ECMO for Cardiac Arrest

1. Emergency ECMO/E-CPR
Sam Phillips

2. Case
PC
• 29 yr old male out of hospital witnessed VF arrest.
HPC
• Call from St John Ambulance to say they had a 29 year old
male complaining of central chest pain.
• ECG performed on route.

3. ECG from ambulance

4. • Cath lab activated and decision to go straight up on arrival.

5. • Call back from SJA to say patient has now had a VF arrest
without ROSC and they are 5 mins away.
• Using the lucas for chest compressions
• Patient now to come through ED.

6. • Further hx from ambulance staff and family
• Patient was well this am.
• Went out of the house for a couple of hours and may
have used methamphetamines.
• Arrived back and then developed central chest pain
and diaphoresis. (around 12.30pm).
• Sister called the SJA who arrived within 10 mins.

7. • Further collateral hx
• Patient has no known medical problems other than
intermittent meth use.
• No medications
• Strong FHx of cardiac disease
• father died age 37 of an MI!
• mother had first MI age 50

8. • 1st ECG by SJA at 1253.
• VF arrest at 1310 on route.
• 6 cycles of CPR with 6 shocks in total given for refractory
VF. Also given amiodarone.
• On arrival in ED at 1335 now in PEA.

9. Would this patient be a potential candidate
for ECMO?

10. Ongoing Management
• Continuation of PEA algorithm, intubated patient.
• I felt good candidate for ECMO, cardiologist (Michael
Muhlman) present and agreed.
• Called intensivist Dave Moxon and cardiothoracic surgeon
down to ED to help to try to facilitate this.
• After a further 10mins PEA, established ROSC but required
adrenaline infusion at 10mls/hr.
• Treatment as per STEMI protocol.

11. • Transferred straight up to the cath lab where he had
another VF arrest on arrival which reverted with one
shock.
• Found blocked prox LAD with one stent inserted.
• IABP inserted to support BP.
• Transferred to ICU on 5mls/hr adrenaline.

12. Clinical course
• Day 1 post arrest;
• increasing lactate and abdominal distension.
• CT confirmed an ischaemic gut involving the caecum and proximal
small bowel.
• Had bowel resected.
• Required haemo-filtration for acute kidney injury.
• Day 4
• Extubated, obeying commands, sedation still wearing off.
• Day 7
• No neurological deficit however still requiring haemo-filtration for
acute kidney injury.
• Day 10
• Off haemo-filtration
• Day 14
• D/C home neurologically intact.

13. ECMO Overview
• What is it?
• Who – patient selection
• What – equipment
• Why – what is the evidence
• What can we expect at Charlies

14. ELSO ECMO Definition
• ECMO (Extracorporeal Membrane Oxygenation)
• is defined as the use of a cardiopulmonary bypass circuit for temporary
life support for patients with potentially reversible respiratory and/or
cardiac failure failing to respond to maximal medical therapy.
• E-CPR (Extracorporeal Cardiopulmonary Resuscitation)
• is the initiation of bypass during resuscitation of the arresting patient.

15. Two types of ECMO
• VV = Veno-venous
• VA = Veno-arterial

16. VV ECMO
• Most common mode used in the ICU.
• Provides respiratory but no haemodynamic support.
• Venous drainage from large central veins oxygenator and CO2
remover venous system near RA.
• Proven to improve survival at 6 months (63% vs 47%) with acute
severe respiratory failure.
(CESAR trial-Conventional Ventilatory Support vs Extracorporeal membrane oxygenation for
Severe Acute Respiratory Failure)

17. VV ECMO

18. VA ECMO/E-CPR
• Performed in the ED setting.
• Provides both respiratory and haemodynamic support.
• Venous drainage from the right atrial inlet via the CFV and
infusion into the iliac artery via the FA.
• Establishment of the circuit is therefore retrograde.

19. VA ECMO

20. Alfred Indications for ED ECMO
Patients with out-of-hospital cardiac arrest which is refractory to standard
ACLS treatment AND:
• The patient meets all of the following criteria:
• Likely primary cardiac or respiratory cause.
• Witnessed arrest.
• Duration of arrest (collapse to arrival in ED ) <60 mins.
• Between 12-70 years.
• No major co-morbidities that would preclude return to independent living.
• Profoundly hypothermic (<32) due to accidental exposure.
• Significant overdose of vaso-active drug(s) (ie B blockers, digoxin, TCA).
• Another cause where there is likely to be reversibility of the arrest if an
artificial circulation is provided.

