Ecpr Is It Worth It Elso 2012

ECPR: Worth the Investment?
David S. Cooper MD, MPH

The Heart Institute
Associate Medical Director, Cardiac Intensive Care Unit
Medical Director, Cardiac Extracorporeal Life Support Program
Cincinnati Childrens Hospital Medical Center
Assistant Professor of Pediatrics
University of Cincinnati
Friday, September 21, 12
I have no financial
conflicts of interest....
I have no financial
conflicts of interest....
but would be willing to acquire some
In-hospital Cardiac Arrest

COMMONLY HELD BELIEF:
The outcome from in-hospital cardiac arrests
is good because the hospital environment
contains large numbers of highly qualified
health-care providers with the necessary
training and equipment to respond promptly
to the event

to the event

to the event
High Quality CPR
High Quality CPR

Compression depth Push Hard
High Quality CPR

Compression rate Push Fast
High Quality CPR

Compression Recoil leaning
High Quality CPR

Minimize Interruptions no flow time
High Quality CPR

Minimize Interruptions no flow time
Avoid Hyperventilation
ECPR
ELSO Registry 2012

ECPR
ELSO Registry 2012

ECPR
Technology changes
Resuscitation practices
Timing of cannulation
ELSO Registry 2012

ECPR
Challenges of ECPR
Challenges of ECPR
Low individual center volume (rare)
Challenges of ECPR

Used for the most critically ill patients
(complexity of care)
Challenges of ECPR

High rates of morbidity and mortality
Challenges of ECPR


Uncertain future of patient at time of
implementation
Challenges of ECPR


Uncertain future of patient at time of
implementation
Highly variable and rapidly changing

outcomes based on etiology
Pediatrics 2006
Study of 464 arrest from NRCPR database

2000-2002
Pediatrics 2006
Study of 464 arrest from NRCPR database

2000-2002
Looked at age and survival

Newborn <1 mo
Infants 1m-1y
Young child 1 - <8 yr
Older child 8 - 21 yr
Pediatrics 2006
Newborns were more likely to:
Cardiac surgical patient
Event precipitated by hypotension
Active cardiac failure

History of arrhythmia
Arterial catheter and vasoactive infusions before
cardiac arrest
Treated during the arrest with IV calcium, open-chest
CPR, and extracorporeal life support
Pediatrics 2006
Pediatrics 2006
CPB/ECMO
Odds ratio of 6.2 for survival to hospital discharge
Pediatrics 2006
European Journal of Cardiothoracic Surgery 33 (2008) 409-417

Meta-analysis of ECPR publications (1990-2007)


Median age 6 months, Median weight 4.5kg


Survival to discharge 40%


Neurological complications (all 27%, 14% d/c alive)


Other complications - renal failure (25%), sepsis (17%)


Mortality was higher for the presence of any complication
(OR 3.9), neurological (OR 3.3), renal (OR 5.1) and
implementation of ECMO >30 min (OR 2.1)
Neck vessel cannulation lower mortality ( p < .001)

Mortality was higher for the presence of any complication
(OR 3.9), neurological (OR 3.3), renal (OR 5.1) and
implementation of ECMO >30 min (OR 2.1)
199/6288 (3%) of pediatric cardiopulmonary

arrest events reported received E-CPR
87 (44%) survived to hospital discharge

56/59 (95%) of survivors had favorable Pediatric
Cerebral Performance Category outcomes
recorded
Pediatr Crit Care Med 2010; 11:362371



NO association with the duration of CPR

and survival


Decreased survival
Pre-arrest factor - renal insufficiency
Arrest factors - metabolic/electrolyte abnormality and
pharmacologic intervention of sodium bicarbonate/
THAM
Increased survival - Cardiac illness
Decreased survival
Pre-arrest factor - renal insufficiency
Arrest factors - metabolic/electrolyte abnormality and
Location, presence of invasive monitoring and
pharmacologic intervention of sodium bicarbonate/
time of event did NOT impact outcome
THAM
Increased survival - Cardiac illness
Retrospective chart review (2001-2006)

34 deployments with 73% survival to hospital d/c
82% of patients had underlying cardiac disease
Only serum ALT associated with risk of death (pvalue=0.043; OR, 1.6)
Blood lactate at 24h post-ECPR (p =0.059)

Neurological evaluation - no change in PCPC
scores in 18/24 (75%) survivors.
Resuscitation 2009
Retrospective, single-center, observational study
Propensity score matching was used to balance the

baseline characteristics and CPR variables that could
potentially affect prognosis
Primary end point was survival to discharge with

minimal neurologic impairment (CPC)
406 adult patients with witnessed in-hospital cardiac

arrest receiving CPR for >10 mins from 2003-2009 (85
E-CPR, 321 C-CPR)
Crit Care Med 2011; 39:17








Retrospective review of the Childrens Hospital

Boston ECPR experience (1995-2008) in patients
with cardiac disease (congenital and acquired)
180 ECPR runs in 172 patients. 88 patients (51%)

survived to discharge
Survival in patients who underwent ECPR after

cardiac surgery (54%) did not differ from
nonsurgical patients (46%)
Circulation 2010;122[suppl 1]:S241S248
Survival did not vary by cardiac diagnosis

CPR duration did not differ between survivors
and non-survivors
75% of pediatric overall performance category/
pediatric cerebral performance category scores

were 2, indicating none to mild neurological
injury


Pediatr Crit Care Med 2009; 10:445-451

Retrospective cohort study using ELSO data


Defined acute neurologic injury (ANI) as the
occurrence of brain death, brain infarction, or
intracranial hemorrhage identified by U/S or CT scan

682 E-CPR patients, 147 (22%) patients had ANI. Brain

death occurred in 74 (11%), cerebral infarction in 45
(7%), and intracranial hemorrhage in 45 (7%)


682 E-CPR patients, 147 (22%) patients had ANI. Brain

death occurred in 74 (11%), cerebral infarction in 45
(7%), and intracranial hemorrhage in 45 (7%)
The in-hospital mortality rate in patients with acute

neurologic injury was 89%.



