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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
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
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
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
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) 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 +
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”
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 +
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 +
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…?
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…?
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…?
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 condition Cardiac 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
Approaches to E-CPR (How?)
Time to ECMO Cannulation -Percutaneous or Open
Cannulae Temperature O2 tension
The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO Cannulation -Percutaneous or Open
Cannulae Temperature O2 tension
The Alfred Intensive Care Unit, Melbourne, Australia
Cannulation
Percutaneous with ultra-sound guidance and distal perfusion cannula
The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia
Assessment of Vascular Access
TTE - subcostal TOE - transgastric
Inferior Vena Cava
The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia
Assessment of Vascular Access Abdominal Aorta
Aorta (TTE subcostal) PW Doppler aorta
The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia
J-wire in IVC
Venous Cannulation for ECMO
The Alfred Intensive Care Unit, Melbourne, Australia
Downstream compression
The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia
VA ECMO Backflow Cannulation
CFA
Profunda Artery
SFA
The Alfred Intensive Care Unit, Melbourne, Australia
Coming ….very soon!!
The Alfred Intensive Care Unit, Melbourne, Australia
MTMM bidirectional cannula
The Alfred Intensive Care Unit, Melbourne, Australia
MTMM bidirectional cannula
Transition zone role in downstream compression
The Alfred Intensive Care Unit, Melbourne, Australia
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
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
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
The Alfred Intensive Care Unit, Melbourne, Australia
Alternative cannulation
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
The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO Cannulation -Percutaneous or Open
Cannulae Temperature O2 tension
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
The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO Cannulation -Percutaneous or Open
Cannulae Temperature O2 tension
The Alfred Intensive Care Unit, Melbourne, Australia
Training and team
The Alfred Intensive Care Unit, Melbourne, Australia
Team work
The Alfred Intensive Care Unit, Melbourne, Australia
Management of the AMI CA
ST-AMI
Cath lab
PCI
CABG
The Alfred Intensive Care Unit, Melbourne, Australia
Management of the AMI CA
ST-AMI +CA
E-CPR
PCI
CABG
Cath lab
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
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
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 study Propensity Matching ELSO Risk Prediction -Biomarkers
Organ Donation
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
The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(2+) 5/30 (16%) 12/32 (37.5%)
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
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
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)
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
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
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……
The Alfred Intensive Care Unit, Melbourne, Australia