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ECPR by Vincent Pellegrino 2016

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Slides for a talk by Vincent Pellegrino (ECMO Director at The Alfred ICU) on ECPR. For videocast and audio only versions of this talk go to the RAGE podcast (http://ragepodcast.com/ecpr-vincent-pellegrino/) or The Alfred ICU's INTENSIVE blog (http://intensiveblog.com/ecpr-vin-pellegrino/).

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ECPR by Vincent Pellegrino 2016

  1. 1. The Alfred Intensive Care Unit, Melbourne, Australia The use of VA ECMO following Cardiac Arrest E-CPR Vincent Pellegrino Aidan Burrell Steven Bernard Richard Lin Deirdre Murphy Lloyd Roberts Jayne Sheldrake Carol Hodgson D. Jamie Cooper Vinodh Nanjayya Bishoy Zachary Daniel Brodie
  2. 2. The Alfred Intensive Care Unit, Melbourne, Australia Cardiac Arrest VA ECMO Survival Condition Treatment Outcome Assessing the impact of E-CPR
  3. 3. The Alfred Intensive Care Unit, Melbourne, Australia Assessing the impact of E-CPR Out Hospital CA VA ECMO Survival Condition Treatment Outcome In Hospital CA +ROSC +CS +ROSC +CS - ROSC - ROSC Neuro Cost QOL Organ Donation Unsupportable
  4. 4. The Alfred Intensive Care Unit, Melbourne, Australia Approach 1.  Define the population considered for E-CPR (Who?) 2.  Examine the different approaches to E-CPR (how?) 3.  Outcomes from E-CPR (what seems to work?) 4.  Going forward
  5. 5. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Alfred Hospital - Melbourne ECMO commenced within 30 minutes of a cardiac arrest which has been associated with c-CPR for greater than 10 minutes or has rendered the patient unconscious Based on the CA definition for therapeutic hypothermia i.e. the CA has contributed to the patient neurological outcome
  6. 6. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Taipei, Taiwan JACC 2003 “Briefly, patients were recruited into the ECPR group only if they: 1) were in cardiac arrest that necessitated external or open- chest cardiac massage and a large amount of epinephrine (5 mg) during CPR; 2) could not be returned to spontaneous circulation within 10 to 20 min; and 3) subsequently received ECMO in the hospital” no ROSC ROSC+
  7. 7. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Japan, SAVE-J 2014
  8. 8. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates ELSO: Ann Thor Surg 2009 “The registry defines E-CPR as the following: “extracorporeal life support (ECLS) used as part of initial resuscitation from cardiac arrest. Patients who are hemodynamically unstable and placed on ECLS without cardiac arrest are not considered E-CPR” [1]. no ROSC ROSC+
  9. 9. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Korea “The ECPR was defined as use of venoarterial ECMO intended to treat cardiac arrest” “received veno-arterial ECMO upon the recurrence of CA within 20 min after the return of spontaneous circulation (ROSC) or due to no signs of ROSC after >10 min of CPR following AMI- induced CA (Figure 1). All patients underwent ECMO during ongoing continuous chest compressions”
  10. 10. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Korea “In previous studies, the definition of ECPR included both successful veno-arterial ECMO implantation and pump-on during cardiac massage [10,11]. However, various unexpected situations occurred in ongoing ECPR scenes. Actually, when a return of spontaneous circulation (ROSC) occurs during ECMO cannulation, the practitioner does not remove the already inserted cannula and does not stop the process of ECMO pump-on. We included such cases in our ECPR definition as intention-to-treat. Accordingly, ECPR was defined as an intention-to-treat with hemodynamic ECMO support during cardiac massage regardless of interim ROSC [11]” no ROSC ROSC+
  11. 11. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates The Problem The majority of patients that may benefit from emergency ECMO following cardiac arrest have some return of circulation Also, it is common for patients receiving ECMO for cardiac failure to have had a preceding CA Universal definitions of ROSC are lacking Cardiac arrest occurs in many different settings (in hospital and out of hospital) no ROSC ROSC+ IHCA OHCA+
  12. 12. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Does it matter much…?
  13. 13. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Does it matter much…?
  14. 14. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates Does it matter much…?
  15. 15. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates How to proceed … ? Out of Hospital
  16. 16. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates How to proceed … ? In Hospital
  17. 17. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates How to proceed … ?
  18. 18. The Alfred Intensive Care Unit, Melbourne, Australia 21 minutes
  19. 19. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Defining the condition Cardiac arrest of greater than 20 min (conventional CPR) Sub-classifications • Pathological Classification • +/- ROSC • + out-of-hospital • (initial rhythm) Diagnostic groups
  20. 20. The Alfred Intensive Care Unit, Melbourne, Australia Patient Population (Who?) Exclusion Criteria These will vary greatly from centre to centre
  21. 21. The Alfred Intensive Care Unit, Melbourne, Australia Approaches to E-CPR (How?) Time to ECMO Cannulation -Percutaneous or Open Cannulae Temperature O2 tension
  22. 22. The Alfred Intensive Care Unit, Melbourne, Australia Approaches to E-CPR (How?) Time to ECMO Cannulation -Percutaneous or Open Cannulae Temperature O2 tension