21. Absolute Contraindications
• Patients with active bleeding.
• No realistic prospect of reversal of the underlying
cardiac/respiratory condition.
• Advanced age precludes prolonged intensive care and mechanical
support.
• Limitation of medical treatment or advanced care plan that
precludes further resuscitation.

22. E-CPR Requirements
• In addition to the standard ACLS, there are three key components of
E-CPR, all of which must be provided concurrently;
1. External chest compression using the Autopulse machine, and
2. Peri-arrest cooling with a rapid infusion of 40ml/kg of ice cold
saline and
3. Rapid percutaneous cannulation using small cannulae (15F
arterial, 17F venous) and connection to the pre-primed ECMO
machine.

23. Steps
1. Identify ECMO suitable patient.
2. Activate team (0800-1800)
• ED duty consultant, US consultant, 1-2
intensivists, cardiothoracic surgeon,
perfusionist, ICU/ED ECMO certified nurse.
• Plus if likely to go to cath lab – cardiologist,
cardiac anaesthetist.
3. Continue Autopulse compressions.
4. Actively cool with 40ml/kg of ice cold
saline.
5. US guided femoral lines – venous and
arterial (convert to 15F art and 17F
venous) (training required).
6. Attach pre-primed circuit (training
required).
7. Optimize and treat potential causes.
8. Transfer to cath lab/theatre for
definitive treatment.

24. Alfred E-CPR Equipment
4L Cold
Saline
Primed
ECMO
circuit
Autopulse
Drapes,
gowns,
gloves, etc
Arterial and
Venous
Cannula

25. Staff required for E-CPR
• 11 staff in total who have predetermined roles.
1. ED Consultant – team leader runs resus.
2. ED Reg – ensures patient is intubated early and hand ventilates until patient on ECMO.
3. 4x ED nurses
• Airway - assists with airway management.
• Circulation – transfers to ED defibrillator and continues Lucas compressions.
• Drug – prepares adrenaline infusion and runs at 50micrograms/min during compressions
- draws up sedation (midazolam) and muscle relaxant (rocuronium)
• Scribe
4. ED USS consultant/ICU consultant 1 – opens ECMO pack and prepares cannulation
equipment, images FA and FV and places guidewires in these.
5. ICU consultant 2 – gowns and gloves and assists with cannulation and circuit connection.
6. ICU Reg – administers 40mL/kg of ice-saline IV bolus during CPR.
7. ED USS or ICU consultant - images IVC and aorta to determine correct placement of guide-
wires pre dilation.
8. ECMO nurse/perfusionist – checks primed ECMO circuit and connects cannulae . Runs
ECMO flow at 3L/min and oxygen flow at 3L/min.

26. Steps in Femoral Cannulation for VA ECMO
Step 1
• Cannulating the femoral vein and contralateral
femoral artery under direct ultrasound guidance.
Step 2
• Check placement of wires with ultrasound by a
second consultant.
Step 3
• Progressive dilation of each cannula up to 17Fr
(venous) and 15 Fr (arterial).
• Requires 2 operators
• One making incision and dilation while the other ensures the
guidewire continues to slide freely.
Step 4
• Checking positioning of the cannula before
commencing ECMO.
• Arterial cannula in iliac artery and venous cannula sitting in the RA
inlet.
Step 5
• Ensuring there is no air in either the arterial or
venous lines and ECMO circuit before connection to
the circuit.

27. VA ECMO Cannulation

28. The Circuit

29. What Can Go Wrong with ECMO…ALot!!

30. The Evidence so far…
• 6% of Out of Hospital Cardiac Arrests met the following “Load and Go”
criteria.
• Shockable rhythm
• <75 yr old
• Witnessed collapse
• Bystander CPR
• No ROSC after 15 mins ALS
• Poppe-M. The Incidence of “load&go” out of hospital cardiac arrest candidates for emergency
department utilization of emergency extracorporeal life support: A one-year review.
Resuscitation 2015;91:131

31. CHEER trial
• Refractory cardiac arrest treated with; mechanical CPR, Hypothermia,
ECMO and Early Reperfusion.
Stub D, et al. Resuscitation January 2015. Volume 86, Pages 88–94 .
Design
• A prospective pilot observational study.
Setting
• Single centre
• The Alfred Hospital Melbourne
• 45 ICU beds and referral centre for ECMO.
• Data collected over a 32 month period

