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ECPR: An emerging strategy for cardiac arrest · Cardiac Arrest n=40; Vienna • Hyperinvasive...
Transcript of ECPR: An emerging strategy for cardiac arrest · Cardiac Arrest n=40; Vienna • Hyperinvasive...
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ECPR: An emerging strategy for cardiac arrest
Steven Brooks MD MHSc FRCPC
Associate Professor
Department of Emergency Medicine, Queen’s University
November 2016
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Conventional CPR is ineffective
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Conventional CPR is ineffective
25% of
normal
cardiac
output
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Circulation. 2015;131:e29-e322
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JAMA 1961 178 1063
24% survival to hospital discharge
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Other inventions from the 1950s
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Other inventions from the 1950s
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Still at it…
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ECPR
• Initiation of extracorporeal membrane oxygenation (ECMO) for the treatment of cardiac arrest
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Why ECPR?
• Failed conventional ACLS
• Pre-morbid status good
• Reversible cause
– A bridge to definitive treatment
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ECPR: The Setup
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ECPR: The setup
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ECPR: The Setup
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ECPR: The Setup
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Current Evidence and Guidelines
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Is an emergency department-based ECPR program feasible?
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Opportunities and Barriers for ECPR in Canada
• Estimated 10% of all EMS-treated cases of
OHCA fulfilled their ECPR criteria
• approximately 1/3 of these (12 pts/year)
refractory to conventional resuscitation.
PILOT STUDY UNDERWAY
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• Take home points
– An ER-based ECPR program is feasible
– ER docs can be trained to put patients on pump but it isn’t easy
– 27% eligible for ECPR survived with good neuro function
– 63% on pump survived with good neuro function
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The CHEER Trial
• Case series
• Refractory OHCA and IHCA (>30 mins)
• Age 18-65
• Cardiac etiology
• VF
• <10 minutes to CPR
• IHCA – MD discretion
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The CHEER Trial
CPC 1-2
CPC
1-2
45%
Survival
60%
Survival
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• 20 studies (n=833)
• Heterogeneity
• Observational studies and case reports
• age 16-75yrs
• failed CPR prior to ECPR 10-30 min
• Time to cannulation
• Post arrest care
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• Survival
– Discharge: 22%, 13% with CPC 1-2 (n=833)
– 3 months: 21%, 15% with CPC 1-2 (n=115)
– 6 months: 16%, 9% with CPC 1-2 (n=377)
Resuscitation 2016 101 12-20
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Does ECPR improve outcomes compared to conventional CPR?
The jury is out….
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Resuscitation 2016 103 106-16
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Challenges with ECPR observational studies
• Patient selection
– Inclusion/exclusion criteria
– Selection bias
• Variable ECPR implementation
– Primary management strategy for cardiac arrest versus after failed conventional CPR
– Time to cannulation
– Variable co-intervention
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NO RCTs
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ECPR RCTs are happening!
• Emergency Cardiopulmonary Bypass for Cardiac Arrest n=40; Vienna
• Hyperinvasive Approach in Cardiac Arrest, n=170; Prague
• A Comparative Study Between a Pre-hospital and an In-hospital Circulatory Support Strategy (ECMO) in Refractory Cardiac Arrest NCT02527031; n=210; France
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Can ECPR provide new opportunities for deceased donation?
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Opportunities and Barriers for ECPR in Canada
Treatment Recommendation:
We recommend that all patients who have restoration
of circulation after CPR and who subsequently
progress to death be evaluated for organ donation
(strong recommendation, low-quality evidence).
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• 88/160 potential and 17/160 actual deceased organ donors (15 NDD, 2 DCD) were identified among the non-survivors in 8 studies
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Organ donation after ECPR
• Needs to be considered as an outcome in all future studies of ECPR
• Thorny ethical issues need to be addressed
– Distinction between using ECMO for organ preservation in the dead versus ECPR resuscitation attempt and organ donation considered if non survivor
• Neuroprognostication during ECPR is poorly understood
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3
4
OPPORTUNITIES AND CHALLENGES
FOR ECPR IN CANADA
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Sponsor and Enablers
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Why have a meeting?
• Emergence of ECPR as a viable strategy to save lives
• Pioneering ECPR programs launched in Canada and the United States
• Resuscitation and Organ Donation communities exploring strategies to optimizing donation after cardiac arrest
Deceased Donation
Advisory Committee
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Unique Canadian Opportunities
• Established and developing Canadian infrastructure for collaborative research in resuscitation
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Short Term Objectives and Outcomes
1. To review evidence in support of ECPR as it relates to the Canadian health care setting;
2. To identifying barriers and opportunities for ECPR implementation and study in Canada;
3. To determine the feasibility of a research program for ECPR in the Canadian setting;
4. To Identify overarching issues outside the clinical setting which may impact on ECPR implementation in Canada (e.g., ethics, costs vs benefits, training and education requirements, etc.).
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Long Term Objectives
1. To develop commitment and engagement of interdisciplinary clinical investigators in the development of a collaborative resuscitation outcomes research network;
2. Informing others of this work through the publication of a proceedings paper based on the meeting.
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MEETING CONCLUSIONS
• Consensus ECPR is a potentially viable strategy to save lives in Canada.
• Efficacy has not been proven, equipoise remains• High priority research questions identified• Cost-effectiveness and ethical implications in the
Canadian setting need to be determined• Opportunities for multidisciplinary research
• Next meeting – CIHR Planning and Dissemination Grant
• Meeting report publication pending
Opportunities and Barriers for ECPR in Canada
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