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Patient Selection

Goodwin G, Picache D, Louie BJ, et al. Optimal Scene Time to Achieve Favorable Outcomes in Out-of-hospital Cardiac Arrest: How Long Is Too Long? Cureus. October 2018. doi:10.7759/cureus.3434

PEA In the Field

PEA OOH Arrest with mean time of 41 minutes low-flow had 23.8% survival to discharge (neuro status not listed in the paper; small study)4

No-Flow Time

Initial rhythm shockable is a surrogate for no-flow time < 10 minutes5

but not so great for less than 10 minutes [10.1136/emermed-2021-211823]

Favorable outcome can still be seen up to 20 minutes of no-flow

Low Flow Time

Debaty G, Resuscitation. 2017 Mar;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011.

  • 6 lactate in non-survivors
  • 55 vs 65 minutes
  • Bystander CPR did not matter—not that we don’t think it matters
  • Gender and age did not seem to matter—selection criteria probably trumps (comorbidities)
  • Sign of life trumps all

: Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of
extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac
arrest-An ELSO registry study
. Resuscitation. 2017 Oct;119:56-62. doi:
10.1016/j.resuscitation.2017.08.003. Epub 2017 Aug 5. PubMed PMID: .

  • No age difference when stratified by decades of life

While low-flow >30 minutes (37 to be precise) had rare survival in prior studies in non-ecpr patients, this can’t be extended to ecpr patients. Even in non-ecpr trials, this time cut-off does not seem to hold.6,7

41 of 135 patients with a mean cpr time of 55.7 min had d/c with good neuro outcome (In-hosp arrest)8

17.7% of survival with CPR > 60 min9

Fjolner et al. had a median time of 54 minutes low flow (Acta Anaes Scandi 2017;61:176)

Change in EMS Protocols

Immediate transport of viable ECPR patients would mean much shorter low-flow times. Incidence of Load and Go is 6% of EMS responses.10

Large percentage of survivors met termination of resus rules11

Robert Pyo–Interventional

 

Comparison of Protocols

SAMU

Signs of life trumps all other

No-Flow < 5 OR initial shockable

100 minutes low flow time

Alfred (Exclusion)

  • Age> 65
  • Unwitnessed arrest
  • First checked rhythm is asystole
  • > 10 minutes before CPR
  • > 45 minutes of CPR prior to commencing cannulation
  • Known symptomatic chronic organ failure
    • Multiple past coronary revascularizations
    • Cirrhosis (jaundice, ascities, encephalopathy)
    • ESRF (dialysis)
    • Cardiomyopathy (VAD or inotropes)
    • Chronic lung disease (NYHA III or IV)
    • Chronic pulmonary arterial hypertension

 

 

 

 

 

1.

Ahn H, Lee J, Joo K, et al. Point-of-Care Ultrasound-Guided Percutaneous Cannulation of Extracorporeal Membrane Oxygenation: Make it Simple. J Emerg Med. 2018;54(4):507-513. [PubMed]

2.

Voicu S, Henry P, Malissin I, et al. Improving cannulation time for extracorporeal life support in refractory cardiac arrest of presumed cardiac cause – Comparison of two percutaneous cannulation techniques in the catheterization laboratory in a center without on-site cardiovascular surgery. Resuscitation. 2018;122:69-75. [PubMed]

3.

Javaudin F, Leclere B, Segard J, et al. Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest. Resuscitation. 2018;127:8-13. [PubMed]

4.

Pabst D, Brehm C. Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support? Am J Emerg Med. 2018;36(4):637-640. [PubMed]

5.

Tanguay-Rioux X, Grunau B, Neumar R, Tallon J, Boone R, Christenson J. Is initial rhythm in OHCA a predictor of preceding no flow time? Implications for bystander response and ECPR candidacy evaluation. Resuscitation. 2018;128:88-92. [PubMed]

6.

Bradley S, Liu W, Chan P, et al. Duration of resuscitation efforts for in-hospital cardiac arrest by predicted outcomes: Insights from Get With The Guidelines – Resuscitation. Resuscitation. 2017;113:128-134. [PubMed]

7.

Goldberger Z, Chan P, Berg R, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473-1481. [PubMed]

8.

Chen Y, Yu H, Huang S, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med. 2008;36(9):2529-2535. [PubMed]

9.

Chen Y, Lin J, Yu H, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554-561. [PubMed]

10.

Poppe M, Weiser C, Holzer M, et al. The incidence of “load&go” out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: A one-year review. R. 2015;91:131-136. doi:10.1016/j.resuscitation.2015.03.003

11.

