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10/23/2019
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ECLS in CPR and Pulmonary EmbolismAnd how to use ECLS as a bridge to definitive therapy
John C. Gurley, MDUniversity of KentuckyGill Heart and Vascular Institute
None
Disclosures
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Time to treatment is very critical in CPR and PE. The use of ECLS in these patients can improve survival rates. Providers need to be aware of these timelines in the decision to use ECLS.
Education Need/Practice Gap
After this presentation, attendees will be able to: Discuss advantages of ECLS in CPR and pulmonary embolismDiscuss implications of ECLS in CPR and pulmonary embolism
Learning Objectives
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The desired change/result in practice is to be able to
determine if ECLS is needed in cases of CPR and PE.
Expected Outcomes
Suspected PE Pre-Hospital Cardiac ArrestECLS can be utilized for out-of-hospital cardiac arrest due to suspected PE
When to activate the ECLS team
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ECPR Timeline for Patient SelectionKey time intervals in the decision to utilize ECLS for resuscitation of cardiac arrest in patients with PE
0 5 60 min.20 25 min.
No Flow
Low Flow ECLS Flow No ECLS
Neuro Recovery LimitAcceptable neuro outcome falls to 2% after 15 minutes of CPR.4
Cutoff Time for Switch to ECPRSuggested transition to ECLS at 21 minutes of CPR.5,6
35 min.
Definition of Refractory OHCAUnresponsive to 30 min. of CPR3
ECLS LimitNo reasonable chance of acceptable outcome.2,6
CARDIAC ARREST
10 15 50 min.
Time to BLS The most important determinant of outcome.1
Early, high‐quality chest compressions determine the success of all subsequent interventions.Immediate bystander CPR or a no‐flow time < 5 min.
CPR initiates a Low Flow StateLonger CPR yields worse outcomes.2
1. Rajan S, et al. Circulation 2016;134:2095–2104.2. Wengenmayer T, et al. Critical Care 2017;21:157. 3. Morrison LJ, et. N Engl J Med. 2006;355:478–487.
4. Reynolds JC, et al. Circulation 2013;128:2488‐2494. 5. Kim SJ, et al. Critical Care. 2014;18(5):535. 6. Hutin A, et al. https://doi.org/10.1016/j.resuscitation.2018.05.004
ECPR Timeline for Patient SelectionAfter 15 min. of conventional CPR, survival is 2% and hope of neuro recovery is fading rapidly.
0
5
10
15
20
25
Survival (Percent)
0 5 20 25 min.
No Flow
Low Flow ECLS Flow
Neuro Recovery Limit
35 min.
CPR
10 15
Survival to D/C with mRS 0‐3
30‐Day Survival
When is the best time to call the ECLS team?The proportion of patients with out-of-hospital arrest that survive to discharge with acceptable neurological function (mRS 0-3) declines rapidly with each minute of CPR
Immediately
Not at all
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Out-of-Hospital Arrest ECLS ChecklistHow to decide if ECLS is appropriate for suspected PE presenting as out-of-hospital cardiac arrest
GO
Reasonable at the start
Expectations?
Early CPR?
Early ROSC?
Immediate CPR w/ no flow <5 minutes is an essential
Start within 5 minutes
Overall survival very poor
Early ECLS?
Subsets?
Unfavorable• Age >75• Malignancy• Et CO₂ < 10 • Lactate > 6 Favorable
• Shockable rhythm• Signs of life• Pupil reflex• Gasping
Within 15 minutes
Within 20 minutes
No unfavorable
Survival
6-10%Out-of-hospital
Meaningful neuro recovery depends on CPR duration of ≤16 minutes
Confirmed PE In-hospital Cardiac ArrestCardiac arrest due to massive PE typically occurring in the ED, ICU or OR
When to activate the ECLS team
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1. George B, et al. A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving VA ECMO support. Resuscitation 2018; 122:1-5. 2. Dowlati A, et al. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine (Baltimore) 1999;78:285–91.
In-Hospital Cardiac ArrestMuch better outcomes with 25% survival a reasonable expectation.
Overall survival with ECLSOverall survival for patients who are placed on ECLS during or after cardiac arrest is about 25%.
Survival
26.6%In-hospital arrest
Few PredictorsMost clinical variable fail to predict survival with ECLS
(age, gender, prior DVT, BMI, CAD, diabetes, HTN).
Start within 5 minutes
Three clinical predictors of non‐survival1
1History of malignancy• Predicts non‐survival (p = .04). • The only clinical variable predictive of non‐survival.1,2
2Systemic thrombolysis• Predicts non‐survival (p = .015). • Catheter‐directed lysis associated with survival.