Cardiology in the Young (2011), 21(Suppl. 2), 118123




NEJM 2010
NEJM 2010
NEJM 2010
122/549 (22%) required CPR and /or ECMO within

30 days of the Norwood procedure
NEJM 2010
IMPACT OF EXTRACORPOREAL MEMBRANE

OXYGENATION AND CARDIOPULMONARY
RESUSCITATION ON NORWOOD PROCEDURE
OUTCOMES: DATA FROM THE SINGLE
VENTRICLE RECONSTRUCTION TRIAL
Chitra Ravishankar, Sarah Tabbutt, Kerstin Allen, David S. Cooper,
Deborah Frank, Peter Frommelt, Nancy Ghanayem, Caren Goldberg,
Eric Graham, Joel Kirsh, Catherine Dent Krawczeski,
Wyman Lai, Alan Lewis, Andrew Lodge, Lynn Mahony, Janet Simsic,
Lynn Sleeper, Mario Stylianou, Yanli Wang and Peter Laussen
for the Pediatric Heart Network Investigators
Long-term Transplant-Free Survival

(mean follow-up 3311 months)
No ECMO/CPR (N=427)
E-CPR (N=36)
ECMO (N=49)
CPR (N=37)
P<.0001

Cross-sectional study of cardiac ECMO survivors

currently 518 yrs old


Quality of life was assessed by parent proxy report

using the Child Health Questionnaire Parent Form 50
and was compared to that of a general U.S. population
sample and other cardiac populations


Quality of life was assessed by parent proxy report

using the Child Health Questionnaire Parent Form 50
and was compared to that of a general U.S. population
sample and other cardiac populations
Factors associated with lower quality of life were

sought.













Pediatrics 2006;117;1640
Prospective economic evaluation in which 185 infants

were randomly allocated to ECMO (n=93) or
conventional management (n=92) and then followed up
to 7 years of age

to 7 years of age
Health services was combined with unit costs (, 2002

2003 prices) to obtain a net cost per child.

to 7 years of age
Health services was combined with unit costs (, 2002

2003 prices) to obtain a net cost per child.
The cost-effectiveness of neonatal ECMO was

expressed in terms of incremental cost per additional
life year gained and incremental cost per additional
disability-free life year gained.
.98
.69
J Thorac Cardiovasc Surg 2005;129:1084-90

Patients with CHD receiving salvage cardiac
ECMO between January 2000 and May 2004

Charges for all medical care after the institution

of ECMO were determined and converted to
costs by published standards

Charges for all medical care after the institution

of ECMO were determined and converted to
costs by published standards
The quality-of-life status of survivors was
determined with the Health Utilities Index Mark

II

Accepted cost-efficacy
$50,000 per quality-adjusted life-year
saved


Ecpr Is It Worth It Elso 2012

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ECPR: Worth the Investment?

David S. Cooper MD, MPH

Friday, September 21, 12

Friday, September 21, 12

but would be willing to acquire some

Friday, September 21, 12

Friday, September 21, 12

Friday, September 21, 12

Friday, September 21, 12

In-hospital Cardiac Arrest

In-hospital Cardiac Arrest

In-hospital Cardiac Arrest

High Quality CPR

Friday, September 21, 12

High Quality CPR

Friday, September 21, 12

High Quality CPR

Friday, September 21, 12

High Quality CPR

Friday, September 21, 12

High Quality CPR

Friday, September 21, 12

High Quality CPR

Friday, September 21, 12

Friday, September 21, 12

Friday, September 21, 12

ELSO Registry 2012

ELSO Registry 2012

ELSO Registry 2012

Friday, September 21, 12

Friday, September 21, 12

Low individual center volume (rare)

Friday, September 21, 12

Low individual center volume (rare)

Friday, September 21, 12

Low individual center volume (rare)

High rates of morbidity and mortality

Friday, September 21, 12

Low individual center volume (rare)

High rates of morbidity and mortality

Friday, September 21, 12

Low individual center volume (rare)

High rates of morbidity and mortality

Highly variable and rapidly changing

Friday, September 21, 12

Study of 464 arrest from NRCPR database

Study of 464 arrest from NRCPR database

Looked at age and survival

Newborns were more likely to:

Cardiac surgical patient

Event precipitated by hypotension

Active cardiac failure

Friday, September 21, 12

European Journal of Cardiothoracic Surgery 33 (2008) 409-417

Meta-analysis of ECPR publications (1990-2007)

European Journal of Cardiothoracic Surgery 33 (2008) 409-417

Meta-analysis of ECPR publications (1990-2007)

European Journal of Cardiothoracic Surgery 33 (2008) 409-417

Meta-analysis of ECPR publications (1990-2007)

European Journal of Cardiothoracic Surgery 33 (2008) 409-417

Meta-analysis of ECPR publications (1990-2007)

European Journal of Cardiothoracic Surgery 33 (2008) 409-417