extracorporeal membrane oxygenation in cardiac arrest. · zangrillo a, crit care resusc. 2013...
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Medical University of Vienna Speidl WS
Extracorporeal Membrane Oxygenation in Cardiac Arrest
Assoc. Prof. Priv.-Doz. Walter Speidl
Medizinische Universität WienUniversitätsklinik für Innere Medizin II
Abteilung für Kardiologie
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Medical University of Vienna Speidl WS
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Overview• Introduction• Outcomes• Prognostic factors• Cannulation• Post-resuscitation care• Complications
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Medical University of Vienna Speidl WS
Publications
Pubmed: extracorporeal and CPR
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Definition
ECPR: Extracorporeal cardiopulmonary resuscitationECLS: Extracorporeal live supportThe rapid deployment of extracorporeal membrane oxygenation (ECMO) to provide immediate cardiovascular support for patients who have cardiac arrest unresponsive to conventional CPR measures.
Morris MC, Crit Care Med. 2004 Apr;32(4):1061-9.
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Veno-Arterial ECMO
V-A ECMOOxygenatorFiO2 40-60%
Pumpflow 3-4 l/min
Femoral accesscannulas 15-21F
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ECLS in-hospital and out-of-hospital
Image courtesy of Lamhaut L.
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Guidelines
K.G. Monsieurs et al. / Resuscitation 95 (2015) 1–80
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Guidelines
Brooks SC, Circulation. 2015 Nov 3;132(18 Suppl 2):S436-43
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OutcomesMeta-analysis
Xie A, J Cardiothorac Vasc Anesth. 2015 Jun;29(3) 637-45
• 8 observational studies after 2000 • 343 patients with cardiac arrest• Survival to discharge 35.9%
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OutcomesVienna 1993-2010
Wallmüller C, Resuscitation. 2013 Mar;84(3):326-30
• 3621 patients with cardiac arrest at the ED • 55 patients treated with ECPR (2%)• 60 % out-of-hospital cardiac arrest• Time till start of canulation 52 min• Cannulation time 33 min
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OutcomesVienna 1993-2010
Wallmüller C, Resuscitation. 2013 Mar;84(3):326-30
• Weaning from ECMO 14 (25%) • 6 month survival 8 (15%)• CPC-Score 1 or 2 8 (15%)
• Cardiac 19 (35%) • Hypothermic 14 (25%)• Pulmonary 11 (20%)• Intoxication 8 (15%)• Diabetic coma 3 (5%)• Total 55
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OutcomesIn-hospital cardiac arrest
Chen YS, Lancet. 2008 Aug 16;372(9638):554-61
• 3-year prospective observational study
• ECMO for 59 patients• Age 18–75 years• Witnessed in-hospital cardiac arrest of cardiac origin• Undergoing CPR for >10 minutes• Propensity-score matched with conventional CPR
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OutcomesIn-hospital cardiac arrest
Chen YS, Lancet. 2008 Aug 16;372(9638):554-61
conventional CPR
ECPR
p=0.003
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OutcomesIn-hospital cardiac arrest
Chen YS, Lancet. 2008 Aug 16;372(9638):554-61
ECPR CCPR• Weaning from ECMO 49%• Survival to discharge 29% 12%• CPC 1 or 2 at discharge 24%
11%• CPC 1 or 2 at one year 15%
9%
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OutcomesCardiac origin
Kagawa E, Circulation. 2012 Sep 25;126(13):1605-13
• 7-year retrospective study• ECMO for 86 patients• Age 18–74 years• Cardiac arrest of cardiac origin, 49% out-of-hospital• VF on ECG during CPR• Undergoing ALS for >20 minutes
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OutcomesCardiac origin
Kagawa E, Circulation. 2012 Sep 25;126(13):1605-13
• Weaning from ECMO 50%• 30-days survival 29%• CPC 1 or 2 at discharge 24%
• Survivors 28% out-of-hospital cardiac arrest• Non-survivors 57% out-of-hospital cardiac
arrest
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OutcomesOut-of-hospital cardiac arrest
Sakamoto T, Resuscitation. 2014 Jun;85(6):762-8.
• 3 year prospective study• 26 hospitals ECPR
20 hospitals non-ECPR• VF/VT initial ECG, 20-70 years• Hospital arrivial within 45min after EMS call
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OutcomesOut-of-hospital cardiac arrest
Sakamoto T, Resuscitation. 2014 Jun;85(6):762-8.