3Lactate level >6 mmol/L• Predicts non‐survival (p = .004). • Strongest predictor of non‐survival.
Cardiogenic Shock Prior to Cardiac ArrestECLS for PE with progressive cardiogenic shock and impending arrest
When to activate the ECLS team
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1. George B, et al. A retrospective comparison of survivors and non‐survivors of massive pulmonary embolism receiving VA ECMO support. Resuscitation 2018; 122:1‐5. 2. Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion 2015;30:611–6. 3. Sakuma M, et al. Percutaneous cardiopulmonary support for the treatment of acute pulmonary embolism: sum‐marized review of the literature in Japan including our own experience. Ann Vasc Dis 2009;2:7–16.
In-Hospital Progressive ShockMuch better outcomes with 75% survival a reasonable expectation.
Progressive shock without cardiac arrestPE patients placed on ECLS prior to cardiac arrest have much better odds of survival.
Overall Survival
76.4%In‐hospital shock without cardiac arrest
Survival is 3x better when ECLS is used prior to arrest.1Patients who suffer cardiac arrest prior to ECLS cannulation have greatly reduced odds of survival. In the review by George, survival
Post‐arrest
26.6%Survival
Post 30 min.
10%Survival
was 26.6% for patients placed on ECLS during or after cardiac arrest, compared with 76.4% survival among patients placed on ECLS prior to arrest.1 Yusuff also reported that initiation of ECLS while in cardiopulmonary arrest yielded a higher risk of death.2
When ECLS is initiated more than 30 minutes post‐arrest, survival is less than 10%.3
Whenever You Think About IntubationSemi-elective ECLS is probably much safer than intubation in massive PE
When to activate the ECLS team
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1. Rosenberger P, Shernan SK, Shekar PS, et al. Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy. Anesth Analg 2006;102:1311-5. 2. Bennett JM, et al. Hemodynamic instability in patients undergoing pulmonary embolectomy: institutional experience. Journal of Clinical Anesthesia (2015) 27, 207–213.
The Intubation Hazard of Massive PEIntubation—essentially induction of anesthesia—extremely hazardous in patients with massive PE1,2
Start within 5 minutes
Hemodynamic CollapseAbrupt, profound hypotension and cardiac arrest requiring CPR and immediate cardiopulmonary bypass.
Immediate on induction
19%Cardiac arrest
Subsequent
17%Shortly after
Not PredictableNot predicted by any clinical variable; same
outcomes whether hemodynamically stable or unstable.
AND HOW TO MANAGE IT
1It’s the heart (not the lungs). • RV can fail suddenly and unpredictably. • Sedation blunts endogenous catecholamines. • Positive pressure ventilation affects RV filling.
2Give a DO NOT INTUBATE order. • Use epinephrine 50‐100 mcg boluses. • Support BP and circulation until cannulated.
3Get to a safe place. • OR with patient prepped and surgeon scrubbed. • Cath lab with access secured.
4Avoid the situation altogether. • Patient on ECLS is immediately comfortable. • Does not need a ventilator.
Before You Offer Surgical EmbolectomyECLS makes surgery safer and may eliminate the need for surgery
When to activate the ECLS team
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1. Pasrija C, et al. Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism. J Thorac Cardiovasc Surg 2018.
Routine ECLS Before Surgical EmbolectomyUsing ECLS to triage and optimize patients referred to the surgical service for embolectomy
Massive PEEnd Organ Failure? Neuro Status
VA ECMO(n=27)
Thrombus Resolution
Normal RV function
Persistent ThrombusRV dysfunction
NeurologicalDeath
Decannulated(52%)
Embolectomy(44%)
Withdraw (4%)
Thrombus Resolution
52%With heparin alone
Most patients referred for embol-ectomy can avoid surgery.1Despite a surgical bias, only 3 days of unfractionated heparin, and no attempt at catheter‐directed lysis or thrombus extraction.
SurgicalReferral
1. Pasrija C, et al. Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism. J Thorac Cardiovasc Surg 2018.
Routine ECLS Before Surgical EmbolectomyUsing ECLS to triage and optimize patients referred to the surgical service for embolectomy
The large early hazard of surgical embolectomy is avoidable.1The early hazard of surgery is not offset by later benefit. Early surgery leads to significantly reduced survival at 12 months.
High rate of cardiac arrest with induction of anesthesia or opening pericardium.
Difficulty separating from bypass due to RV stunning.
Postop issues: bleeding, AKI, ventilator problems, prolonged hospital time.
