Jim Manning - Selective Aortic Arch Perfusion
4 likes5,686 views
Selective Aortic Arch Perfusion (SAAP) is a resuscitation technique that allows for isolated perfusion of the heart and brain during cardiac arrest, utilizing a large-lumen balloon occlusion catheter. The method aims to enhance survival rates by implementing better artificial perfusion and monitoring during critical pre-hospital and in-hospital interventions. While SAAP shows promise as part of the resuscitation toolkit, it is not a definitive answer but can aid in saving lives before it's too late.
Jim Manning - Selective Aortic Arch Perfusion
- 1. Is Selective Aortic Arch Perfusion the Answer? James E. Manning, MD Departments of Emergency Medicine and Surgery University of North Carolina at Chapel Hill School of Medicine SMACC 2015 Chicago, IL June 25, 2015 Disclosure: Inventor on patents for the Selective Aortic Arch Perfusion assigned to the University of North Carolina at Chapel Hill. Co-Founder of Resusitech, Inc., a medical device company developing resuscitation technologies.
- 2. What is Selective Aortic Arch Perfusion? (SAAP)
- 3. Selective Aortic Arch Perfusion Selective Aortic Arch Perfusion is a resuscitationtechnique that involves the blind insertionof a large-lumenballoon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the balloon inflated, the heart and brain are relativelyisolated for resuscitative perfusionwith an oxygen-carrying fluid in an effort to promote restoration of spontaneous circulationby the heart while protecting the brain from further ischemic insult.
- 4. Ann Emerg Med 1992; 21:1068-1065
- 5. Why SAAP?
- 6. Resuscitation Medicine Key Concept: The āChain of Survivalā Early Recognition & Activation(911) Early CPR Rapid Defibrillation ACLS & Transport Post-Resuscitation ICU/Neuro Care
- 7. Two Principles In Order to Improve Cardiac Arrest Survival: (1)We Need Better Methods of Artificial Perfusion (2)We Need Better Monitoring Technology
- 8. Selective Aortic Arch Perfusion Time-critical pre-hospital / in-hospital resuscitation intervention intended to compensate for āweak linksā in the Chain of Survival .ā¦an effort to āturn back the clockā in cardiac arrest
- 9. āEndovascular-Extracorporeal Resuscitation Eraā Momentum from two different directions (1) Endovascular hemorrhage control: Trauma / Severe Hemorrhagic Shock REBOA ā¦ā¦ā¦/ SAAP ā¦ā¦../ EPR (2) Extracorporeal perfusion: Medical Cardiac Arrest / Sudden Death CPB / EMCO / ECLS / ECPR ā¦.ā¦./ SAAP
- 11. ECLS/ECMO/ECPR Joe Bellezzo, Zack Shinar, Scott Weingart Josh Ihle, Paul Nixon, Paul Forrest
- 12. Selective Aortic Arch Perfusion for Medical Cardiac Arrest/Sudden Death Manning et al, Ann Emerg Med 1992; 21:1068-1065 Medical Cardiac Arrest: Aortic balloon occlusionallows relativelyisolatedperfusion of the heart and brain Heart and brain perfusion with an oxygen-carrying fluid Hemoglobin-based(HBOC) Fluorocarbon emulsion(PFC) Blood (allogeneic / autologous) Intra-aortic drug administration - Epinephrine / vasoactive agents - Ischemia-reperfusion agents - Hemostatic products Rapid hypothermia induction
- 15. Selective Aortic Arch Perfusion SAAP can generate āsupra-normalā myocardial blood flow Baseline NSR CPR SAAP
- 16. 00041 ā VF CA ā 1 min SAAP
- 17. VF Cardiac Arrest - SAAP with Oxygenated Blood Oxygenated packed RBCs Aortic Epinephrine 0.01 mg/kg included CaCl2 continuous infusion in the initial SAAP bolus
- 19. A W
- 20. A SAAP catheter: 11.5 Fr OD, 7.3 Fr ID of infusion lumen ECMO arterial cannulas: 15 Fr & 19 Fr
