HCMC refractory arrest protocol: extracorporeal CPR for

$Page 1: HCMC refractory arrest protocol: extracorporeal CPR for$
Refractory Arrest v4.2 03/02/2021

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HCMC REFRACTORY ARREST PROTOCOL: EXTRACORPOREAL CPR FOR OUT-OF-HOSPITAL CARDIAC ARREST


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TABLE OF CONTENTS Section .......................................................................................................................................... Page 1. Target audience and purpose .......................................................................................................... 3

2. Definition .......................................................................................................................................... 3

3. Overview .......................................................................................................................................... 3

Fig 3.1. E-CPR process overview

4. Indications ....................................................................................................................................... 4

5. Contraindications ............................................................................................................................. 5

6. Equipment .................................................................................................................................... 5-6

Fig 6.1. ECMO procedure cart

Fig 6.2. ECMO circuit (Cardiohelp)

7. Personnel ........................................................................................................................................ 7

8. Protocol activation ........................................................................................................................... 8

Fig 8.1. Pathway for E-CPR activation

9. Process of care ................................................................................................................................ 9

Fig 9.1. E-CPR process of care

10. Cannulation standard work and roles ...................................................................................... 10-11

11. Cardiac arrest management ......................................................................................................... 12

12. Initiation of E-CPR ........................................................................................................................ 13

13. Maintenance on VA ECMO ........................................................................................................... 13

14. Patient transport ........................................................................................................................... 14

15. Prognostication ........................................................................................................................ 14-15

a. Adequate hemodynamics to support recovery ............................................................... 14-15

b. ICU neuro-protection and prognostication .......................................................................... 15

16. ECMO weaning ............................................................................................................................ 16

17. Transfer to Advanced HF Center ................................................................................................... 16

18. References ................................................................................................................................... 17

19. Contributors .................................................................................................................................. 17

20. Appendices ................................................................................................................................... 18

APPENDIX 1. Emergency Department Checklist for Refractory Arrest Protocol Candidate ....... 18

APPENDIX 2. Reference Card: Initial Vascular Access Using Micropuncture Kit (4F SMAK) .... 19

APPENDIX 3. Working With Family of E-CPR Patient Prior to ICU Admission ........................... 20


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1. TARGET AUDIENCE AND PURPOSE

This guideline is intended for the medical, nursing, and paramedic staff of Hennepin Emergency Medical Services (EMS), the Emergency Department (ED), Cardiac Catheterization Laboratory (Cath Lab), and Intensive Care Unit (ICU). This guideline defines the “refractory arrest protocol” of extracorporeal cardiopulmonary resuscitation (E-CPR) at HCMC in partnership with Hennepin EMS.

2. DEFINITION

E-CPR is defined as the extracorporeal augmentation of systemic oxygen delivery in cases of refractory cardiac arrest thought to be due to a reversible etiology. This augmentation of perfusion and gas exchange is achieved by pumping femoral venous blood through an oxygenator (a semi-permeable membrane allowing oxygen and carbon dioxide diffusion) and then returning the oxygenated blood to vital organs via a femoral arterial catheter. This configuration of extracorporeal support is termed peripheral veno-arterial [VA] ECMO and is analogous to partial cardiopulmonary bypass; it can replace chest compressions.

3. OVERVIEW

Select outpatients with refractory cardiac arrest meeting eligibility criteria will be transported on mechanical CPR to the ED stabilization room and initiated on VA ECMO as a bridge to intervention and recovery. If pre-defined resuscitation targets (including return of an organized rhythm) are achieved, patients will be admitted to the ICU for neuro-prognostication and ECMO weaning. Figure 3.1. E-CPR for Refractory Cardiac Arrest: Process of Care Overview


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4. INDICATIONS E-CPR may be considered in outpatients with cardiac arrest that is refractory to advanced cardiac life support (ACLS) who meet the following criteria:

• The patient has severe hypothermia (core temperature 28 C), age < 75 years, and no signs of irreversible death [See HCMC Emergency Department ECMO Rewarming Using VA-ECMO for Patients with Severe Hypothermia (< 28 ⁰C)]

–OR—

• The patient meets ALL of the following criteria:

1. Age 18 to 75

2. Not a permanent resident of a skilled nursing facility (i.e. nursing home)

3. Shockable initial rhythm1

4. No sustained return of spontaneous circulation (ROSC) after defibrillation and

administration of an anti-arrhythmic drug IV/IO

5. Body habitus allows LUCAS CPR

6. No known pre-existing organ failures or co-morbidities which would preclude a return

to independent living2

7. Meets 2 physiologic parameters3:

▪ Serum lactate <17.5 mmol/L

▪ End-tidal carbon dioxide (EtCO2) >10 mmHg

1 Shockable rhythm defined as (1) AED advising shock and/or (2) ventricular fibrillation or ventricular tachycardia on EMS monitor 2 Pre-existing organ failure would include end-stage renal disease (i.e. hemodialysis), end-stage liver disease (i.e. ascites, esophageal varices, fixed coagulopathy, encephalopathy), end-stage cardiomyopathy (known left ventricular ejection fraction <20%), or advanced solid organ or hematologic malignancy (i.e. metastatic disease) 3 Lactate will be measured from point-of-care venous or arterial specimen


