Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department

Extracorporeal Cardiopulmonary Resuscitation In The Emergency Department

Brought to you exclusively by the publisher of: EM Critical Care Emergency Medicine Practice EM Practice Guidelines Update Pediatric Emergency Medicine Practice The Lifelong Learning and Self-Assessment Study Guide Authors CME Objectives Joseph M. Bellezzo, MD Upon completion of this article, you should be able to: Clinical Medical Director, Emergency Department, Sharp Memorial 1. Describe the basic function of ECLS in the management of patients Hospital, San Diego, CA with acute cardiopulmonary decompensation. Zack Shinar, MD, FACEP 2. Describe the concept of ECPR and its role in the management of the Emergency Department, Sharp Memorial Hospital, San Diego, CA arresting patient. 3. Explain the different configurations of ECLS (VA-ECLS vs VV-ECLS) Peer Reviewers and in what circumstances each is applicable. David A. Farcy, MD, FCCM, FAAEM 4. Describe how the emergency physician can incorporate ECPR into a Chief of Emergency Department, Director of Surgical Intensive Care Unit, successful advanced resuscitation strategy. Mount Sinai Medical Center, Miami Beach, FL 5. Summarize the current evidence-based data supporting the use of Chad M. Meyers, MD ECPR, including the limitations of the available data. Director, Emergency Critical Care, Assistant Professor, Clinical Emergency Medicine, Bellevue Hospital Center - Department of Emergency Medicine, NYU School of Medicine, New York, NY Physician CME Information

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Editor-in-Chief Center for Resuscitation Science, Andy Jagoda, MD, FACEP Julie Mayglothling, MD Emanuel P. Rivers, MD, MPH, IOM Robert T. Arntfield, MD, FRCPC Philadelphia, PA Professor and Chair, Department Assistant Professor, Department Vice Chairman and Director Assistant Professor, Division of Emergency Medicine, Mount of Emergency Medicine, of Research, Department of of Critical Care, Division of Lillian L. Emlet, MD, MS, FACEP Sinai School of Medicine; Medical Department of Surgery, Division Emergency Medicine, Senior Emergency Medicine, The Assistant Professor, Department of Director, Mount Sinai Hospital, New of Trauma/Critical Care, Virginia Staff Attending, Departments University of Western Ontario, Critical Care Medicine, Department York, NY Commonwealth University, of Emergency Medicine and London, Ontario, Canada of Emergency Medicine, University Richmond, VA Surgery (Surgical Critical Care), of Pittsburgh Medical Center, William A. Knight, IV, MD Henry Ford Hospital, Detroit, MI; Pittsburgh, PA; Program Director, Assistant Professor of Emergency Christopher P. Nickson, MBChB, Clinical Professor, Department of Associate Editor EM-CCM Fellowship of the Medicine, Assistant Professor MClinEpid Emergency Medicine and Surgery, Scott Weingart, MD, FACEP Multidisciplinary Critical Care of Neurosurgery, Emergency Senior Registrar, Emergency Wayne State University School of Associate Professor, Department of Training Program, Pittsburgh, PA Medicine Mid-Level Program Department, Alice Springs Medicine, Detroit, MI Emergency Medicine, Mount Sinai Medical Director, University of Hospital, Alice Springs, Australia School of Medicine, New York, Michael A. Gibbs, MD, FACEP Cincinnati College of Medicine, Isaac Tawil, MD NY; Director of Emergency Critical Professor and Chair, Department Cincinnati, OH Jon Rittenberger, MD, MS Assistant Professor, Department of Care, Elmhurst Hospital Center, of Emergency Medicine, Carolinas Assistant Professor, Department Surgery, Department of Emergency New York, NY Medical Center, University of North Haney Mallemat, MD of Emergency Medicine, Medicine, University of New Carolina School of Medicine, Assistant Professor, Department University of Pittsburgh School Mexico Health Science Center, Editorial Board Chapel Hill, NC of Critical Care / Emergency of Medicine, Pittsburgh, PA; Albuquerque, NM Medicine, University of Maryland Attending, Emergency Medicine Benjamin S. Abella, MD, MPhil, Robert Green, MD, BSc, DABEM, Medical Center, Baltimore, MD; and Post-Cardiac Arrest Services, Research Editor FACEP FRCPC Department of Critical Care, Shock UPMC-Presbyterian Hospital, Assistant Professor, Department Associate Professor, Department Trauma Center, Baltimore, MD Pittsburgh, PA Jennifer L. Galjour, MD, MPH Department of Emergency of Emergency Medicine and of Anaesthesia: Division of Critical Medicine, Mount Sinai School of Department of Medicine / Section Care Medicine, Department of Evie Marcolini, MD, FAAEM Medicine, New York, NY of Pulmonary Allergy and Critical Emergency Medicine, Dalhousie Assistant Professor, Department of Care, University of Pennsylvania University, Halifax, Nova Scotia, Emergency Medicine and Critical School of Medicine, Philadelphia, Canada Care, Yale School of Medicine, PA; Clinical Research Director, New Haven, CT

Extracorporeal Cardiopulmonary Resuscitation 2 ebmedicine.net • Special Report Abstract Introduction

