​Extracorporeal Cardiopulmonary Resuscitation (ECPR) for Cardiac Arrest – Adults

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ILCOR staff

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) for Cardiac Arrest – Adults

Citation

Donnino MW, Andersen LW, Deakin CD, Berg KM, Böttiger BW, Callaway CW, Drennan I, Neumar RW, Nicholson TC, O’Neil BJ, Paiva EF, Parr MJ, Reynolds JC, Ristagno G, Sandroni C, Wang TL, Welsford M, Morley PT, Nolan JP, Soar J.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) for Cardiac Arrest – Adults Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2018 November 09.  Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of the Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of ECPR (Holmberg 2018 91 – PROSPERO Registration CRD42018085404) with involvement of clinical content experts. Evidence from adult and pediatric literature was sought and considered by the Advanced Life Support Task Force and the Pediatric Task Force groups respectively. The Consensus on Science with Treatment Recommendations for children will be published separately by the Pediatric Task Force. 

Systematic Review

Holmberg MJ, Geri G, Wiberg S, Guerguerian A-Marie, Donnino MW, Nolan JP, Deakin CD, Andersen LW, Extracorporeal cardiopulmonary resuscitation for cardiac arrest: a systematic review. Resuscitation 2018;131:91–100. doi: 10.1016/j.resuscitation.2018.07.029. Epub 2018 Jul 29.

PICOST The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe) 

Population: Adults (≥ 18 years) and children (<18 years) with cardiac arrest in any setting (out-of-hospital or in-hospital).

 Intervention: ECPR including extracorporeal membrane oxygenation or cardiopulmonary bypass, during cardiac arrest. 

Comparator: Manual CPR and/or mechanical CPR.

Outcomes: Clinical outcomes, including short-term survival and neurological outcomes (e.g. hospital discharge, 28-days, 30-days, and 1-month), and long-term survival and neurological outcomes (e.g. 3-months, 6-months, and 1-year).

Study design: Randomized trials, non-randomized controlled trials, and observational studies (cohort studies and case-control studies) with a control group were included. Animal studies, ecological studies, case series, case reports, reviews, abstracts, editorials, comments, and letters to the editor were not included.

Time frame: All years and all languages were included.

PROSPERO Registration CRD4201808540 

Consensus on Science

Out of hospital cardiac arrest

For the critical outcome of survival to hospital discharge/one month survival (n=12 studies; Agostinucci 2011 1169; Cesana 2018 432; Choi 2016 132; Hase 2005 1302; Kim 2014 535; Lee 2015 318; Maekawa 2013 1186; Poppe 2015 131; Sakamoto 2014 762; Siao 2015 70; Tanno 2008 649; Venturini 2017 56), long-term survival (n=6 studies; Cesana 2018 432; Kim 2014 535; Maekawa 2013 1186; Sakamoto 2014 762; Siao 2015 70; Tanno 2008 649), favorable neurological outcome at hospital discharge/one month (n=8 studies; Choi 2016 132; Hase 2005 1302; Kim 2014 535; Poppe 2015 131; Sakamoto 2014 762; Siao 2015 70; Yannopoulos 2016 e003732; Yannopoulos 2017 1109), and long-term favorable neurological outcomes (n=6 studies; Kim 2014 535; Maekawa 2013 1186; Sakamoto 2014 762; Schober 2017 277; Siao 2015 70; Tanno 2008 649), only observational studies were identified. 

The overall certainty of evidence was rated as very low for all outcomes. Individual studies were all at a very serious risk of bias, primarily due to confounding. Because of this and a high degree of heterogeneity, no meta-analyses could be performed, and individual studies are difficult to interpret.

In-hospital cardiac arrest 

For the critical outcome of survival to hospital discharge/one month survival (n=5 studies; Blumenstein 2015 13; Chen 2008 554; Chou 2013 441; Lin 2010 796; Shin 2011 1; Shin 2013 3424), long-term survival (n=5 studies; Blumenstein 2015 13; Chen 2008 554; Chou 2013 441; Lin 2010 796; Shin 2011 1; Shin 2013 3424), favorable neurological outcome at hospital discharge/one month (n=4 studies; Blumenstein 2015 13; Chen 2008 554; Lin 2010 796; Shin 2011 1; Shin 2013 3424), and long-term favorable neurological outcomes (n=4 studies; Blumenstein 2015 13; Chen 2008 554; Cho 2014 280; Lin 2010 796), there were only observational studies identified.

The overall certainty of evidence was rated as very low for all outcomes. Individual studies were all at a very serious risk of bias, primarily due to confounding. Because of this and a high degree of heterogeneity, no meta-analyses could be performed, and individual studies are difficult to interpret.

