Upload
smacc-conference
View
239
Download
3
Embed Size (px)
Citation preview
ECPR
Peter McCanny
……Rapid deployment of VA-ECMO during cardiac arrest, when conventional CPR has failed to provide return of spontaneous circulation (ROSC)……
……or when repetitive arrests occur without sustained ROSC……
ECMO for low output cardiac states
What is ECPR?
37yo massive PE post-op pelvic surgery
‘Temporary CPB provided 15mins of circulatory support while removal of bilateral pulmonary emboli was accomplished’
‘A battery- powered portable cardiopulmonary bypass machine has been used in 39 patients whose condition precluded transport to the operating room……’
‘……successfully placed on CPB at the bedside within 15mins of cardiac arrest using femoral artery and femoral vein cannulation’
No RCT comparing ECPR with conventional CPR (CCPR)
Limited to observational studies, case series
Propensity- matched modelling to compare ECPR with CCPR
Recent systematic review and meta-analysis
Evidence quality
ECPR for IHCA
Fagnoul D, Combes A, De Backer D. Extracorporeal cardiopulmonary resuscitation. Curr Opin Crit Care. 2014 Jun;20(3):259-65.
3 year prospective observational study (Taiwan 2004-2006)
IHCA >10mins, deemed likely cardiac origin All rhythms included
Primary outcome: survival to hospital D/C Secondary outcomes: 30-day, 1-year survival, rate of ROSC
Propensity matching to compare ECPR vs CCPR
Chen et al……Results
Retrospective 2003-2009, single centre (Korea)
Primary outcome: survival to D/C with CPC 1-2
85 patients ECPR vs 321 patients CCPR
Propensity matched 60 pairs
Shin et al……Results
ECPR for OOHCA
Fagnoul D, Combes A, De Backer D. Extracorporeal cardiopulmonary resuscitation. Curr Opin Crit Care. 2014 Jun;20(3):259-65.
Retrospective, multicentre cohort study (Japan 2004- 2011)
Refractory cardiac arrest (>20mins) due to ACS ECPR combined with PCI
86 patients total 42 OOHCA patients, (29 PCI)
30 day survival with favourable neuro outcome 14% (21% PCI group)
Retrospective review (Berlin 2010-2011)
ECPR for refractory OOHCA
Aim: to identify predictors of mortality in OOHCA ECPR
Mechanical chest compression not used
ECPR in cath lab, followed by Angiography
28 patients
30 day survival rate of 39% (72% survivors had CPC<2)
Only predictor of survival was door to ECMO implantation time
Leick et al……Results
• 35 OOHCA patients• 28% Survival to hospital D/C
1583 studies screened
10 studies (with propensity- based analysis available)
7 patients: 1 survived, 3 brain dead
Cannulation time: 22 mins (+/- 6)
Time to ECMO flow: 57 mins (+/- 21)
26 patients
14/26 (54%) survival to D/C with good neuro outcome
OOHCA survival 3/9 (33%) vs IHCA survival 9/15 (60%)
Retrospective review of outcomes for ECPR cases to date.
Patients identified from ECMO databases in SVH and RPA.
Data gathered from medical charts, databases, and local IT systems:
- Patient demographics- Cardiac arrest details (initial rhythm, downtime
etc…)- ECMO details (setting, cannulation, complications,
duration..)- Echo and Cath lab findings- Intervention details (PCI, CABG, VAD, HTx)- Outcomes and follow-up data
ECPR: the Sydney experience
September 2009- January 2016
42 patients
37 included for analysis
Median age 53yrs (17- 70)
73% male
SVH: n= 23 (62%) RPA: n= 14 (38%)
Results
Overall (%)Predictor of Mortality(p- value)
Initial rhythm VT 19 (51%) 0.25
VF 1 (3%)PEA 14 (38%)Asystole 3 (8%)
Aetiology ACS 11 (30%) 0.79PE 5 (14%)Arrhythmia 3 (8%)Other * 18 (49%)
Location IHCA 25 (68%) 0.87
OOHCA 12 (32%)
Time to ECMO flow (minutes) 52 (+/- 28) 0.42
Arrest data
Number of patientsCoronary vasospasm 1Overdose/ toxins 2Myocarditis 1Chemo- related cardiomyopathy 1Congenital heart disease 1Hyperacute rejection (post-CTx) 1LVAD failure 1Hypothermia 1Sepsis 1Tamponade 1TAVI deployment 2Unclear 3
Aetiology
Angio PCI CABG0
5
10
15
20
25
INTERVENTIONS
54%
24%
3%
Duration in days
ECMO run 4.1 (+/- 3.9)
ICU stay 12.3 (+/- 11)
Hospital stay 20.1 (+/- 19)
ECMO data
Number of patients (%) Predictor of mortality (p- value)
Bleeding event 17 (46%) 0.48
Major bleeding (BARC 3-5)
14 (38%) 0.44
DVT 3 (8%) 0.23
PE 1 (3%) 0.3
Backflow clot 2 (5%) 0.52
Limb ischaemia 7 (19%) 0.63
Haemolysis 1 (3%) 0.46
CVA (embolic) 1 (3%) 0.46
ECMO complications
No. of patients (%)
OOHCA survival 4 (33%)
IHCA survival 9 (36%)
Survival to ICU Discharge 15 (40%)
Survival to Hospital Discharge 13 (35%)
Outcomes
All survivors (13/37) discharged CPC 1/2
Outcomes
Odds ratio (95% CI)
Overall p-value
Pre- ECMO lactate 1.35 (1.06- 1.73) 0.016
Collapse to ECMO flow <60 mins 0.33 (0.06- 1.88) 0.17
Predictors of mortality
ECPR for refractory cardiac arrest:
ECPR outcomes favourable vs conventional CPR
Data gathered from centres with experience and expertise
Development of ‘well- oiled’ systems and protocols crucial to achieve good outcome – Logistics are crucial
If you’re going to do, make sure you do it well
Summary