Extracorporeal cardiopulmonary resuscitation is an The Limitations Of Traditional available salvage adjunct that allows time to iden- Cardiopulmonary Resuscitation tify and correct the insult causing cardiopulmonary Advanced cardiac life support (ACLS) and tradi- arrest. Until recently, successful use of this bridg- tional cardiopulmonary resuscitation (CPR) have ing device by emergency physicians had not been been the mainstays in the resuscitation of emergency demonstrated. In this review, optimal resuscitative department (ED) patients who suffer cardiopulmo- conditions and the relationships between traditional nary arrest or refractory cardiovascular collapse. A techniques and extracorporeal cardiopulmonary continuous focus on each of the elements involved resuscitation are reviewed. Available evidence sup- in the resuscitation of the arresting patient has led porting the use of emergency percutaneous cardio- to the evolution of ACLS and resuscitative science.1 pulmonary bypass, in addition to the indications, Nevertheless, survival to discharge ranges from methods, maintenance, complications, and weaning, 8.2% to 22% in hospitalized patients and below 5% are discussed. Until recently, there was little evidence in out-of-hospital patients who are resuscitated by to support the use of extracorporeal cardiopulmo- conventional CPR.2 nary resuscitation in the emergency department. A In many cases, the cause of the arrest (or 3-staged approach to this algorithm, which allows refractory cardiovascular collapse) is correctable, initiation of bypass to occur in parallel with tradi- and the initial goals of therapy are to maintain tional resuscitative measures, has produced encour- circulatory support, and thus perfusion, to the vital aging results, and the percutaneous procedure is well organs until the cause of the arrest can be cor- within the scope of the emergency physician. When rected. Adequate perfusion of the brain remains used in conjunction with current advanced resusci- paramount, and the success of any resuscitative tative techniques, extracorporeal cardiopulmonary intervention should be measured by neurologic resuscitation may be a powerful bridging adjunct for outcomes. Intrinsic perfusion, defined by a return arresting emergency department patients. of spontaneous circulation (ROSC), or resolution of refractory shock (RORS), usually provides the Case Presentation best opportunity for adequate cerebral perfusion. However, until ROSC is achieved, extrinsic perfu- As your 5pm shift at an urban ED begins, you reach for sion is initiated via external chest compressions. We the first chart in the rack. You are notified that paramedics now understand that high-quality chest compres- are en route with a 59-year-old male complaining of chest sions, combined with minimizing interruptions, 1,3 pain, with a field ECG showing evidence of STEMI. The increase the possibility of ROSC. Unfortunately, coronary catheterization laboratory team is called, and the chest compressions do not provide a level of car- cardiologist is paged back to the hospital. Moments later, diac output that can fully maintain adequate tissue the paramedics report that the patient has sustained a perfusion, so the efficacy of this intervention dete- ventricular fibrillation arrest in the ambulance. They be- riorates in short time. Additionally, survival rates gin chest compressions and attempt defibrillation without decline exponentially as CPR continues beyond 10 4-6 success. The ambulance arrives 5 minutes later, and the minutes. Consequently, chest compressions are patient is still in full arrest. The monitor shows ventricu- continued until an arbitrary time when the practi- lar fibrillation. CPR continues, and traditional ACLS tioner decides that further efforts are futile. protocols are followed. You intubate. Defibrillation is attempted in the usual intervals, and intermittent returns Extracorporeal Cardiopulmonary of spontaneous circulation are unsustained. Amiodarone, Resuscitation epinephrine, and sodium bicarbonate are given intrave- nously. Over the next 60 minutes, refractory ventricular Background fibrillation persists despite continuous chest compressions and 6 attempts at defibrillation. The cardiologist is stand- Extracorporeal life support (ECLS) has emerged over ing outside the room and points out the obvious futility the past few decades as a powerful salvage adjunct of the case. You ask the usual rhetorical question, “Does in the resuscitation of hospitalized patients who suffer cardiac arrest or refractory cardiovascular anyone in the room identify a reason not to cease efforts?” 7,8 The code is called, the patient is pronounced dead, and collapse. ECLS systems are portable mechanical you go have ‘the talk’ with family members. With frustra- circulatory support systems that allow temporary tion and disappointment, you reach again for that first support for patients who suffer cardiac or pulmo- chart. You are an hour behind. nary failure (or both). In contrast to the types of heart-lung machines used in the operating room since the 1950s,9 ECLS systems use smaller, often percutaneously placed catheters to access the central ebmedicine.net • Special Report 3 Extracorporeal Cardiopulmonary Resuscitation circulation. Two catheters are placed: one through ing a 3-stage algorithm to rapidly initiate ECPR in the femoral vein and extended up to the right atrial appropriate candidates.10 In this study, all patients inlet and the second through the femoral artery who met inclusion/exclusion criteria were followed and extended into the distal aorta. Deoxygenated over a 1-year period; of 8 patients who were placed blood is drawn away from the right atrium via the on bypass in our ED, 5 were discharged from the venous catheter, pumped through an oxygenator in hospital neurologically intact. The size of this study the extracorporeal system, and returned to the body was too small to extract any statistically significant through the arterial catheter. (See Figure 1.) The conclusions regarding ED ECPR efficacy, but the oxygenator simultaneously removes carbon dioxide study demonstrates that emergency physicians can while providing oxygenation. This results in retro- successfully initiate ECLS in the ED. grade flow of blood from the ECLS circuit into the aorta via the arterial cannula. Oxygenated blood is Configurations Of ECLS therefore delivered to the coronary and cerebral vas- There are 2 primary configurations of ECLS: venous- culature while maintaining perfusion of the aortic venous (VV) and venous-arterial (VA). branch vessels. VV-ECLS provides oxygenation but no circula- Extracorporeal cardiopulmonary resuscitation tory support; it is strictly used for patients with (ECPR) refers to the initiation of ECLS during CPR. severe respiratory failure who are not responding This is possible because percutaneous access of the to mechanical ventilation. This mode can be per- femoral vessels can occur in conjunction with ongo- formed either via 2 separate venous cannulas or 1 ing chest compressions. Once extracorporeal circula- dual-chambered cannula; both types of cannulas tion is established, the chest compressions can be are commercially available. In either case, blood is stopped. Since ECLS provides tissue perfusion com- drained from the venous system at the right atrial parable to intrinsic perfusion (ie, ROSC), prolonged inlet and returned to the venous system at the hemodynamic stability can be maintained despite inferior or superior vena cava. A recent large ran- absence of a perfusing cardiac rhythm or intrinsic domized controlled trial showed a 16% benefit for blood pressure. adult patients with severe respiratory failure who Historically, portable ECLS units have been were treated with VV-ECLS support over those relegated to the operating room, cardiac catheteriza- who received conventional therapy.11 However, it tion laboratory, and the intensive care unit (ICU). would be rare to utilize this mode of ECLS in the Since these systems are now smaller and can be ED because most initial causes of severe respirato- maintained on portable carts that are similar in size ry failure can be initially managed with mechani- to typical crash-carts, they are well suited for use cal ventilation. in the ED. Nonetheless, until recently the initiation VA-ECLS is synonymous with percutaneous to- of ECPR by emergency physicians had not been tal cardiopulmonary bypass and is the only modali- demonstrated. Our ED has had recent success with ty used for the arresting ED patient. With VA-ECLS, emergency physician-initiated ECPR by implement- blood is drained from the central venous system and returned to the arterial system. Our protocol for placement of these catheters is discussed below. Figure 1. ECLS Circuit Indications For ED ECPR ED ECPR is indicated for any potential reversible cause of cardiac or pulmonary failure (or both) unresponsive to conventional therapy. Conceptually, the decision to consider a patient for ED ECPR is not different from the decision to begin aggressive resuscitation in the first place. That can be broken down into 3 broad ideals: 1. The patient was generally healthy prior to the arrest. This requires an attempt at a global assessment of the patient’s pre-arrest condition and is a challenging concept that requires an adept emergency physician with good clinical judgment. 2. Overall goals of therapy are curative (as op- posed to palliative). 3. The event that caused the arrest is thought to Abbreviation: ECLS, extracorporeal life support. be reversible with a specific medical or surgical intervention. The classic example is the patient ©Maquet Cardiopulmonary AG. Used with permission.

