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Thoughts From A Clinician

Thoughts from a Clinician:ECMO in Out Of Hospital Cardiac Arrest!

 

 

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Extracorporeal Membrane Oxygenation has been around for a long time. The utility of this modality has widely been used in children for a long time, and is slowly becoming a standard of critical care for the acutely ill adult.  Many critical care transport programs safely and efficiently move ECMO patients on a regular basis without compromising or interrupting their therapy. With such success it has hard to imagine how ECMO can continue to integrate its way into more patient populations, but it has.  The ED ECMO movement has been targeting the utilization of ECMO in patients who present to the emergency department in cardiac arrest.  This concept is referred to as ECPR.  When these patients are placed on mechanical CPR devices in the field and transported straight to an ECMO center, data demonstrates that there is improved benefit to the patient.  Individuals leading the way with the use of ECMO in the emergency department are Doctors Joe Bellezzo, Scott Weingart (of EMcrit fame), and Zack Shinar.  All of these gentlemen are the main contributors to EDecmo.org and the ED ECMO podcast.  Dr. Weingart has literature and podcasts available on the EMcrit site regarding use of ECMO in cardiac arrest (2).  Doctors Bellezzo and Shinar are Emergency Medicine physicians at Sharp Memorial Hospital in San Diego, California.  While they serve the west coast, Dr. Weingart serves the east coast as an attending physician at Stony Brook in New York.  Before we say “ECMO for EVERYONE” it needs to be stated that these patients must meet certain criteria prior to being placed on pump.  The indications for ECPR/ECLS are listed below. 

Indications and Contraindications of ECLS

ECPR Indications

In the heat of battle, deciding which patients are appropriate candidates for ECPR is probably the single most difficult decision to make.  To date, there is simply no way to predict, with any reliability, which patients will have the most functional outcomes.  While possibilities are on the horizon, there are currently no reliable technologic devices that can accurately predict which patients will survive with functional neurologic outcomes. Today, “Time-Zero Prognostication” of the arresting patient is an imperfect endeavor at best because it currently relies solely on the information that is provided to you when the patient is delivered to your door.  Third-party information from bystanders, questionable quality of initial CPR, variable medic transport times, variations in the quality of medic CPR, and a paucity of information about the patients pre-arrest medical condition are all inherently inaccurate variables. Because of this, we are all going to have to all agree to an accept a certain “flail factor.”  The flail factor reflects the percentage of patients who were put on the pump with the best of intentions but later determined to have been poor candidates.  With that in mind, here are some of the factors that determine which patients might be good candidates:

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Indications

ED ECPR is indicated for any potential reversible cause of cardiac or pulmonary failure (or both) unresponsive to conventional therapy. Conceptually, the decision to consider a patient for ED ECPR is not different from the decision to begin aggressive resuscitation in the first place. That can be broken down into 3 broad ideals:

  1. The patient was generally healthy prior to the arrest. This requires an attempt at a global assessment of the patient’s pre-arrest condition and is a challenging concept that requires an adept emergency physician with good clinical judgment.
  2. Overall goals of therapy are curative (as opposed to palliative).
  3. The event that caused the arrest is thought to be reversible with a specific medical or surgical intervention. The classic example is the patient complaining of chest pain who has electrocardiogram findings of a myocardial infarction and arrests in the ED (or en route to the ED). If traditional resuscitative efforts fail, ECLS would be considered a bridge to allow the time necessary to perform a coronary angiogram with potential percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery.

One of the first white papers presented on this topic, Emergency Physician Initiated Extracorporeal Cardiopulmonary Resuscitation, used very strict inclusion/exclusion criteria:

ECPR is indicated when all other traditional resuscitative strategies have been exhausted and the only alternative is death.

Indications for VV-ECMO in Respiratory Failure

Perhaps the best validated criteria are the ones used in the CESAR Trial:

  • Murrey Score > 3
  • Ventilation < 7 Days
  • Age < 65
  • Reversibility (1)

Before, during, and after the patient is placed on the pump, the patient receives Advanced Cardiac Life Support as necessary.

The success of doing ECPR has spoken for itself.  The ED ECMO podcast guys believe in it so much that they actually are seeing utility for its use in the field.  In Paris, France there is an ECMO response teams that utilizes ECMO in the streets of Paris.  This team utilizes such things like Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), Selective Aortic Arch Perfusion (SAAP), and ECMO to keep patients alive to the hospital.  This team in Paris is a physician led team and is pushing the envelope of what is possible in cardiac arrest care. 

So, our European counterparts are utilizing this treatment modality in the field what are we doing in the United States?  The United States may take a little while to get routine use field ECMO as a common treatment of OHCA.  The logistics and legalities of this still need to be worked out within our current healthcare climate.  Within the logistics the question is who responds to these and how do we get it done?  We don’t have the answers today, but we do know that this treatment modality works.  The Minnesota Resuscitation Consortium paper on the use of ECMO with patients in OHCA showed efficacy in the treatment modality (3). The patients were placed on mechanical CPR devices, given ACLS treatments as needed, and transported to the nearest ECMO center.  In this study, the nearest ECMO center was the University of Minnesota.  The outcomes reported from this study were very positive and showed that the use of ECPR can be and is efficacious to these individuals. 

According to Dr. Joe Bellezzo we need to start small and work our way to field ECPR use.  “For the immediate future let’s get every ambulance a Mechanical CPR device and start transporting young people with VF/PVT/PEA to an ECMO center.  I believe we will go from 8% CPC1-2 to 40-50%.”  The other part that Dr. Bellezzo is working diligently on is figuring out what size catheter to utilize for cannulation.  All of this is about getting the patient on pump as quickly as possible.  With the standard size catheters that are currently in use it is just taking longer than physicians would like to get these patients on the pump.  Testing a lot of different catheter sizes and experimenting in the lab will lead to great success with patients in the future.  One main point that can be taken away from the use of ECPR is the importance of collaboration.  Finding the sweet spot with cannulation and speed of the same will come with time and the cases that give the physicians the opportunity to use ECMO. 

Want to learn more about ECMO and ECPR?  A great resource to learn more about ECMO, aside from edecmo.com would be to attend the reanimate 2 conference in San Diego, California (4).  Not only are there lectures, but also hands on training available.  Learning how to cannulate, why, and also how to care for patients after resuscitation.  From those who have attended a reanimate conference there has been nothing but positive feedback.  Check it out and register today!  As I close out this blog post, I remind you that it if we continue to push the envelope with patient care we will never fail our patients.  There is always someone or something that creates limits for us and our care.  Let’s push beyond that and see where we end up.  Be safe out there and as always think like a clinician! 

Klint is a Flight Paramedic in Nebraska, USA. He is a critical care educator for Distance CME, LLC, blog writer for FlightBridgeED, and is very active in FOAMed. You can follow Klint on Twitter @NoDesat.    

Klint W. Kloepping, FP-C, NRP, C-NPT, AAS

FlightBridgeED, LLC

This email address is being protected from spambots. You need JavaScript enabled to view it.

References:

  1. edecmo
  2. emcrit
  3. http://jaha.ahajournals.org/content/5/6/e003732
  4. http://reanimateconference.com/register/

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