How Feasible is Extracorporeal Cardiopulmonary Resuscitation in a Medium Urban Population Centre?

Background

Patients suffering from out-of-hospital cardiac arrest (OHCA) experience poor survival and neurological outcomes, with rates remaining relatively unchanged despite advancements. Extracorporeal membrane oxygenation (ECMO), termed extracorporeal cardiopulmonary resuscitation (ECPR) in arrests, may offer improved outcomes. We developed local screening criteria for ECPR and then estimated the frequency of use by applying those criteria retrospectively to a cardiac arrest database. The purpose was to determine if an ECPR program is feasible in a medium urban population centre in Atlantic Canada.

Methods

A three-round modified Delphi survey, building upon data from a literature review, was conducted in collaboration with external experts. The resulting selection criteria for potential ECPR candidates were applied to a pre-existing local cardiac arrest database, supplemented by health records review, identifying potential candidates eligible for ECPR.

Results

Consensus inclusion criteria included witnessed cardiac arrest, age <70, refractory arrest, no-flow time <10min, total downtime <60min, and presumed cardiac or selected non-cardiac etiologies. Consensus exclusion criteria were an unwitnessed arrest, asystole, and select etiologies and comorbidities. Simplified criteria were developed to facilitate emergency medical services transport. Historically, 20.0% (95% CI 16.2-24.3%) of OHCA would be transported to the Emergency Department (ED), with 4.9% (95% CI 3.0% to 7.6%) qualifying for ECPR.

Conclusion

Despite conservative estimates based upon historically small numbers of select cardiac arrest patients meeting eligibility for transport and initiation of ECPR, a dedicated program may be feasible in our regional hospital setting. Patient care volumes suggest it would not be resource intensive yet would be sufficiently busy to maintain competency.

Introduction of an Extracorporeal Cardiopulmonary Resuscitation Eligibility Protocol for Paramedics in Atlantic Canada: A Pilot Knowledge Translation Project

Introduction

There is currently no protocol for the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest (OHCA) in Atlantic Canada. Advanced care paramedics (ACPs) perform advanced cardiac life support in the prehospital setting often completing the entire resuscitation on-scene. Implementation of ECPR will present a novel intervention that is only available at the receiving hospital. Our objective is to determine if an educational program can improve identification of ECPR candidates by paramedics. Establishing paramedic competence will ensure rapid transfer of eligible patients for a potentially life-saving intervention.

Methods

An educational program was delivered to paramedics including a short seminar and pocket card coupled with simulated OHCA cases. A before-and-after study design using a case-based survey was employed. Paramedics were scored on their ability to correctly identify patients suffering OHCA who met the inclusion criteria for our ECPR protocol. A Wilcoxon matched-pairs signed rank test was employed to compare paramedics’ scores before and after the education delivery. A six-month follow-up is planned to assess retention. Qualitative data was also collected from paramedics during simulation to help identify practical issues, potential barriers, and to refine inclusion and exclusion criteria prior to the implementation of our protocol in the prehospital setting.

Results

The median score pre-education was 10 (IQR: 9-10.5) compared to 14 (IQR: 13-15) after education delivery. The median difference between groups was 5. The Wilcoxon matched-pairs test demonstrated a significant improvement in the paramedics’ ability to correctly identify ECPR candidates after completing our educational program z = -2.67, p = 0.0039.

Conclusion

Paramedic training through a didactic session coupled with a pocket card and simulation appeared to be a feasible method of knowledge translation. Six-month follow-up data will help ensure knowledge retention is achieved.