Extracorporeal Cardiopulmonary Resuscitation 4 ebmedicine.net • Special Report complaining of chest pain who has electrocar- same time, we know that successful neurologic out- diogram findings of a myocardial infarction and comes are inversely associated with the time it takes arrests in the ED (or en route to the ED). If tra- to re-establish brain perfusion (either intrinsic perfu- ditional resuscitative efforts fail, ECLS would be sion with ROSC or extracorporeal perfusion with considered a bridge to allow the time necessary ECLS).12-15 Therefore, we developed a 3-stage algo- to perform a coronary angiogram with potential rithm for early initiation of ECPR at our institution. percutaneous coronary intervention (PCI) or The ED ECPR algorithm requires 2 emergency coronary artery bypass graft surgery. physicians. With the first physician supervising ACLS (or “running the resuscitation”), the second With these concepts in mind, specific inclu- physician is responsible for percutaneous femoral sion and exclusion criteria were established at our venous and arterial access. On average, it takes 20 to institution. (See Table 1.) Currently, ED ECPR is 30 minutes to complete all 3 stages, which provides indicated when all other traditional strategies have enough time to allow the ongoing resuscitation to been exhausted or maximized and the patient would achieve ROSC and/or RORS via traditional means. have otherwise been pronounced dead. However, Concomitantly, the critical care ECLS nursing team placement of the ECLS cannulas occurs in a stepwise is called, and the portable ECLS unit is brought from fashion and is started early in the resuscitation. the intensive care unit to the ED. The 3-staged ap- Table 2 shows the patients from our institution proach is shown in Figure 2 (page 6). in whom we have initiated ED ECPR with successful Stage 1 involves placement of percutaneous arte- and full neurological recovery. While not all-inclu- rial and venous angiocatheters in the femoral vessels. sive, Table 3 lists conditions in which, conceptually, Our institution uses commercially available central ED ECPR should also be beneficial. line kits (9F percutaneous sheath introducer kit, Ar- ED ECPR: Cardiopulmonary Bypass In The ED Table 2. Characteristics Of Patients Who Survived ED ECPR With Full Neurologic The ED ECPR Algorithm: A 3-Staged 10 Approach Recovery When patients present to the ED in the peri-arrest Cause of Arrest Bridge to? phases of cardiovascular collapse, decisive action by STEMI with refractory VFIB PCI with LADCA stent the emergency physician can make the difference STEMI with refractory VFIB PCI with RCA stent between life and death. Additionally, critical infor- Cardiomyopathy with refractory VFIB LVAD mation necessary to determine whether a patient Hypothermia with refractory VFIB Re-warming + medical is a candidate for aggressive intervention is often management unavailable or becomes available piecemeal. At the Aortic dissection, Type A Operative repair

