outcomes with ecmo for in hospital cardiac arrest...ihca: public perception of cpr • public...
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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 SymposiumMarch 8, 2018. Houston, TX
Disclosures• Nothing
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
• 13 to 22% Survival to Hospital Discharge (STHD)
• 33% to 28% for significant neurologic disability
Girotra. NEJM 2012;367:1912-20.
Uchenna R. Ofoma et al. JACC 2018;71:402-411
2018 American College of Cardiology Foundation
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
2 Shif. Resuscitation 2015;90:73-78.1 Ouelette. Amer. Jrnl Emerg Med. 2018 IN PRESS
Goldhaber ZD. Lancet 2012;380:1473-81.
-- 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%)
What do the Guidelines Tell Us about Extracorporeal CPR (E-CPR)?
•Not Much
Brooks SC. CIRCULATION 2015;132(18 Supp2):S436-43.
Monsieurs KG. Resuscitation 2015;95:1-80
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 48-72 hrs after cannulation
Outcomes
1976N=3541% survival
ECPR outcomes in IHCAStudy, Country Design N Age (yrs)
Male (%)Time to ECLS (mts)
Neurologically Favorable Survival
Chen et al (2008)Taiwan
Prospective 59 18-75 <3030-4545-60>60
42%30%30%18%(33% Overall)
Lin et al (2010)Taiwan
Prospective 59 5985%
40 24%
Shin et al. (2011)Taiwan
Retrospective
85 6062%
42 28%
Chou et al. (2014)Taiwan
Retrospective
43 6193%
60 35%
Zhao et al. (2014)China
Retrospective
24 5979%
36 33%
Blumenstein et al (2016) Germany
Retrospective
52 7254%
33 21%
Chen. Lancet 2008;372:554-561. Lin. Resuscitation 2010;81:796-803. Shin. Crit Care Med. 2011;39:1-7. Chou. Emerg Med. Jrnl 2014;31:441-447. Zhao. Eur J Med Res. 2015;20:83. Blumenstein. Eur Hrt Jrnl. J Acute Cardiovasc Care 2016;5:13-22.
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”
Outcomes: Meta-analyses
30-day survival for CA= 36% (23-50%) vs. CS= 53% (44-61%)
- ECPR better survival (RR=2.37) and Neuro (2.79) than CCPR- ECPR no significant difference in IHCA but was in OHCA
40% ECMO Survival30% STHD
27% Survival
IHCA Outcomes
• 3 year Prospective Observational Study
• Age 18-75• Witnessed IHCA and CPR>10”• ECMO (n=59) vs. Conv CPR
(n=113) Propensity matched
Chen YS. Lancet 2008;372:554-561.
ECPR
CCPR
19% @ 1y29% @ 30d
12% @ 30d 10% @ 1y
Chen YS. Lancet 2008;372:554-561.
Prognostic Factors
Duration of CPR to Survival Discharge
Chen YS. Lancet 2008;372:554-561.
Duration & Survival
<30” = 63% > 30” = 29%
<45” = 50% > 45” = 22%
<60” = 47% > 60” = 9%
Chen YS. Crit Care Med 2008;36:2529-35
Age, CPR duration, Rhythm, ROSC
Lee SW. Ann Intensive Care 2017;7:87.
Lactate < 4.6
88%
44%
HR 3.55 (2.29-5.49, p<0.001)
Jung. Clin Res Cardiol 2016;105:196-205
Time to Coronary Intervention Matters
Chou TH. Emerg Med J 2014;31:441-47.
20%
40%
60%
80%
100%
Who Should Not Have ECMO with IHCA
Patel JK. Jrnl Int Care Med 2016;31:359-68
Age<75VF/VT>>> OtherCPR start < 5-15”Cardiac/PE causeNo ROSC after 10-20”
Terminal illnessMajor comorbiditiesCNS Disease/ICHBleeding/AC ContraindSepsis ArrestAD/AI/PVD
Conduct of E-CPR
Lee. Lancet 2008;372:512-4.
Swol J. Perfusion 2016;31:182-88.
10-20”
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
E-CPR Algorithm
N=26 (15=IHCA, 11=OHCA)
92% had ECMO
Median 56”54% STHD
Mechanical CPRHypothermiaECMOEarly Reperfusion
Stub. Resuscitation 2015;86:88-94.
Complications
20 studies; 1866 patients
Cheng. Ann Thorac Surg 2014;97:610-6.
17% LE Ischemia10% Fasciotomy5% Amputation
6% Stroke13% Neurologic
45-55% AKI/RRT40% Major Bleed/Takeback30% Infection
Cheng. Ann Thorac Surg 2014;97:610-6.
ECMO Program Volume
0
20
40
60
80
100
120
140
2014 2015 2016 2017
E-CPR Survival Rate
0
5
10
15
20
25
2016 2017
<7% Survival
Perc
ent S
urvi
val
Bloom HL. Am Heart J. 2007;153(5):831-6.
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)
E-CPR Survival Rate
0
5
10
15
20
25
2016 2017
Perc
ent S
urvi
val
Conclusions
•20-30% STHD for IHCA•Witnessed arrest, rapid CPR, VT/VF, < 60” to ECMO
•Higher rate of complications
Questions