Zhang W, Liao J, Liu Z, et al. Out-of-hospital cardiac arrest with Do-Not-Resuscitate orders signed in hospital: Who are the survivors? Resuscitation. 2018;127:68-72. [PubMed]

12.

Leick J, Liebetrau C, Szardien S, et al. Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Clin Res Cardiol. 2013;102(9):661-669. [PubMed]

13.

Chung M, Shiloh A, Carlese A. Monitoring of the adult patient on venoarterial extracorporeal membrane oxygenation. ScientificWorldJournal. 2014;2014:393258. [PubMed]

14.

Nolan J, Sandroni C. In this patient in refractory cardiac arrest should I continue CPR for longer than 30 min and, if so, how? Intensive Care Med. 2017;43(10):1501-1503. [PubMed]

15.

Hirose H, Pitcher H, Baram M, Cavarocchi N. Issues in the Intensive Care Unit for Patients with Extracorporeal Membrane Oxygenation. Crit Care Clin. 2017;33(4):855-862. [PubMed]

16.

Streitberger K, Leithner C, Wattenberg M, et al. Neuron-Specific Enolase Predicts Poor Outcome After Cardiac Arrest and Targeted Temperature Management: A Multicenter Study on 1,053 Patients. Crit Care Med. 2017;45(7):1145-1151. [PubMed]


 

CREST Score to predict early decline to ECMO16

 


Yanno Papers

Early Access to Cath Lab from Minnesota Yanno Paper17 [full text]

Yanno’s Main Paper

ECPR Paper18 [full text]

18 Patients. ECMO was placed in 83%. Seventy‐eight percent of patients had significant coronary artery disease with a high degree of complexity and 67% received PCI. Seventy‐eight percent of patients survived to hospital admission and 55% (10 of 18) survived to hospital discharge, with 50% (9 of 18) achieving good neurological function (cerebral performance categories 1 and 2). No significant ECMO‐related complications were encountered.

MRC refractory VF/VT inclusion criteria (must have all)

  1. OHCA with presumed cardiac etiology cardiac arrest.
  2. First presenting rhythm was shockable (VF or VT).
  3. Age 18 to 75 years.
  4. Received at least 3 direct current (DC) shocks without sustained ROSC.
  5. Received amiodarone 300 mg.
  6. Body could accommodate a Lund University Cardiac Arrest System (LUCAS) automated CPR device.
  7. Transfer time from the scene to the CCL of <30 minutes.

Exclusion criteria for early mobilization (presence of 1 would exclude the patient)

  1. ROSC before 3 shocks were delivered (transferred to nearest hospital).
  2. Nursing home residents.
  3. Do Not Resuscitate/Do Not Intubate.
  4. Known terminal illness, (eg, cancer, end‐stage liver, kidney, or heart disease)
  5. Traumatic arrest
  6. Pulseless electrical activity and asystole
  7. Significant bleeding
  8. Manual CPR as the only option.

Table 2

Cardiac Arrest Characteristics (18 Patients) N (%)
Arrest location
Home 7 (39)
Public place 11 (61)
Initial cardiac rhythm
VF/VT 18 (100)
Other 0
Bystander CPR
Yes 12 (66)
No 6 (33)
Times, min
911 to first responder 5.8±3.1
911 to CCL arrival 60.1±11
CCL arrival—on ECMO 6.3±2

 

Of the patients on ECMO admitted to the CICU who survived, average time to decannulation was 52±21 hours. All but 3 patients had ongoing CPR upon arrival to the CCL. Two of the 3 patients with pulses were hypotensive and in cardiogenic shock requiring ECMO initiation.

So 15 came to lab still in Arrest

What is CPC survival in these 15?

Is intermittent ROSC a positive predictor

 

Cardiac function was severely depressed for an average of 3 days, at which point a progressive recovery was observed in the majority of patients continuing until the day of discharge (Figure 3).

