E-CPR STRIKES AGAIN

iPhoneIcon_BigECMO for cardiac arrest, E-CPR, has been shown several times to increase survival more than any other intervention we have available. Here’s yet another retrospective study to support the findings in previous trials (links at end of post). Survival with good neurological outcome increased from 7.5% to 40% with E-CPR!

The study
Patients in cardiac arrest between 2011 and 2013 were examined. No-flow time <5min and age <70years and refractory VF. The conventional CPR (C-CPR) arm included patients with more than 10 mins of CPR. Findings
C-CPR gave a survival to discharge of 27.5%, but of these, only 7.5% had CPC 1-2. E-CPR had a 50% survival to discharge, with 40% having CPC 1-2!

Both groups had kept the same number of patients surviving with CPC 1-2 after 1 year, meaning C-CPR 7.5% and E-CPR 40%.

Discussion
So E-CPR doubled survival compared to C-CPR in this study, but even more important: survival with good neurological outcome was more than 5 times higher in the E-CPR group!

The standard limitations to retrospective studies apply, and we can’t rule out a selection bias for patients put on ECMO – they will usually be the ones you think stand a good chance. This will also remove potential survivers from the C-CPR group. On the other hand, CPR had been going for at least 10 mins to be included in the study, and the E-CPR group had CPR for 40-50 mins before getting on pump.

In addition to this a 27.5% survival in the C-CPR group for refractory VF (>10 mins) is quite good, and 7.5% with good neurology is also not far from comparable numbers in other C-CPR studies where no ECMO selection has been involved. The 50% and 40% with good neurology survival numbers in the E-CPR group are very good, but comparable to other studies.

Our take
There’s so much evidence mounting showing these patients do so much better on VA-ECMO support than with conventional CPR, that it will be hard to ignore using your ECMO machine for E-CPR if you have one available in your institution. Some say it’s time for an RCT – but I sure wouldn’t like to end up in the C-CPR arm…

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation, Resuscitation, 2015.

Previous E-CPR posts on ScanCrit:
I AM THE RESURRECTION: The CHEER trial and SAVE-J
ECMO CPR: Shin 2011, Chen 2008

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11 Responses to E-CPR STRIKES AGAIN

  1. Jordan Schooler says:

    Nice summary. I believe an RCT is recruiting somewhere in Europe (since we’re always behind in the U.S.) but I’d probably like to avoid getting into either arm!

  2. Jon Henrik Laake says:

    Not only Dies this study tick all the boxes with respect to bias. Also, ScanCrits reviewer admits to being biased – trustworthy?

    • Thomas D says:

      Thanks for your comment! Yes, I think we’re trustworthy, in the sense that we don’t try to disguise our preferences. The whole point of posts like this is to point to articles and pieces of interest, and hopefully get people thinking and discussing. (In our opinion this is much preferred to bias hidden in academic speak and statistics (IST-3 trial springs to mind)). Everyone should read the litterature and make up their own mind.

      Of course, a study like this that’s retrospective and looks at the same center’s patients that’s been put on ECMO or not, will have a selection bias for deciding to put them on ECMO and other weaknesses. They also have small numbers in their E-CPR group, so an extra bad case would make the statistics look worse – but still impressive in a cardiac arrest setting. So their survival of 50%, and 40% with CPC 1-2, is impressive enough when we’re all too familiar with the abysmal outcomes of standard CPR for refractory VF in prolonged resuscitation.

      In that sense we stand by that ECMO and E-CPR in this article again seems to be vastly improving survival and protect neurological function. And we appreciate all input, for or against this standpoint! The discussion helps medicine move forward. So hearing your take on this article and on ECPR in general would be great.

  3. Jon Henrik Laake says:

    “Trustworthiness” does not refer to whether the reviewer is an honorable individual or not, but rather if we can feel confident that any advice or recommendation issued reflects “high quality evidence” (i.e. evidence that most likely will not be altered following new trials). Surely, the evidence so far does not allow for such confidence. And as long as the reviewer confides that he is biased in favour of ECMO following CPR, we must conclude that this is not a trustworthy statement. Nothing personal.

    • Thomas D says:

      “Trustworthy” seems a highly charged label that’s not useful in a discussion like this. You are using “untrustworthy” in the meaning “I don’t agree”. A real discussion would be much more useful than just posting labels.

      As far as evidence based medicine goes, we’re not stating anywhere that this is high quality evidence, you seem to be reading too much into this.

      And surely, RCTs are not the holy grail. They have their own pitfalls. Tight glucose control springs to mind. And, even despite several RCTs, the actual evidence on thrombolysis in stroke is murky to say the least, but we still seem to think that is a fantastic treatment.

      What I’m getting at, is that RCTs in themselves need scrupulous critique, and even then we’re often left with choosing sides based on a mix of classic EBM and basic medical understanding, and sometimes even a gut feeling.

      And for some treatments, we don’t get good evidence. Dutton’s Damage Control Resuscitation technique fits in here. No proof, no RCT, no trial, no hard outcome measures. Just a sound medical basis and a feeling this is helping the patient. Still, many of us think this is a sound approach.

      Which leads us into the progression of medicine. If we were all waiting for an RCT, there would be no progression. There’s the well known “innovation curve”, where I believe it is important to have people spread out from innovators, early adopters and early majority. Late majority, OK. Laggards – not so much.

