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Both of these articles are fantastic. We review these two articles and describe their impact on the ECMO World:

Article 1: Conventional CPR vs. ECPR for In-House Cardiac Arrest (CPS Chen Lancet Study)

Identification:

Title:  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

Authors: Chen, Lin, et al.

Location: National Taiwan University Hospital; Taipei, Taiwan

Source: Lancet 2008; 372: 554-61

ClinicalTrials.gov #: NCT00173615

Introduction:

Problem: Comparing ECPR to conventional CPR for in-hospital cardiac arrest. Prior studies that showed a  benefit of ECPR over conventional CPR may have had selection bias. Prior studies also included all causes of arrest whereas this study attempts to focus on arrest of cardiac origin.

Purpose:  Is ECPR superior to conventional CPR for in-hospital cardiac arrest of cardiac origin?

Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for in-house arrest.

Methods:

Study Type:  Prospective Observational with Propensity-Score analysis matching

• Single-Center
• 3 years
• 975 total patients; 172 patients: conventional CPR = 113; ECPR = 59

Subjects:  18-75 YOA; witnessed cardiac arrest of cardiac origin who underwent CPR for longer than 10 min. Matching based on propensity-score;

• CPR team: senior medical resident, junior residents, RT, several ICU RN's. *residents were cannulating!

Primary End-Point: Survival to hospital discharge, with sub-analysis of neurologic outcomes.

Analysis: Intention to treat

Results/Conclusions: 

• Main conclusion:
  • Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.
  • Survival to Hospital discharge:
    • Unmatched: 28.8% ECPR vs. 12.3% conventional CPR
    • Matched: 32.6% ECPR vs. 17.4% conventional CPR

****THE BOTTOM LINE:  EDECMO Critical Assessment:

• Good study that showed a benefit of ECPR over conventional CPR for in-house arrest for short and long-term patient-oriented outcomes.
• Propensity matching method reasonably mitigated selection bias
• 3 patients in the ‘conventional CPR' arm were later put on ECMO because of persistent shock > Is there an implied benefit of ECMO for the post-cardiac arrest syndrome?
• Criticisms/Confounders
  • Single-Center
  • Patients in the ECMO group had higher incidence of LVAD, intervention, and heart transplant.
  • first documented rhythm of VT/VF (49% ECPR vs. 32% CPR) was significantly higher in ECPR group; and asystole (22% ECPR vs. 27% CPR) was higher in the CPR group: ? selection bias?
  • Location of arrest/CPR may make a difference (Emergency Department vs. ICU/Operating room)
  • Failed conventional CPR was defined as CPR without ROSC at 30 minutes – is this timeframe too short.  What if conventional CPR were continued for 60 min?
  • No TTM or hypothermia in either group.

 

Article 2:  CPR vs. ECPR for Out-of-Hospital Cardiac Arrest (SAVE-J)

Identification:

Title:  Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study

Authors: Sakamoto, Morimura, Nagao, Asai, Yokota, Nara, Hase, Tahara, Atsumi, SAVE-J Study Group

Location: Yokohoma City University Graduate School of Medicine, Yokohama, Kanagawa, Japan

Source:  Resuscitation 2014 Jun;85(6):762-8

Introduction:

Problem: Does ECPR improve patient-oriented outcomes after OHCA? Prior to this study, the effects of ECPR on long-term neurologic outcomes were unknown.

Purpose:  To determine whether ECPR is better than conventional CPR for short and long term neurologic recovery for patients who suffer OHCA

Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for OHCA.

Methods:

Study Type:  Prospective Observational;

• multi-center: 46 centers: 26 ECPR, 20 non-ECPR
• 3 years
• 454 patients: Conventional CPR = 194; ECPR = 260

Subjects: 20-75 YOA; VF/VT arrest; <45 total arrest time;

Primary End-Point: Rate of favorable outcomes (CPC 1 or 2) at 1 and 6 months after OHCA.