Abbreviations: ED ECPR, emergency department extracorporeal Table 1. ED ECPR Inclusion And Exclusion cardiopulmonary resuscitation; LADCA, left anterior descending Criteria* coronary artery; LVAD, left ventricular assist device; PCI, percutaneous coronary intervention; RCA, right coronary artery; STEMI, ST- segment elevation myocardial infarction; VFIB, ventricular fibrillation. Inclusion Criteria: • Persistent cardiopulmonary arrest despite traditional resuscitative efforts (ACLS) Table 3. Potential Applications For ED ECPR • Shock (SBP < 70 mm Hg) refractory to standard therapies Cardiac Arrest Refractory Dysrhythmia Refractory shock • Cardiogenic shock Exclusion Criteria: n Myocardial infarction • Initial rhythm asystole n Metabolic acidosis • Chest compressions not initiated within 10 min of arrest (either • Pulmonary embolus by bystanders or EMS personnel) • Drug toxicity/overdose • Estimated EMS transport time > 10 min • Amniotic fluid embolism • Total arrest time > 60 min • Suspicion of shock due to sepsis or hemorrhage Refractory hypoxia • Congestive heart failure • Pre-existing severe neurological disease prior to arrest (including (consider VV-ECLS) • Pulmonary embolus traumatic brain injury, stroke, or severe dementia) • Status asthmaticus • Pneumonia/influenza *These criteria are specific to the authors’ institution. Environmental • Rewarming of severe accidental hypothermia Abbreviations: ACLS, Advanced Cardiac Life Support; ED ECPR, emergency department extracorporeal cardiopulmonary resuscitation; EMS, Abbreviation: ED ECPR, emergency department extracorporeal car- emergency medical systems; SBP, systolic blood pressure. diopulmonary resuscitation. ebmedicine.net • Special Report 5 Extracorporeal Cardiopulmonary Resuscitation row, Reading, PA or 5F central venous catheter kit, adequate flow through the circuit is confirmed, chest Cook, Bloomington, IN) to gain access to the femoral compressions can be stopped. Figure 3 shows the artery and vein, typically under ultrasound guidance. ECLS cannulas in the correct position. The figure also These catheters will serve as conduits for placement demonstrates the antegrade femoral artery perfusion of the ECLS cannulas in the next stage; however, catheter, which necessarily allows perfusion of the they also serve as immediate vascular resources in ipsilateral leg distal to the arterial ECLS cannula. the resuscitation of the patient. If the patient has not achieved ROSC or RORS at the completion of Stage 1, The ECLS Circuit the physicians consider moving to Stage 2. The portable ECLS unit is comprised of a centrifu- Stage 2 is defined by exchange of the original gal pump (Rotaflow, Maquet, Bridgewater, NJ), femoral catheters with larger ECLS cannulas. Our in- a heat exchanger (which can be used to warm or stitution uses commercially available ECLS catheters cool), and an oxygenator (Quadrox iD, Maquet, (Bio-Medicus percutaneous catheter kit, Medtron- Bridgewater, NJ) that are heparin-lined (Bioline, ic®, Minneapolis, MN). A guide wire is placed Maquet, Bridgewater, NJ). These components re- through the conduit catheters in the femoral vessels, side on a portable cart (Figure 4) that can be easily and serial dilation is performed. The ECLS cannulas relocated to the ED. are then inserted into the femoral vessels (venous While the emergency physician is cannulating 19-25 Fr; arterial 15-19 Fr). Simultaneously, the ECLS the femoral vessels, the critical care nursing team nurses begin priming the ECLS circuit with Isolyte begins the process of priming the ECLS circuit. The S electrolyte solution (Braun Medical®, Irvine, CA). ECLS components are filled with priming solution Successful placement of the ECLS cannulas and (Isolyte M, Braun Medical, Irvine, CA), which is an- priming the system concludes Stage 2. ticoagulated with 2500 units of heparin. The patient Stage 3 is considered when Stage 2 is completed is also systemically anticoagulated with 5000 units and resuscitative efforts have failed thus far. The of heparin by IV push. Heparinization is optimized ECLS cannulas are connected to the ECLS circuit, and to a goal activated clotting time of 180 to 240 sec- total cardiopulmonary bypass is established. Once onds. After de-airing the circuit (an important step to prevent air embolism), the tubing from the ECLS Figure 2. ED ECPR Stages

Figure 3. Cannulas In A Real Patient Cardiac arrest or refractory shock Meets criteria for ED ECPR: continue full ACLS resuscitation

NO ROSC/ RORS

ED ECPR Stage 1 Place femoral venous and arterial catheters

ROSC/ ROSC or RORS RORS

ED ECPR Stage 2 Replace femoral lines with ECLS cannulas (venous 19-25 Fr; arterial 15-19 Fr) NO ROSC/ RORS

ED ECPR Stage 3 Initiate cardiopulmonary bypass (ED ECPR)

ECLS

Circulation established (ROSC, RORS, or ECLS) Manage medical and/or surgical issues

Abbreviations: ACLS, advanced cardiac life support; ECLS, extracorporeal life support; ED ECPR, emergency department extracorporeal cardiopulmonary resuscitation; RORS, resolution of refractory shock; ROSC, return of spontaneous circulation.