Treatment Recommendations

We suggest extracorporeal cardiopulmonary resuscitation (ECPR) may be considered as a rescue therapy for selected patients with cardiac arrest when conventional cardiopulmonary resuscitation is failing in settings where this can be implemented (weak recommendation, very-low certainty of evidence).

Justification and Evidence to Decision Highlights

  • In making this weak recommendation, we note that this patient population (i.e. cardiac arrest where conventional CPR is failing) has an extremely high mortality rate, particularly when refractory to standard ACLS. Therefore, the potential for benefit and value of this intervention remains despite the overall poor quality of evidence and lack of randomized trials.
  • The published studies use select patients for ECPR and not the general population of all cardiac arrest cases. Guidelines for clinical practice should ideally apply to similar populations, although RCTs have not been performed to define the optimal population.
  • We acknowledge that ECPR is a complex intervention that requires considerable resources and training that are not universally available, but also acknowledge the value of an intervention that may be successful in individuals where usual CPR techniques have failed. In addition, ECPR can sustain perfusion while another intervention such as coronary angiography and percutaneous coronary intervention can be performed 

Knowledge Gaps

  • 1)There are no published randomized trials of ECPR at this time though several are pending.
  • 2)What is the optimal post-cardiac arrest care strategy for patients resuscitated using ECPR?
  • 3)Which patient groups benefit from ECPR?
  • 4)What are the optimal ECPR techniques?
  • 5)What is the optimal timing for ECPR (i.e. early, late, when in the sequence)? Would ECPR be beneficial during the peri-arrest period?
  • 6)What are the population-specific differences in performing ECPR for in-hospital cardiac arrest and out-of-hospital cardiac arrest?
  • 7)What are the differences in quality of life between ECPR survivors and standard CPR survivors? 

References

  •  Agostinucci, J.M., et al., Out-of-hospital use of an automated chest compression device: facilitating access to extracorporeal life support or non-heart-beating organ procurement. Am J Emerg Med, 2011. 29(9): p. 1169-72.Blumenstein, J., et al., Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis. Eur Heart J Acute Cardiovasc Care, 2016. 5(7): p. 13-22.
  • Cesana, F., et al., Effects of extracorporeal cardiopulmonary resuscitation on neurological and cardiac outcome after ischaemic refractory cardiac arrest. Eur Heart J Acute Cardiovasc Care, 2018;7:432–441.
  • Chen, Y.S., et al., Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet, 2008. 372(9638): p. 554-61.
  • Cho, Y.H., et al., Management of cardiac arrest caused by acute massive pulmonary thromboembolism: importance of percutaneous cardiopulmonary support. ASAIO J, 2014. 60(3): p. 280-3.
  • Choi, D.H., et al., Extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest. Clin Exp Emerg Med, 2016. 3(3): p. 132-138.
  • Chou, T.H., et al., An observational study of extracorporeal CPR for in-hospital cardiac arrest secondary to myocardial infarction. Emerg Med J, 2014. 31(6): p. 441-7.
  • Hase, M., et al., Early defibrillation and circulatory support can provide better long-term outcomes through favorable neurological recovery in patients with out-of-hospital cardiac arrest of cardiac origin. Circ J, 2005. 69(11): p. 1302-7.
  • Kim, S.J., et al., An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Crit Care, 2014. 18(5): p. 535.
  • Lee, S.H., et al., Comparison of Extracorporeal Cardiopulmonary Resuscitation with Conventional Cardiopulmonary Resuscitation: Is Extracorporeal Cardiopulmonary Resuscitation Beneficial? Korean J Thorac Cardiovasc Surg, 2015. 48(5): p. 318-27.
  • Lin, J.W., et al., Comparing the survival between extracorporeal rescue and conventional resuscitation in adult in-hospital cardiac arrests: propensity analysis of three-year data. Resuscitation, 2010. 81(7): p. 796-803.
  • Maekawa, K., et al., Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med, 2013. 41(5): p. 1186-96.
  • Poppe, M., et al., The incidence of "load&go" out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: A one-year review. Resuscitation, 2015. 91: p. 131-6.
  • Sakamoto, T., et al., Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation, 2014. 85(6): p. 762-8.
  • Schober, A., et al., Emergency extracorporeal life support and ongoing resuscitation: a retrospective comparison for refractory out-of-hospital cardiac arrest. Emerg Med J, 2017. 34(5): p. 277-281.
  • Shin, T.G., et al., Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med, 2011. 39(1): p. 1-7.
  • Shin, T.G., et al., Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation. Int J Cardiol, 2013. 168(4): p. 3424-30.
  • Siao, F.Y., et al., Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation. Resuscitation, 2015. 92: p. 70-6.
  • Tanno, K., et al., Utstein style study of cardiopulmonary bypass after cardiac arrest. Am J Emerg Med, 2008. 26(6): p. 649-54.
  • Venturini, J.M., et al., Mechanical chest compressions improve rate of return of spontaneous circulation and allow for initiation of percutaneous circulatory support during cardiac arrest in the cardiac catheterization laboratory. Resuscitation, 2017. 115: p. 56-60.
  • Yannopoulos, D., et al., Minnesota Resuscitation Consortium's Advanced Perfusion and Reperfusion Cardiac Life Support Strategy for Out-of-Hospital Refractory Ventricular Fibrillation. J Am Heart Assoc, 2016. 5: e003732.
  • Yannopoulos, D., et al., Coronary Artery Disease in Patients With Out-of-Hospital Refractory Ventricular Fibrillation Cardiac Arrest. J Am Coll Cardiol, 2017. 70(9): p. 1109-1117.

