ECMO

ACEM Fellowship

Table of Contents

Evidence

Neonatal

Adults and VV-ECMO

CESAR showed improved survival at 6mo (63% vs. 47%) in severe acute respiratory failure
ANZ ECMO influenza showed mortality rate of 21%
Systemic review of H1N1 found insufficient evidence of benefit

Adults and V-A EMCO

Meta-analysis (Ouweneel et al. ICM 2016) showed improve survival by 33% compared to standard care (IABP) but no improvement compared to LVAD

Adults and E-CPR

Minimal evidence thus far
Meta-analysis (Ouweneel et al. ICM. 2016) showed improved survival by ~13% and improved neurologically intact survival (Cerebral Performance Category 1 or 2) by about the same with a NNT of 7-9
ARREST trial
- Phase 2 single-centre open-label randomised control trial
- Inclusion:
  - Adult patients (known or presumed) 18 – 75 years old
  - Initial rhythm of VF or pulseless VT
  - No ROSC after 3 shocks (ROSC after >4 shocks did not result in exclusion)
  - Body habitus able to support mechanical CPR
  - Estimated transport time < 30 minutes
- Exclusion:
  - Valid DNR
  - Mechanisms: Drowning, blunt or penetrating trauma, burns, overdose
  - Pregnancy
  - Terminal Cancer
  - Active GI or internal bleeding
  - Prisoner or nursing home resident
  - Cath Lab unavailable, absolute contraindications to emergent angiography or contrast allergy
  - 2 or more of: Lactate >18, PaO2 <50, etCO2 <10
- 15 underwent ECMO (1 withdrew later)
- Outcomes
  - 6/14 survived to hospital discharge vs. 1/15 in usual care
  - Those that survived had fairly good neurological outcomes (CPC 1 -2)
At what cost?

Acute, severe reversible respiratory or cardiac failure with a high-risk of death that is refractory to conventional management

Progressive non-recoverable cardiac disease (not transplant candidate)
Progressive non-recoverable respiratory disease (irrespective of transplant status)
Chronic severe pulmonary hypertension
Advanced malignancy
GVHD
>120kg
Unwitnessed cardiac arrest

Most common method utilised
Support for severe respiratory failure only
Oxygenated blood is returned to the right side of heart so can lose oxygen at lungs if FiO2 is low
Conditions to consider
- ARDS of any cause
- Status asthmaticus

Rationale
- Provides full circulatory support for reversal of cause i.e. revascularisation
- Evidence shows may improve survival from 0-10% to 10-40% in refractory cardiac arrest over 30 minutes duration
Asystole as initial rhythm is a strict absolute contraindication
VF/VT have better outcomes with ECPR
No flow time = Time from arrest to start of CPR
Low flow time = Time from start of CPR to commencement of ECMO
Maximum 45-60 min in most studies but neurologically intact survivors have been seen with times up to 1.5 hours
Inclusion criteria (RBWH)
- Age <65
- Independent living
- WITNESSED Arrest
- IMMEDIATE Bystander CPR
- First rhythm VF or VT
- DC shocks x 3
- Amiodarone 300mg
- Arrest to ED <45 min
Exclusion criteria (RBWH)
- Asystole or PEA <40/min as first rhythm
- Arrest to ED >45 min OR
- Age + Arrest time >100
- Not For Resuscitation
- Terminal illness
- Significant chronic organ failure
- Significant haemorrhage
Exclusion criteria (Alfred)
- Age >65
- Unwitnessed
- Asystole initial rhythm
- No flow time >10 min
- Low flow time >60 min
- Terminal illness
- Known severe neurological injury
Relative exclusion criteria (Alfred)
- Lactate >18
- pH <6.8
- etCO2 <10
Minnesota E-CPR Protocol
- If 2 or more below poor prognostic features, patient excluded:
  - EtCO2 <10
  - PaO2 <50mmHg
  - Lactate >18

Last Updated on December 16, 2021 by Andrew Crofton