EDECMO 19 – ECPR for Out-of-Hospital Cardiac Arrest Japanese-Style!

Tetsuya Sakamoto is the principal investigator of a multi-center prospective observational study that was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Sakamoto during the 2014 AHA RESS conferences and talked all things ECPR. After that, Shinar sat down with Dr. Sakamoto to get his take on how the Japanese EMS system is setup and how they are able to implement ECPR into their resuscitation protocols.

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Tetsuya Sakamoto is the principal investigator of a multi-center prospective observational study comparing ECPR vs. traditional resuscitation for out of hospital cardiac arrest. His study was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Sakamoto during the 2014 AHA RESS conferences and talked all things ECPR. After that, Shinar sat down with Dr. Sakamoto to get his take on how the Japanese EMS system is setup and how they are able to implement ECPR into their resuscitation protocols.

The Japanese Emergency Care System

Ambulance Crew = 1 EMT paramedic + 2 EMT’s
- EMT paramedic
  - Epi
  - Intubate
- 2 Basic-trained EMT’s
Hospital Systems:
- General Hospital
- Tertiary Hospital Receiving Centers (271 Centers)
  - Trauma
  - Resuscitation
  - Critical Care
Emergency Department at Japanese Tertiary Care Center
- Emergency ICU
- Trauma resuscitation, PCI, etc.
Pre-hospital protocols for Termination of Resuscitation protocols in Japan
- In Japan, prehospitals providers are not empowered to pronounce
- Average time on Scene = 10-20 min (scoop and run!)
- They transport everyone!

Percutaneous Cardiopulmonary Support (ECMO) and the Save-J team

20 years ago: initial case reports in Japan suggested a benefit for ECPR for in-hospital cardiac arrest failing ACLS.
In 2009 a landmark paper by Ken Nagao showed benefit of ECPR + therapeutic hypothermia in a single hospital for out-of-hospital arrest.: Early Induction of Hypothermia During Cardiac Arrest Improves Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Who Undergo Emergency Cardiopulmonary Bypass and Percutaneous Coronary Intervention
So, a multi-center study was needed. 5 years ago several investigators in Japan created a multi-center study: The SAVE-J study:
- Save J was a multi-center RCT for out-of-hospital cardiac arrest by comparing resuscitation success rates for hospitals who provided ECPR with those that did not.
- reviewed by Joe and Zack for EVID-ECMO.
- Save J inclusion criteria:
  - Transport to hospital within 45 min of arrest
  - Age < 75
  - VF/VT as initial rhythm
  - No ROSC before intiation of ECPR
- Compared extremely ill patients with very little chance of survival
- Results:
  - ECPR: 10-20% survival
  - No-ECPR: 2% survival

Final Thoughts

ECPR has huge promise for saving the lives of patients who would otherwise not survive with standard ACLS. But the cost is not trivial. So,
1. we need to drill down into the inclusion criterion to ensure we are using this therapy on patients who will gain the most benefit.
2. ECPR requires a team-approach, much like a trauma team activation. The successful ECPR team still demands good-quality chest compressions, appropriate use of ACLS protocols, etc.
3. Training is important because cannulation during arrest is tough.
The Save-J approach to cannulation: much like we do it here in the US, ultrasound-guided percutaneous approach is usually the go-to approach, with cut-down used as a rescue intervention.