Advertisement

A pragmatic parallel group implementation study of a prehospital-activated ECPR protocol for refractory out-of-hospital cardiac arrest

  • Brian Grunau
    Correspondence
    Corresponding author at: 1081 Burrard St. Vancouver, B.C., Canada.
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Department of Emergency Medicine, University of British Columbia, Canada

    Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada

    British Columbia Emergency Health Services, British Columbia, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada
    Search for articles by this author
  • Jamil Bashir
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Division of Cardiovascular Surgery, University of British Columbia, Canada
    Search for articles by this author
  • Anson Cheung
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Division of Cardiovascular Surgery, University of British Columbia, Canada
    Search for articles by this author
  • Robert Boone
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Division of Cardiology, University of British Columbia, Canada
    Search for articles by this author
  • Ken McDonald
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada
    Search for articles by this author
  • Frank Scheuermeyer
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Department of Emergency Medicine, University of British Columbia, Canada

    Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada
    Search for articles by this author
  • Joel Singer
    Affiliations
    Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada
    Search for articles by this author
  • Sandra Jenneson
    Affiliations
    Department of Emergency Medicine, University of British Columbia, Canada

    British Columbia Emergency Health Services, British Columbia, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada

    Royal Columbian Hospital, New Westminster, B.C., Canada
    Search for articles by this author
  • Ron Straight
    Affiliations
    British Columbia Emergency Health Services, British Columbia, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada
    Search for articles by this author
  • Brian Twaites
    Affiliations
    British Columbia Emergency Health Services, British Columbia, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada
    Search for articles by this author
  • Luke Harris
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Division of Cardiovascular Surgery, University of British Columbia, Canada
    Search for articles by this author
  • Scott Haig
    Affiliations
    British Columbia Emergency Health Services, British Columbia, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada
    Search for articles by this author
  • Devin Harris
    Affiliations
    Department of Emergency Medicine, University of British Columbia, Canada

    Kelowna General Hospital, Kelowna, B.C., Canada
    Search for articles by this author
  • Richard Vandegriend
    Affiliations
    Royal Columbian Hospital, New Westminster, B.C., Canada

    Division of Critical Care, University of British Columbia, Canada
    Search for articles by this author
  • Hussein Kanji
    Affiliations
    Royal Columbian Hospital, New Westminster, B.C., Canada

    Division of Critical Care, University of British Columbia, Canada

    Vancouver General Hospital, Vancouver, B.C., Canada
    Search for articles by this author
  • Jim Christenson
    Affiliations
    St. Paul’s Hospital, Vancouver, BC, Canada

    Department of Emergency Medicine, University of British Columbia, Canada

    Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada

    BC Resuscitation Research Collaborative, British Columbia, Canada
    Search for articles by this author

      Abstract

      Objectives

      Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival among patients with refractory out-of-hospital cardiac arrest (OHCA). We evaluated outcomes after incorporating ECPR into a conventional resuscitation system.

      Methods

      We introduced a prehospital-activated ECPR protocol for select refractory OHCAs into one of four metropolitan regions in British Columbia. We prospectively identified ECPR-eligible patients in both the ECPR region and the three other regions to serve as the control group. We compared the proportion with favorable neurological outcomes at hospital discharge (cerebral performance category 2) and used logistic regression to estimate the association with treatment region.

      Results

      The study was terminated prematurely due to changes in hospital protocols and COVID-19. In the ECPR region, 15/58 (25.9%) patients had favourable neurological outcomes owing to conventional resuscitation and 2/58 (3.4%) owing to ECPR, for a total of 17/58 (29.3%). In the control regions, 67/250 (26.8%) patients had a favourable outcome owing to conventional resuscitation, for a between-group difference of 2.5% (95% CI −10 to 15%). We did not detect a statistically significant association between treatment region and outcomes.

      Conclusion

      In this prematurely-terminated study of ECPR for refractory OHCA, we did not detect an association between a regional ECPR protocol and neurologically favorable outcomes. However, our data suggests that outcomes owing to conventional resuscitation were similar, with the potential for additional survivors due to ECPR therapies.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Morimura N.
        • Sakamoto T.
        • Nagao K.
        • et al.
        Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A review of the Japanese literature.
        Resuscitation. 2011; 82: 10-14https://doi.org/10.1016/j.resuscitation.2010.08.032
      1. Stub D, Bernard S, Pellegrino V, et al. Refractory Cardiac Arrest Treated with Mechanical CPR, Hypothermia, ECMO and Early Reperfusion (the CHEER Trial). Resuscitation. Published online September 30, 2014:1-7. http://doi.org/10.1016/j.resuscitation.2014.09.010.

