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In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?” Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important. Guillaume’s data shows importance of short low times, lower lactates and higher pH values. The real question is what number for each of these should we consider a hard stop on initiation. This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial. He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions. With many ECMO studies having average arrest to
initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide. This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65. We conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival. This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this.
Bibliography:
1: 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: 1.
2: Reynolds JC, Grunau BE, Elmer J, Rittenberger JC, Sawyer KN, Kurz MC, Singer
B, Proudfoot A, Callaway CW. Prevalence, natural history, and time-dependent
outcomes of a multi-center North American cohort of out-of-hospital cardiac
arrest extracorporeal CPR candidates. Resuscitation. 2017 Aug;117:24-31. doi:
10.1016/j.resuscitation.2017.05.024. Epub 2017 May 25. PubMed PMID: 2.
3: Debaty G, Babaz V, Durand M, Gaide-Chevronnay L, Fournel E, Blancher M,
Bouvaist H, Chavanon O, Maignan M, Bouzat P, Albaladejo P, Labarère J. Prognostic
factors for extracorporeal cardiopulmonary resuscitation recipients following
out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.
Resuscitation. 2017 Mar;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011. Epub
2016 Dec 19. Review. PubMed PMID: 3.
all very interesting, Zack. thank you and your guests.
Hey guys
Once again a fantastic discussion, thank you for that!
Im a resident in the emergency medicine program way up in Halifax Nova Scotia. A group of us here are trying to establish an ED ECPR program for our OHCA population. We are currently working on our criteria and I had a thought that I hope you could clarify.
There seems to be some variability in how the “low flow” interval is defined. In some discussions you refer to it as being the interval from arrest to ECMO flows (essentially encompassing the no flow interval), while in others, as well as in the literature, it seems to be defined by the interval between chest compressions and ECMO flows. Based on your 2012 Resuscitation publication it seems like you guys are using Total arrest time >60 minutes as your exclusion – which sounds like an interval from arrest to ECMO flows. The discussions from this pod cast seem to be advocating for a 60 minute “low flow time” which reading into Debaty’s paper seems to be from compressions to ECMO flows.
Here in Halifax we are planning a prehospital activation for ECPR, and trying to set a catchment area that would facilitate appropriate times to ECMO flows. My question is: does the literature support us using 60 minutes from time of arrest to ECMO flows, or from time of chest compressions by EMS to ECMO flows? I ask because in a system using a no flow cut off of 10 min, which we plan to use, a low flow interval defined as 60 min from time of chest compressions would allow for potentially 10 additional minutes of EMS transport time. Which would greatly increase our catchement area compared to a system that uses 60 minutes from time of arrest.
Any advice would be appreciated!