      On ECMO for cardiac arrest, it seems we are past the innovators, and into the early adopters stage. No, we don’t have good, high quality evidence that E-CPR is as good as the recent trials have shown, but with the sound rationale behind it and so many trials showing similar numbers, there’s a very good chance this is a good treatment. I think we can agree on that. Should everyone really run back to their hospital and fire up their Cardiohelp just because they read it on ScanCrit? Of course not. I sure hope not. This is just an opinion piece backed by a growing number of medium quality evidence.

      Still, this evidence and the sound physiology behind it, together with a good gut feeling, has gotten many doctors and hospitals to believe this is a worthwhile pursuit – to provide E-CPR for a selected number of their cardiac arrest patients. While others are waiting for the RCT. Either group might end up being right. Pick your poison. I know where my money is.

      In conclusion, many of the discussions in FOAM are more akin to the discussions one might have in the hallways of the hospital, two doctors walking along and discussing medicine, and the possibilities of medicine. The same goes for some of the blog posts. And to us, this is what makes medicine interesting and inspiring again.

      In these discussions and writings, we trust other participants to be able to judge between opinion and EBM themselves. We might be placing too much trust in human kind.

      Hopefully you’ll engange in the debate, as I would still love to hear your take on this article and E-CPR in general – where you think today’s stance should be and where you think the future lies for ECMO in cardiac arrest, based on current data and medicine.

  4. Jon Henrik Laake says:

    Actually, the phrase is taken from here: Institute of Medicine – Standards for Developing Trustworthy Clinical Practice Guidelines – http://iom.nationalacademies.org/Activities/Quality/ClinicPracGuide

    • Thomas D says:

      OK, whatever.

      I tried to engage you in a meaningful discussion on the subject. Twice. You’ve been unwilling to do so, and just hammered on with the “trustworthy” issue. And how does “Standards for Developing Trustworthy Clinical Practice Guidelines” have anything to do with an opinion post on a medical blog?

      Anyway, your labeling has been without any good arguments pointing to what you base your exact bias charges on (although I agree it’s biased), why you believe it is so, or how we can discuss E-CPR in a meaningful way.

      How, exactly, are the three comments you’ve posted here going to help anyone? You’re adding nothing to the discussion. As I said, FOAM is about engaging in discussions, sharing ideas and experiences. Try it. You might like it.

      Meanwhile, go watch this talk instead: Crack the chest – get crucified.

  5. Jon Henrik Laake says:

    The field of critical care is littered with interventions that once were supported by ‘common sense’, ‘physiological rationale’ and observational studies. Only recently, randomised trials of decent design and size have appeared and now allow us to start ‘clearing out’ costly and/or harmful procedures (dopamine and diuretics for renal failure, colloids for fluid resuscitation, unnecessary transfusions, hypothermia after cardiac arrest, harmful ventilation strategies etc etc). This is because there are people among us with the talent and resources to organise multi centre trials. They need our full support.

    ECMO for cardiac arrest victims is often very costly, in both the medical and economic sense, as well as from a human perspective (caregivers, proxies, patients). It should be tested in a proper trial. If I understand things correctly, such a trial(s) is underway. Then, we’ll know. There will remain issues regarding patient selection, outcome prediction, futility issues, end-of-life care etc.

    • Thomas D says:

      Thank you for your reply! Of course, well designed and executed RCTs are important. we can all agree on that. And they have brought us a lot of good and more robust knowledge.

      But I’m not sure you really believe this “wait for the RCT, then we’ll know” stuff. We might be a little closer to knowing. Because, surely, the RCT will have its strengths and weaknesses, and these will be debated and interpreted. They always are. And should be.

      I know the last part of the post here, with “our take” on E-CPR is opinionated. I know it is slightly over the top. It’s meant to be. Taking sides instead of staying safe is more interesting for the discussion.

      Your concerns about ECMO are certainly valid, but very generic. They apply to a wide range of our treatments in hospital, and especially the ICU. And we hardly have better evidence for many of these other treatments (that are in common use) than we currently have for ECMO.

      FOAM needs knowledgable participants with a lot of experience as part of their community. We have many, from clinicians and dedicated educators like Scott Weingart and Cliff Reid, to more traditional clinical researchers like Perner, Myburgh, Finfer and Maitland, who were all at the SMACC conference and on SoMe. The sepsis treatment panel debate at SMACC was epic. The top researchers moved beyond academic speak, and put their knowledge into more simple and practical terms. Great stuff for the audience. And this is also the bonus for the whole FOAM community, that everyone is hungry for knowledge and discussion, and eager to share and take in new ideas.

      This blog is dedicated to the inspiration and thrill of learning and exploring new treatments and techniques. I was looking for that side of you with the same drive and passion you show when talking on Dutton’s Damage Control Resuscitation.

      Even if our training is academic, and a cool head is needed, I think we have to be passionate at some level to do what we do. I wager your experience with ECMO is most likely driven by part medicine evidence, and part passion.

      I would think with your personal experience with ECMO in rescue situations and in cardiac arrest, you must’ve made some personal thoughts, besides the science available. The patient outcomes, complications and feasibility of the set-up. Good or bad, those sides would be interesting to hear – and I promise not to take them as ‘evidence’ for ECMO’s superiority in these settings 🙂

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