Download - BERNARD on ECMO CPR: It's ON
Stephen Bernard MD FACEM FCICM FCCM
Refractory Cardiac Arrest
The CHEER Protocol
The Victorian setting
• 000 call system
• Computer aided dispatch
• Post dispatch instructions (ECM only)
• “3-tier” system
– PAD/ Firefighters/ CERT
– ALS paramedics
– Intensive Care Paramedics
• ACLS at scene
• Transport to ED if ROSC
The Victorian setting
• If no ROSC at ~30 minutes- declared deceased
– All ACLS provided at scene
– Asystole as final rhythm
– No compelling other factors (hypothermia/ OD)
• EMS transport with effective CPR not practical
• Hazardous for EMS crew
• No new therapy in ED
• Considered futile
The Victorian setting
• Data from Victorian Ambulance Cardiac Arrest Register for Melbourne
– 12 month period (2012)
– Age < 65 years
– VF as initial cardiac rhythm
• 222 patients
• 149 ROSC (Survival of these = 55%)
• 68 no ROSC
• 5/68 transported with CPR (Autopulse)
• 63 declared deceased at scene
The Victorian setting
• Data from Victorian Ambulance Cardiac Arrest Register for Melbourne
– 12 month period (2012)
– Age < 65 years
– VF as initial cardiac rhythm
• 222 patients
• 149 ROSC (Survival of these = 50%)
• 68 no ROSC
• 5/68 transported with CPR (Autopulse)
• 63 declared deceased at scene
ECMO
• 2008 Swine flu
• Increasing experience in VV ECMO
• Intensivists at Alfred undertake training program
– 2 day program
– Cannulation in dogs
– Circuit management
E-CPR
Reports from Japan in 2000-2012
J Am Coll Cardiol 2000; 36(3):776-83.
E-CPR
• January 2004 and May 2011
• E-CPR in 86 patients with ACS
• Median age 63 years/ 81% were male
• Intra-arrest PCI was performed in 61 patients (71%).
• ROSC 88%
• 30-day survival 29%
• Favorable neurological outcome 24%
Kagawa E, et al. Should we emergently revascularize occluded coronaries for cardiac arrest?: Rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 2012 Sep 25;126(13):1605-13
The CHEER Trial
– Pilot observational trial
– Post-VF arrest
– <70 years old
– No ROSC at 30 minutes
• CPR to ED with Autopulse
• Hypothermia
• ECMO
• Emergency
• Reperfusion
The CHEER Trial
– Mechanical CPR to ED
The CHEER Trial
– Notification by AV
– Equipment
immediately available in ICU
– Brought to ED by ICU team
Autopulse Primed circuit
Cold fluidCannulae
Drapes etc
In the ED
• Clearly defined roles to prevent chaos
– ED Consultant manages airway/ventilator
– No shocks or cannulation during ECPR
– ED nurses (x 2) equipment and scribe
– ICU SR pumps ice cold saline x 3L
– ICU Consultants x 2 cannulate
– ICU/ED manage U/S upper abdo for wires
– ICU nurse manages Autopulse and ECMO circuit
– Cardiology review need for PCI
– All others stand back
In the ED
– Percutaneous
cannulation by Intensivists x 2
– 15F arterial/ 17F venous
– Ultrasound of femoral vessels
– Ultrasound of IVC
– No defibs/ CVC during cannulation
VENO-ARTERIAL ECMO
V-A ecmo for CPR
Low flow configuration
(3-4L/min)
Oxygen vs Air?
The CHEER Trial
– Cold IV saline
– 3 L bolus IV
– Cools rapidly
Bernard SA, et al. Therapeutic hypothermia induced during
cardiopulmonary resuscitation using large-volume, ice-cold intravenous
fluid. Resuscitation 2008; 76:311-3
In the cath lab:
•Coronary angiogram
•Stent any blockages
•Then the heart will start!
To the ICU:
•Cooling for 24 hours
•33°C
•Slow rewarming over 12 hours @ 0.25°C/hr
In-hospital cardiac arrest
– Refractory cardiac arrest following in-hospital arrest
– No ROSC at 30 minutes
– The “CHEER” approach
– Reversible cause
• Age <70
• ACS in ED
• Reperfusion arrest in Cath lab
• Pulmonary embolism
Experience to date
Definitions for this presentation
• OHCA- CPR into the ED and > 30 minutes
• IHCA- CPR > 30 minutes
• Excludes
– VA-ECMO for shock with arrest < 30 minutes
– IHT from other centre
Experience to date
Site ECMO Survival
OHCA 7/9 3/7
IHCA 13/13 8/13
E-CPR Good neurological outcome 11/20 (55%)
IHCA-1
IHCA-11
“Jenny thanks 'miracle workers'
who saved her life”
What we are doing now…
– Extra 10 Autopulses donated to AV by Zoll
– Covers most of Melbourne
– 24/7 ICU Consultant roster
– Strategy to move patients within 20 minutes of arrest- ECMO < 60 minutes
– Scenario training for the team
Summary
– Every large city should have E-CPR available
– Safe transfer to hospital with CPR now possible
– Intensivist rapid percutaneous cannulation in ED feasible
– Cooling during CPR is recommended (40mL/kg cold fluid bolus)
– Normal neurological outcomes possible with up to 125 minutes of CPR
– 55% good outcomes at The Alfred (11/20)