ecpr by vincent pellegrino 2016

The Alfred Intensive Care Unit, Melbourne, Australia

The use of VA ECMO following Cardiac Arrest

E-CPR

Vincent Pellegrino

Aidan Burrell Steven Bernard

Richard Lin Deirdre Murphy

Lloyd Roberts Jayne Sheldrake

Carol Hodgson D. Jamie Cooper Vinodh Nanjayya

Bishoy Zachary Daniel Brodie

The Alfred Intensive Care Unit, Melbourne, Australia

Cardiac Arrest VA ECMO Survival

Condition Treatment Outcome

Assessing the impact of E-CPR

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

The Alfred Intensive Care Unit, Melbourne, Australia

Approach 1.  Define the population considered for E-CPR

(Who?) 2.  Examine the different approaches to E-CPR

(how?) 3.  Outcomes from E-CPR (what seems to work?) 4.  Going forward

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

hypothermia i.e. the CA has contributed to the

patient neurological outcome

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 +

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

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) used as 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 +

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates

Korea

“The ECPR was defined as use of venoarterial ECMO intended to treat cardiac arrest”

“received veno-arterial ECMO upon the recurrence of CA within 20 min after the return of spontaneous circulation (ROSC) or due to no signs of ROSC after >10 min of CPR following AMI-induced CA (Figure 1). All patients underwent ECMO during ongoing continuous chest compressions”

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates

Korea “In previous studies, the definition of ECPR included both successful veno-arterial ECMO implantation and pump-on during cardiac massage [10,11]. However, various unexpected situations occurred in ongoing ECPR scenes. Actually, when a return of spontaneous circulation (ROSC) occurs during ECMO cannulation, the practitioner does not remove the already inserted cannula and does not stop the process of ECMO pump-on. We included such cases in our ECPR definition as intention-to-treat. Accordingly, ECPR was defined as an intention-to-treat with hemodynamic ECMO support during cardiac massage regardless of interim ROSC [11]”

no ROSC ROSC +

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates

The Problem The majority of patients that may benefit from emergency ECMO following cardiac arrest have some return of circulation Also, it is common for patients receiving ECMO for cardiac failure to have had a preceding CA Universal definitions of ROSC are lacking Cardiac arrest occurs in many different settings (in hospital and out of hospital)

no ROSC ROSC +

IHCA OHCA +

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates

Does it matter much…?

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates

Does it matter much…?

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the Condition: • Cardiac Arrest Definitions • Patient Diagnostic Groups • Cardiac Arrest Rates

Does it matter much…?

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

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

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 … ?

The Alfred Intensive Care Unit, Melbourne, Australia

21 minutes

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Defining the condition Cardiac arrest of greater than 20 min (conventional CPR) Sub-classifications •  Pathological Classification •  +/- ROSC •  + out-of-hospital •  (initial rhythm)

Diagnostic groups

The Alfred Intensive Care Unit, Melbourne, Australia

Patient Population (Who?)

Exclusion Criteria

These will vary greatly from centre to centre

The Alfred Intensive Care Unit, Melbourne, Australia

Approaches to E-CPR (How?)

Time to ECMO Cannulation -Percutaneous or Open

Cannulae Temperature O2 tension

The Alfred Intensive Care Unit, Melbourne, Australia

Approaches to E-CPR (How?)

Time to ECMO Cannulation -Percutaneous or Open

Cannulae Temperature O2 tension

The Alfred Intensive Care Unit, Melbourne, Australia

Cannulation

Percutaneous with ultra-sound guidance and distal perfusion cannula

The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia

Assessment of Vascular Access

TTE - subcostal TOE - transgastric

Inferior Vena Cava

The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia

Assessment of Vascular Access Abdominal Aorta

Aorta (TTE subcostal) PW Doppler aorta

The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia

J-wire in IVC

Venous Cannulation for ECMO

The Alfred Intensive Care Unit, Melbourne, Australia

Downstream compression

The Alfred Intensive Care Unit, Melbourne, Australia The Alfred Intensive Care Unit, Melbourne, Australia

VA ECMO Backflow Cannulation

CFA

Profunda Artery

SFA

The Alfred Intensive Care Unit, Melbourne, Australia

Coming ….very soon!!

