pellegrino - ecmo cpr - getting it right
TRANSCRIPT
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The Alfred Intensive Care Unit, Melbourne, Australia
The use of VA ECMO following Cardiac Arrest
E-CPR
Vincent Pellegrino
Aidan BurrellSteven Bernard
Richard LinDeirdre Murphy
Lloyd RobertsJayne Sheldrake
Carol HodgsonD. Jamie CooperVinodh Nanjayya
Bishoy ZacharyDaniel Brodie
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The Alfred Intensive Care Unit, Melbourne, Australia
Cardiac Arrest VA ECMO Survival
Condition Treatment Outcome
Assessing the impact of E-CPR
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The Alfred Intensive Care Unit, Melbourne, Australia
Assessing the impact of E-CPR
Out Hospital CA
VA ECMO Survival
Condition Treatment Outcome
In Hospital CA
+ROSC +CS
+ROSC +CS
- ROSC
- ROSC
Neuro
Cost QOL
Organ Donation
Unsupportable
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
Alfred Hospital - Melbourne
ECMO commenced within 30 minutes of a cardiac arrest which has been associated with c-CPR for greater than 10 minutes or has rendered
the patient unconscious
Based on the CA definition for therapeutic
hypothermiai.e. the CA has contributed to the
patient neurological outcome
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
Taipei, Taiwan JACC 2003
“Briefly, patients were recruited into the ECPR group only if they: 1) were in cardiac arrest that necessitated external or open-
chest cardiac massage and a large amount of epinephrine (5 mg) during CPR; 2) could not be returned to spontaneous circulation within 10 to 20 min; and 3) subsequently
received ECMO in the hospital”
no ROSC ROSC+
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
Japan, SAVE-J 2014
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
ELSO: Ann Thor Surg 2009
“The registry defines E-CPR as the following: “extracorporeal life support (ECLS) usedas part of initial resuscitation from cardiac arrest. Patients who are hemodynamically
unstable and placed on ECLS without cardiac arrest are not considered E-CPR” [1].
no ROSC ROSC+
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
How to proceed … ?
Out of Hospital
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
How to proceed … ?
In Hospital
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:•Cardiac Arrest Definitions•Patient Diagnostic Groups•Cardiac Arrest Rates
How to proceed … ?
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The Alfred Intensive Care Unit, Melbourne, Australia
21 minutes
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the conditionCardiac arrest of greater than 20 min (conventional CPR)Sub-classifications• Pathological Classification • +/- ROSC• + out-of-hospital• (initial rhythm)
Diagnostic groups
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The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Exclusion Criteria
These will vary greatly from centre to centre
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The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR (What seems to work?)
SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers
Organ Donation
Strongest trial design for E-CPR
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The Alfred Intensive Care Unit, Melbourne, Australia
Out of Hospital Cardiac Arrest Survival and ECMO
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The Alfred Intensive Care Unit, Melbourne, Australia
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The Alfred Intensive Care Unit, Melbourne, Australia
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The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR (What seems to work?)
SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers
Organ Donation
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The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR (What seems to work?)
SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers
Organ Donation
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The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
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The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR (What seems to work?)
SAVE-J studyPropensity MatchingELSORisk Prediction -Biomarkers
Organ Donation
Future Models are essential1. Age2. First monitored rhythm3. Time to ECMO4. Biomarkers (early
lactate)5. No/minimal physiological data
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The Alfred Intensive Care Unit, Melbourne, Australia
Conclusions
E-CPR has strong physiological and evidence base to support its use and ongoing developmentLarge database with accurate data to build risk prediction models to assess performance
•allow better case selection•allow comparison between services•allow comparison between different treatments
Only one thing better than successfully treating a cardiac arrest case with ECMO……
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The Alfred Intensive Care Unit, Melbourne, Australia