Hospital-administered ECPR for out-of-hospital cardiac arrest: an observational cohort study
Tuukka Puolakka1, Ari Salo2, Marjut Varpula3
1Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland tuukka.puolakka@hus.fi.
Insights
Extracorporeal cardiopulmonary resuscitation (ECPR) was activated in 73 cases of out-of-hospital cardiac arrest (OHCA). Survival with good neurological outcome was achieved in 25% of ECPR candidates and 33% of those receiving ECMO.
Area of Science:
- Cardiology
- Emergency Medicine
- Critical Care
Background:
- Extracorporeal cardiopulmonary resuscitation (ECPR) is a complex treatment for refractory out-of-hospital cardiac arrest (OHCA).
- The ECPR protocol involves mechanical cardiopulmonary resuscitation (CPR) and transport directly to a cardiac catheterisation laboratory for potential extracorporeal membrane oxygenation (ECMO) implementation.
- This study focuses on normothermic OHCA cases, excluding hypothermic arrests.
Purpose of the Study:
- To analyze the outcomes of the ECPR protocol activation in a real-world setting.
- To determine the rate of ECMO implementation among ECPR candidates.
- To evaluate survival rates and neurological outcomes in patients undergoing ECPR.
Main Methods:
- A retrospective study of OHCA cases where the ECPR protocol was activated between January 2016 and December 2021.
- Inclusion criteria: OHCA patients in the Helsinki University Hospital catchment area meeting ECPR protocol criteria.
- Data collected included ECPR activations, prehospital and in-hospital times, ECMO use, survival, and neurological function (Cerebral Performance Category - CPC).
Main Results:
- The ECPR protocol was activated in 73 cases of normothermic OHCA. The majority of patients were male (91.8%), with witnessed arrests (91.8%) and shockable rhythms (83.6%).
- 37 patients (50.7%) received venoarterial ECMO. Survival to discharge with CPC 1-2 was 29.7% for ECMO patients.
- Of ECPR candidates not receiving ECMO, 16.7% survived to discharge with CPC 1-2.
Conclusions:
- Half of ECPR protocol activations did not result in ECMO treatment.
- Approximately 25% of all ECPR candidates and 33% of those treated with ECMO survived with good neurological outcomes (CPC 1-2).
- ECPR remains a critical intervention for selected OHCA patients, demonstrating potential for survival with favorable neurological recovery.
Background:
Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment method for refractory out-of-hospital cardiac arrest (OHCA) requiring a complex chain of care.
Methods:
All cases of OHCA between 1 January 2016 and 31 December 2021 in the Helsinki University Hospital catchment area in which the ECPR protocol was activated were included in the study. The protocol involved patient transport from the emergency site with ongoing mechanical cardiopulmonary resuscitation (CPR) directly to the cardiac catheterisation laboratory where the implementation of extracorporeal membrane oxygenation (ECMO) was considered. Cases of hypothermic cardiac arrest were excluded. The main outcomes were the number of ECPR protocol activations, duration of prehospital and in-hospital time intervals, and whether the ECPR candidates were treated using ECMO or not.
Results:
The prehospital ECPR protocol was activated in 73 cases of normothermic OHCA. The mean patient age (SD) was 54 (±11) years and 67 (91.8%) of them were male. The arrest was witnessed in 67 (91.8%) and initial rhythm was shockable in 61 (83.6%) cases. The median ambulance response time (IQR) was 9 (7-11) min. All patients received mechanical CPR, epinephrine and/or amiodarone. Seventy (95.9%) patients were endotracheally intubated. The median (IQR) highest prehospital end-tidal CO2 was 5.5 (4.0-6.9) kPa.A total of 37 (50.7%) patients were treated with venoarterial ECMO within a median (IQR) of 84 (71-105) min after the arrest. Thirteen (35.1%) of them survived to discharge and 11 (29.7%) with a cerebral performance category (CPC) 1-2. In those ECPR candidates who did not receive ECMO, 8 (22.2%) received permanent return of spontaneuous circulation during transport or immediately after hospital arrival and 6 (16.7%) survived to discharge with a CPC 1-2.
Conclusions:
Half of the ECPR protocol activations did not lead to ECMO treatment. However, every fourth ECPR candidate and every third patient who received ECMO-facilitated resuscitation at the hospital survived with a good neurological outcome.
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