Analysis: Intention to treat

Results/Conclusions: 

• Main conclusion: In OHCA due to VF/VT, a treatment bundle of ECPR, TH (TTM?), and IABP was associated with improved neurologic outcomes at 1 and 6 months.
  • Intention-to-treat Analysis:
    • 1 month:
      • ECPR  = 12.3%
      • Non-ECPR = 1.5%
    • 6 months
      • ECPR = 11.2%
      • Non-ECPR = 2.6%
  • Per-protocol Analysis:
    • 1-month
      • ECPR = 13.7%
      • Non-ECPR = 1.9%
    • 6-month
      • ECPR = 12.4%
      • Non-ECPR = 3.1%

****THE BOTTOM LINE:  EDECMO Critical Assessment:

• Excellent multi center study a benefit of ECPR over conventional CPR for OHCA for short and long-term patient-oriented outcomes.
• Criticisms/Confounders:
  • Rate of use of TTM/TH and IABP were higher in ECPR group.
  • Choice of ECPR vs Non-ECPR was dependent on individual centers with each center doing one or the other but not both.  In other words, does the quality of care at an ECPR center trump the quality of care at a non-ECPR center and does that impose bias?

Podcast: Play in new window | Download (Duration: 35:20 — 32.4MB)

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Paris ECMO Course

The excellent lecturer was Dr. Guillaume Lebreton,

Associate Professor and Cardiothoracic Surgeon
Director of the CPB and ECMO program,
Department of Cardio-Thoracic Surgery
Pitié Salpêtrière Hospital

How Not to Frack Up

• DO NOT ADAPT TECHNIQUE TO YOUR CAPACITY
• Fixed Point for Wire–meaning wire must be held stationary as you dilate, otherwise dilator will back wall through vessel with anything but the stiffest guidewire. We get a false sense of security from smaller line placement.
• Discussed being fooled by echo
• They do cutdowns for all ECPR

Inflow

• Crap flow if too small
• If you measure from the puncture site directly to the middle of the sternum, that should be your insertion. Too deep is better, with Maquet you want the tip in the RA
• 24-29 F with 25 being the sweet spot
• 55 cm Maquet for all adults
• When the holes are through the vessel, PULL Back the Dilator

Outflow

• Hemolysis if too small
• 17-21 F for VA
• 19-23 F for VV
• IJ catheter length-15 cm on right, 23 cm on left
• Don't pull back dilator for arterial placement

Placement

• Pad behind buttocks to straighten vessels 4″ or so
• Needle bevel facing up and wire's j facing up
• Gentle Angle for  Needle Placement
• Guidewire-go fast and it goes straight
• Always use the 150 cm guidewire. Leave 1 meter out, 50 cm in pt
• Scalpel-1 cm cut and plunge
• Doesn't bother rotating the dilators
• VV-do the femoral first as it is harder to knock out

Femoral-Femoral VV

• Return close to tricuspid, not multi-stage
• Drainage as central as possible, but in IVC, not RA
• Put in both guidewires first
• Put the longer cannula (return) in first
• Inflow-21-23 short insertion, but same length cannula (Maquet)
• Outflow-17-19, single stage (Medtronic)

TroubleShooting

• If at the same speed, decreased flow–think thrombosis

Starting VVECMO

1. Clamp on tubing
2. Start slow, 2000 rpm then slowly declamp
3. Start sweep at 6 lpm (or 1:1 with flow)
4. Go up to the max flow you can get at first to see your max
5. You want to provoke reflow
6. You should be able to get big flows (6-7 lpm)
7. Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture)
8. You should be able to get to 100% sat quickly
9. If you are seeing recirc, pull back inflow slightly (max 1-3 cm)

• Treat the pt not the xray when it comes to cannula positioning

Factors that increase Recirc

• Proximate venous tips
• Low CO
• Hypovolemia
• Increased pump flow rates

Avalon

Turn Head all the way to the left to align IVC and SVC

VA

FEM/FEM
do venous 1st if doing cutdown

Image by Cedric Lange

Podcast: Play in new window | Download (Duration: 31:16 — 28.7MB)

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Joe and I discuss ECPR cannulae placement from a cognitive task analysis (sort of) perspective. Beware: agonizing detail follows.