The Alfred Intensive Care Unit, Melbourne, Australia

MTMM bidirectional cannula

The Alfred Intensive Care Unit, Melbourne, Australia

MTMM bidirectional cannula

Transition zone role in downstream compression

The Alfred Intensive Care Unit, Melbourne, Australia

The Alfred Intensive Care Unit, Melbourne, Australia

Out Hospital CA

VA ECMO Survival

Condition Treatment Outcome

In Hospital CA

+ROSC +CS

+ROSC +CS

- ROSC

- ROSC

Neuro

Cost QOL

Organ Donation

Unsupportable

The Alfred Intensive Care Unit, Melbourne, Australia

VA ECMO Maintenance: Cardiac Management: Left Ventricular Failure

Causes Severe left ventricular failure with any AR or MR

• Fatal pulmonary hemorrhage

Severe AR/MR with LV ejection

First sign = Access

Insufficiency

The Alfred Intensive Care Unit, Melbourne, Australia

VA ECMO Maintenance: Cardiac Management: Left Ventricular Failure

Causes Severe left ventricular failure with any AR or MR

• Fatal pulmonary hemorrhage

Severe AR/MR with LV ejection

First sign = Access

Insufficiency

The Alfred Intensive Care Unit, Melbourne, Australia

Alternative cannulation

The Alfred Intensive Care Unit, Melbourne, Australia

Approaches to E-CPR (How?)

Time to ECMO Cannulation -Percutaneous or Open

Cannulae Temperature O2 tension

The change to 36 degrees as a targeted temperature has not been successful at our centre due to the low use of internal cooling devices

The Alfred Intensive Care Unit, Melbourne, Australia

Approaches to E-CPR (How?)

Time to ECMO Cannulation -Percutaneous or Open

Cannulae Temperature O2 tension

The Alfred Intensive Care Unit, Melbourne, Australia

Approaches to E-CPR (How?)

Time to ECMO Cannulation -Percutaneous or Open

Cannulae Temperature Blood-flow, Gas-flow O2 tension

The Alfred Intensive Care Unit, Melbourne, Australia

Approaches to E-CPR (How?)

Time to ECMO Cannulation -Percutaneous or Open

Cannulae Temperature O2 tension

The Alfred Intensive Care Unit, Melbourne, Australia

Training and team

The Alfred Intensive Care Unit, Melbourne, Australia

Team work

The Alfred Intensive Care Unit, Melbourne, Australia

Management of the AMI CA

ST-AMI

Cath lab

PCI

CABG

The Alfred Intensive Care Unit, Melbourne, Australia

Management of the AMI CA

ST-AMI +CA

E-CPR

PCI

CABG

Cath lab

The Alfred Intensive Care Unit, Melbourne, Australia

Management of the AMI CA

ST-AMI +CA + ROSC or +Shock

E-CPR

PCI

CABG

Cath lab

Other resus

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

Strongest trial design for E-CPR

The Alfred Intensive Care Unit, Melbourne, Australia

Out of Hospital Cardiac Arrest Survival and ECMO

The Alfred Intensive Care Unit, Melbourne, Australia

The Alfred Intensive Care Unit, Melbourne, Australia

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR

(2+) 5/30 (16%) 12/32 (37.5%)

The Alfred Intensive Care Unit, Melbourne, Australia

WWW.SAVE-SCORE.COM WWW.RESPSCORE.COM

Risk adjustment for adult patients undergoing ECMO for cardiac support 2003 to 2013

Risk adjustment for adult patients undergoing ECMO for respiratory support 2000 to 2012

ELSO Adult Datasets

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

Excellent prospective dataset • Data rich • Includes post cannulation data (i.e. isn’t intended for case selection)

Excellent performance (internal validation)

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

The Alfred Intensive Care Unit, Melbourne, Australia

Outcomes from E-CPR (What seems to work?)

SAVE-J study Propensity Matching ELSO Risk Prediction -Biomarkers

Organ Donation

Future Models are essential 1.  Age 2.  First monitored rhythm 3.  Time to ECMO 4.  Biomarkers (early lactate) 5.  No/minimal physiological data

The Alfred Intensive Care Unit, Melbourne, Australia

Conclusions

E-CPR has strong physiological and evidence base to support its use and ongoing development Large 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……

The Alfred Intensive Care Unit, Melbourne, Australia