        • Wang C.-H.
        • Chou N.-K.
        • Becker L.B.
        • et al.
        Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest - A comparison with that for extracorporeal rescue for in-hospital cardiac arrest.
        Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022
        • Leick J.
        • Liebetrau C.
        • Szardien S.
        • et al.
        Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest.
        Clin Res Cardiol. 2013; 102: 661-669https://doi.org/10.1007/s00392-013-0580-3
        • Yannopoulos D.
        • Bartos J.
        • Raveendran G.
        • et al.
        Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.
        Lancet. 2020; 396: 1807-1816https://doi.org/10.1016/S0140-6736(20)32338-2
        • Alm-Kruse K.
        • Sørensen G.
        • Osbakk S.A.
        • et al.
        Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol.
        Resuscitation. 2021; 162: 35-42https://doi.org/10.1016/j.resuscitation.2021.01.038
        • Grunau B.
        • Kime N.
        • Leroux B.
        • et al.
        Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest.
        JAMA. 2020; 324: 1058https://doi.org/10.1001/jama.2020.14185
        • Stiell I.G.
        • Nichol G.
        • Leroux B.G.
        • et al.
        Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest.
        N Engl J Med. 2011; 365: 787-797https://doi.org/10.1056/NEJMoa1010076
        • Hallstrom A.P.
        • Ornato J.P.
        • Weisfeldt M.
        • et al.
        Public-access defibrillation and survival after out-of-hospital cardiac arrest.
        N Engl J Med. 2004; 351: 637-646https://doi.org/10.1056/NEJMoa040566
        • Kudenchuk P.J.
        • Brown S.P.
        • Daya M.
        • et al.
        Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
        N Engl J Med. 2016; 374: 1711-1722https://doi.org/10.1056/NEJMoa1514204
        • Grunau B.
        • Kawano T.
        • Dick W.
        • et al.
        Trends in care processes and survival following prehospital resuscitation improvement initiatives for out-of-hospital cardiac arrest in British Columbia, 2006–2016.
        Resuscitation. 2018; 125: 118-125https://doi.org/10.1016/j.resuscitation.2018.01.049
      2. BCEHS. British Columbia Emergency Health Services. Accessed May 2, 2020. www.bcehs.ca.

        • Kleinman M.E.
        • Brennan E.E.
        • Goldberger Z.D.
        • et al.
        Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2015; 132: S414-S435https://doi.org/10.1161/CIR.0000000000000259
        • Link M.S.
        • Berkow L.C.
        • Kudenchuk P.J.
        • et al.
        Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2015; 132https://doi.org/10.1161/CIR.0000000000000261
      3. BCEHS Treatment Guidelines. British Columbia Emergency Health Services. Accessed July 20, 2012. https://handbook.bcehs.ca.

        • Callaway C.W.
        • Donnino M.W.
        • Fink E.L.
        • et al.
        Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2015; 132https://doi.org/10.1161/CIR.0000000000000262
        • Grunau B.
        • Carrier S.
        • Bashir J.
        • et al.
        A comprehensive regional clinical and educational ECPR protocol decreases time to ECMO in patients with refractory out-of-hospital cardiac arrest.
        CJEM. 2017; 19: 424-433https://doi.org/10.1080/10903127.2017.1356412
        • Perkins G.D.
        • Jacobs I.G.
        • Nadkarni V.M.
        • et al.
        Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: A Statement for Healthcare Professionals From a Task Force of the International Liaison Committee.
        Resuscitation. 2015; 96: 328-340https://doi.org/10.1016/j.resuscitation.2014.11.002
        • Grunau B.
        • Reynolds J.C.
        • Scheuermeyer F.X.
        • et al.
        Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation.
        Resuscitation. 2016; 101: 50-56https://doi.org/10.1016/j.resuscitation.2016.01.021
        • Reynolds J.C.
        • Grunau B.E.
        • Elmer J.
        • et al.
        Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates.
        Resuscitation. 2017; 117: 24-31https://doi.org/10.1016/j.resuscitation.2017.05.024
      4. Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. Published online July 18, 2018. http://doi.org/10.1056/NEJMoa1806842.

      5. Richardson ASC, Tonna JE, Nanjayya V, et al. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J. Published online February 2021. http://doi.org/10.1097/MAT.0000000000001344.

        • Bartos J.A.
        • Carlson K.
        • Carlson C.
        • et al.
        Surviving refractory out-of-hospital ventricular fibrillation cardiac arrest: Critical care and extracorporeal membrane oxygenation management.
        Resuscitation. 2018; 132: 47-55https://doi.org/10.1016/j.resuscitation.2018.08.030
        • Ha T.S.
        • Yang J.H.
        • Cho Y.H.
        • et al.
        Clinical outcomes after rescue extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest.
        Emerg Med J. 2017; 34: 107-111https://doi.org/10.1136/emermed-2015-204817
        • Ko R.E.
        • Ryu J.A.
        • Cho Y.H.
        • 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: 121-127https://doi.org/10.1016/j.resuscitation.2020.01.015
        • Ortega-Deballon I.
        • Hornby L.
        • Shemie S.D.
        • Bhanji F.
        • Guadagno E.
        Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes.
        Resuscitation. 2016; 101: 12-20https://doi.org/10.1016/j.resuscitation.2016.01.018
      6. Bougouin W, Dumas F, Lamhaut L, et al. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J. Published online 2019:1-11. http://doi.org/10.1093/eurheartj/ehz753.

      Linked Article