Associate Professor Vincent Pellegrino is a Senior Intensive Care Specialist at The Alfred Hospital and head of the ECMO Clinical Service. He has had a lead role in the development of ECMO services at The Alfred since 2003. From the ECMO CPR ICN Victoria meeting he discusses how to get patient selection and outcomes right for eCPR.

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. The Alfred Intensive Care Unit, Melbourne, Australia
Cardiac
Arrest
VA ECMO Survival
Condition Treatment Outcome
Assessing the impact of E-CPR

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. 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

5. 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+

6. 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

7. 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+

8. 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

9. 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

10. 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 … ?

11. The Alfred Intensive Care Unit, Melbourne, Australia
21 minutes

12. 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

13. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Exclusion Criteria
These will vary greatly from
centre to centre

14. 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

15. The Alfred Intensive Care Unit, Melbourne, Australia
Out of Hospital Cardiac Arrest Survival
and ECMO

16. The Alfred Intensive Care Unit, Melbourne, Australia

17. The Alfred Intensive Care Unit, Melbourne, Australia

18. 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

19. 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

20. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR

21. 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

22. 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……

23. The Alfred Intensive Care Unit, Melbourne, Australia