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E-CPR amp ECMO Post
Cardiac Arrest Care
Anne-Marie Guerguerian MD PhD
Critical Care Medicine The Hospital for Sick Children
University of Toronto
eclsprogramsickkidsca
Disclosures
bull Health Canada Special Access Program
bull Volunteer
bull Heart and Stroke Foundation of Canada
Resuscitation Paediatric Task Force
bull International Liaison Committee on Resuscitation
Pediatric Task Force 2015 amp 2019 Evidence Reviewer for
E-CPR
bull Chair AHA GWTGreg Pediatric Research Task Force
Rescue ECMO in Children
Methodhellip
Video-tape as a learning and evaluation tool following series of Mock Rescue ECMO
Crisis resource management paradigms amp
Team education and competency in 2007
Dr Afrothite Kotsakis
Learning objectives
bull Learn what is E-CPR and ECMO during Post
Cardiac Arrest Care
bull To understand the roles of extracorporeal
membrane oxygenation in the context of
resuscitation in children and in general
Standard Conventional CPR for
Cardiopulmonary Arrest
Causes CPA In Pediatrics
Cardiac
Respiratory
Cardiac
Respiratory
Out-of-hospital CPA In-hospital CPA
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Disclosures
bull Health Canada Special Access Program
bull Volunteer
bull Heart and Stroke Foundation of Canada
Resuscitation Paediatric Task Force
bull International Liaison Committee on Resuscitation
Pediatric Task Force 2015 amp 2019 Evidence Reviewer for
E-CPR
bull Chair AHA GWTGreg Pediatric Research Task Force
Rescue ECMO in Children
Methodhellip
Video-tape as a learning and evaluation tool following series of Mock Rescue ECMO
Crisis resource management paradigms amp
Team education and competency in 2007
Dr Afrothite Kotsakis
Learning objectives
bull Learn what is E-CPR and ECMO during Post
Cardiac Arrest Care
bull To understand the roles of extracorporeal
membrane oxygenation in the context of
resuscitation in children and in general
Standard Conventional CPR for
Cardiopulmonary Arrest
Causes CPA In Pediatrics
Cardiac
Respiratory
Cardiac
Respiratory
Out-of-hospital CPA In-hospital CPA
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Rescue ECMO in Children
Methodhellip
Video-tape as a learning and evaluation tool following series of Mock Rescue ECMO
Crisis resource management paradigms amp
Team education and competency in 2007
Dr Afrothite Kotsakis
Learning objectives
bull Learn what is E-CPR and ECMO during Post
Cardiac Arrest Care
bull To understand the roles of extracorporeal
membrane oxygenation in the context of
resuscitation in children and in general
Standard Conventional CPR for
Cardiopulmonary Arrest
Causes CPA In Pediatrics
Cardiac
Respiratory
Cardiac
Respiratory
Out-of-hospital CPA In-hospital CPA
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Learning objectives
bull Learn what is E-CPR and ECMO during Post
Cardiac Arrest Care
bull To understand the roles of extracorporeal
membrane oxygenation in the context of
resuscitation in children and in general
Standard Conventional CPR for
Cardiopulmonary Arrest
Causes CPA In Pediatrics
Cardiac
Respiratory
Cardiac
Respiratory
Out-of-hospital CPA In-hospital CPA
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Standard Conventional CPR for
Cardiopulmonary Arrest
Causes CPA In Pediatrics
Cardiac
Respiratory
Cardiac
Respiratory
Out-of-hospital CPA In-hospital CPA
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Causes CPA In Pediatrics
Cardiac
Respiratory
Cardiac
Respiratory
Out-of-hospital CPA In-hospital CPA
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
CPA with CPR
Problem With An Imperfect Solution
SURVIVAL
Setting In ADULTs In PEDS
In-hospital 223 Girortra 2012 35 Girortra 2013
Out-of-hospital 14 Grunau 2016
37Tijssen 2015
98
163
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Pulseless and non-pulseless CPA
bull In-Hospital Trends GWTG-Registry in 2000-2018
from 351 hospitals in the US Holmberg 2019
bull Survival
bull 32 Pulseless
bull 63 Non-pulseless = bradycardia with poor perfusion
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States Volume
140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Pulseless CPA
bull 19 absolute increase in survival in pulseless events
over time
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Lars W Andersen Circulation Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States
Volume 140 Issue 17 Pages 1398-1408 DOI (101161CIRCULATIONAHA119041667)
copy 2019 American Heart Association Inc
Survival Trends in Non-Pulseless
CPA
