Pellegrino - ECMO CPR - Getting it Right

The Alfred Intensive Care Unit, Melbourne, Australia

The use of VA ECMO following Cardiac Arrest

E-CPR

Vincent Pellegrino

Aidan BurrellSteven Bernard

Richard LinDeirdre Murphy

Lloyd RobertsJayne Sheldrake

Carol HodgsonD. Jamie CooperVinodh Nanjayya

Bishoy ZacharyDaniel Brodie

The Alfred Intensive Care Unit, Melbourne, Australia

Cardiac Arrest VA ECMO Survival

Condition Treatment Outcome

Assessing the impact of E-CPR

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

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

hypothermiai.e. the CA has contributed to the

patient neurological outcome

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+

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

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) usedas 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+

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

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

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 … ?

The Alfred Intensive Care Unit, Melbourne, Australia

21 minutes

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the conditionCardiac arrest of greater than 20 min (conventional CPR)Sub-classifications• Pathological Classification • +/- ROSC• + out-of-hospital• (initial rhythm)

Diagnostic groups

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Exclusion Criteria

These will vary greatly from centre to centre

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers

Organ Donation

Strongest trial design for E-CPR

The Alfred Intensive Care Unit, Melbourne, Australia

Out of Hospital Cardiac Arrest Survival and ECMO

The Alfred Intensive Care Unit, Melbourne, Australia

The Alfred Intensive Care Unit, Melbourne, Australia

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers

Organ Donation

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers

Organ Donation

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers

Organ Donation

Future Models are essential1. Age2. First monitored rhythm3. Time to ECMO4. Biomarkers (early

lactate)5. No/minimal physiological data

The Alfred Intensive Care Unit, Melbourne, Australia

Conclusions

E-CPR has strong physiological and evidence base to support its use and ongoing developmentLarge 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……

The Alfred Intensive Care Unit, Melbourne, Australia