 

JEMS Article from Yanno19

 

CRITICAL STUDY of ecpr outcome based on 3 factors

initial shockable, time to hospital arrival within 45 minutes, and age <75 years
Favourable neurological outcomes were as follows: patients meeting no or one criterion: 2.3% (1/43), those meeting
two criteria: 8% (13/163), and those meeting all criteria: 16.1% (50/311) (P-value = 0.004).
Conclusions: In this study, approximately 60% of patients treated by ECPR met the three criteria (initial shockable, time to hospital arrival within 45
minutes, and age <75 years), and the greater the number of criteria met, the better were the neurological outcomes achieved.
[10.1016/j.resuscitation.2022.06.007]

 

A2BCDE3

  • 3 Rhythm Checks
  • Age < 75
  • Activity Signs of Life
  • Bystander Witnessed
  • CPR within 5 minutes of arrest
  • Defibbable (or PEA)
  • Endstage disease excluded
  • ETCO2 >=10
  • Estimated time to ECPR < 60 minutes
  • Estimated Complications (for cannulation)

[10.1016/j.resuscitation.2021.12.031]

References

1.
Ahn H, Lee J, Joo K, et al. Point-of-Care Ultrasound-Guided Percutaneous Cannulation of Extracorporeal Membrane Oxygenation: Make it Simple. J Emerg Med. 2018;54(4):507-513. [PubMed]
2.
Voicu S, Henry P, Malissin I, et al. Improving cannulation time for extracorporeal life support in refractory cardiac arrest of presumed cardiac cause – Comparison of two percutaneous cannulation techniques in the catheterization laboratory in a center without on-site cardiovascular surgery. Resuscitation. 2018;122:69-75. [PubMed]
3.
Javaudin F, Leclere B, Segard J, et al. Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest. Resuscitation. 2018;127:8-13. [PubMed]
4.
Pabst D, Brehm C. Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support? Am J Emerg Med. 2018;36(4):637-640. [PubMed]
5.
Tanguay-Rioux X, Grunau B, Neumar R, Tallon J, Boone R, Christenson J. Is initial rhythm in OHCA a predictor of preceding no flow time? Implications for bystander response and ECPR candidacy evaluation. Resuscitation. 2018;128:88-92. [PubMed]
6.
Bradley S, Liu W, Chan P, et al. Duration of resuscitation efforts for in-hospital cardiac arrest by predicted outcomes: Insights from Get With The Guidelines – Resuscitation. Resuscitation. 2017;113:128-134. [PubMed]
7.
Goldberger Z, Chan P, Berg R, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473-1481. [PubMed]
8.
Chen Y, Yu H, Huang S, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med. 2008;36(9):2529-2535. [PubMed]
9.
Chen Y, Lin J, Yu H, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554-561. [PubMed]
10.
Poppe M, Weiser C, Holzer M, et al. The incidence of “load&go” out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: A one-year review. R. 2015;91:131-136. doi:10.1016/j.resuscitation.2015.03.003
11.
Zhang W, Liao J, Liu Z, et al. Out-of-hospital cardiac arrest with Do-Not-Resuscitate orders signed in hospital: Who are the survivors? Resuscitation. 2018;127:68-72. [PubMed]
12.
Leick J, Liebetrau C, Szardien S, et al. Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Clin Res Cardiol. 2013;102(9):661-669. [PubMed]
13.
Chung M, Shiloh A, Carlese A. Monitoring of the adult patient on venoarterial extracorporeal membrane oxygenation. ScientificWorldJournal. 2014;2014:393258. [PubMed]
14.
Nolan J, Sandroni C. In this patient in refractory cardiac arrest should I continue CPR for longer than 30 min and, if so, how? Intensive Care Med. 2017;43(10):1501-1503. [PubMed]
15.
Hirose H, Pitcher H, Baram M, Cavarocchi N. Issues in the Intensive Care Unit for Patients with Extracorporeal Membrane Oxygenation. Crit Care Clin. 2017;33(4):855-862. [PubMed]
16.
Bascom KE, Dziodzio J, Vasaiwala S, et al. Derivation and Validation of the CREST Model for Very Early Prediction of Circulatory Etiology Death in Patients Without ST-Segment–Elevation Myocardial Infarction After Cardiac Arrest. C. 2017;137(3):273-282. doi:10.1161/circulationaha.116.024332
17.
Garcia S, Drexel T, Bekwelem W, et al. Early Access to the Cardiac Catheterization Laboratory for Patients Resuscitated From Cardiac Arrest Due to a Shockable Rhythm: The Minnesota Resuscitation Consortium Twin Cities Unified Protocol. J Am Heart Assoc. 2016;5(1). [PubMed]
18.
Yannopoulos D, Bartos J, Martin C, et al. Minnesota Resuscitation Consortium’s Advanced Perfusion and Reperfusion Cardiac Life Support Strategy for Out-of-Hospital Refractory Ventricular Fibrillation. J Am Heart Assoc. 2016;5(6). [PubMed]
19.
Yanno in JEMS. JEMS. https://www.jems.com/articles/supplements/special-topics/ems-state-of-the-science/ecmo-refractory-ohca.html. Published July 14, 2018. Accessed July 14, 2018.

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