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Extracorporeal Membrane Oxygenation Performed
Under Cardiopulmonary Resuscitation.
Hitsohi Hirose, MD; Harrison T. Pitcher, MD; Qiong Yang, MD; Nicholas Cavarocchi, MD.
Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
Introduction
Background on Cardiopulmonary
resuscitation (CPR)
CPR is not terrifically successful.
<50% of patients survive CPR. <20% of
patients survive CPR and are discharged
from the hospital.
Peberdy et al. Pefusion 2003.
Ebell et al. J Gen Intern Med 1998.
E-CPR gives patients unresponsive to
conventional CPR (CCPR) another opportunity
at life.
E-CPR: Previous Studies
20% increase in survival (compared to
CCPR) without neurological consequence.
Provides significant increases in survival 1
year and 2 years after procedure when
compared to CCPR.
Most research on E-CPR has come from
institutions with dedicated E-CPR/Code
teams
Available 24/7. Always on call.
E-CPR teams are very successful.
Chen et al. Lanset 2008.
Shin et al. Int J Cardiol 2013
But not generalizable to majority of hospitals
(including ours)
Methods
Study period: 2010-2013
Total number of E-CPR caases: 24 (out of 100
ECMO runs)
Demographics of patients
24 patients: 15M; 9F
47 ± 15 y/o
Mean duration of CPR: 53 ± 33 min.
Mean duration of ECMO: 5.1 ± 4.7 days.
All patients who qualified were placed on
24hr. Hypothermia protocol.
Retrospective analysis with IRB approval.
Results
Etiologies for E-CPR
Results
Hospital survival rate from conventional CPR
(previous study): 15 % Ebell et al. J Gen Intern
Med 1998.
Hospital survival rate after E-CPR (current
study): 29% (p= 0.04 better than CCPR)
Risk factors for E-CPR death:
Elevated Pre-ECMO creatinine:
Survivors Cr: 1.1 mg/dL , Non-survivors
Cr: 1.7 mg/dL; p=0.02
Metabolic acidosis:
Survivors pH: 7.24 , Non-survivors pH:
7.05; p=0.04
Neurological complications remain an issue to
be resolved, as the majority of deaths were from
anoxic brain injuries (n=9) or stroke (n=4)
Organ preservation is good among survivors
Two patients who died of anoxic brain
injuries were able to donate multiple organs
for transplant.
All hospital survivors demonstrated full
neurological recovery
Contact Information
ECMO Survival
Hospital Survival
Post-ECMO Organ Function Among Survivors
Acute
Myocardial
Infraction,
9
Malignant
Arrhythmia
, 4
Myocarditi
s, 3
[CATEGO
RY NAME]
Other, 4
Hypothermia,
2
54% 46%
0
1
2
3
4
5
6
7
8
Hospital Survivors Hospital Non-Survivors
# Patients
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Kidney
Function
Liver
Function
Metabolic
Function
# Patients
Improved
Unchanged
Anoxic brain
injury, 9
Stroke, 4
Other, 4
Causes of Death
Determination of ECPR
Code team leader assess eligibility of patient
for ECPR.
ECMO team nofied, and evaluates the
patient.
Perfusionists bring ECMO cart.
Veno-arterial cannulaiton while CPR is in
progress.
Stop CPR as soon as ECMO is started.
Exclusion criteria for E-CPR
Patient >70 years old
Non-witnessed arrest
DNR orders
Uncontroled baseline issue: sepsis, bleeding,
Uncorrectable baseline disease: terminal
cancer
Limited daily activity
Dr. Hitoshi Hirose: Hitoshi.Hirose@jefferson.edu
Objectives
To observe viability of E-CPR for successful
resuscitation and survival in the setting of an
academic institution without a designated E-
CPR/Code Team.
Determine end-organ function in survivors.
Determine pre-ECMO parameters that
correlate with survival (risk scores, blood
values, demographics).
Conclusion
E-CPR provided improved survival and
neurological recovery compared to national
in-hospital post-CPR statistics.
E-CPR made multi-organ procurement
possible.
The protection of patients’ brains remains an
issue to be addressed in order for survival
rates to be further improved.
54% 46%
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
ECMO Survivors ECMO Non-survivors
# Patients
Full neurological recovery in hospital survivors:
100%