I believe this episode may help you even if you never do ECMO, as it is directly applicable to large central line placement as well.

Podcast: Play in new window | Download (Duration: 18:49 — 17.3MB)

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In this episode we talk about how we prepare for, and run, our codes.  When we began incorporating ECPR into our resuscitation strategy we found ourselves saving patients who would have otherwise died.  The traditional nihilistic approach to the arresting patient was overturned with ECPR by providing hope that wasn't previously there. Naturally,  we took a closer look at each element of the code, from the time the patient hit the door to the time we started the pump.  And we realized we were doing a lot of stuff wrong.  Here is how I do it:

1.  Medic gurney entry:    If you're doing ECPR, then vascular access of the femoral vessels is a top priority. Most of us are right handed and prefer to access the femoral vasculature on the patient's right.  But that's EXACTLY where the medic gurney offloads the patient- big mistake. Time is wasted waiting for the medics to move the patient to your hospital gurney, remove monitor leads, pack up the monitor, avoid pulling out IV's and then leave the room.  Only then could the “line doctor” push the ultrasound machine into the room, disrobe the patient, gown up, place a sterile US probe cover, prep the field and get to work.  That's precious minutes wasted.  Stop doing that!  Bring the medic gurney in on the other side!  Your “line doctor” is already completely ready to go.

2. Protocolize EVERYTHING:  ACLS provides  a protocolized framework for running a code.  But what about all that stuff that happens from the ambulance bay until care is transferred to you?  And can we improve on the current ACLS algorithm?  Most of us appreciate that protocoling doesn't restrict us; in fact, quite the opposite.  A protocol allows cognitive offloading of important, yet routine, steps in a process which frees us to focus on tasks specific to that patient.

If you are considering establishing an ED ECMO or ECPR program at your facility, I highly recommend that you take a close look at everything that is done from the time the patient hits your door to the time the ECLS pump is started. We aren't saying this is the only way to do it, but this is how we do it:

Anticipating the Arrival of an Arresting Patient:

• Staging the room: not unlike a theatrical play, each person and each piece of equipment has a specific role and a specific position in resuscitation suite.  Do it the same way every single time.

 

Some roles that are unique to our resuscitation team:

• “Line Doctor”: MD responsible for femoral vascular access
• “Code Doctor”: MD responsible for running the code and decision-making
• “Code Team Leader”: RN responsible for timing of important events (ie drug delivery, shocking, pulse checks, etc). This RN also does computer-based charting.
• “Med/Electric Nurse”: RN responsible for pushing drugs and delivering shocks
• “Resuscitation Cart”: lives just outside the room and has two shelves and house the following:

• Quiet the room: as the medics enter the room, quickly remind everyone to limit unnecessary noise.

Patient Arrival:

• The paramedic gurney (with ongoing CPR) enters the room on the right side of the room (if you are looking from outside to inside the room), not the left (which is how you are likely accepting your patients now.)

 

• After transfer of the patient from the medic gurney to the ED bed, chest compressions are immediately assumed by “Chest compressor #1”.  compressions then move back and forth between the two “Chest compressors” at pulse checks.
• Since femoral vascular access is a huge focus, I would also recommend that you assign a free hand (RN or tech) to “groin access,” who is standing outside the room with trauma shears in one hand a bottle of betadine in the other.  Once the patient is moved from the medic gurney to the ED Bed, that individual is tasked with stripping the pants off (by cutting or pulling) and drenching the groins in betadine.  It becomes an efficient task for the “line doc” to drop a drape, place the US probe, and gain femoral vascular access.
• Of course, the need for both of these human chest compressors (and valuable real estate in the resuscitation room) is eliminated if you have a mechanical chest compression device such as the LUCAS2: