Extracorporeal cardiopulmonary resuscitation

You have a patient in cardiac arrest who has had excellent resuscitation from the point of collapse, and who has treatable underlying pathology (eg. PE or STEMI). However you’re unable to get return of spontaneous circulation so you call it. Someone just died for whom the technology exists to save them. Extracorporeal life support (ECLS) supports heart and lung function by externally providing circulatory flow and gas exchange until the patient’s underlying cause of arrest is treated or recovers.

ECLS requires an extracorporeal membrane oxygenation (ECMO) circuit to be placed during the cardiac arrest resuscitation. This may sound like extreme stuff, but there have been some amazing saves with this technology, and large numbers of in-hospital and out-of-hospital arrest patients have been treated in Japan, Korea, and Taiwan. ECMO has even been commenced in the field by prehospital emergency physicians.

An inspiring EMCrit podcast with Dr Joe Bellezzo described how this technology is applied at Sharp Memorial Hospital in San Diego. Bellezzo and colleagues have now published a series of their out-of-hospital arrest cases who received ECLS initiated by emergency physicians(1).

Coming back to the Japanese, a multicentre prospective cohort study of ECLS for out-of hospital cardiac arrest (the ‘SAVE-J’ study) selected patients with VF or pulseless VT in whom no ROSC was achieved with standard resuscitative measures. Their striking results mirror other ECLS studies and were published in abstract form in November 2011(2).

To me, the overwhelming take home messages from what I’ve seen and read on this are:

1. ECLS can provide dramatic saves with neurologically intact survival in cardiac arrest cases that otherwise would be dead.

2. The critical factor for successful clinical outcomes and avoidance of wasted resources and clinical futility is case selection. The underlying cause of arrest needs to be reversible (eg. myocarditis) or treatable (eg. STEMI) and good resuscitation needs to have been in place prior to ECLS.

3. In the right hospital with the right resuscitation team, it can be done.

1. Emergency physician-initiated extracorporeal cardiopulmonary resuscitation
Resuscitation. 2012 Aug;83(8):966-70

CONTEXT: Extracorporeal cardiopulmonary resuscitation (ECPR) refers to emergent percutaneous veno-arterial cardiopulmonary bypass to stabilize and provide temporary support of patients who suffer cardiopulmonary arrest. Initiation of ECPR by emergency physicians with meaningful long-term patient survival has not been demonstrated.

OBJECTIVE: To determine whether emergency physicians could successfully incorporate ECPR into the resuscitation of patients who present to the emergency department (ED) with cardiopulmonary collapse refractory to traditional resuscitative efforts.

DESIGN: A three-stage algorithm was developed for ED ECPR in patients meeting inclusion/exclusion criteria. We report a case series describing our experience with this algorithm over a 1-year period.

RESULTS: 42 patients presented to our ED with cardiopulmonary collapse over the 1-year study period. Of these, 18 patients met inclusion/exclusion criteria for the algorithm. 8 patients were admitted to the hospital after successful ED ECPR and 5 of those patients survived to hospital discharge neurologically intact. 10 patients were not started on bypass support because either their clinical conditions improved or resuscitative efforts were terminated.

CONCLUSION: Emergency physicians can successfully incorporate ED ECPR in the resuscitation of patients who suffer acute cardiopulmonary collapse. More studies are necessary to determine the true efficacy of this therapy.

2. Multicenter Non-Randomized Prospective Cohort Study of Extracorporeal Cardiopulmonary Resuscitation for Out-of Hospital Cardiac Arrest: Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan (SAVE-J)
Circulation 2011; 124: A18132

Background: This study is aimed to examine the efficacy of extracorporeal cardiopulmonary resuscitation (ECPR) for patients in out-of hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).

Method: The design of this study is a multicenter non-randomized prospective cohort study. Hypothesis is that the outcome of OHCA with VF or pulseless VT is similar between ECPR and conventional advanced life support (ALS). During from Oct. 2008 to Dec. 2010, forty six tertiary emergency hospitals were participated in this study. Patient inclusion criteria were 1) VF or pulseless VT on scene, 2) cardiac arrest on arrival at hospital, 3) within 45 minutes from a call to an arrival of hospital, and 4) non-ROSC by conventional ALS during 15 minutes after an arrival at hospital. Exclusion criteria were 1) age: 75 yr, 2) poor activities of daily livings, 3) non-cardiac verified cardiac arrest, and 4) hypothermia. According to the inclusion criteria, ECPR was adopted for OHCA in 26 hospitals (ECPR group) and conventional ALS was planned in 20 hospitals (non-ECPR group). Both groups (Intention-to-treat) were analyzed about the proportion of patients with favorable outcome (CPC1 or 2) assessed with the Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories at 1 month by chi square test and Fisher exact probability test.

Results: One hundred and eighty patients of ECPR group and 134 patients of non-ECPR group were enrolled. There was no difference between the background of ECPR group and non-ECPR group; Average age (56.0 VS 56.9), Witnessed (72.8% VS 75.4%), Lay-rescuer CPR (49.4% VS 45.5%), Acute coronary syndrome (65.6% VS 61.4%), Minutes from collapse to emergency department (26.8 VS 30.0). The favorable outcome rate in ECPR group (12.4%, 22 patients) was statistically higher than the rate in non-ECPR group (1.6%, two patients) (p<0.001).

Conclusion: Extracorporeal cardiopulmonary resuscitation may improve the outcome of out-of hospital cardiac arrest with VF or pulseless VT without ROSC by conventional ALS during 15 minutes after an arrival at hospital.