scholarly journals Evaluating the potential impact of an emergency department extracorporeal resuscitation (ECPR) program: a health records review

CJEM ◽  
2020 ◽  
Vol 22 (3) ◽  
pp. 375-378
Author(s):  
Laura McDonald ◽  
George Mastoras ◽  
Michael Hickey ◽  
Bernard McDonald ◽  
Edmund S.H. Kwok
Keyword(s):  
Emergency Department ◽  
Cardiac Arrest ◽  
Inclusion Criteria ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Health Records ◽  
Initial Rhythm ◽  
Bystander Cpr ◽  
Academic Teaching Hospital ◽  
Extracorporeal Resuscitation ◽  
Refractory Cardiac Arrest

ABSTRACTObjectivesExtracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program.MethodsThis retrospective health records review included patients aged 18–75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both “liberal” and “restrictive” ECPR criteria were defined and applied to our cohort.ResultsA total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31–53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR.ConclusionAt our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Abstract 170: Challenges in Implementing an ECPR Program for Out of Hospital Cardiac Arrest

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Meshe Chonde ◽  
Jeremiah Escajeda ◽  
Jonathan Elmer ◽  
Frank X Guyette ◽  
Arthur Boujoukos ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Inclusion Criteria ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Implementation Challenges ◽  
Shockable Rhythm ◽  
Bystander Cpr ◽  
Stay And Play ◽  
Load And Go ◽  
Mechanical Cpr ◽  
Hospital Cardiac Arrest

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapy. Many institutions are interested in developing their own ECPR program. However, there are challenges in logistics and implementation. Hypothesis: Development of an ECPR team and identification of UPMC Presbyterian as a receiving center will increase recognition of potential ECPR candidates. Methods: We developed an infrastructure of Emergency Medical Services (EMS), Medic Command, and an in-hospital ECPR team. We identified inclusion criteria for patients with an out of hospital cardiac arrest (OHCA) likely to have a reversible arrest etiology and developed them into a simple checklist. These criteria were: witnessed arrest with bystander CPR, shockable rhythm, and ages 18 to 60. We trained local EMS crews to screen patients and review the checklist with a Command Physician prior to transport to our hospital. Results: From October 2015 to March 31 st 2018, there were 1165 dispatches for OHCA, of which 664 (57%) were treated and transported to the hospital and 120 to our institution. Of these, five patients underwent ECPR. Of the remaining cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. Prehospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) underwent mechanical CPR with LUCAS device. Time from arrest to arrive on scene was 5 [IQR 4-6] min and time call MD command was 13 [IQR 7-21] min. Time to transport was 20 [IQR 19-21] min. Time from arrest to initiation of ECMO was 63 [IQR 59-69] min. Conclusions: ECPR is a relatively infrequent occurrence. Implementation challenges include prompt identification of patients with reversible OHCA causes, preferential transport to an ECPR capable facility and changing the focus of EMS in these select patients from a “stay and play” to a “load and go” mentality.

scholarly journals Potential Candidates for a Structured Canadian ECPR Program for Out-of-Hospital Cardiac Arrest

CJEM ◽  
2016 ◽  
Vol 18 (6) ◽  
pp. 453-460 ◽  
Author(s):  
Brian Grunau ◽  
Frank Xavier Scheuermeyer ◽  
Dion Stub ◽  
Robert H. Boone ◽  
Joseph Finkler ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Discharge ◽  
Secondary Analysis ◽  
Secondary Outcome ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
High Performing ◽  
Canadian Health ◽  
Bystander Cpr ◽  
Hospital Cardiac Arrest ◽  
Refractory Cardiac Arrest

AbstractObjectiveExtracorporeal cardiopulmonary resuscitation (ECPR), while resource-intensive, may improve outcomes in selected patients with refractory out-of-hospital cardiac arrest (OHCA). We sought to identify patients who fulfilled a set of ECPR criteria in order to estimate: (1) the proportion of patients with refractory cardiac arrest who may have benefited from ECPR; and (2) the outcomes achieved with conventional resuscitation.MethodsWe performed a secondary analysis from a 52-month prospective registry of consecutive adult non-traumatic OHCA cases from a single urban Canadian health region serving one million patients. We developed a hypothetical ECPR-eligible cohort including adult patients <60 years of age with a witnessed OHCA, and either bystander CPR or EMS arrival within five minutes. The primary outcome was the proportion of ECPR-eligible patients who had refractory cardiac arrest, defined as termination of resuscitation pre-hospital or in the ED. The secondary outcome was the proportion of EPCR-eligible patients who survived to hospital discharge.ResultsOf 1,644 EMS-treated OHCA, 168 (10.2%) fulfilled our ECPR criteria. Overall, 54/1644 (3.3%; 95% CI 2.4%-4.1%) who were ECPR-eligible had refractory cardiac arrest. Of ECPR-eligible patients, 114/168 (68%, 95% CI 61%-75%) survived to hospital admission, and 70/168 (42%; 95% CI 34-49%) survived to hospital discharge.ConclusionIn our region, approximately 10% of EMS-treated cases of OHCA fulfilled our ECPR criteria, and approximately one-third of these (an average of 12 patients per year) were refractory to conventional resuscitation. The integration of an ECPR program into an existing high-performing system of care may have a small but clinically important effect on patient outcomes.