Extracorporeal Cardiopulmonary Resuscitation 6 ebmedicine.net • Special Report unit and the cannulas from the patient are ‘topped low-flow states therefore requires an understand- off’ with saline and the lines are then connected. ing of these issues. Relatively small reductions in Once the bypass circuit is established, the sys- flow can often be managed with a fluid challenge or tem is able to optimize perfusion to the vital organs repositioning of the cannulas. But acute alterations by providing a tissue perfusion pressure of > 40 mm of flow require the physician to rule out pneumotho- Hg (mean arterial pressure minus central venous rax, pericardial tamponade, mechanical obstruction pressure) and maintaining a cardiac index over 2 L/ of the ECLS circuitry, and abdominal compartment min/m2. ECLS flow (measured in L/min) is estimat- syndrome. Finally, hypertension can exacerbate the ed based on the patient’s body surface area. Adjust- afterload issues identified above, resulting in low- ments to flow are guided by measuring continuous flow states, and should be addressed accordingly. mixed venous oxygen saturation (SvO2) and mean Pulmonary considerations should also be arterial pressure monitoring, with a goal SvO2 of addressed since these patients should already > 70% and MAP > 65 mm Hg. Adjustments to the be mechanically ventilated. Understanding the sweep of the membrane oxygenator are guided by management of hypoxemia is crucial. Hypoxemia measuring patient carbon dioxide (PaCO2), with a is managed by increasing the sweep rate and/or goal of < 50 mm Hg. the FiO2 of the ECLS circuit, not by adjusting the ventilator settings. A lung-protective ventilation Maintenance, Adjustments, And Weaning Of strategy should be used while the patient is on the ECLS ventilator. The lung can be ‘rested’ by using low Optimizing ECLS blood flow provides appropriate tidal volumes of 4-6 mL/kg of the predicted ideal perfusion of the brain and vital organs. Flow is de- body weight and maintaining plateau pressures pendent on volume, cannula position, and mechani- < 30 cm H2O in order to prevent ventilator-in- cal obstruction of the flow circuitry. Trouble-shooting duced lung injury. Weaning ECLS support is a multifactorial process. The weaning protocol involves monitoring Figure 4. Mobile ECLS Cart hemodynamics while assessing myocardial function by echocardiography during progressive reductions in pump flow. ECLS support is weaned when a stable left ventricular ejection fraction is established. If functional cardiac recovery doesn’t occur, ECLS can represent a bridge to a ventricular assist device. Termination of ECLS should be considered in patients in whom no medical or surgical intervention is possible, when all bridging has been deemed medically futile, and in cases of profound neurologic dysfunction or outcome.

Therapeutic Hypothermia And ECLS Therapeutic hypothermia has been shown to mitigate neurologic reperfusion injury in patients who achieve ROSC after cardiac arrest without a return of neurologic function.16,17 Nagao reported a 2- to 5-fold increase in the neurologic recovery when combining ECLS with percutaneous coronary intervention and therapeutic hypothermia.8 Re-establishment of perfusion by extracorporeal means produces a similar reperfusion injury as those who achieve ROSC after cardiac arrest. Therapeutic hypothermia seems to mitigate the reperfusion injury and is therefore recommended in combination with ECLS. The ECLS system incorporates a heat exchanger that can warm or cool and is ideally suited for rapid therapeutic hypothermia. The goal temperature (typically 32°C-34°C) is adjustable via the ECLS control panel.

Complications Of ED ECPR Several complications of ECLS and ECPR can Abbreviation: ECLS, extracorporeal life support. occur during the process of initiating, maintain- ebmedicine.net • Special Report 7 Extracorporeal Cardiopulmonary Resuscitation ing, and weaning bypass. However, one should require surgical repair. Bleeding from cannulas that keep in mind that the alternative to ECPR is death. are in the correct position can also occur. Kurusz Complications that occur during, or after, ECPR reported cannula-related bleeding rates of 4% to can be broken down into: (1) primary compli- 14%.18 Explanations include multiple punctures of cations: those that occur during the process of the vessels during attempted cannulation, antico- initiating bypass, and (2) secondary complications: agulation with heparin, decreased platelet function, those that develop in response to the pathophysi- and hepatic dysfunction. ology of extracorporeal circulation. Complications Secondary complications are those that develop are outlined in Table 4. after successful establishment of bypass. The main Primary complications typically involve issues cannula-related secondary complication is ischemia with cannulation of the femoral vessels. The most of the limb ipsilateral to the arterial cannula. This common issue experienced in the ED is difficulty is remedied by placement of an additional, smaller in cannulating the femoral artery in a pulseless femoral artery catheter, which allows perfusion of patient. During cardiac arrest, the pressure in the the limb distal to the ECLS cannula.19 venous and arterial systems equalizes, and the Anticoagulation is necessary to prevent clotting femoral vein becomes very large in comparison to associated with large caliber cannulation of the great the artery. Even under ultrasound guidance, can- vessels but may lead to hemorrhage complications. nulation of the femoral artery presents a challenge, Hemorrhage in the gastrointestinal tract or brain is especially with ongoing chest compressions. For particularly problematic. this reason, we try to anticipate a potential ECPR The effect of ECLS on the right and left ventri- candidate before full arrest occurs and establish cle is worth discussion. The ECLS circuit efficiently early arterial access. offloads the right ventricle as blood is drawn from Perforations, tears, and rupture of the femoral the right atrial inlet and into the pump. However, vessels, vena cava, and aorta have all been re- retrograde flow of blood towards the left ventricle ported. In patients who survive, those vessels often may cause increased left ventricular afterload, especially if ventricular ejection is unable to over- come this pressure gradient. If uncorrected, this Table 4. Complications Of ECPR results in progressive left ventricular dilation, increased pulmonary venous congestion, and hemor- Primary Complications rhagic pulmonary edema. To mitigate this, inotro- Cannula compli- Failure to cannulate pic support is useful, intra-aortic balloon pumps cation Vessel perforation may be beneficial, and any ventricular dysrhyth- Aortic dissection mias should be cardioverted. When these measures Retroperitoneal hemorrhage fail, it may be necessary to surgically decompress Arterio-arterial cannulation the left ventricle (via several possible techniques) to Veno-venous cannulation preserve function. Cannula malposition Circuit complica- Circuit obstruction The ECLS Program tion Low volume state Pump malfunction Oxygenator malfunction Over 150 hospitals in the United States support an Hemorrhagic Bleeding at cannulation site ECLS program. Most hospitals that offer surgical placement of ventricular assist devices will also maintain a Secondary Complications portable ECLS support system. There are several ways Cannula compli- Distal limb ischemia to maintain a continuously available ECLS program, cation Pseudo-aneurysm and each is institution specific. Some institutions use Hemorrhagic Pulmonary hemorrhage perfusionists from the time of initiation, while others Gastrointestinal hemorrhage use nurses. Still others use a combination of nurses, Cerebrovascular hemorrhage perfusionists, and respiratory therapists. Systemic coagulopathy Our facility maintains an inhospital, nurse- Thromboembolic Cerebrovascular based, continuously available ECLS program.20 The Pulmonary embolus team is trained to prime the circuit and initiate flow Limb ischemia through the system. ICU nurses are cross-trained in Infectious ECLS, and the ICU is staffed to always have at least Insufficient perfu- Anoxic brain injury 2 ECLS-trained nurses available 24 hours per day. sion Renal failure Perfusionists are on-call to run the ECLS pump for Hepatic failure the duration of support. Multi-organ failure