32. CHEER trial continued…
Population
• Inclusion
• Out of hospital cardiac arrest (OHCA)
• Refractory cardiac arrest (>30min)
• Aged 18-65
• Arrest due to suspected cardiac aetiology
• Compressions commenced within 10mins
• Initial rhythm of VF
• Mechanical CPR machines available.
• In hospital cardiac arrest (IHCA)
• At the discretion of the attending physician providing cause of the arrest is likely reversible and ECMO is
immediately available.
• Exclusion
• OHCA: none specified
• IHCA: known significant pre-existing comorbidities.
• 26 patients
• 11 OHCA
• 15 IHCA
• Mean age 52, predominantly male
• Initial rhythm VF 73%

33. Intervention
• CHEER protocol
• Mechanical Chest compressions using the Autopulse.
• Rapid IV administration of ice-cold saline (30ml/kg)
• to induce Hypothermia with target temp of 33°C maintained for 24 hrs then slow
rewarming (0.24C/hr)
• ECMO
• Percutaneous cannulation of the femoral artery and vein by two critical care
physicians and commencement of veno-arterial ECMO.
• Early Reperfusion with urgent percutaneous coronary intervention.

34. Outcomes from the CHEER Study
• Primary
• Survival with full neurological recovery (CPC score 1) 14/26 (54%)
• Of the 26 patients that received ECMO
• 45% (5/11) of the OHCA patients survived.
• 60% (9/15) of the IHCA patients survived.
• Secondary
• ROSC achieved in 25/26 (96%) of patients.
• Survival to hospital discharge 14/26 (54%)

35. Outcomes continued
• Complications
• Vascular injury
• Surgical intervention required in 10/24 (42%) who underwent cannulation however mostly due to surgical
placement of backflow cannula.
• Blood loss
• 16/26 (69%) required blood transfusions.
• Median packed RBC requirement 3.5 units.
• 2 patients died primarily of major bleeding.
• 2 patients had cerebral haemorrhage.
• Of the 14 survivors
• Median time from collapse to initiation of ECMO was 40 mins (IQR 27-57).
• Greatest time to ECMO was 125min with normal neurological outcome.
• Median time from arrival of E-CPR team to initiation of ECMO was 16mins.
• Median time on ECMO was 3 days.
• Median time in ICU was 9.6 days.
• Median length of hospital stay 20 days.

36. CHEER Conclusion
• A protocol involving ECMO-CPR instituted by critical care
physicians for refractory cardiac arrest which includes mechanical
CPR, peri-arrest therapeutic hypothermia and ECMO is feasible
and associated with a relatively high survival rate.

38. Worldwide ECLS Centres

39. What can we expect at SCGH?

40. SJA data for OHCA transferred to SCGH between
2014-2015
• 21 patients over 2 years met the following criteria;
• Primary ambulance attendance (ie arrest in community not inter-hospital transfer)
• Age between 12-70
• VF as the initial rhythm
• Destination SCGH
• What this data doesn’t capture is;
• Timing of arrest to CPR
• Distance to SCGH from arrest event
• If SJA use a 20km radius around SCGH for consideration of E-CPR then
likely to draw some extra cases from RPH, JHC and PMH.
• Approximately 5 cases transferred to SCGH/year following OHCA would
likely fulfil E-CPR criteria.

41. Increasing support for ECMO/E-
CPR service at SCGH
• Now buy in from key stakeholders including;
• SJA
• ICU
• Currently physicians undergoing cannulation/ECMO training at the Alfred (2 every
6 months).
• Nurses recently had an ECMO training day.
• Cardiology
• support urgent percutaneous angioplasty in this patient cohort.
• Cardiothoracics
• who now support percutaneous cannulation with their surgical backup.
• ?Emergency
• USS team to potentially undergo cannulation training/ECMO course at the Alfred.

42. Cost
• Approximately $250000 of ABF generated for each patient placed on ECMO.
• Cost of maintaining a pre-primed ECMO circuit
• $5000/circuit which needs changing every month ie $60000/year
• Mean admission duration for a patient placed on ECMO from the CHEER study was
20 days.
• Including 10 days in ICU and 10 days on the ward
• SCGH costs approximately $5500/ICU day and $3000/ward day
• ie admission cost per patient approximately $85000
• Given ECMO service would initially only run in hours (0800-1800) there wouldn’t be
a huge additional staffing cost.
• ABF should therefore cover costs incurred with setup/maintenance of the service.

43. The Future
• Should SCGH be the cardiac arrest/E-CPR centre for Perth?
• Have a *55 number similar to stroke calls and STEMIs to activate the SCGH
ECMO team.
• Initially offer 0800-1800 E-CPR service with potential to expand in the
future.
• Have ongoing ECMO simulation team training.
• Participate in the ongoing E-CPR research.
• multi-centre clinical trial ‘2CHEER’ involving St Vincent’s, Royal Prince Alfred and
Sydney hospital currently underway.