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

Abstract

Objective: Extracorporeal 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. Methods: We performed a secondary analysis from a 52-month prospective registry of consecutive adult nontraumatic 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. Results: Of 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. Conclusion: In 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. RÉSUMÉObjectif: La réanimation cardiorespiratoire extracorporelle (RCREC), bien qu'elle soit exigeante sur le plan des ressources, peut améliorer les résultats cliniques chez certains patients ayant subi un arrêt cardiaque extrahospitalier (ACEH) réfrac-taire. Les auteurs de l'étude cherchaient à déterminer les patients qui répondaient aux un ensemble de critères de la RCREC afin d'estimer, d'une part, la proportion de patients ayant subi un arrêt cardiaque réfractaire qui auraient pu profiter de la méthode de réanimation et, d'autre part, les résultats cliniques obtenus par la méthode habituelle de réanimation. Méthode: Les auteurs ont procédé à une analyse secondaire d'un registre prospectif, constitué de cas consécutifs d'ACEH non traumatique, survenus chez des adultes, sur une période de 52 mois, dans une seule région sanitaire urbaine d'un million de personnes, au Canada. Les auteurs ont formé une cohorte fictive d'adultes, âgés de moins de 60 ans, susceptibles d'être traités par la RCREC après avoir subi un ACEH devant des témoins et avoir fait l'objet de manoeuvres de réanimation cardiorespiratoire par des passants ou avoir reçu des soins donnés par des services médicaux d'urgence (SMU), et ce, en l'espace de cinq minutes. Le principal critère d'éval...

Prehospital extracorporeal cardiopulmonary resuscitation for out‐of‐hospital cardiac arrest: A retrospective eligibility study

“…Thus, seven (58.3%) of the sustained ROSC patients, in addition to the eligible non‐sustained ROSC patients may have benefitted from ECPR. Under our criteria, we hypothesise that 63 of the 68 eligible patients identified could have derived some benefit from ECPR with regard to an increased chance of ROSC and/or neurologically intact survival . In a future prehospital ECPR programme, this could potentially translate to an additional 13 lives saved a year based on the 22% survival rate found by one retrospective review of international ECPR practices in OOHCA patients .…”

“…Our data suggests that there will likely be sufficient ECPR cases for at least one centre, depending on the criteria chosen. However, this is likely to represent a considerable burden in terms of equipment, logistics and coordination, physical space, blood bank capability, human resources and finances …”

“…It has been most commonly applied in selected patients with refractory cardiac arrest . Success has been mixed, with survival rates of 15–60% reported . Many factors could account for this outcome variation including heterogeneity of health systems, populations, interventions and follow up .…”

“…The present study aims to delineate the OOHCA patients in a moderately sized Australian city who might benefit from a future prehospital ECPR programme. This will be achieved by describing a year of Adelaide's OOHCA data for patients aged 18–65 years, and identifying and describing OOHCA patients who fulfil proposed ECPR intervention criteria …”

Extracorporeal Life Support and New Therapeutic Strategies for Cardiac Arrest Caused by Acute Myocardial Infarction - a Critical Approach for a Critical Condition

“…A Canadian registry on consecutive adults with non-traumatic OHCA showed that the integration of an ECPR program into an existing high-performance system of care might have a significant impact on patients outcome, with 68% of OHCA patients surviving to hospital admission and 42% surviving to hospital discharge [64,65].…”