- 21. Sequential Invasive Resuscitation Interventions in Medical/Non-Trauma Cardiac Arrest If initial CPR, Defibrillation, ACLS is unsuccessful (No ROSC) Femoral artery SAAP balloon catheter insertion & initiate SAAP with O2 carrier (HBOC, PFC, WB/pRBC) (obtain venous access during this initial SAAP phase) If ROSC not achieved, venous blood W/D & transition to SAAP with Autologous Blood (partial ECMO/ECLS) If ROSC not achieved, larger femoral arterial cannula & convert to whole body ECLS/ECPR If ROSC not achieved, Consider: Cardiac Cath for PCI, LVAD, VIR, CT/Vasc Surgery, profound hypothermia (?), and cessation of resuscitation efforts
- 22. Impending Cardiovascular Collapse, especially in NCTH Hemorrhage-induced Traumatic Cardiac Arrest (HiTCA) SAAP in Trauma
- 23. Aortic Hemostasis and Resuscitation AHR NCTH/decompensated Hemorrhage-induced hemorrhagic shock Traumatic Cardiac Arrest (HiTCA) but NOT impending CV collapse/CA if CA occurs REBOA SAAP ROSC not achieved ROSC but EPR myocardial dysfx ECLS ECLS inadequate (ECMO) REBOA ā Resuscitative Endovascular Balloon Occlusion of the Aorta SAAP ā Selective Aortic Arch Perfusion EPR ā Emergency Preservation & Resuscitation ECLS ā Extracorporeal Life Support (Extracorporeal Membrane Oxygenation)
- 24. Selective Aortic Arch Perfusion for Hemorrhage-Induced Cardiac Arrest Manning et al, Crit Care Med 2001; 29:2067-2074 Trauma / Hemorrhagic Shock: Aortic balloon occlusionto limit abdominal/pelvic blood loss caudal to the balloon (functional aortic cross-clamp) Perfusion of the heart & brain with an oxygenated solution (HBOC, fluorocarbon, whole blood) to ROSC & to restore intravascular volume rapidly Intra-aortic administration - Epinephrine / vasoactive agents - Ischemia-reperfusion agents - Hemostatic products Temperature regulation(??)
- 26. Oxygen-Carrier Perfusate for SAAP: PFCs & HBOCs ā still āfuture capabilityā in the USA Present capability Whole Blood Packed RBCs (citrate anticoagulant issue) SAAP in Hemorrhage-induced Cardiac Arrest
- 27. Selective Aortic Arch Perfusion with Hemoglobin-BasedOxygen Carrier-201 for resuscitationfrom exsanguination cardiac arrest in swine Manning et al. Crit Care Med 2001; 29:2067-2074 SAAP with oxygenated HBOC-201 vs. SAAP with oxygenated LR Swine liver lacerationmodel, rapid exsanguination, cardiac arrest at 10-13 mins Sustained ROSC in 6/6 SAAP ā HBOC-201 1-hour survival in 5/6 Transient ROSC in 2/6 SAAP ā LR (with Ao-Epi) 1-hour survival in 0/6 ROSC time for SAAP ā HBOC-201 was 1.9Ā±1.0 min
- 28. Oxygen-Carrier Perfusate for SAAP: PFCs & HBOCs ā still āfuture capabilityā in the USA Present capability Whole Blood Packed RBCs (citrate anticoagulant issue) SAAP in Hemorrhage-induced Cardiac Arrest
- 29. 00031 ā HiTCA ā 1 min SAAP
- 30. SAAP with HBOC-201 in Hemorrhage-induced Cardiac Arrest
- 31. AHR: SAAP with Oxygenated Stored Blood SAAP-whole blood (10 mL/kg/min) + intra-aortic Ca++ infusion ROSC at about 1.5 min
- 32. Ann Emerg Med 1993; 22:703-708
- 33. AHR: SAAP with Oxygenated Stored Blood SAAP-packed RBCs (10 mL/kg/min) + intra-aortic Ca++ infusion Aortic epinephrine (0.01 mg/kg) at 3 min of SAAP, ROSC
- 34. AHR: SAAP with Oxygenated Stored Blood SAAP-whole blood (10 mL/kg/min)+ intra-aortic Ca++ infusion ROSC but MAP < 60 mmHg, Aortic epinephrine (0.003 mg/kg)
- 35. Aortic Hemostasis and Resuscitation AHR NCTH/decompensated Hemorrhage-induced hemorrhagic shock Traumatic Cardiac Arrest (HiTCA) but NOT impending CV collapse/CA if CA occurs REBOA SAAP ROSC not achieved ROSC but EPR myocardial dysfx ECLS ECLS inadequate (ECMO) REBOA ā Resuscitative Endovascular Balloon Occlusion of the Aorta SAAP ā Selective Aortic Arch Perfusion EPR ā Emergency Preservation & Resuscitation ECLS ā Extracorporeal Life Support (Extracorporeal Membrane Oxygenation)
- 37. Is Selective Aortic Arch Perfusion the answer?
- 38. Is Selective Aortic Arch Perfusion the answer? Maybe, in partā¦ā¦ SAAP is one of the interventions we could have in our āresuscitation toolkitā to help us save the lives of our cardiac arrest patientsā¦.before itās too late.
- 39. Thank You! & A Toast to SMACC!