Extracorporeal CPR in the Emergency Department
By Greg King
Case
KM is a 36 y.o. female with a past medical history significant for recent PEA arrest during intubation with ROSC (05/30/2023), HTN, NICM/HFrecEF (5/2023 EF 45-50%), T2DM (c/b DKA), and PE (5/2022, indefinite AC) who was brought in by EMS for acute agitation, suicidal ideation, and self-harm with head banging.
· Given 4 mg lorazepam (2345 and 0007) prior to CT scan (0027) for acute agitation.
· Given 5 mg of midazolam at 0042 for continued agitation and self-harm
· At 0050 was bradypneic, hypoxic on physician reassessment, 2 person BVM initiated.
· At 0055 became bradycardic and went into cardiac arrest due to presumed hypoxic, hypercarbic respiratory failure. CPR and ACLS immediately initiated.
· ECMO team consulted at 0129. They declined cannulation at 0138.
· After exhausting all options, KM remained in cardiac arrest; time of death occurred at 0238
Clinical Question: What are indications for extracorporeal CPR (eCPR) during resuscitation of adult patients in cardiac arrest?
Summary of Evidence
There is no gold standard for eCPR inclusion criteria, but common eCPR inclusion criteria include1,2: age, comorbidity, witnessed arrest with early conventional CPR (cCPR), and shockable rhythm
· Previously it was thought that advanced age was a poor prognostic indicator, more recent literature found that age related comorbidity is a stronger predictor, and age alone is not a good prognostic indicator.1-4
· The preponderance of evidence shows that short no-flow and low-flow times are consistently associated with improved neurological outcomes. Most articles recommend a no-flow time of less than 5 minutes and a cCPR to eCPR time of less than 60 minutes.1-11
· Initial asystole and to a lesser degree, non-shockable rhythms tend to have negative outcomes than patients with initial shockable rhythms.1,3,4,9,11,12
· Many protocols list non-cardiac cause of death as an exclusion criterion for eCPR, but a review of eCPR protocols found that those using eCPR for exclusively non-cardiac etiologies had better outcomes than those with cardiac etiologies. eCPR, however, has primarily been studied in patients with cardiac etiologies, therefore, further investigation is warranted to determine if etiology is an important prognostic indicator for eCPR.2,3,13
· Signs of life, lactate, pH, and other inclusion criteria have been suggested by various studies and guidelines. Not as much research exists for these factors compared to those discussed above.1-4,11
Johns Hopkins also has its own inclusion and exclusion criteria for eCPR13
Recommendations
· If you are ever in doubt, consult the ED ECMO team to aid in decision-making.
· As seen in the figure4 below, eCPR is a complex intervention and takes time to implement. Time to eCPR is the most important prognostic factor. Therefore, consider your patient’s eligibility for eCPR within the first 10 minutes.
· Resuscitations have many moving parts. Assign a team member to activate the ED ECMO team after 10 minutes of resuscitation.
· When establishing inclusion criteria, use a low cut-off time (10 min) in the definition of refractory cardiac arrest, as this may facilitate shorter cCPR to eCPR times, which is associated with improved neurological outcomes.
· Consider using shorter no-flow (<5 min) and low-flow time (<60 min) cutoffs in protocols, as this is associated with improved neurological outcomes.
· Advanced age alone should not be an absolute contraindication to eCPR.
· There remains a dearth of high quality literature regarding indications and contraindications for eCPR. Stay current with the evidence and be prepared to update your protocols as new data is published.
REFERENCES
1. Karve S, Lahood D, Diehl A, et al. The impact of selection criteria and study design on reported survival outcomes in extracorporeal oxygenation cardiopulmonary resuscitation (ECPR): A systematic review and meta-analysis. Scandinavian journal of trauma, resuscitation and emergency medicine. 2021;29(1):142. https://search.proquest.com/docview/2729545525. doi: 10.1186/s13049-021-00956-5.
2. Koen ’J, Nathanaël T, Philippe D. A systematic review of current ECPR protocols. A step towards standardisation. Resuscitation plus. 2020;3:100018. https://dx.doi.org/10.1016/j.resplu.2020.100018. doi: 10.1016/j.resplu.2020.100018.
3. Dennis M, Lal S, Forrest P, et al. In‐Depth extracorporeal cardiopulmonary resuscitation in adult Out‐of‐Hospital cardiac arrest. Journal of the American Heart Association. 2020;9(10):e016521. https://www.ncbi.nlm.nih.gov/pubmed/32375010. doi: 10.1161/JAHA.120.016521.
4. Kim H, Cho YH. Role of extracorporeal cardiopulmonary resuscitation in adults. Acute and Critical Care. 2020;35(1):1-9. https://www.ncbi.nlm.nih.gov/pubmed/32131575. doi: 10.4266/acc.2020.00080.
5. Felix A, Campbell DD. Extracorporeal cardiopulmonary resuscitation: The golden hour. https://www.emra.org/emresident/article/extracorporeal-cardiopulmonary-resuscitation/#:~:text=ECPR%20involves%20the%20application%20of%20percutaneous%20veno-arterial%20extracorporeal,cause%20of%20cardiac%20failure%20can%20be%20definitively%20treated. Updated 2022. Accessed 06/16/, 2023.
6. Wengenmayer T, Rombach S, Ramshorn F, et al. Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR). Critical Care. 2017;21(1):157. https://www.ncbi.nlm.nih.gov/pubmed/28637497. doi: 10.1186/s13054-017-1744-8.
7. Kim SJ, Jung JS, Park JH, Park JS, Hong YS, Lee SW. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: A propensity-matched study. Critical Care. 2014;18(5):535. https://www.ncbi.nlm.nih.gov/pubmed/25255842. doi: 10.1186/s13054-014-0535-8.
8. Gravesteijn B, Schluep M, Disli M, et al. Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: A systematic review and meta-analysis. Critical care (London, England). 2020;24(1):505. https://www.narcis.nl/publication/RecordID/oai:pure.eur.nl:publications%2F385d1fbc-c267-4798-83aa-50431f7ca06f. doi: 10.1186/s13054-020-03201-0.
9. Schmitzberger FF, Haas NL, Coute RA, et al. ECPR2: Expert consensus on PeRcutaneous cannulation for extracorporeal CardioPulmonary resuscitation. Resuscitation. 2022;179:214-220. https://dx.doi.org/10.1016/j.resuscitation.2022.07.003. doi: 10.1016/j.resuscitation.2022.07.003.
10. Ghobrial M, Nugent K. A review of ECMO in the ED: History, mechanics, common indications, and future implications. https://www.emra.org/emresident/article/ecmo-in-the-ed/. Updated 2019. Accessed 06/16/, 2023.
11. Richardson ASC, Tonna JE, Nanjayya V, et al. Extracorporeal cardiopulmonary resuscitation in adults. interim guideline consensus statement from the extracorporeal life support organization. ASAIO journal (1992). 2021;67(3):221-228. https://www.ncbi.nlm.nih.gov/pubmed/33528154. doi: 10.1097/MAT.0000000000001344.
12. Ko R, Ryu J, Cho YH, et al. The differential neurologic prognosis of low-flow time according to the initial rhythm in patients who undergo extracorporeal cardiopulmonary resuscitation. Resuscitation. 2020;148:121-127. https://dx.doi.org/10.1016/j.resuscitation.2020.01.015. doi: 10.1016/j.resuscitation.2020.01.015.
13. Swedien D, Mann E, Peterson S, et al. ECMO cannulation for refractory vfib/VT arrest (eCPR). Johns Hopkins Medicine Evidence Based Guidelines. 2021.