Transcript ECPR - Society of Clinical Perfusion

Extracorporeal
Cardiopulmonary
Resuscitation (ECPR) in
Adults:
Improving the Odds?
Christopher Bishop
Clinical Perfusionist
Barts Heart Centre
Cardiac Arrest Outcomes
• Out-of-hospital arrest (OHCA) – 8.6%
survival to discharge
• In-hospital arrest (IHCA) – 14.6%
survival to discharge
Cardiac Arrest – The Chain of Survival
CPR Haemodynamics and Survival
• Optimal CPR generates
CI 0.6 L/min/m2 (25-33% of normal)
• ↑Coronary/cerebral perfusion pressure
vital for ROSC during CPR
• Interruptions to compressions
↓survival
• Could extracorporeal resuscitation
better target haemodynamics and
oxygenation?.........
Advanced Life Support – Guidelines 2015
CoSTR 2015 – Extracorporeal CPR (ECPR)
Recommendation: “We suggest ECPR is
a reasonable rescue therapy for selected
patients with cardiac arrest when initial
conventional CPR is failing in settings
where this can be implemented”
What is ECPR?
•
Emergency initiation of ECLS
during refractory cardiac arrest
•
Cannulation and high-quality CPR
undertaken simultaneously
•
Variety of settings – ED, ITU,
Catheterisation Laboratory, Prehospital
•
Augments end-organ perfusion
and haemodynamics during arrest
•
Buys time to identify/treat
underlying cause and achieve
ROSC (e.g. PE, MI, drug overdose
ECPR Set-Up
ECPR “without walls”….
ECPR following mechanical chest compressions
From: Menegazzi et al. Resuscitation (2012) 83(1): 130-133
Haemodynamic and metabolic
parameters following ECPR
•
↑pH
•
↑MAP
•
↑Tissue O2 saturations (NIRS)
•
↑PO2
•
↓PCO2
•
↓Plasma K+
From: Mlcek et al. (2012) Physiol. Res. 61 (Suppl. 2): S57S65, 2012
ECPR Outcomes - ELSO
Ouweneel et al. 2016
Patient Selection for ECPR
• Age <60 years
• Initial rhythm VF/VT
• Chest compressions within 10 mins arrest
• Refractory arrest >30 mins
• No ROSC despite standard ALS
• No major comorbidities
• Likely reversible cause
(hypothermia/intoxication/ACS)
CHEER Results
54 %
Survival!
55% Survival!
ECPR in the Future?
Pre-hospital ECMO
Heart Attack Centre
Cardiac Cath Lab
ECMO ICU
Summary
•
ECPR has strong physiological and evidence base to support use and
ongoing development
•
Larger studies required:
- To improve case selection
- Allow comparison between services
-Compare conventional CPR and ECPR outcomes
Thank You!