scholarly journals A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest

2019 ◽  
Vol 20 (4) ◽  
pp. 347-357 ◽  
Author(s):  
Callum J Twohig ◽  
Ben Singer ◽  
Gareth Grier ◽  
Simon J Finney
Keyword(s):  
Cardiac Arrest ◽  
Literature Review ◽  
Meta Analysis ◽  
Secondary Analysis ◽  
Low Flow ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Shockable Rhythm ◽  
Resuscitation Guidelines ◽  
Bystander Cpr ◽  
Refractory Cardiac Arrest

Introduction The probability of surviving a cardiac arrest remains low. International resuscitation guidelines state that extracorporeal cardiopulmonary resuscitation (ECPR) may have a role in selected patients suffering refractory cardiac arrest. Identifying these patients is challenging. This project systematically reviewed the evidence comparing the outcomes of ECPR over conventional-CPR (CCPR), before examining resuscitation-specific parameters to assess which patients might benefit from ECPR. Method Literature searches of studies comparing ECPR to CCPR and the clinical parameters of survivors of ECPR were performed. The primary outcome examined was survival at hospital discharge or 30 days. A secondary analysis examined the resuscitation parameters that may be associated with survival in patients who receive ECPR (no-flow and low-flow intervals, bystander-CPR, initial shockable cardiac rhythm, and witnessed cardiac arrest). Results Seventeen of 948 examined studies were included. ECPR demonstrated improved survival (OR 0.40 (0.27–0.60)) and a better neurological outcome (OR 0.10 (0.04–0.27)) over CCPR during literature review and meta-analysis. Characteristics that were associated with improved survival in patients receiving ECPR included an initial shockable rhythm and a shorter low-flow time. Shorter no-flow, the presence of bystander-CPR and witnessed arrests were not characteristics that were associated with improved survival following meta-analysis, although the quality of input data was low. All data were non-randomised, and hence the potential for bias is high. Conclusion ECPR is a sophisticated treatment option which may improve outcomes in a selected patient population in refractory cardiac arrest. Further comparative research is needed clarify the role of this potential resuscitative therapy.

Abstract 184: AED Application in Non-Shockable Out-of-Hospital Cardiac Arrest Does Not Reduce Survival

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Ross A Pollack ◽  
Siobhan P Brown ◽  
Thomas Rea ◽  
Peter J Kudenchuk ◽  
Myron L Weisfeldt
Keyword(s):  
Cardiac Arrest ◽  
Primary Outcome ◽  
Patient Characteristics ◽  
Neurological Status ◽  
Relative Safety ◽  
Initial Rhythm ◽  
Bystander Cpr ◽  
Rhythm Analysis ◽  
In Transit ◽  
Hospital Cardiac Arrest

Introduction: It is well established that AEDs improve outcome in shockable out-of-hospital cardiac arrest (OHCA). An increasing proportion (now the majority) of OHCAs present with non-shockable rhythms. Survival from non-shockable OHCA depends on high-quality CPR in transit to definitive care. Studies of AED use in non-shockable in-hospital arrest (as opposed to OHCA) have shown reduced survival with AED application possibly due to CPR interruptions to apply pads and perform rhythm analysis. We sought to determine whether AED application in non-shockable public, witnessed OHCA has a significant association with survival to discharge. Methods: This is a retrospective analysis of OHCA from 2010-2015 at 10 Resuscitation Outcomes Consortium centers. All adult, public, witnessed non-shockable OHCAs were included. Non-shockable arrest was defined as no shock delivered by the AED or by review of defibrillator tracings (10%). The initial rhythm on EMS arrival was used to confirm the rhythm. The primary outcome was survival to hospital discharge with favorable neurological status (modified rankin score <3). The OR was adjusted for the Utstein variables. Results: During the study period there were 1,597 non-shockable public, witnessed OHCA, 9.8% of which had an AED applied. The initial rhythm on EMS arrival was PEA or asystole in 86% of cases. Significantly more OHCA in the AED applied group had CPR performed. 6.5% of those without an AED applied survived with favorable neurologic status compared to 9% with an AED. After adjustment for the Utstein variables including bystander CPR, the aOR for survival with favorable neurologic outcome was 1.38 (95% CI:0.72-2.65). Conclusion: After adjusting for patient characteristics and bystander CPR, the application of an AED in non-shockable public witnessed OHCA had no significant association with survival or neurological outcome supporting the relative safety and potential benefit of AED application in non-shockable OHCA.