Abbreviation: ECPR, extracorporeal cardiopulmonary resuscitation.

Extracorporeal Cardiopulmonary Resuscitation 8 ebmedicine.net • Special Report Evidence Supporting ED ECPR 5. Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary Evidence supporting the use of ED ECPR is limited. reperfusion therapy and mild hypothermia in pa- 8 Most available evidence is extrapolated from inpa- tients with cardiac arrest outside the hospital. tient studies. Some important studies are summa- Summary: This prospective study evaluated 50 rized here: patients with out-of-hospital cardiac arrest who met their inclusion criteria. Thirty-six of the 50 1. Emergency physician-initiated extracorporeal patients received ECPR and intra-aortic bal- cardiopulmonary resuscitation.10 loon pump after failed standard ACLS therapy. Summary: This case series followed all patients Immediate coronary reperfusion was performed who presented to a large suburban ED with in those with suspected myocardial infarction. either cardiac arrest or refractory shock. Forty- While ROSC was achieved in 88.5% of those pa- two such patients presented over a 1-year tients, the recovery rate was only 3.8%; however, period. Of these, 18 were entered into the 3-stage these were all cases of out-of-hospital arrest, algorithm, 8 were started on bypass, and 5 were where the historic recovery rate is below 3%. discharged from the hospital neurologically intact. This is the first paper to document success- 6. CESAR: conventional ventilatory support vs ful initiation of ED ECPR in North America. The extracorporeal membrane oxygenation for severe 11 authors concluded that emergency physicians adult respiratory failure. could successfully initiate ECPR. Summary: This study represents the largest, and best, randomized controlled trial evaluating the 2. Cardiopulmonary resuscitation with assisted efficacy of ECMO in the management of adult re- extracorporeal life-support versus conventional spiratory failure. Overall, the trial showed a 16% cardiopulmonary resuscitation in adults with survival benefit for patients in the ECMO referral in-hospital cardiac arrest: an observational group over the control group (conventional criti- study and propensity analysis.21 cal care). Although the actual benefit of ECLS in Summary: This observational study followed 975 the study group has been scrutinized, most pro- patients with inhospital cardiac arrest over a ponents agree that the CESAR trial demonstrates 3-year period. Propensity-score matched groups a true benefit of ECLS. However, because this trial demonstrated a significant benefit in those studied VV-ECLS, not VA-ECLS, its conclusions receiving ECPR compared with traditional CPR. are less applicable to ED ECPR, where VA-ECLS Benefit was demonstrated at 30-day and 1-year is typically more appropriate. survival intervals. Unmatched patients showed even greater benefit. 7. A 20-year experience with urgent percutaneous cardiopulmonary bypass for salvage of poten- 3. ELSO Registry.22 tial survivors of refractory cardiovascular col- 7 Summary: The Extracorporeal Life Support lapse. Organization (ELSO) registry is maintained at Summary: This was a retrospective review of the University of Michigan under the guidance 1 center’s 20-year experience using ECLS for of Dr. Robert Bartlett, one of the pioneers of salvage of hospitalized patients who suffered ECLS. The registry logs all known cases of ECLS cardiac arrest or refractory shock. The study among member centers. As of July 2011, the demonstrated an overall long-term survival rate registry has documented 516 hospitalized adult of 26%, which is a significant improvement over 5 patients who received ECPR as a result of inhos- the 17% rate associated with conventional CPR. pital cardiac arrest and shows a 30% survival-to- discharge rate. Conclusion