ECPR non-ECPRNumber of patients 260 194Time from EMS call to arrival 29min 30minCPC 1 or 2 at 6 months 12.4% 3.1%
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OutcomesCHEER trial
Stub D, Resuscitation. 2015 Jan;86:88-94
• Prospective study• Age 18-65 years• Cardiac arrest of cardiac origin• Initial rhythm ventricular fibrillation• CPR > 30min• 26 patients, 11 OHCA, 15 IHCA
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OutcomesCHEER trial
Stub D, Resuscitation. 2015 Jan;86:88-94
• Mechanical chest compression (Autopulse®)• 2 liter ice-cold saline• Transfer to the ED, immediate ECMO
• Cardiac arrest to ECMO 56min (40-85min)• Arrival to ECMO flow 20min (15-30min)• Weaning from ECMO 54%• Hospital discharge 54%(IHCA 60%,OHCA 45%)• CPC 1 of survivors: 100%
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Accidential Hypothermia ECPR associated with 6.6-fold survival
IntoxicationBeta-blockersCalcium-antagonistsAntiarrhytmicsTricyclic antidepressantsBenzodiazepines
Patient selection
Case reports with good outcome
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Prognostic factorsNo flow time
Le Guen M, Crit Care. 2011;15(1)
51 consecutive patienswitnessed OHCA, 2 survivors
Causes of death afer ECPR• Multi organ failure 47%• Brain death 20%• Hemorrhagic shock 14%
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Prognostic factorsTime until ECMO-flow
Chen YS, Lancet. 2008 Aug 16;372(9638):554-61
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Prognostic factorsTime of CPR
Kim SJ, Crit Care. 2014 Sep 26;18(5):535
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Prognostic factorsSerum lactate
Jung C, Clin Res Cardiol. 2015 Aug 25.
117 patients: multivariate analysis only serum lactate
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• No flow time• VF/VT at initial ECG• Cardiac origin • Signs of live
movement, respiration, pupillary response• Time to ECMO flow
no differences IHCA/OHCA when adjusted for time• ETCO2>10 mmHg• Lactate levels
Prognostic factors
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Cannulation• Surgeon• Emergency physician• Cardiologist• Intensivist
Arterial 15-19FVenous 19-21F
PercutaneusOpenMixed
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CannulationTechnique
Percutaneus• Seldinger technique• Ultrasound or fluoroscopy to locate
wire in V. cava inf. and Ao. desc.• Risk of failure• Distal limb perfusion catheter
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CannulationTechniqueOpen• Needs a Surgeon• Time consuming• Not for out of hospital ECMO• Lowest risk of failure
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CannulationTechniqueMixed• Incision in the groin• Insertion of guidewire, dilator
and cannula under vision with Seldinger• Increased bleeding• Best for out-of-hospital ECMO
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Post-resuscitation care
• MAP 60-70 mmHg• Normoxia, normocapnia• Ice-cold saline for volume loading
and mild hypothermia• Immediate coronary angiography
or CT scan for pulmonary embolism
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Post-resuscitation careno flow – pulmonary oedema
24 hours after ECMO
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Post-resuscitation careno flow – watershed phenomenon
No contrast in coronariesand Ao. ascendens
Hoeper MM, Circulation. 2014 Sep 2;130(10):864-5
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Post-resuscitation careno flow – myocardial ischemia
• Decrease afterload as much as possiblelow ECMO flowMAP 60-70 mmHg
• Use inotropic agentsdobutamine, levosimendan
• Increase FiO2 and PEEPat respirator
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Post-resuscitation careno flow – pulmonary oedema
4 days after ECMO
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Post-resuscitation careno flow – pulmonary oedema
IABP Impella LV-vent
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ComplicationsAcute setting
Zangrillo A, Crit Care Resusc. 2013 Sep;15(3):172-8.
• Wrong cannulationvenous-venous or arterial-arterial
• Bleeding• Accidental decannulation• „Harlequin” syndrome
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Complications in the ICU
Zangrillo A, Crit Care Resusc. 2013 Sep;15(3):172-8.
• renal failure requiring haemofiltration 52%
• bacterial pneumonia 33%• any bleeding 33%• sepsis 26%• haemolysis 18%• central nervous system complications 15%• liver dysfunction
16%• leg ischaemia 10%• venous thrombosis 10%• gastrointestinal bleeding 7%• aspiration pneumonia
5%• disseminated intravascular coagulation 5%
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Patient selectionLoad & Go Criteria Vienna
Poppe M, Resuscitation 91 (2015) 131–136
• Age < 75 years• Witnessed OHCA• Basic life support• Ventricular fibrillation/ventricular tachycardia• No ROSC within 15 min of advanced-life-support
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Patient selectionLoad & Go Criteria Vienna
Poppe M, Resuscitation 91 (2015) 131–136
Population 1.8 MillionVICAR Study:August 1, 2013 to July 31, 2014
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Summary
• Only small non-randomized studies• Survival in ECPR ranges from 4% to 54%• Decision for ECMO after 15-20 min• ECMO should start within 60 min• Need for efficient ECMO rescue teams
for IHCA and OHCA