Heart surgery on patients who are brain-injured patients or have uncertain neurological status.
Good reasons for the early hazard of surgery.
ECLS
Surgeryp = .018
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When Other Therapies are ContraindicatedPE patients often have contraindications to thrombolysis and surgery
When to activate the ECLS team
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1. ACCP Guidelines. Kearon C, et al. Chest. 2012; 141(2 Suppl):e419S-e496S.2. Curtis GM, et al. Risk factors associated with bleeding after alteplase administration for PE. Pharmacotherapy. 2014 Aug; 34(8):818-25. 3. Konstantinides S, et al. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol 1998;82:966–70. 4. Becattini C, et al. Bolus tenecteplase for right ventricle dysfunction in hemodynamically stable patients with pulmonary embolism. Thromb Res 2010;125:e82–6.
Thrombolytic Contraindications: CommonPatients with PE often have associated conditions that make them poor candidates for systemic thrombolysis and surgery.
.
KEY POINTS:ABSOLUTE CONTRAINDICATIONS TO THROMBOLYSIS1
• Spine surgery within 3 months• Stroke within 2 months• History of intracranial
hemorrhage• Known intracranial neoplasm • A‐V malformation or aneurysm• Significant head trauma• Active internal bleeding• Known bleeding diathesisIntracranial surgery (3 months)
RELATIVE CONTRAINDICATIONS • Attempted femoral access• Prolonged CPR• Pregnancy • Recent surgery (3 weeks)• Recent trauma• Age >75 years• Current oral anticoagulation• Prolonged CPR• Recent bleeding • Current oral anticoagulation• History uncontrolled
hypertension• Remote ischemic stroke • Major surgery within 3 weeks
RISK FACTORS FOR MAJOR BLEEDING2
• Recent trauma• Recent spine surgery• Recent joint replacement• Low body weight• Chronic DAPT• History of hypertension • History of stroke• Aortic dissection• Pancreatitis• Dementia• History of GI bleed (3 months)• Stool occult positive• Internal bleeding (4 weeks)• GI bleeding in prior 3 months• Esophageal varices• Elevated bilirubin (> 3 mg/dl)• Coagulopathy (defined INR >1.7)• Presence of IABP• Femoral venous access • Uncertain neurological status• Prolonged CPR• Recent bleeding• History uncontrolled
hypertension• Remote ischemic stroke • Major surgery within 3 weeks
Hospital patients are often poor candidates for thrombolytic therapy and heart surgery. 1Systemic thrombolysis is risky: major bleeding up to 33% (intracranial up to 7.4%). 2Major bleeding predicts in-hospital mortality and 90-day mortality.3Anticoagulation alone has similar benefit within a few days.3,44
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Massive PE Thrombus in TransitMobile right heart thrombus predicts impending cardiac arrest and death
When to activate the ECLS team
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1. Kronik G. The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J 1989;10(12):1046- 59. 2. Chartier L, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99(21):2779-83. 3. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121(3):806-14. 4. Torbicki A, et al.; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003;41(12):2245-51.
Massive PE with Thrombus-in-TransitRight heart thrombus is a predictor of hemodynamic decompensation, cardiac arrest and death.1-4
Heparin
29%Mortality
Surgery
24%Mortality
A high risk subset of PE that does not benefit from surgery.1-4
Right heart thrombus is a predictor of hemodynamic decompensation, cardiac arrest and death. RA or RV thrombus
Identifies a high risk subset of patients with PE. Surgical hrombectomy is often considered lifesaving, but cardiac surgery in this high risk population has never been shown to improve outcomes. In a meta‐analysis of 177 patients with right heart thrombi, hospital mortality was 29% with anticoagulation and 24% with surgery). .
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Filter
Pump
ECLS Skills Directly Transferrable to Percutaneous Thrombus RemovalThe catheter skills necessary for ECLS can be utilized for percutaneous thrombus removal. Some of these techniques such as aspiration thrombectomy, require a close, collaborative, interdisciplinary relationship. The ideal team may include CT Surgery, IC, IR, Perfusion and Intensive Care specialists.
Managing intracardiac thrombus
* The risks and benefits of percutaneous removal are unknown; there is currently no expert consensus regarding management. There is no practice guidelines that apply to this problem.
Percutaneous Removal of Thrombus in PFO*An unconventional approach to this problem may be appropriate when the risk of surgery is prohibitive.
