CPR with ECMO

CPR with ECLS vs conventional CPR in IHCA from Sun YaiCheng

Cardiopulmonary Resuscitation with Assisted Extracorporeal Life-Support versus Conventional Cardiopulmonary Resuscitation in Adults with In-Hospital Cardiac Arrest:
An Observational Study & Propensity Analysis
Lancet 2008; 372:554-561

Setting

• National Taiwan University Hospital, in Taipei, is an extracorporeal life-support referral centre.
• The CPR team consisted of a senior medical resident, several junior residents, a respiratory therapist, a head nurse, and several registered nurses from the ICU.

Patients
Adults with IHCA of cardiac origin (as established by 2 independent committees), aged between 18 and 75 years, who underwent CPR for longer than 10 min between Jan 1, 2004, and Dec 31, 2006.

Exclusion criteria:

• CPR of less than 10 min
• age over 75 years
• previously known severe irreversible brain damage
• terminal malignancy
• a traumatic origin with uncontrolled bleeding
• non-cardiac arrest
• previously signed “Do not attempt resuscitation”

Conventional CPR was stopped when spontaneous circulation returned and was maintained for 20 min.

The decision to discontinue unsuccessful CPR (no return of spontaneous circulation [ROSC] for 30 min) was made after communication with the family.

Procedures

• Average duration from the call to team arrival was 5–7 min during the day and 15–30 min during the night shift
• If ROSC was sustained for more than 20 min after the team arrived, ECLS would not be installed.
• If was continued for less than 20 min, the team would wait at least 10 min and begin ECLS in case of reoccurrence of arrest.
• 10–15 min was usually needed to set up ECLS.
• Weaning, defined as successful separation from ECLS without mortality in 12 h, was not attempted until 72 h after initiation.
• Ventricular assist device and heart transplantation were alternatives in the absence of contraindications when weaning was unsuccessful in 5–7 days.
• Cessation of ECLS was considered if severe neurological impairment persisted for more than 7 days without signs of recovery.

Results
17 patients in the extracorporeal group (28.8%) and 14 patients (12.3%) in the conventional group survived to discharge.

Relation between CPR duration and the survival rate to discharge

Kaplan-Meier plot of the survival curves in the extracorporeal CPR-M and conventional CPR-M groups for 1 year

Discussion

• Extracorporeal circulation had previously been applied in several critical conditions, including ARDS, cardiogenic or postcardiotomy shock, and bridge to ventricular assist device, transplantation, or next decision.

• Compared with VT or VF as the initial rhythm, those who showed PEA or asystole had higher mortality. 

•  The main factors associated with outcome are baseline condition, underlying cause, and the rapid response of the CPR team.

• Extracorporeal CPR might be recommended for adult IHCA of cardiac origin who have undergone CPR for more than 10 min and could provide a short-term and long-term survival advantage.