Attachments

Should ECPR vs. no ECPR be used for adult patients with cardiac arrest?

 


CPR

Discussion

GUEST
Malin Zachau
I strongly recommend that "in any setting" needs to be altered to "in a setting where the patient is normothermic" or "where the cause of cardiac arrest is not accidental hypothermia". The survival outcomes for Hypothermic Cardiac arrest is totally different from normothrmic cardiac arrest as is eloquently described in the article "Normothermic and hypothermic cardiac arrest—Beware of Jekyll and Hyde" Article in Resuscitation 129 · April 2018  DOI: 10.1016/j.resuscitation.2018.04.020 The survival data particularly form Dr Tomasz Darocha and his team in Krakow are not approaching 70% with neurological intact outcome. The overall European survival of hypothermic cardiac arrest treated with mechanical CPR and ECLS with intact neurological status is about 50% , thus way better than in normothermic cardiac arrest
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GUEST
IVAN ORTEGA-DEBALLON
To be fair, "the continuous evidence evaluation process for the production of the Consensus on Science with Treatment Recommendations (CoSTR)" actually did not started with a systematic review of ECPR (Holmberg 2018 91 – PROSPERO Registration CRD42018085404) as stated in this provided link, but with another one (2016 Ortega-Deballon I et al. Resuscitation. 2016;101:12-20. PROSPERO, CRD 42014015259). http://dx.doi.org/10.1016/j.resuscitation.2016.01.018. This PREVIOUS, and to our knowledge the first systematic review performed on ECPR topic until that moment, followed PICOTS question format, PRISMA format, explored both level of evidence (following the LOE scale tool proposed by ILCOR) and quality of guidelines (following AGREE II) from ECPR for refractory OHCA of cardiac origin in adults. In short, did pretty the same that Holmberg et al have been published. We do not understand, at first, why previous work is not referenced at any moment, why the research question, methodology and search strategy is close to duplicate and already did research and why if findings are pretty a duplication of our previous systematic review, the efforts were not focused on reducing knowledge gap while recognizing previous research work from colleagues instead. In any case, although, again, findings and results from the latter (2018 Holmberg et al) are practically identical to the former that we authorized (and conducted less than 2 years later) we are sure that running RCTs will help to really increase LOE and reduce knowledge gap in order to inform future research. At the same time, many other questions will remain despite of RCT publication, as such a methodology have also limitations when referred to Resuscitation Research environment. Finally, from a comprehensive approach to sudden cardiac arrest in the prehospital environment, we suggest that the option of Deceased Organ Donation (both after neurologic determination of death -NDD- and after circulatory determination of death -DCD-) should be explored between non eligible for/non survivors from "ECPR strategy", as also between patients with a very poor neurologic prognosis (CPC>3) despite of ROSC after ECPR strategy. This approach, has been already encouraged by ILCOR in 2015 Guidelines and should not be disregarded from a more effective, efficient and ethically sound point of view. Rowing together, both Resuscitationists/ECMOlogists community and Organ Donation & Transplant community, we really will do our best for both patients, their proxies, health providers confidence and thrutfulness of whole system from society according with best scientific evidence and ethical principles, taking into account the specific legal frame and cultural believes at each country. We really stress that this opportunity should not be lost again. We will continue working on it. The final goal, to increase survival from OHCA with QOL first and organ donation pool to reduce organ shortage for transplant when not possible, deserve to do so.
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