bull 9 absolute increase in survival for non-pulseless
events
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Extracorporeal Cardiopulmonary
Resuscitation what is E-CPR in 2019
E-CPR is the rapid deployment of veno-arterial
extracorporeal membrane oxygenation (ECMO) -
or cardiopulmonary bypass - to provide immediate
cardiovascular and oxygenation support for
patients in cardiopulmonary arrest during CPR
or lt 20 min of return of spontaneous circulation
2018 New Harmonized Definition ILCOR Utstein + ELSO
Conrad et 2018
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
WHAT IS THE ROLE OF E-CPR
1 Purpose
2 Motivation
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
PURPOSE
To restore circulation for gas exchange amp
support metabolism
bull Oxygenation and substrate delivery
bull Removal of carbon dioxide
bull Deliver restorative therapies to organs
(stop using potentially harmful pharmacological
therapies)
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Preclinical ndash Restoring Coronary
Perfusion Pressure
CPB
CPR
Angelos 1990
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
MOTIVATIONS
ECPR or
ECMO PCAC
Neuro-Cardiopulmonary
resuscitation
Organ preservation for donor support
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
MOTIVATION
1 Applied for neuro-cardio-pulmonary
resuscitation in patients intended to survive
and to achieve best functional outcomes in
survivors - used in pediatrics and adults
2 Applied for donor support and organ
preservation ndash used in adults
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Indications - Historically
Early application for refractory
CPA and conventional CPR
Initial pediatric reports by Del Nido 1992
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
E-CPR Indications
bull lsquoRefractoryrsquo CPA to conventional CPR
bull Not suited for conventional CPR
bull Functional physiology considerations
that may limit effectiveness of
conventional CPR Marino 2018 AHA Statement Resuscitation in Infants and children with cardiac disease
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Functional physiology considerations
Then ECPR may be considered earlier
If the functional physiology may limit the
effectiveness of conventional CPR
(1) patients with limited stroke volume with chest
compressions
(2) limited effective pulmonary blood flow and
oxygenation with compressions
(3) limited cerebral perfusion
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Bridge to TherapyBridge to organ recovery
Provides capacity to facilitate therapy
bull surgical
bull interventional
bull pharmacological
bull diagnostic imaging
bull therapy
Provides time needed for recovery of function
May allow to remove harmful interventions
Bridge to decisionbull To palliative care
bull To other type of mechanical device
bull To receive organ transplant
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
2000-2005
80 children
54 survived ECMO
34 survived hospital
discharge
Cause of death
ischemic brain injury
Alsoufi 2007
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Benchmark lt 30 min
How to reduce time to ROC
A + B + C lt 30 min
A 0 min
B lt 10 min for C-CPR
C lt 20 min for E-CPR
CPA C-CPR E-CPR
A B C
ROC
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
O2 titration + CO2 removal
+ Pump + HeaterCooler
bull Suitable vascular access
bull Systemic anticoagulation
bull Transfusion therapy
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
EVENT CPA CPR ECMO PCAC
INTERVALS
Laussen 2018
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
PediatricsFirst Author Year Diagnosis Institution Total Survival
Pediatric IH Cardiac Arrests
del Nido 1992 Cardiac Pittsburg 11 64
Dalton 1993 Cardiac Pittsburg 29 45
Duncan 1998 Cardiac Boston 11 54
Morris 2004 All Philadelphia 64 33
Thiagarajan 2007 All ELSO-R 682 38
Alsoufi 2007 All Toronto 80 34
Huang 2008 All Taiwan 27 41
Tajik 2008 All Meta-analysis 288 40
Chan 2008 Cardiac ELSO-R 492 42
Prodhan 2009 All Arkansas 32 73
Kane 2010 Cardiac Boston 172 51
Raymond 2010 All GWTG-R 199 44
Ortmann 2011 All GWTG-R 185 NR
Wolf 2012 Cardiac Atlanta 150 56
Odegaard 2014 Cath lab Boston 18 55
Lasa 2016 All GWTG-R 591 40
Meert 2018 All THAPCA 147 41
Bembea 2019 All ELSO-R amp
GWTG-R
593 31
ELSO-R Extracorporeal Life Support Organization Registry GWTG-R Get With The Guidelines Registry
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Pediatric ECPR GWTG-R amp ELSOBembea 2019
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
bull 593 ECPR cases from 32 American hospitals
