A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis

doi:10.1016/j.resuscitation.2017.04.014

Resuscitation

Volume 117, August 2017, Pages 109-117

https://doi.org/10.1016/j.resuscitation.2017.04.014 Get rights and content

Abstract

Background

Out of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies.

Methods

We consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30 min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20 min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28.

Findings

A total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20 min (p < 0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P < 0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2.

Interpretation

Our data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.

Section snippets

1 Introduction

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide [1].

The use of Extracorporeal Cardio-Pulmonary Resuscitation (ECPR) has been described for the treatment of refractory in-hospital cardiac arrest with survival rates ranging from 20% to 30% [2], [3], [4], [5], [6]. However, this technique remains controversial [7], [8], [9], [10], [11], [12], [13], [14]. Limitations include access to ECPR with reasonable timing, cost-effectiveness and optimal patient selection.

2 Methods

The study was performed in Paris area, a city of 105 square kilometers with 2,2 million residents and an influence area of more than 12 million residents.

In 2011, the SAMU of Paris initiated a feasibility study on the use of pre-hospital ECPR for refractory OHCA [21]. The management of OHCA involves basic life support (BLS) and mobile intensive care units (MoICU), simultaneously dispatched to provide BLS and advanced life support (ALS) according to international guidelines.

The current

3.1 Baseline characteristics and management

During the period of the study 15 680 OHCA occurred in Paris.

All 156 patients who received ECPR were included, 114 patients were included during Period 1 and 42 patients were included in Period 2.

Baseline and procedural characteristics are shown in Table 1.

Patients treated during the 2 periods had no significant differences in terms of demographic variables. Mean low-flow duration was shorter by more than 20 min in Period 2 (p < 0.0001). As expected from the selection criteria of Period 2,

4 Discussion

Our results in this large series of ECPR suggest improved survival rates in refractory OHCA using an aggressive ECPR strategy. Compared with the initial period when a less stringent protocol was used, survival increased from 8% to 29% (Table 1).

As shown by the different analyses, a more stringent patient selection and the overall management strategy appeared to be the main drivers of improved survival, which did not appear related to any single specific procedure. Patients without the

5 Conclusion

In conclusion, in one of the largest series of patients treated with ECPR for OHCA, an aggressive ECPR strategy based on an aggressive management of OHCA by a dedicated emergency team with pre-hospital implementation of ECPR in selected patients is feasible, with a favorable survival rate. Larger registries and randomized trials are warranted to confirm these results.

Conflict of interest statement

None.

Funding

None.

Acknowledgments

We would like to acknowledge all personnel involved with ECPR in the Necker ICU and the SAMU de Paris.

Dr Lamhaut and Hutin declare receiving Travel and congress fees from Maquet.

Other authors declare have no conflicts of interest.

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Clinical paperA Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis

Abstract

Background

Methods

Findings

Interpretation

Section snippets

1 Introduction

2 Methods

3.1 Baseline characteristics and management

4 Discussion

5 Conclusion

Conflict of interest statement

Funding

Acknowledgments

J Am Coll Cardiol

Lancet

Resuscitation

Chest

Ann Thorac Surg

J Am Coll Cardiol

Resuscitation

Resuscitation

Best Pract Res Clin Anaesthesiol

Resuscitation

Int J Cardiol

J Thorac Cardiovasc Surg

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Clinical paper
A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis