E-CPR for all – just a dream, or the future?

A new meta-analysis of ECMO in cardiogenic shock and arrest showed an impressive 30-day survival rate of over 30% but at the cost of significant levels of complications (neurological/infective/renal).

A couple of months ago CHEER trial team published their results with a protocol that reads like science-fiction for many of us:

A senior team leader, 2 crit care doctors ready with femoral cannulae, another manning the IVC ultrasound, an ECMO nurse to run the mechanical CPR device and initiate the V-A ECMO circuit, and someone else to start the iced-saline.

Autopulse mechanical chest-compressor and cold infusion en-route to hospital. On arrival compressions are briefly paused while femoral cannulae go in (guidewire visualized in the IVC). Chest X-ray, heparinization then ECMO initiation. Coronary occlusion or pulmonary embolism is then addressed by PCI or thrombectomy. Cool for 24 hours and wean the ECMO using echo.

In-hospital as well as out of hospital arrests were included in this Melbourne single hospital prospective observational study. 24 of the intended 26 patients actually got ECMO. The arrests were largely VF and the aetiology was mainly ischemic but cardiomyopathies/channelopathies, PE and respiratory causes also featured. Fairly standard mix!

14 of the 26 got out of hospital. Unsurprisingly more in-hospital than out-of-hospital arrests survived (9/15 v 5/11). None survived asystole despite E-CPR. From arrest to starting ECMO  40 mins (median) passed in survivors and 78 mins in non-survivors (seems to take 15-30 mins from arrival of team to ECMO initiaition).

A highly-staffed process gives good ROSC and survival rates. Refine it by restricting to non-asystole and those who can get cannulated asap.

Given this protocol will never be achievable in smaller hospitals, is it more evidence for centralizing arrest management, or does it really emphasize that the priorities are:

• shortening the time from arrest to arrest team
• prompt definitive management thereafter.