  23. 23. The Alfred Intensive Care Unit, Melbourne, Australia Cannulation Percutaneous with ultra-sound guidance and distal perfusion cannula
  24. 24. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia Assessment of Vascular Access TTE - subcostal TOE - transgastric Inferior Vena Cava
  25. 25. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia Assessment of Vascular Access Abdominal Aorta Aorta (TTE subcostal) PW Doppler aorta
  26. 26. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia J-wire in IVC Venous Cannulation for ECMO
  27. 27. The Alfred Intensive Care Unit, Melbourne, Australia Downstream compression
  28. 28. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia VA ECMO Backflow Cannulation CFA Profunda Artery SFA
  29. 29. The Alfred Intensive Care Unit, Melbourne, Australia Coming ….very soon!!
  30. 30. The Alfred Intensive Care Unit, Melbourne, Australia MTMM bidirectional cannula
  31. 31. The Alfred Intensive Care Unit, Melbourne, Australia MTMM bidirectional cannula Transition zone role in downstream compression
  32. 32. The Alfred Intensive Care Unit, Melbourne, Australia
  33. 33. The Alfred Intensive Care Unit, Melbourne, Australia Out Hospital CA VA ECMO Survival Condition Treatment Outcome In Hospital CA +ROSC +CS +ROSC +CS - ROSC - ROSC Neuro Cost QOL Organ Donation Unsupportable
  34. 34. The Alfred Intensive Care Unit, Melbourne, Australia VA ECMO Maintenance: Cardiac Management: Left Ventricular Failure Causes Severe left ventricular failure with any AR or MR • Fatal pulmonary hemorrhage Severe AR/MR with LV ejection First sign = Access Insufficiency
  35. 35. The Alfred Intensive Care Unit, Melbourne, Australia VA ECMO Maintenance: Cardiac Management: Left Ventricular Failure Causes Severe left ventricular failure with any AR or MR • Fatal pulmonary hemorrhage Severe AR/MR with LV ejection First sign = Access Insufficiency
  36. 36. The Alfred Intensive Care Unit, Melbourne, Australia Alternative cannulation
  37. 37. The Alfred Intensive Care Unit, Melbourne, Australia Approaches to E-CPR (How?) Time to ECMO Cannulation -Percutaneous or Open Cannulae Temperature O2 tension The change to 36 degrees as a targeted temperature has not been successful at our centre due to the low use of internal cooling devices
  38. 38. The Alfred Intensive Care Unit, Melbourne, Australia Approaches to E-CPR (How?) Time to ECMO Cannulation -Percutaneous or Open Cannulae Temperature O2 tension
  39. 39. The Alfred Intensive Care Unit, Melbourne, Australia Approaches to E-CPR (How?) Time to ECMO Cannulation -Percutaneous or Open Cannulae Temperature Blood-flow, Gas-flow O2 tension
  40. 40. The Alfred Intensive Care Unit, Melbourne, Australia Approaches to E-CPR (How?) Time to ECMO Cannulation -Percutaneous or Open Cannulae Temperature O2 tension
  41. 41. The Alfred Intensive Care Unit, Melbourne, Australia Training and team
  42. 42. The Alfred Intensive Care Unit, Melbourne, Australia Team work
  43. 43. The Alfred Intensive Care Unit, Melbourne, Australia Management of the AMI CA ST-AMI Cath lab PCI CABG
  44. 44. The Alfred Intensive Care Unit, Melbourne, Australia Management of the AMI CA ST-AMI +CA E-CPR PCI CABG Cath lab
  45. 45. The Alfred Intensive Care Unit, Melbourne, Australia Management of the AMI CA ST-AMI +CA + ROSC or +Shock E-CPR PCI CABG Cath lab Other resus
  46. 46. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation Strongest trial design for E-CPR
  47. 47. The Alfred Intensive Care Unit, Melbourne, Australia Out of Hospital Cardiac Arrest Survival and ECMO
  48. 48. The Alfred Intensive Care Unit, Melbourne, Australia
  49. 49. The Alfred Intensive Care Unit, Melbourne, Australia
  50. 50. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation
  51. 51. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation
  52. 52. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR
  53. 53. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR
  54. 54. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (2+) 5/30 (16%) 12/32 (37.5%)
  55. 55. The Alfred Intensive Care Unit, Melbourne, Australia WWW.SAVE-SCORE.COM WWW.RESPSCORE.COM Risk adjustment for adult patients undergoing ECMO for cardiac support 2003 to 2013 Risk adjustment for adult patients undergoing ECMO for respiratory support 2000 to 2012 ELSO Adult Datasets
  56. 56. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation
  57. 57. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation Excellent prospective dataset • Data rich • Includes post cannulation data (i.e. isn’t intended for case selection) Excellent performance (internal validation)
  58. 58. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation
  59. 59. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes from E-CPR (What seems to work?) SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers Organ Donation Future Models are essential 1.  Age 2.  First monitored rhythm 3.  Time to ECMO 4.  Biomarkers (early lactate) 5.  No/minimal physiological data
  60. 60. The Alfred Intensive Care Unit, Melbourne, Australia Conclusions E-CPR has strong physiological and evidence base to support its use and ongoing development Large database with accurate data to build risk prediction models to assess performance • allow better case selection • allow comparison between services • allow comparison between different treatments Only one thing better than successfully treating a cardiac arrest case with ECMO……
  61. 61. The Alfred Intensive Care Unit, Melbourne, Australia

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