Elsevier

Resuscitation

Volume 86, January 2015, Pages 88-94
Resuscitation

Clinical Paper
Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial)

https://doi.org/10.1016/j.resuscitation.2014.09.010Get rights and content

Abstract

Introduction

Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia.

Methods

The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24 h in the intensive care unit.

Results

There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38–60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40–85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1–5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients.

Conclusions

A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.

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.

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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.

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