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When Team Masters Safe CannulationThe risks of ECLS can be minimized by meticulous cannulation technique
When to activate the ECLS team
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1. Cheng R, et al. Complications of ECMO for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97(2):610-6. 2. Ischemia Image: By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15335626. 3. Fasciotomy Image: Krticka M, et al. Fasciotomy closure using negative pressure wound therapy in lower leg compartment syndrome. Bratisl Lek Listy. 2016;117(12):710-714. 4. Amputation Image: Talving, P., Varga, S, et al. (2015). Lower extremity amputations. In D. Demetriades K (Ed.), Atlas of Surgical Techniques in Trauma (pp. 314-322). Cambridge: Cambridge University Press.
Access Site ComplicationsLimb ischemia is one of the most feared and potentially irreversible complications of VA ECLS
Ischemia1
12.5 to 22.6%Pooled 16.9%
Fasciotomy or compartment1
7.3 to 14.5%Pooled 10.3%
Amputation1
2.3 to 9.3%Pooled 4.7%
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1. Cheng R, et al. Complications of ECMO for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97(2):610-6
Access Site Complications AvoidableAdapted from 2014 meta-analysis by Cheng, et al.1
Limb Ischemia and bleedingIn meta‐analysis, limb ischemia (including
compartment syndrome, gangrene, toe necrosis,
neuropathy, fasciotomy and amputation) is very
common, occurring in about one fourth of
patients on VA ECMO.1
Major Bleeding
Bleeding, primarily related to access site,
occurs in nearly half of VA ECMO patients.
Complications of VA ECMO for Cardiogenic Shock and Arrest
0
10
20
30
40
50
60
70
80
90
100
Poole
d Est
imat
e (Pe
rcen
t)
Infection
Many access site‐related infections can be
avoided through careful percutaneous
cannulation techniques.
* University of Kentucky approach
Total Percutaneous Insertion and Removal*Totally percutaneous, imaging-guided insertion and removal with distal perfusion key to avoiding complications
Pre‐closure
Distal Perfusion
KEY ELEMENTS:100% ultrasound-guided access (CO2 or contrast angio available). 1100% distal perfusion (percutaneous common femoral or tibial access). 2Routine percutaneous decannulationin vascular-capable cath lab. 3Highly experienced operators (vascular intervention / TAVR skill sets). 4
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When Risks of ECLS are Under 10%ECLS becomes preferred therapy when major complications are less than 10%
When to activate the ECLS team
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Shifting Risk vs. Benefit to Favor of ECLSThe utility of VA ECLS is limited mainly by access site bleeding and limb ischemia
How to shift the risk-versus-benefit balance in favor of VA ECLSAccess site bleeding and limb ischemia are among the most common complications of VA ECLS
Eliminating limb ischemia and access site bleeding shifts the balance in favor of ECLS, permitting more liberal use. It also allows VA ECLS to be utilized before the patient develops irreversible end organ failure; this leads to better clinical outcomes.
Limb IschemiaAccess BleedThrombosis
Stroke
Survival BenefitThrombosis
Stroke
Survival Benefit
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All Patients with Unstable Massive PEECLS may be the safest and best option for patients with unstable massive PE
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1. Avgerinos ED, et al. Catheter-directed interventions compared with systemic thrombolysis... J Vasc Surg Venous Lymphat Disord. 2018;6(4):425-432. 2. Extrapolation from large vessel access and closure
ECLS Risk Threshold in Unstable PEWhen access site risks are held under 10%, ECLS becomes the preferred modality for initial stabilization.
0
5
10
15
20
25
30
35
40
45
50
Risks of Managing Massive PE
Overall Mortality
Surgical Mortality
Major Bleed CDT1
Major Bleed ST1
Intubation Arrest
Sudden
Mortality (%
)
Patients on ECLS will not die suddenly due to acute RV failure. When cannulation risks are held under 10%, ECLS becomes safer than any other option for patients with hemodynamically unstable PE.
Cannulation risk <5% is a reasonable expectation for an experienced team.2
Cannulation Risk Threshold 5%
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0
20
40
60
80
100
Benefit to Patient (%
)
Risk Tolerance, Risk Aversion and Patient Benefit
Risk Tolerance and ECLS DataProof of efficacy requires clinical us of ECLS in a risk environment
Max. Risk ToleranceType I ErrorsPt exposed to risk without benefit
Max. Risk AvoidanceType II ErrorsPt deprived of
beneficial therapy
100
80
60
40
20
Avoidance of Harm (%)
Ideal
100%
80%
60%
40%
20%
100%
80%
60%
40%
20%
Maybe ECLS isdefinitive therapy. And everything else is second-line or adjunctive.
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Thank you for listening. John C. Gurley, MDUniversity of KentuckyGill Heart and Vascular Institute