bull Age 29 months [IQR 11 d ndash 20 m] (70 lt 1 y)
bull 59 Surgical Cardiac Cases
bull 99 witnessed
bull 96 monitored
bull CPR duration 48 min [IQR 28-70 min]
bull ECMO duration 39 days [IQR 2-67 days]
Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
240 (405) died prior to decannulation
352 (594) died prior to hospital discharge
Odds of Death increasedbull Non-cardiac diagnosis aOR 185 [95 CI 119-289]
bull Preexisting renal insufficiency aOR 474 [95 CI 206-109]
Outcomes Pediatric ECPR GWTG-R amp ELSO
Bembea 2019
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Time from t0 to ECMO Flow
Median 48 minutes [IQR 28-70 min]
Longer time increased OR death
aOR per 5 min 104 [95 CI 101-107]
Bembea 2019
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Adverse events during ECMOEach individual adverse event documented
during the extracorporeal membrane
oxygenation course increased aOR death
bull Neurologic
bull Pulmonary
bull Renal
bull Metabolic
bull Cardiovascular
bull HemorrhagicBembea 2019
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Overall published comparative
evidence in humans Holmberg 2018
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Pediatric IHCA Survival
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Javier J Lasa et al Circulation 2016133165-176
Copyright copy American Heart Association Inc All rights reserved
GWTG-R C-CPR vs E-CPR
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
THAPCA ECMO GROUP (n=147)
bull 415 Survival ECPR at 1 year
bull 13 survived with favorable neurobehavioral outcome
bull 52 among cardiac surgery group
bull Predictors of better outcomes
bull shorter time to cannulation
bull open compression vs closed chest(Time CPR-ECMO 37 min[IQR 22-51] vs 53 min [IQR 37-69])
Meert 2019
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Adult selected studies
Adult Studies
First Author Year Type Site Total Survival
Younger 1999 Cardiac Ann Arbor 25 36
Chen 2008 All Taiwan 59 24
Thiagarajan 2009 All ELSO 297 27
Fagnoul 2013 IHCA OHCA Brussels 24 25
Chou 2014 IHCA Taiwan 43 35
Sawamoto 2014 Hypothermia Sapporo 26 39
Sakamoto 2014 OHCA Japan 260 123
Stub 2013 IHCAOHCA Melbourne 24 50
Yannopoulos 2017 OHCA Minnesota 50 45
Outcome rate of favorable neurological outcome (Cerebral performance categories 1 amp 2) at one month
Survivors are reported among the prospectively enrolled cohort 2862 a subgroup of 47 underwent percutaneous coronary intervention (PCI) after OHCA 62 OHCA prospectively enrolled
where 50 were placed on ECMO 5 had ROSC and 7 died 8 of 50 ECMO died early 42 ECMO and 5 with ROSC underwent PCI of which 28 survived
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Adult OHCA Survival
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Adult IHCA Survival
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
EXPERTISE amp CONTINUED TRAINING
REQUIRED
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
DECONSTRUCT
PERFORMANCE
OF EACH CASE
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
E-CPR ndash Feb 20XX
A min
B 34 min
C 31 min
Total 65 min
Target lt 30 min
CPA C-CPR E-CPR
A B C
No ROC
945 1019 Launch 1050TIME
FactorsOut-of-hospital unwitnessed AsystoleLocation ERDelegated call
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
E-CPR ndash August 20XX
A 0 min
B 0 min
C 22 min
Total 22 min
Target lt 30 min
CPA C-CPR
E-CPR
AB
C
ROC
945 1002TIME
FactorsIn hospital witnessed Bradycardia post tracheal intubationLocation CCCUTeam ready at bedsideMyocarditisPatient discharged home
945 945
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
IN SUMMARY
E-CPR or ECMO PCAC IHCA gtgtgt OHCA
May be beneficial in
bull Select populations
bull Select settings
bull Purpose amp motivation
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Post Resuscitation Care
Therapies
bull Controlled re-oxygenation and CO2 normalization
bull Cardiopulmonary support with removal of pharmacological
support and re-introduction of cardiopulmonary therapies
bull Normothermia or Hypothermia
bull Overall supportive care
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
E-CPR Applied In Pediatrics
In Hospital Cardiopulmonary Arrest
bull Selected populations
bull High performing systems
bull Robust performance tracking
bull Environments that can take responsibility for both
favorable and unfavorable outcomes
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
Adult Trials Cardiac Arrest amp
ECMO Recruiting or almost ready
eclsprogramsickkidsca
eclsprogramsickkidsca