4. Back from irreversibility: extracorporeal life The primary goal in CPR, and ACLS, is to re-estab- 23 support for prolonged cardiac arrest. lish intrinsic circulation with a blood pressure suffi- Summary: This retrospective observational study cient to maintain vital organ perfusion. When either reviewed 40 patients where EPCR was used to is lost during the course of resuscitation, rescuers resuscitate patients suffering cardiac arrest. Of typically begin external chest compressions. When these, 18 patients survived to ECLS support. done properly, and without interruption, chest com- Among those, 6 were weaned off the pump, 9 pressions create coronary perfusion pressures suffi- were bridged to ventricular assist device, and 2 cient to establish ROSC but not to maintain adequate were bridged directly to cardiac transplantation. perfusion of the brain.1 So, achieving ROSC or its Long-term survival to 18 months was achieved surrogate, extracorporeal circulation, is paramount in 8 patients (44%). to functional neurologic recovery. ebmedicine.net • Special Report 9 Extracorporeal Cardiopulmonary Resuscitation ECLS has been used successfully for the past 3 pulmonary arrest suggests that transporting patients decades to temporarily support hospitalized patients to the ED offers little advantage toward meaningful with cardiopulmonary arrest or refractory shock.12,21,24 outcomes. Paramedics can intubate and deliver As ECLS systems have evolved, they have become IV fluids and chest compressions, but the quality more portable and simpler to operate. Recently, ECLS of CPR diminishes during transport.25 Emergency has found its way to the ED, the point-of-entry for medical services personnel are therefore encouraged many critically ill patients. While cardiothoracic sur- to continue resuscitation on-site until either ROSC geons, intensivists, or cardiologists have traditionally occurs or efforts are discontinued. The emergence of initiated ECLS, it is impractical to consider summoning ED ECPR may challenge this paradigm and encour- their assistance in the acutely ill, crashing ED patient. age transport of select patients. For this therapy to be successful in the ED, emergency An unintended positive consequence of ECPR in physicians will have to initiate it. our ED is a heightened enthusiasm for the resuscita- The emergency physician can initiate ECLS.10 Most tive process and increased focus on the sequence of emergency physicians are experts at vascular access, events that occur throughout the code. Debriefings and the femoral vessels are a familiar anatomy. In addi- occur after each case to try to identify areas of poten- tion, the wide availability of bedside ultrasound makes tial improvement. ED staff members are showing in- femoral vascular access even more reliable. The ECLS creased interest in improving the individual elements cannulas are in a commercially available, all-inclusive involved in resuscitating the critically ill patient. package that contains a guide wire, #11 blade, and Our initial institutional experience with ED dilators. Most emergency physicians who are famil- ECPR has been promising. Survival of these patients iar with the Seldinger technique can learn the entire was unlikely with conventional ACLS, and ECPR procedure in a matter of minutes. We recommend that appears to provide a benefit when used as a salvage the physician supervising ACLS continue doing so and adjunct. Additionally, the procedure is not techni- recruit a second physician to access the femoral vessels. cally difficult. This parallel approach allows time for the first physician to attempt to regain intrinsic perfusion while the Case Conclusion second physician completes the cannulation process. The cannulation process occurs in 3 distinct stages, The clinical scenario presented at the beginning of this which allows discontinuation of the algorithm if ROSC review was an actual patient who presented to our ED or RORS occurs. in July 2010. He happened to be the first patient who The concept of incorporating extracorporeal presented to our ED in full arrest after we implemented bypass in the resuscitation of the acutely arresting the ED ECPR algorithm. The events described in the patient has recently emerged as a potential salvage scenario occurred as described; however, what wasn’t adjunct. While ECLS has potential complications, the mentioned were the concomitant efforts by the second benefits are clear and the risks do not outweigh the emergency physician. The 3-stage ED ECPR algorithm alternative - death. was followed as outlined in this article. By the sixty- Therapeutic hypothermia is easily performed first minute of the patient’s resuscitation, cannulation with ECLS; the heat exchanger built into the of the femoral vessels was complete, and the patient was system can warm or cool patients to any thera- started on VA-ECLS. The interventional cardiologist peutic temperature. When applied appropriately, was called back to the hospital, and the patient was taken therapeutic hypothermia is a powerful tool with to the coronary catheterization lab. A 100% occlusion 16,17 well-established benefits, and the combination of the left anterior descending artery was identified, therapies of ECPR and hypothermia have shown opened, and stented. Post-procedural echocardiogram 8 promising results. showed an ejection fraction of 21%. The patient regained Determining whether a patient is salvageable is full neurologic recovery. On post-arrest day 5, a repeat difficult when a patient presents to the ED in car- echocardiogram showed an ejection fraction of 53%. The diopulmonary arrest. Vital information that could patient walked out of the hospital (refusing to take a effect the decision to initiate ECPR must be consid- wheelchair) on post-arrest day 9 without any neurologic ered. Inclusion criteria are therefore necessary, albeit sequelae. In November 2010, 4 months after his arrest, somewhat arbitrary, to narrow its application to the the patient participated in a 5k event in San Diego, patients most likely to regain neurologic function. California, with the emergency physicians involved in As the science of resuscitation evolves, more studies his resuscitation. are published, and experience with ED ECPR grows, we may be able to expand the inclusion criteria to capture a broader spectrum of patients. An important consideration is the potential im- pact of ED ECPR on emergency medical services systems. Historic data regarding out-of-hospital cardio-

