CPR What Works, What Doesn t
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1 Resuscitation 2017 ECMO and ECLS April 1, 2017 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN Circulation 2013;128: Cardiac arrest claims more lives per year than colorectal, breast and prostate cancer, influenza, pneumonia, MVCs, HIV, house fires and guns combined Current survival from out of hospital arrests range from 3%-16.3% (ROC and NHS data) Variable CPR quality greatly affects survival CPR What Works, What Doesn t Authoritative and comprehensive review What works and what doesn t 99 references Insightful recs for PEA and Post Resus care Effect of Intervention on Outcome Effect of Intervention on Outcome Intervention Effect on Outcomes Intervention Effect on Outcomes Compressions only CPR Single vs multiple stacked shocks Mechanical chest compressions Advanced airway placement Uncertain Impedance threshold device Intravenous line placement Active compression /decompression Delayed vs immediate CPR Epinephrine vs placebo High vs standard epinephrine dose, possible harm 1
2 Effect of Intervention on Outcome Intervention Amiodarone vs nifekalant Lidocaine vs placebo Amiodarone vs placebo Atropine vs placebo Aminophylline vs placebo Effect on Outcomes Possible benefit Uncertain Therapeutic Hypothermia New Engl J Med 2013, 369: (32º - 34º) Therapeutic Hypothermia significantly improves survival ( 26%) and neurologic outcome ( 40%) after VF/pVT cardiac arrest What temperature for Therapeutic Hypothermia? 939 patients in randomized trial 36 ICUs in Europe and Australia Evaluated: mortality & neuro outcome at 180d 80% VF/VT; 20% AS and PEA (12%/7%) Hypothermia vs Normal Temp Survival and Neuro Outcomes New Engl J Med 2013, 369: New Engl J Med 2013, 369: % Compared to TH No unwitnessed Asystole patients P = NS 24% intravascular; 76% surface cooled 28 hours of cooling Rewarmed at 0.5 /hour Survival Poor Neuro 36 Survival Poor Neuro 33 2
3 Therapeutic Hypothermia Take Homes The future of deep TH is unclear Preventing Hyperthermia appears crucial Future studies will determine optimal TH temp looks like the new Resuscitation 2015;96: There is no benefit to prehospital hypothermia regardless of cooling method, time to induce TH, continuation of TH in ED or initial arrest rhythm Maximizing In-Hospital Survival JAMA Cardiol 2016;1: JAMA Cardiol 2016;1: What strategies can maximize CPR survival 131 GWTG Resuscitation registry hospitals with 20 arrest Minimizing interruptions Frequent review of CPR cases High quality CPR training Data is from 1/ /2013 Median survival = 23.6% 5 Keys to Optimal CPR compressions/min Depress 2 inches Allow full recoil Minimize interruptions Ventilate Q 6 seconds (8-10 min) Resuscitation 2016;108:54-60 Is PCI indicated s/p VF/pVT arrests if no STEMI on 12-lead? Systematic review and meta-analysis 11 articles involving 2,885 pts. STEMI pts 13 x for transport to CCL Evaluated STEMI in CCL if no STEMI ECG 3
4 Resuscitation 2016;108:54-60 Immediate CCL s/p VF/pVT Arrest Resuscitation 2016;108: % of STEMI on ECG pts had an acute culprit lesion 32.2% of non-stemi ECG pts had an acute culprit lesion Improves survival by a factor of 3.7 (CI ) regardless of STEMI or no STEMI on ECG survival by 30% if no STEMI on ECG Effect of Intervention on Outcome Intervention Sodium bicarbonate vs placebo Magnesium sulfate vs placebo Calcium chloride vs placebo Out-of-hospital cooling Extracorporeal CPR vs conventional CPR Effect on Outcomes Uncertain Uncertain Possible benefit ECMO and ECLS Do they have a role in CPR? ECMO E-CPR Mechanical CPR Resuscitation 2015;86:88-94 ECLS Therapeutic Hypothermia Immediate post ECMO PCI 24 hours of TH Am J Respir Crit Care Med 2014;190:
