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Extracorporeal Pulmonary Resuscitation (ECPR) of Out-of-Hospital Cardiac Arrest

For decades, extracorporeal life support (commonly referred to as extracorporeal membrane oxygenation, or ECMO) was used in the operating room (OR) and ICU to treat refractory shock, typically after surgery. More recently, ECMO has been used to treat refractory cardiac arrest; in this indication, it takes the name “ECPR.” Today, ECPR is used in many places.

Although there are published case reports, series and after/before studies, there have been no randomized controlled trials to illustrate its effectiveness in the resuscitation of out-of-hospital cardiac arrest (OHCA) patients.

However, ECPR is now recommended by international guidelines in the management of refractory OHCA of suspected reversible cause, such as acute myocardial infarction, refractory cardiac arrest of suspected reversible cause, pulmonary embolism and intoxication.1 The 2015 American Heart Association Guidelines recommend ECPR could be considered in refractory cardiac arrest of suspected reversible cause.2

ECPR is the second line of treatment for OHCA not responding to usual BLS and ALS treatments (e.g., cardiac compressions/ massage, ventilation, defibrillation, drug administration, etc.). ECPR brings respiratory and circulatory support, ensuring sufficient blood and oxygen supply to the whole body, especially the brain.

The ECPR response team in Paris implements ECMO on scene to restore blood flow to the body and limit ischemic consequences to the brain and coronary arteries. The hybrid implementation technique used by Service d’Aide Medical d’Urgence (SAMU) in Paris, which uses a surgical cutdown followed by insertion of the cannula in the femoral artery, is quick, safe and accessible to emergency physicians, with low failure rates.3

Selection of Patients Eligible for ECPR

ECPR is a neuroprotective treatment. Neuroprotective treatments are therapies that block the cellular, biochemical and metabolic elaboration of injury during or after exposure to ischemia and have a potential role in ameliorating brain injury in patients with acute ischemic stroke.4

Patients with neuroprotection need to be cannulated. These patients include hypothermia below 32°C, intoxication (with neuroprotection) and general anesthesia.

For other patients, the selection needs to be based on brain criteria. At this time, the selection criteria include “signs of life” (e.g., breathing movements, gasping, spontaneous movements and pupillary reactivity). Other criteria like no flow and rhythm aren’t related to the prognosis.

The quality of the CPR is crucial, as is the quality of care after ECPR.

Who and Where?

Today surgeons, intensivists, cardiologists and emergency physicians can perform ECPR. However, new ECMO devices may enable highly trained prehospital clinical specialists to perform ECMO in the field.

The objective of ECPR is to get the patient on ECMO within 60 minutes of an OHCA. If a patient has some persistent signs of life, they can undergo ECPR at any time. For neuroprotected patients, the low flow time can be very long (e.g., five hours of hypothermia).

The location to initiate ECPR insertion is usually the OR, ICU or ED, and insertion can be done by surgical technique, percutaneous under ultrasound control or by a hybrid technique. The location for ECPR needs to be selected based on the site most advantageous to reduce the low-flow time. Since 2011, some teams in Europe have started to do prehospital ECPR with good results, in order to reduce the low-flow time.

Recommendation

In 2018, all communities should have a pre-established protocol of ECPR for selected refractory cardiac arrest patients. This protocol needs to describe the selection criteria, the technique of insertion and the site of insertion. This protocol should try to reduce the period of low flow. Prehospital ECPR can be done effectively and should be considered when adequately trained medical personnel are available. This protocol needs to be collaborative with EMS, ED, ICU and cardiologists. ECPR has the potential to significantly increase survival rates when incorporated into an optimal OHCA bundle of care.

References

1. Hutin A, Abu-Habsa M, Burns B, et al. Early ECPR for out-of-hospital cardiac arrest: Best practice in 2018. Resuscitation. 2018;130:44–48.

2. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S444–S464.

3. Hutin A, Corrocher R, Loosli F, et al. ECMO on the streets of Paris. JEMS. 2017;42(2):39–42.

4. Ovbiagele B, Kidwell CS, Starkman S, et al. Potential role of neuroprotective agents in the treatment of patients with acute ischemic stroke. Curr Treat Options Cardiovasc Med. 2003;5(6):441–449.

5. Lamhaut L, Hutin A, Puymirat E, et al. A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis. Resuscitation. 2017;117:109–117.