A Brief Conversation with...Jacob Gutsche

by Kevin W. Hatton, MD, FCCM
University of Kentucky College of Medicine

Volume 28 | Issue 1 | Winter 2017

Dr. Jacob Gutsche, M.D. is an Assistant Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania and is the System Director for Cardiovascular Critical Care and Postoperative Care for the University of Pennsylvania Health System.  In addition, he is the co-medical director of the Penn Lung Rescue Program.  His research interests and clinical expertise center around the implementation and management of ECMO in severe respiratory failure.

Can you briefly describe your recent research article for our readers?

In this article, we describe the results from our retrospective study of 17 patients with severe respiratory failure and hemodynamic instability who required vasopressor infusion.  These patients, despite mild to moderate right or left ventricular dysfunction, received only veno-venous extracorporeal life support (VV ECLS) as systemic rescue mechanical support.  After VV ECLS cannulation, we demonstrated a rapid and significant decrease in vasopressor requirements, as well as, an improvement in the acid-base balance (resolution of acidosis).  In fact, we found that even though all of these patients had severe hemodynamic instability secondary to their respiratory failure, none of these patients ultimately required conversion to veno-arterial ECLS (VA ECLS) for circulatory support after VV ECLS was initiated.

That is really incredible…so what were your article’s most important conclusions? 

Based on the results of our analysis, we believe that a multidisciplinary ECLS program for severe respiratory failure that targets VV ECLS cannulation prior to transport is safe and effective.  The use of peripheral bi-caval VV ECLS in this setting can rapidly reverse the systemic effects of respiratory failure, including secondary hemodynamic instability that may require vasopressor infusion to support blood pressure and cardiac output.  Bi-Caval VV ECLS is able to significantly improve acidosis and vasopressor requirements within 6 hours of cannulation.

I’ll admit that I’m struck by the elegant simplicity of your basic hypothesis (although I know it’s really not simple to initiate VV ECLS).  What drove you to look at this topic?

In January 2015, we set up a mobile ECLS program that would triage patients with severe respiratory failure from outside hospitals and coordinate the care necessary for ECLS cannulation and transport.  Using this system, if the patient met appropriate inclusion and exclusion criteria, our mobile ECLS team would go to the patient at the referring hospital, initiate VV ECLS through bi-caval cannulation, continue stabilizing maneuvers with vasopressor and ventilator management, and then transport back to our hospital.  This mobile team included an Anesthesiology Critical Care team leader, a perfusionist, and a RN with OR experience.  We believed this team was able to provide excellent care to patients but we wondered in the simplest, most practical terms, should we be doing this…and could we do better?  So, we looked at our own institutional data and were pleased to see that our outcomes were even better than we had hoped they were. 

In many ways, you may have just described a very important new way to provide safe and effective stabilization for some of our most complex and unstable patients.  How could members of SOCCA apply your methods to their practice?

In our hospital, Anesthesiology Critical Care members play an important role in this mobile ECLS team.  Not only do anesthesiology critical care members triage the initial calls from the outside hospital, but they are also responsible for coordinating the transport of the patient and supplies and for manipulating the ventilator as well as sedative and vasopressor infusions to optimize patient stability before, during, and after cannulation.  In addition, our team members are also responsible for performing the initial bedside ECHO to determine the degree of right ventricular dysfunction as a determinant of whether a trial of VV ECLS is appropriate.  Finally, in many circumstances, the anesthesiology critical care team members are also responsible for the bi-caval cannulation procedure, following established clinical guidelines.  While many of these roles may not be appropriate for all SOCCA members in all hospitals, many different opportunities exist to be a part of your local or regional VV ECLS teams. 

I want to express my appreciation for taking time to speak with me about this topic.  As a final though, what advice about research would you give to junior faculty and fellows?

My best advice about research for junior faculty and fellows is to just do something…to just start somewhere.  It is easy to get stuck sitting and pondering the very best way to do the very best research to answer life’s biggest questions.  However, it is far better to start somewhere small and work outward from that point.  Collect data at your starting point.  Review that data.  Make a change and then repeat over and over.  It really is just a matter of practice.  Whether it be practice to write better grants or IRB proposals or to develop your abstract or publication.  The key is to just start somewhere and to keep practicing.