5 Am J Respir Crit Care Med 2014;190: Uses of ECMO and ECLS Respiratory failure ARDS, H 1 N 1, SARS Bridge to heart transplant Bridge to lung transplant Cardiogenic shock ECLS s/p cardiac arrest Resuscitation 2015;86:88-94 Does ECMO improve post-arrest resuscitation outcomes The CHEER trial Refractory VF x 30 minutes No known underlying severe disease CPR within 10 minutes of arrest Mechanical CPR available ECMO Team with 2 MDs present 26 patients (11 OHCA, 15 IHCA) ECMO within 56 minutes; 2 days on 96% ROSC E-CPR Results Resuscitation 2015;86: % (14/26) survived to discharge with CPC score of 1 full neurologic recovery ECMO CPR Requires large team and planning Careful patient selection 76% complication rate May require transfer to OR 5
6 Resuscitation 2015;88: Can ECMO improve survival from hypothermic drowning patients? 11 year retrospective study ( ) 43 drowning patients, core temp < 30 C All directly admitted to ICU in asystolic arrest 20 patients received ECMO Resuscitation 2015;88: Results & Outcomes 4/20 ECMO patients survived 24 hours 2 discharged, 2 died in ICU 1 (5%) good cerebral performance (CPC 1) 1 severe cerebral disability (CPC 3) ECMO For Drowning Take Homes Rarely effective, but can work All survivors were warmer than 26 C and had a K less than 6 meq/l Drowning + hypothermia is likely worse than acute hypothermia alone This series is scene to immediate ELS at specialty hospital and hard to improve upon Resuscitation 2016;99:26-32 Korean national database of OHCA 36,547 pts, , 320 ECLS pts Propensity matched evaluation (1:1, 2:1, 3:1) Compared ECMO ECLS vs standard care 20% 15% 10% 5% 0% Survival ECMO vs Standard CPR Resuscitation 2016;99: % Std CPR ECLS Std CPR ECLS Survival to DC 18% P=NS 7% 9% Discharge with Good Neuro P=NS Resuscitation 2017;112:34-40 Has CPR survival improved over time with ECMO? Extracorporeal Life Support Organization 1,796 pts from 53 countries in ELSO Divided into 3 groups: ; ; Use of ECMO has increased 10 x Comorbidities while complications over time 6
7 ECPR from Resuscitation 2017;112:34-40 ECPR Survival Over Time Resuscitation 2017;112:34-40 Complications of ECLS After adjusting for severity, there has been no difference in ECMO survival over the past decade Average survival is 29% Major bleeding Infection Lower extremity ischemia Stroke and neurologic complications Lower extremity amputation ECMO Complications and Survival Resuscitation 2017;112:34-40 CVA rate of 7% GI bleeding requiring transfusion > 6% Cannula site bleeding requiring intervention > 20% Indicators for ECMO and ECLS survival: PE, myocarditis, transplant, s/p VF/VT survival: sepsis, ARF, hematologic dsx 7
8 ECPR ECPR Shockable arrest rhythm or known precipitant Reversible cause of arrest Witnessed arrest with CPR Duration of pulselessness < min or transient ROSC Absence of major life-limiting comorbidities No ECLS Survival Improvement with ECLS (CPC 1-2) Resuscitation 2016;103: Elderly or serious underlying diseases Irreversible neurologic insult Morbid obesity or arterial disease ECLS team not readily available Contraindications to LVAD, Heart Transplant Chen 2008 Shin 2011 Meekawa 2013 Sakamoto x (12.3 vs 28.8) 3.6 x (7.8 vs 28.2) 5.0 x (6.4 vs 32.1) 8.2 x (1.5 vs 12.3) ECLS clearly improves in-hospital arrest outcomes if begun within minutes of arrest ECLS of variable benefit for out of hospital arrests unless transported rapidly to the ED J Am Heart Assoc 2016;5:e Rapid ECLS for VF/pVT ECLS s/p 3 shocks + amio in 18 pts 911 to CCL 60 min + 6 min for ECMO No significant complications 50% good neuro outcomes 9/18 8
9 Resuscitation 2016;107:38-46 ED ECMO done infrequently Many centers do 3 cases / year Most programs do not have strict criteria Many did not exclude no CPR > 10 min J Am Heart Assoc 2016;5:e Many did not exclude trauma or comorbidities ECMO costs $42,000 - $537,000 depending on indication & duration In Conclusion The benefits and risks of ECPR remain uncertain ECPR improves survival and good neuro outcomes ECPR increases survival in coma and vegetative status Do not let it be a bridge to nowhere Resuscitation 2015;91:73-5 Think about ECMO in relatively healthy patients with acute reversible diseases like massive PE, refractory VF or shock due to acute AMI that can be cardiogenic with thrombectomy, PCI or bypass. Team needs to be ready to go in under an hour Need high-quality CPR while waiting 9
10 10
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