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ECMO CPR
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ECMO CPR ECMO in Cardiac arrest has increased exponentially in the past 10 years, on the back of, up until very recently, non-randomised, predominantly retrospective studies. What is the efficacy? Appropriate patient selection? Cost effectiveness and model of delivery of ECPR? Finally is ECMO really the intervention or just optimising the chain of survival?
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ECMO CPR
- ECMO CPR where are we in 2021? Dr Mark Dennis Cardiologist, RPAH, Sydney, Australia Clinical Senior Lecturer, Usyd Hadaya J, Dobaria V, Aguayo E, et al. National trends in utilization and outcomes of extracorporeal support for in- and out-of-hospital cardiac arrest. Resuscitation 2020.
- ECPR “Truths” 1. ECPR is HARD 2. ECPR is HARD and training is required 3. The intervention is NOT ECMO it is the system 4. It is effective in SELECTED patients (which ones????) 5. Time to mechanical support (low flow) time is key 6. The need for it (number of arrests) in locations is not clear 7. The model to deliver ECPR with best results is not clear 8. Cost effectiveness at system level not clear 9. Prospectively defined trials please!
- ECPR Evidence up to December 2020 Is ECPR like dialysis or an IABP? Minimal prospective studies Heterogenous patient populations and inclusion criteria (if they had one) Survival ~ 15 – 25%
- ECPR in OHCA Evidence…exemplified by
- ARREST Trial – finally and RCT • You can do an RCT – impressive in itself and we should take note • Trial of a system not of ECMO itself • Inclusion/exclusion criteria • 2 of ETCO2 <10mmHg, paO2 <50mmHg, O2 sats <85%, lactate >18 mmol = excluded • Stopped early: • 1 of 15 (7%) survivors conventional • 6 of 14 (43%) ECMO facilitated
- Is it generalisable? • Training effect – well trained expert group • Population density • Population age • Health of demographic • Distribution of hospitals • Traffic??
- ECPR for OHCA Models • Hospital based? • Only certain hospitals? • Centralised cannulators? • Pre-hospital? • Pre-hospital bus?
- Potential number of ECPR “Eligible Pts” is it needed? • Only 4-11% of all OHCA maybe eligible for ECPR on basic criteria • Patient selection criteria affects survival but also eligible patients • What about in and out of hours and the model of care to serve? Ramanan M, Gill D, Doan T, et al: Assessing need for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest using Power BI for data visualisation. Emerg Med Australas, 2020
- Who should consider for ECPR in OHCA? Established VT/VF and not asystole Witnessed arrest Bystander CPR Age to 65 or 70 years Arrest to ECMO flow time < 1 hour at least! Lactate <18mmol/l Mechanical CPR PEA O2 sats >85% ETCO2 pH.
- When to transfer for ECPR? • Reynolds et al1,2 ~ 21 minutes • Kim et al > 213 minutes • Grunau et al 164 minutes Probably around 15-20 mins but should be tested with trial
- Cost effectiveness of ECPR • Costly intervention - $100,000 AUD per survivor but cost effective on current data QALY • Cost effectiveness is heavily dependent on your results and inclusion criteria – change these and reassess • Does not include system level costs
- ECPR Post Arrest Care – unanswered questions 1. Pa CO2 management 2. Pa O2 management 3. Anticoagulation management 4. Temperature management
- ECPR.. Some progress but still so many questions 1. Evidence for it? 2. Who do you put on? 3. How many patients qualify? 4. Cost effectiveness? 5. What model to provide ECPR and how do you train or prepare? 6. Post arrest care – clinical and emotional Without consideration for all of these and training ECPR programs will likely fail
- ECPR for OHCA some answers are coming.. Clinicaltrials.gov Feb 2021 Selective Cerebral Hypothermia Trial - Under Extracorporeal Cardiopulmonary Resuscitation (SHOT-ECPR) ECPR for Refractory Out-Of-Hospital Cardiac Arrest BC ECPR Trial for Out-of-Hospital Cardiac Arrest Observational Study to Assess Optimal ECPR Settings After Resuscitation Rapid Response VA-ECMO in Refractory Out-of-hospital Cardiac Arrest Induced Hypothermia in Cardiac Arrest Patients Rescued by Extracorporeal Cardiopulmonary Resuscitation. ON-SCENE Initiation of Extracorporeal CardioPulmonary Resuscitation During Refractory Out-of-Hospital Cardiac Arrest Platelet Function During Extracorporeal Membrane Oxygenation in Adult Patients Early Initiation of Extracorporeal Life Support in Refractory OHCA (INCEPTION) Prague OHCA - hyperinvasive approach Sub 30 CHEER3
- Thank you Twitter: @DrMDCardio Email: mark.dennis@sydney.edu.au
- Training
Editor's Notes
- Focus will be on OHCA Hadaya et al: All patients admitted after out-of-hospital cardiac arrest (OHCA) and those who experienced in-hospital cardiac arrest (IHCA) from 2005 to 2014 were identified in the National Inpatient Sample. During the study period, use of ECLS increased from 77 to 564 per 100,000 arrests for OHCA, and 60 to 632 per 100,000 arrests for IHCA. Survival among patients on ECLS for OHCA and IHCA increased from 34.2% to 54.2% and from 4.7% to 19.2%
- We know from large registry data looking at termination of CPR, the declining probability of survival of OHCA irrespective of initial rhythm with time – such that at 35 minutes basically <1% of people will survive. Given that the average time to ROSC or ECMO support in MANY observational trials is >50 minutes – you could assume that ECPR maybe beneficial? Like dialysis? There is a plethora of studies have come out looking at ECPR observational – prospective or retrospective. This is work done by a couple of research fellows for me:
- Lunz et al Retrospective database analysis of prospective observational cohorts of patients undergoing ECPR (January 2012-December 2016) The primary outcome was 3-month favorable neurologic outcome (FO), defined as the cerebral performance categories of 1-2. A subgroup of patients with stringent selection criteria (i.e., age </= 65 years, witnessed bystander CPR, no major co-morbidity and ECMO implemented within 1 h from arrest) was also analyzed. A total of 423 patients treated with ECPR were included (median age 57 [48-65] years; male gender 78%); ECPR was Initiated for OHCA in 258 (61%) patients. Time from arrest to ECMO implementation was 65 [48-84] min. Eighty patients (19%) had favorable neurological outcome. Favorable neurological outcome rate was lower (9% vs. 34%, p < 0.01) in out-of-hospital than in-hospital cardiac arrest and was significantly associated with shorter time from collapse to ECMO. The application of stringent ECPR criteria (n = 105) resulted in 38% of patients with favorable neurologic outcome. Bougoin et al A prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). Bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC, In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002). Of note, pre- hospital ECPR was associated with both higher survival and more favourable neurological outcomes (OR 2.9, 95%CI 1.5–5.9, p = 0.002, and OR 2.9, 95%CI 1.3–6.4, p = 0.008, respectively) than in those patients receiving ECPR after arrival to hospital, only 7% of whom survived compared to 15% of prehospital ECPR patients. However, there were limitations to the study, most notably the selection bias. ECPR was not initiated per protocol but rather at the discretion of individual clinicians, and therefore influenced by both known and unknown confounders. This was reflected in the difference in baseline characteristics of the ECPR patients, who were younger and more likely to receive bystander CPR (81% vs 49%, p < 0.001) yet, importantly, were also more likely to have CPR duration exceed 30 min (99% vs 77%, p < 0.001).
- Arrest trial details: The mean age was 59 years (range 36–73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6–30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3–67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7–59·2; posterior probability of ECMO superiority 0·9861). Posterior probability: A posterior probability, in Bayesian statistics, is the revised or updated probability of an event occurring after taking into consideration new information. In statistical terms, the posterior probability is the probability of event A occurring given that event B has occurred. Inclusion and exclusion The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Exclusion Criteria In the catheterisation laboratory, patients undergoing cardiopulmonary resuscitation had arterial blood gas collected and, if resuscitation discontinuation criteria were met (two or more of the following: end-tidal CO2 <10 mm Hg, PaO2 <50 mm Hg or oxygen saturation <85%, and lactic acid >18 mmol/L), all further efforts were terminated and the patient was declared dead
- Of 25 518 ambulance attended OHCA in Queensland during the study period, 540 (2%) patients met criteria of refractory arrest for study inclusion. Further age and arrest rhythm criteria for transport to an ECPR-capable hospital were met in 253 (47%) study patients, an average of 51 patients per year. In 2018, 72 patients met study criteria for transport to an ECPR-capable centre. Based on theoretical on-scene treatment times of 12 and 20 min, in 2018 only 14 (19%) and 11 (15%) patients respectively would potentially arrive at an ECPR-capable hospital within accepted timeframes for ECPR. Explanation of Pics (a) Heatmap showing the geographical distribution and density of out-of- hospital cardiac arrest (OHCA) in the state of Queensland, Australia. Red represents a high density of OHCA, white medium density and blue low density. The OHCA distribution closely follows the population density in Queensland. A close-up of the greater Brisbane region is also presented. (b) The number of OHCA patients who met inclusion criteria for the study and extracorporeal cardiopulmonary resuscitation (ECPR)-eligibility criteria and their distances from the Prince Charles Hospital are demonstrated. The assumptions for each map are as follows: (1) OHCA patients from 2014–2018 who met study inclusion criteria, assuming paramedics spend 6 min on- scene and travel at 1 km per minute; (2) OHCA patients who in addition to (1) met ECPR eligibility criteria (received bystander CPR and age ≤60 years) while assuming that paramedics spent 20 min at the scene; (3) OHCA patients from (2) who had their cardiac arrest in 2018. ( ), the Prince Charles Hospital; ( ), <20 min; ( ), 21–30 min; ( ), 31–45 min; ( ), >45 min.
- What are the relative contributions of each? Do we include one or all? Does one over-ride all the rest? E.g. arrest ECMO flow
- Reynolds et al15,18 investigated the balance between advanced therapies and risk of trans- port in patients meeting ECPR criteria gathered from observational studies, including age of 18 to 65 years, witnessed cardiac arrest, CPR started within 10 minutes of EMS activation, and absence of asystole as the initial cardiac rhythm at the time of EMS arrival. They found that 90% of neurologically favorable survivors achieved ROSC within 21 minutes and that the likelihood of neurologically favorable survival with CPR duration beyond 20 minutes was 8.4%. They therefore proposed 21 minutes of standard resuscitation before transport for ECPR. Grunau JAMA within the first 15 minutes intra-arrest transport was associated with significantly decreased survival; (2) between 15 and 30 minutes results were neutral; (3) but the greater than 30-minute strata showed a significant association with improved survival. Relatively small number of MCPR devices Should apply ECPR criteria on scene to pick patients which should be transferred
- Specialist or Fellow Successful completion of a written test Demonstrated competency through part task and in-vivo cannulation training Have completed whilst observed by an accredited cannulator who did not need to intervene: a minimum of 10 venous or arterial cannulations a minimum of 5 supervised retrograde arterial cannulations a minimum of 5 anterograde (distal perfusion) cannulations Consensus decision of accreditation panel that above standard met based on multi-source feedback
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