Outcomes with ECMO for In Hospital Cardiac Arrest
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1 Outcomes with ECMO for In Hospital Cardiac Arrest Subhasis Chatterjee, MD, FACS, FACC, FCCP. ECMO Program Director CHI Baylor St. Lukes Medical Center/ Texas Heart Institute Asst. Professor of Surgery, Baylor College of Medicine American Association for Thoracic Surgery. Mechanical Circulatory Support Symposium March 8, Houston, TX
2 Nothing Disclosures
3 In Hospital Cardiac Arrest (IHCA) 1. Outcomes of IHCA with Conventional CPR 2. Results of Outcomes of ECMO in IHCA 3. Prognostic Factors predicting success/failure 4. Conduct of ECMO 5. Complications
4 13 to 22% Survival to Hospital Discharge (STHD) 33% to 28% for significant neurologic disability Girotra. NEJM 2012;367:
5 Uchenna R. Ofoma et al. JACC 2018;71: American College of Cardiology Foundation
6 IHCA: Public Perception of CPR Public perception: 75% watch medical dramas 57% believed an 80yo man with IHCA would survive with complete recovery. 1 72% believe that chance of full recovery after IHCA CPR is 75%. 2 1 Ouelette. Amer. Jrnl Emerg Med IN PRESS 2 Shif. Resuscitation 2015;90:73-78.
7 -- 49% ROSC; 15% STHD -- + ROSC= 12 min (6-21) CPR - Hosp. in Longest quartile CPR 25 vs. 16 had higher ROSC (51 vs. 45%) & STHD (16 vs. 14%) Goldhaber ZD. Lancet 2012;380:
8 What do the Guidelines Tell Us about Extracorporeal CPR (E-CPR)? Not Much
9 Brooks SC. CIRCULATION 2015;132(18 Supp2):S
10 Monsieurs KG. Resuscitation 2015;95:1-80
11 ELSO ECPR E-CPR is defined as ECMO initiation during CPR without ROSC or in patients with transient ROSC Defines refractory CPR after 15 Total Body Hypothermia should be included ice to head during CPR and for hrs after cannulation
12 Outcomes
13 1976 N=35 41% survival
14 ECPR outcomes in IHCA Study, Country Design N Age (yrs) Male (%) Time to ECLS (mts) Neurologically Favorable Survival Chen et al (2008) Taiwan Lin et al (2010) Taiwan Shin et al. (2011) Taiwan Chou et al. (2014) Taiwan Prospective < >60 Prospective % Retrospectiv e Retrospectiv e % % 40 24% 42 28% 60 35% 42% 30% 30% 18% (33% Overall) Zhao et al. (2014) China Retrospectiv e % 36 33% Blumenstein et al (2016) Germany Retrospectiv e % 33 21% Chen. Lancet 2008;372: Lin. Resuscitation 2010;81: Shin. Crit Care Med. 2011;39:1-7. Chou. Emerg Med. Jrnl 2014;31: Zhao. Eur J Med Res. 2015;20:83. Blumenstein. Eur Hrt Jrnl. J Acute Cardiovasc Care 2016;5:13-22.
15 Challenges in Interpreting the E-CPR Literature 1. What is E-CPR? Is it cannulation during CPR vs. cannulation immediately after ROSC with ongoing CS? 2. Selection bias in E-CPR over C-CPR felt to be more salvageable
16 Outcomes: Meta-analyses 30-day survival for CA= 36% (23-50%) vs. CS= 53% (44-61%)
17 - ECPR better survival (RR=2.37) and Neuro (2.79) than CCPR - ECPR no significant difference in IHCA but was in OHCA
18 40% ECMO Survival 30% STHD
19 27% Survival
20 IHCA Outcomes 3 year Prospective Observational Study Age Witnessed IHCA and CPR>10 ECMO (n=59) vs. Conv CPR (n=113) Propensity matched Chen YS. Lancet 2008;372:
21 30d 1y ECPR 30d 1y CCPR Chen YS. Lancet 2008;372:
22 Prognostic Factors
23 Duration of CPR to Survival Discharge Chen YS. Lancet 2008;372:
24 Duration & Survival <30 = 63% > 30 = 29% <45 = 50% > 45 = 22% <60 = 47% > 60 = 9% Chen YS. Crit Care Med 2008;36:
25 Age, CPR duration, Rhythm, ROSC Lee SW. Ann Intensive Care 2017;7:87.
26 Lactate < % 44% HR 3.55 ( , p<0.001) Jung. Clin Res Cardiol 2016;105:
27 Time to Coronary Intervention Matters 100% 80% 60% 40% 20% Chou TH. Emerg Med J 2014;31:
28 Who Should Not Have ECMO with IHCA Age<75 VF/VT>>> Other CPR start < 5-15 Cardiac/PE cause No ROSC after Terminal illness Major comorbidities CNS Disease/ICH Bleeding/AC Contraind Sepsis Arrest AD/AI/PVD Patel JK. Jrnl Int Care Med 2016;31:359-68
29 Lee. Lancet 2008;372: Conduct of E-CPR
30 10-20 Swol J. Perfusion 2016;31:
31 Cannulation Who Should Cannulate? Where? Surgeons Cardiologists Intensivists ER Physicians Tradeoff Risk of Complications vs. Rapid Cannulation Watch Out for Inadvertent Malposition i.e. VV or AA
32 E-CPR Algorithm
33 Mechanical CPR Hypothermia ECMO Early Reperfusion N=26 (15=IHCA, 11=OHCA) 92% had ECMO Median 56 54% STHD Stub. Resuscitation 2015;86:88-94.
34 Complications
35 Cheng. Ann Thorac Surg 2014;97: studies; 1866 patients
36 17% LE Ischemia 10% Fasciotomy 5% Amputation 45-55% AKI/RRT 40% Major Bleed/Takeback 30% Infection 6% Stroke 13% Neurologic Cheng. Ann Thorac Surg 2014;97:610-6.
37 ECMO Program Volume
38 E-CPR Survival Rate Percent Survival <7% Survival Bloom HL. Am Heart J. 2007;153(5):831-6.
39 ECMO Program Changes at Baylor St. Lukes/Texas Heart Institute Joined ELSO Monthly Case Review Meetings Routine Neurocritical Care Consultation Routine Hematopathology Consultation (PTT, TEG, antixa)
40 25 E-CPR Survival Rate 20 Percent Survival
41 Conclusions 20-30% STHD for IHCA Witnessed arrest, rapid CPR, VT/VF, < 60 to ECMO Higher rate of complications
42 Questions
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