Extracorporeal Cardiopulmonary Resuscitation 10 ebmedicine.net • Special Report Acknowledgments apparatus to cardiac surgery. Minn Med. 1954;37:171-185. 10.* Bellezzo JM, Shinar Z, Davis DP, et al. Emergency physician- initiated extracorporeal cardiopulmonary resuscitation. The authors would like to thank Marcia Stahovich Resuscitation. 2012 Feb 1. [Epub ahead of print]. RN, CCRN, Suzanne Chillcott BSN, RN, and Walter 11.* Peek GJ, Clemens F, Elbourne D, et al. CESAR: Conventional Dembitsky, MD for their contributions to the article. ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res. 2006;6:163. References 12. Willms DC, Atkins PJ, Dembitsky WP, et al. Analysis of clinical trends in a program of emergent ECLS for cardiovascular Evidence-based medicine requires a critical ap- collapse. Asaio J. 1997;43:65-68. (Retrospective observation- praisal of the literature based upon study methodol- al; 81 patients) 13. Bunch TJ, White RD, Gersh BJ, et al. Long-term outcomes of ogy and number of subjects. Not all references are out-of-hospital cardiac arrest after successful early defibril- equally robust. The findings of a large, prospective, lation. N Engl J Med. 2003;348:2626-2633. (Retrospective; 200 randomized, and blinded trial should carry more patients) weight than a case report. 14. Andreasson AC, Herlitz J, Bang A, et al. Characteristics To help the reader judge the strength of each and outcome among patients with a suspected in-hospital cardiac arrest. Resuscitation. 1998;39:23-31. (Prospective; 216 reference, pertinent information about the study, patients) such as the type of study and the number of patients 15. Dembitsky WP, Moreno-Cabral RJ, Adamson RM, et al. in the study, will be included in bold type following Emergency resuscitation using portable extracorporeal the reference, where available. In addition, the most membrane oxygenation. Ann Thorac Surg. 1993;55:304-309. informative references cited in this paper, as deter- (Review article) 16. Bernard SA, Gray TW, Buist MD, et al. Treatment of coma- mined by the authors, will be noted by an asterisk (*) tose survivors of out-of-hospital cardiac arrest with induced next to the number of the reference. hypothermia. N Engl J Med. 2002;346:557-563. (Randomized controlled trial; 77 patients) 1. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult ad- 17. Hypothermia after Cardiac Arrest Study Group. Mild thera- vanced cardiovascular life support: 2010 American Heart As- peutic hypothermia to improve the neurologic outcome after sociation guidelines for cardiopulmonary resuscitation and cardiac arrest. N Engl J Med. 2002;346:549-556. (Randomized emergency cardiovascular care. Circulation. 2010;122:S729- controlled trial; 136 patients) 767. (American Heart Association guidelines; supported 18. Kurusz M, Zwischenberger JB. Percutaneous cardiopulmo- by numerous studies) nary bypass for cardiac emergencies. Perfusion. 2002;17:269- 2. Nichol G, Thomas E, Callaway CW, et al. Regional varia- 277. (Review article) tion in out-of-hospital cardiac arrest incidence and outcome. 19. Jaski BE, McClendon PS, Branch KR, et al. Anterograde JAMA. 2008;300:1423-1431. perfusion in acute limb ischemia secondary to vascular oc- 3. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardio- clusive cardiopulmonary support. Cathet Cardiovasc Diagn. pulmonary resuscitation during in-hospital cardiac arrest. 1995;35:373-376. (Review article) JAMA. 2005;293:305-310. (Prospective; 67 patients) 20. Chillcott S, Stahovich M, Earnhardt C, et al. Portable rapid 4. Hajbaghery MA, Mousavi G, Akbari H. Factors influencing response extracorporeal life support: A center's 20-year ex- survival after in-hospital cardiopulmonary resuscitation. perience with a registered nurse-run program. Crit Care Nurs Resuscitation. 2005;66:317-321. (Prospective descriptive; 206 Q. 2008;31:211-215. (Retrospective; 176 patients) patients) 21.* Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resus- 5. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary citation with assisted extracorporeal life-support versus resuscitation of adults in the hospital: A report of 14720 conventional cardiopulmonary resuscitation in adults with cardiac arrests from the national registry of cardiopulmonary in-hospital cardiac arrest: An observational study and resuscitation. Resuscitation. 2003;58:297-308. (Prospective propensity analysis. Lancet. 2008;372:554-561. (Prospective multisite observational; 14,720 patients) randomized; 975 patients) 6. Shih CL, Lu TC, Jerng JS, et al. A web-based utstein style reg- 22.* Extracorporeal Life Support Organization. ELSO Registry. istry system of in-hospital cardiopulmonary resuscitation in http://www.elso.med.umich.edu/. Accessed March 1, 2011. Taiwan. Resuscitation. 2007;72:394-403. (Prospective multisite (Registry database) Utstein-based study; 330 patients) 23.* Massetti M, Tasle M, Le Page O, et al. Back from irrevers- 7.* Jaski BE, Ortiz B, Alla KR, et al. A 20-year experience with ibility: extracorporeal life support for prolonged cardiac urgent percutaneous cardiopulmonary bypass for salvage arrest. Ann Thorac Surg. 2005;79:178-184. (Retrospective; 40 of potential survivors of refractory cardiovascular collapse. patients) J Thorac Cardiovasc Surg. 2010;139:753-757. (Retrospective 24. Combes A, Leprince P, Luyt CE, et al. Outcomes and long- observational; 150 patients) term quality-of-life of patients supported by extracorporeal 8.* Nagao K, Hayashi N, Kanmatsuse K, et al. Cardiopulmonary membrane oxygenation for refractory cardiogenic shock. Crit cerebral resuscitation using emergency cardiopulmonary Care Med. 2008;36:1404-1411. (Retrospective; 81 patients) bypass, coronary reperfusion therapy and mild hypothermia 25. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions of in patients with cardiac arrest outside the hospital. J Am Coll chest compressions during emergency medical systems Cardiol. 2000;36:776-783. (Prospective; 50 patients) resuscitation. Circulation. 2005;112:1259-1265. (Retrospective 9. Gibbon JH, Jr. Application of a mechanical heart and lung review; 61 patients)

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