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Information about BERNARD on ECMO CPR: It's ON
Health & Medicine

Published on March 7, 2014

Author: oliflower



Steve Bernard speaks at a meeting on 4/2/14 in Sydney on the reality of ECMO CPR at The Alfred in Melbourne, Victoria, and the upcoming CHEER study.

Exciting times!

See Intensive Care Network for the talk and more.

Refractory Cardiac Arrest The CHEER Protocol Stephen Bernard MD FACEM FCICM FCCM

The Victorian setting • • • • 000 call system Computer aided dispatch Post dispatch instructions (ECM only) “3-tier” system – PAD/ Firefighters/ CERT – ALS paramedics – Intensive Care Paramedics • ACLS at scene • Transport to ED if ROSC

The Victorian setting • If no ROSC at ~30 minutes- declared deceased – All ACLS provided at scene – Asystole as final rhythm – No compelling other factors (hypothermia/ OD) • • • • EMS transport with effective CPR not practical Hazardous for EMS crew No new therapy in ED Considered futile

The Victorian setting • Data from Victorian Ambulance Cardiac Arrest Register for Melbourne – 12 month period (2012) – Age < 65 years – VF as initial cardiac rhythm • 222 patients • 149 ROSC (Survival of these = 55%) • 68 no ROSC • 5/68 transported with CPR (Autopulse) • 63 declared deceased at scene

The Victorian setting • Data from Victorian Ambulance Cardiac Arrest Register for Melbourne – 12 month period (2012) – Age < 65 years – VF as initial cardiac rhythm • 222 patients • 149 ROSC (Survival of these = 50%) • 68 no ROSC • 5/68 transported with CPR (Autopulse) • 63 declared deceased at scene

ECMO • 2008 Swine flu • Increasing experience in VV ECMO • Intensivists at Alfred undertake training program – 2 day program – Cannulation in dogs – Circuit management

E-CPR Reports from Japan in 2000-2012 J Am Coll Cardiol 2000; 36(3):776-83.

E-CPR • January 2004 and May 2011 • E-CPR in 86 patients with ACS • Median age 63 years/ 81% were male • Intra-arrest PCI was performed in 61 patients (71%). • ROSC 88% • 30-day survival 29% • Favorable neurological outcome 24% Kagawa E, et al. Should we emergently revascularize occluded coronaries for cardiac arrest?: Rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 2012 Sep 25;126(13):1605-13

The CHEER Trial – Pilot observational trial – Post-VF arrest – <70 years old – No ROSC at 30 minutes • • • • • CPR to ED with Autopulse Hypothermia ECMO Emergency Reperfusion

The CHEER Trial – Mechanical CPR to ED

The CHEER Trial Cannulae Cold fluid Autopulse Primed circuit – Notification by AV – Equipment immediately available in ICU – Brought to ED by ICU team Drapes etc

In the ED • Clearly defined roles to prevent chaos – – – – – – – – – ED Consultant manages airway/ventilator No shocks or cannulation during ECPR ED nurses (x 2) equipment and scribe ICU SR pumps ice cold saline x 3L ICU Consultants x 2 cannulate ICU/ED manage U/S upper abdo for wires ICU nurse manages Autopulse and ECMO circuit Cardiology review need for PCI All others stand back

In the ED – Percutaneous cannulation by Intensivists x 2 – 15F arterial/ 17F venous – Ultrasound of femoral vessels – Ultrasound of IVC – No defibs/ CVC during cannulation

VENO-ARTERIAL ECMO V-A ecmo for CPR Low flow configuration (3-4L/min) Oxygen vs Air?

The CHEER Trial – Cold IV saline – 3 L bolus IV – Cools rapidly Bernard SA, et al. Therapeutic hypothermia induced during cardiopulmonary resuscitation using large-volume, ice-cold intravenous fluid. Resuscitation 2008; 76:311-3

In the cath lab: •Coronary angiogram •Stent any blockages •Then the heart will start!

To the ICU: •Cooling for 24 hours •33°C •Slow rewarming over 12 hours @ 0.25°C/hr

In-hospital cardiac arrest – Refractory cardiac arrest following in-hospital arrest – No ROSC at 30 minutes – The “CHEER” approach – Reversible cause • • • • Age <70 ACS in ED Reperfusion arrest in Cath lab Pulmonary embolism

Experience to date Definitions for this presentation • OHCA- CPR into the ED and > 30 minutes • IHCA- CPR > 30 minutes • Excludes – VA-ECMO for shock with arrest < 30 minutes – IHT from other centre

Experience to date Site ECMO Survival OHCA 7/9 3/7 IHCA 13/13 8/13 E-CPR Good neurological outcome 11/20 (55%)


IHCA-11 “Jenny thanks 'miracle workers' who saved her life”

What we are doing now… – Extra 10 Autopulses donated to AV by Zoll – Covers most of Melbourne – 24/7 ICU Consultant roster – Strategy to move patients within 20 minutes of arrest- ECMO < 60 minutes – Scenario training for the team

Summary – Every large city should have E-CPR available – Safe transfer to hospital with CPR now possible – Intensivist rapid percutaneous cannulation in ED feasible – Cooling during CPR is recommended (40mL/kg cold fluid bolus) – Normal neurological outcomes possible with up to 125 minutes of CPR – 55% good outcomes at The Alfred (11/20)

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