So a couple of years ago after hearing Scott’s interview of Joe Bellezzo and Zack Shinar (http://emcrit.org/podcasts/ecmo/) I figured this was the future, and promptly got a hold of these guys and got them to present at CCUS 2013 (link to Zack’s lecture below), where their lectures were mind-blowing and instantly made any resuscitationist green with envy, me included.
So just last month, two articles came out in Resuscitation which are highly pertinent and add a lot of legitimacy to the concept of ECMO for CA, one being the CHEER study by Bernard et al (CHEER Study) and the other, a very interesting canadian retrospective observational study by Bednarczyk et al (ecmo arrest canadian).
First, the CHEER study. Very well done, designed to combine ECMO, mechanical CPR and hypothermia, N=26, so not massive, but given the magnitude of the treatment effect, IMHO highly significant. Very good criteria (18-65, VF) so basically working with patients having a reasonable prognosis (aside from the cardiac arrest…), and their starting point was after 30 minutes of unsuccessful ACLS.
Now, for experienced clinicians out there, it is fairly obvious that at around 30 minutes, we start to get a little discouraged. Maybe not ready to throw in the towel, but we know things are looking dim. And most of those who do get a late ROSC don’t tend to do very well on the long term…
So it takes the CHEER team about 56 minutes to ECMO runtime. Now, by 56 minutes of no-ROSC, most arrests would have been called. I think that is a key point to underline – the study essentially begins here, at a point where prognosis is no longer that 8-26% “quoted” survival, but pretty close to 0%.
So what happens? 54% of these patients survive to hospital discharge with good neurological recovery. Lets put this in perspective again. They bring back half the people we probably would have given up on…and discharge them home!!! That’s crazy impressive.
This pretty much correlates with the experience of Zack and Joe (www.edecmo.com), who recently told me the story of a 20 year old diabetic with a K of 9.0 and an arrest of over 45 minutes. Discharge home a week or so later. Completely fine. Back on facebook and skyping with Zack & Joe.
That’s a humbling thing, because in my ED, my ICU, my hands, she’s a goner.
The Canadian Perspective
Ok, so the Bernardczyk article is also really interesting, because it shows that this can be accomplished in a community hospital, and not necessarily only a tertiary care center, and their numbers (albeit retrospectively) are in the same ballpark.
And here is an awesome point of view from their discussion which I completely agree with and ascribe to:
“This (…) challenges our understanding of cardiac arrest as a terminal manifestation of a dis-ease process with treatment options fraught with futility. Rather, for selected patients, cardiac arrest may be better considered anexacerbating symptom of underlying disease with a therapeutic window to effectively restore perfusing circulation while providing definitive therapy.”
So one concern is with bringing back severely neurologically disabled patients. I think the CHEER, the canadian and the japanese data all pretty much refute this. ECMO, particularly paired with hypothermia (probably TTM style now), seems to have remarkable neuroprotective effects, despite prolonged low-flow states. I think we all rarely see patients with 40-50 minute range arrests showing CPC scores of 1…
So why might this occur? Does the sudden flow reverse some of the vasoconstriction caused by the epinephrine? I know from discussing with Joe that if they are thinking that the patient is going to ECMO, they will avoid epinephrine. Recent years have clearly shown that the improved ROSC of epinephrine comes at a cost of greater neurological damage, hence equivocal final result of intact neurological survival.
If you’re a resuscitationist, get on board. Its expensive, but no more than a bunch of other (sometimes dubious or dogmatic) things we do – and the data is there. I’ve been working on my (community) hospital and will not quit until we have it.
What do you need? A cooperating ER chief / ICU chief, and either a cath lab and a vascular surgeon in your institution or in a collaborating neighbourhood one.
…and some cojones.
Absolutely love to hear your thoughts, particularly from anyone with ECMO experience!
…this, of course, and more, at CCUS 2015! http://ccusinstitute.org/Symposium7.html
cheers! (pun intended)
…and here is Zack at CCUS 2013: