Clinical PaperRefractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial)☆
Introduction
Out-of-hospital cardiac arrest (OHCA) is common affecting approximately 424,000 people in the USA and millions more around the world annually.1 In-hospital cardiac arrest (IHCA) also carries a high mortality rate.2 In many cardiac arrest patients, there is a failure to have a return of spontaneous circulation despite advanced cardiac life support and this is often in the setting of severe metabolic acidosis, acute blockage of a coronary artery or massive pulmonary embolism.3, 4 In refractory cardiac arrest, the use of veno-arterial extracorporeal membrane oxygenation (ECMO) assisted CPR (E-CPR) is proposed for both IHCA5, 6, 7 and OHCA.8, 9, 10 Whilst ECMO for patients with severe cardiac or respiratory failure is used in some tertiary hospitals in Australia,11, 12 there are no previous reports of E-CPR in the management of adult patients with refractory cardiac arrest in Australia.
Here, we report our preliminary experience with an E-CPR program that includes mechanical chest compressions, intra-arrest therapeutic hypothermia and cannulation by critical care physicians for the rapid commencement of veno-arterial ECMO in patients with refractory cardiac arrest.
Section snippets
Design
This is a prospective pilot study of a treatment protocol for selected patients with refractory cardiac arrest. The study protocol was approved by the Human Research and Ethics Committee of the Alfred Hospital, Melbourne, Victoria and Ambulance Victoria (NCT01186614). The requirement for informed patient consent was waived in accordance with Victorian Government regulations.
Setting and population
The study was performed at The Alfred Hospital in Melbourne, Victoria, Australia. This state has a population of
Baseline and cardiac arrest characteristics
Over the 32 month period, the ECMO service at The Alfred treated 128 patients with ECMO, of whom 28 had veno-venous ECMO for respiratory failure and 100 had veno-arterial ECMO. Included in the latter group were 26 patients with refractory cardiac arrest (11 OHCA and 15 IHCA) who were treated with the CHEER protocol and who are the subject of this report (Fig. 1). Baseline characteristics of these patients are shown in Table 1. Patients were predominantly male (77%) with a median age of 52 (IQR
Discussion
This study reports the preliminary experience of an E-CPR protocol that includes mechanical chest compressions, intra-arrest therapeutic hypothermia and percutaneous cannulation for ECMO by critical care physicians for the treatment of patients with refractory cardiac arrest.
Our rates of survival to hospital discharge of 60% in patients with refractory IHCA and 45% with refractory OHCA are higher than in other reports. For example, Nagao et al. placed 50 patients with refractory OHCA on ECMO
Conclusions
The CHEER protocol appears to be a successful approach for the management of selected patients with refractory OHCA and IHCA. Whilst further research into the resource implications of E-CPR may be needed, we conclude that establishing an E-CPR program is feasible in a large city with a dedicated ECMO center.
Conflict of interest statement
Mechanical chest compression devices (Autopulse™) donated by ZOLL Medical, Chelmsford, MA, USA. The company had no input into study preparation, analysis, results or publication. The authors have no other competing interests.
Author contributions
SB and DS devised protocol. Approval of Ambulance protocol was provided by KS and TW. Training of Ambulance staff was provided by DS and SB. E&TC training provided by DeS. ECMO data maintained by VP and JS. DS performed statistical analysis. DS, SB, KS, VP, and DK analyzed the results. SB and DS wrote the manuscript. All authors revised and approved the final version of the manuscript.
Acknowledgements
Dr. Dion Stub was supported by a Victoria Fellowship, Royal Australia and New Zealand College Physician Foundation scholarship and Cardiac Society of Australia and New Zealand Award.
References (26)
- et al.
American Heart Association get with the guidelines – resuscitation I. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study
Lancet
(2012) - et al.
Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke
Resuscitation
(2008) - 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) - et al.
Back from irreversibility: extracorporeal life support for prolonged cardiac arrest
Ann Thorac Surg
(2005) - et al.
Assessment of outcomes and differences between in- and out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal life support
Resuscitation
(2010) - et al.
Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital
J Am Coll Cardiol
(2000) - et al.
Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a review of the Japanese literature
Resuscitation
(2011) - et al.
Usefulness of cooling and coronary catheterization to improve survival in out-of-hospital cardiac arrest
Am J Cardiol
(2011) - et al.
Exploring which patients without return of spontaneous circulation following ventricular fibrillation out-of-hospital cardiac arrest should be transported to hospital?
Resuscitation
(2014) - et al.
Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults
Ann Thorac Surg
(2009)
A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest
Resuscitation
Emergency physician-initiated extracorporeal cardiopulmonary resuscitation
Resuscitation
Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest
Resuscitation
Cited by (474)
Can Lightning Strike Twice? Double Sequential External Defibrillation, Extracorporeal Cardiopulmonary Resuscitation, and the International Liaison Committee on Resuscitation Guidelines
2024, Journal of Cardiothoracic and Vascular AnesthesiaImplementation of Extracorporeal CPR Programs for Out-of-Hospital Cardiac Arrest: Another Tale of Two County Hospitals
2024, Annals of Emergency MedicineWolf Creek XVII Part 7: Mechanical circulatory support
2023, Resuscitation Plus
- ☆
A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.09.010.