiratory

failure with high risk for dying despite maximal conventional intensive care supportive measures

• Reported survival rates are 77% for neonatal respiratory failure, 56% for pediatric respiratory failure, 53% for adult respiratory failure, 43% for pediatric cardiac failure, and 32% for adult cardiac failure

• Early initiation of ECMO may be life saving for critically ill patients

Emerg Med Clin N Am 26 (2008) 953–959

EXTRACORPOREAL LIFE SUPPORT-INDICATIONS EXTRACORPOREAL LIFE SUPPORT-INDICATIONS

EXTRACORPOREAL LIFE SUPPORT CONTRAINDICATIONS

EXTRACORPOREAL LIFE SUPPORT CONTRAINDICATIONS

EXTRACORPOREAL LIFE SUPPORT-PROCEDUREEXTRACORPOREAL LIFE SUPPORT-PROCEDURE

Veno-arterial ECMO circuit

EXTRACORPOREAL LIFE SUPPORT-PROCEDUREEXTRACORPOREAL LIFE SUPPORT-PROCEDURE

EXTRACORPOREAL LIFE SUPPORT-COMPLICATIONSEXTRACORPOREAL LIFE SUPPORT-COMPLICATIONS

Mechanical• thrombosis in any

ECMO circuit component

• cannula problems• oxygenator failure• tubing rupture• pump malfunction

Patient-related• site bleeding• intracranial infarct or

bleed• renal insufficiency• seizures • electrolyte abnormalities,• cardiac dysfunction or

arrhythmias• gastrointestinal

hemorrhage, and infection

EXTRACORPOREAL LIFE SUPPORT-EVIDENCEEXTRACORPOREAL LIFE SUPPORT-EVIDENCE

http://emcrit.org/

KEY POINTSKEY POINTS• ECMO provides resuscitation for

patients with intractable reversible respiratory or cardiovascular collapse unresponsive to conventional treatment

• ECMO can be a life-saving modality• It is expensive and labor-intensive and

carries a significant complication risk• Might be implemented in the ED

SUMMARYSUMMARY• Arterial Lines assist in continuous BP

monitoring in patients with hemodynamic instability requiring inotropic or vasopressor support

• IO access provides delivery of medications (pressors), crystalloids, colloids, and blood products

• IABP is indicated for patients with STEMI complicated by Cardiogenic Shock, Acute Heart Failure

• ECMO can be a life-saving modality

QUESTIONS ?QUESTIONS ?

THANK YOUTHANK YOU