Abstract 219: Out-of-Hospital Cardiac Arrest in Vienna 2014

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Markus Keferböck ◽  
Philip Datler ◽  
Mario Krammel ◽  
Elisabeth Lobmeyer ◽  
Alexander Nürnberger ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Outcome Measures ◽  
Primary Outcome ◽  
Sudden Cardiac Arrest ◽  
Cerebral Performance Category ◽  
Medical Personnel ◽  
Shockable Rhythm ◽  
Initial Rhythm ◽  
Bystander Cpr ◽  
Hospital Cardiac Arrest

Background: Sudden cardiac arrest (SCA) and especially the out of hospital cardiac arrest (OHCA) is always an urgent situation, which requires well trained medical personnel. The emergency medical system (EMS) in Vienna took part in the Circulation Improving Care (CIRC) trial form 2008 to 2010. In this time they had an additional training. Therefore we revaluated the outcome of OHCA nowadays. Method: Interim report of a prospective observational study of all humans over eighteen, who suffer an OHCA resuscitated by the EMS in Vienna from August 2013 - April 2014. For those patients, who survived 30 days, a cerebral performance category score (CPC) was evaluated. Results: During nine months 701 patients could be investigated and 625 achieved the protocol for this trial. The median age of the patients was 68 years (IQR 59-79) and 399 (64%) were male. Witnessed by bystanders was the cardiac arrest in 359 (57%) patients. In the latter patients restoration of spontaneous circulation (n=223, 36%)(ROSC) and 30 day survival (n=166, 27%) was significantly more often achieved than in patients with non-witnessed cardiac arrest. Bystanders provided chest compressions in 284 (45%) cases and in this subgroup a shockable initial rhythm was more often (p<0.0001). Still in 189 (53%) of the patients where the cardiac arrest was witnessed, bystander resuscitation wasn′t attempted. An initial shockable rhythm was found in 146 (24%) patients with significant better outcome in all primary outcome measures. Of the 62 (10%) 30-days-survivors, 33 (6%) had good neurological outcome with a CPC 1-2.In 12 (2%) cases the CPC was missing. Conclusion: The results are comparable to findings of our previous studies. A significant better result in all primary outcome measures could be found for witnessed OHCA with an initial shockable rhythm. Furthermore those patients with bystander CPR had significant more often a shockable initial rhythm. Therefore more efforts have to be invested into encouraging the community to start with a bystander CPR if an OHCA is witnessed.

Abstract 12052: A Comprehensive Simulation-Based Training for E-CPR Improves the Neurological Outcome of Patients With Refractory Cardiac Arrest

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Takaaki Toyofuku ◽  
Takashi Unoki ◽  
Junya Matsuura ◽  
Yutaka Konami ◽  
Hiroto Suzuyama ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Training Program ◽  
Neurological Outcome ◽  
Hazard Analysis ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Coronary Syndrome ◽  
Simulation Based ◽  
Favorable Neurological Outcome ◽  
Cpr Training ◽  
Refractory Cardiac Arrest

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with refractory cardiac arrest (CA). To improve the outcome of E-CPR, we developed a comprehensive simulation-based E-CPR training program. In the present study we assessed whether the E-CPR training improved the mortality and the neurological outcome. Methods: We have implemented the comprehensive E-CPR simulation training program twice a year to the medical team, which consists of emergency physicians, cardiologists, nurses, clinical engineers, and radiographers using a mock vascular model for E-CPR (ECMO cannulation). We assessed collapse to ECMO time, cumulative 30-day survival and good neurological outcome at hospital discharge defined as the cerebral performance categories (CPC) of 1 or 2. Results: Fifty-three consecutive patients received E-CPR for OHCA from January 2012 to December 2020 in which 31 patients were prior to (until September 2017) and 22 were after (from October 2017) the initiation of the E-CPR training. No differences were found in age, rates of witnessed and bystander-CPR, shockable rhythms, or acute coronary syndrome (ACS). Intra-aortic balloon pump was used in 87% patients prior to and 27% patients after the training (p<0.001), and a microaxial Impella pump was used in 55% after the training. Collapse to ECMO time was significantly shorter after the training (p<0.001). Cumulative 30-day survival and the rate of favorable neurological outcome were significantly higher after the training (p<0.05). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.38 (10 years increase), 95% confidence interval [CI], 1.12-1.73, p=0.002), Collapse to ECMO time (HR, 1.14, 95%CI, 1.04-1.23, p=0.006), and additional Impella use (HR, 0.23, 95% CI, 0.08-0.69, p=0.0009) were significantly associated with the 30-day survival. Conclusions: The E-CPR training significantly improved the collapse to ECMO time. The faster deployment of ECMO improves the neurological outcome and 30-day survival in patients with refractory CA. Additional use of Impella may improve the survival.

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