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5. CONTRAINDICATIONS

The patient is not an E-CPR candidate and the protocol will be aborted when any of the following criteria are discovered:

• Non-shockable initial rhythm

• Non-cardiac etiology for arrest (e.g. primary respiratory or traumatic arrest)

• Limited medical care plan or advance directive that precludes further resuscitation (e.g. DNR/DNI on POLST)

• Therapeutic anticoagulation poses unacceptable risk to the patient

• Aortic dissection or severe aortic valve insufficiency

• Time interval from collapse to starting ECMO cannulation >75 minutes (target time to ECMO flow is <60 minutes)

6. EQUIPMENT

The ECMO cart is kept in the ICU. Maintaining the ECMO cart stocked and ready is the responsibility of the ECMO program coordinator or a designated ECMO RN specialist. The key components are:

• ECMO procedure cart o Cannulation pack (sterile drape, c-arm covers, sterile PPE) o Chlorhexidine applicators (large size) o Sterile clamps and instruments o Percutaneous access kit (needle, wire, dilators) o Adjunct wires o 15 Fr and 17 Fr x 15 cm cannulae – typical sizes for arterial access o 25 Fr x 55 cm cannula – typical size for venous access o Micro-puncture kits (S-Mak, which includes 22G needle, 0.018” wire, and 4 Fr x 11

cm microcatheter) o Sterile ultrasound probe covers o 6 Fr x 11 cm Arrow braided sheaths


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• Cardiohelp™ ECMO system (Maquet Cardiovascular, Inc.) o Cardiohelp™ machine o HLS disposables kit (cassette, tubing, priming supplies) o Fresh gas flow regulator o Primed by ECMO RN specialist

Figure 6.2. ECMO Circuit

Cardiohelp

FRONT SIDE (cannulas)

Figure 6.1. ECMO Procedure Cart

FRONT SIDE (cannulas)


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7. PERSONNEL

• Prehospital team o Paramedics, BLS providers

• ED team o Attending EM physician(s) o Senior EM resident(s) o Two ED stabilization nurses o ED charge nurse o Stab room HCA o ED patient services coordinator (PSC) o Fluoroscopy technician o ED pharmacist (if available) o Respiratory therapist

• ECMO team o ECMO nurse specialist(s) o Perfusionist (if available) o Cannulating physician (interventional cardiology, ED, critical care, surgery) o MICU fellow on-call

• Cardiology team o Interventional cardiologist o General ECMO cardiologist o Cardiology fellow o Cath lab team (nurse, technician, monitor)

• ICU team o Attending ICU physician o (MICU fellow is included in ‘ECMO team’ above) o Housestaff


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8. PROTOCOL ACTIVATION Out-of-Hospital Cardiac Arrest Paramedics attending a patient with cardiac arrest that is refractory to defibrillation and administration of an anti-arrhythmic drug by IV/IO route will initiate report to medical control (HCMC EM faculty physician) by radio. The Emergency Communications Center (ECC, i.e. “dispatch” or “West MRCC”) will be listening to and recording this communication. Figure 8.1. Pathway for activation of Refractory Arrest Protocol


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9. PROCESS OF CARE

The flowchart below (Fig 9.1) depicts the steps involved in the Refractory Arrest protocol at HCMC. There are three sequential decision nodes (numbered red circles, bottom). They represent branch points in decision-making where the Refractory Arrest protocol can be abandoned if the patient does not meet specific criteria. The standard work around VA ECMO cannulation takes place over three stages (0,1,2). Figure 9.1. Refractory Arrest Process of Care


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10. CANNULATION STANDARD WORK AND ROLES

VA ECMO is most beneficial for cerebral and coronary perfusion when it is deployed in appropriate candidates as early as possible. Time is brain. As illustrated in Fig 9.1, this standard work is divided up into tasks to be accomplished prior to patient arrival (Stage 0), during the short interval between arrival and the decision to cannulate (Stage 1), and finally from the decision to cannulate to establishing ECMO flow (Stage 2). Furthermore, three key roles are highlighted below: Team Leader, ECMO RN Specialist, and Cannulating MD. These individuals will don a red bouffant for ease of identification during a case.

• TEAM LEADER – EM Faculty 1 o Receives paramedic report and assumes overall care of the patient o Ensures that patient is transferred to fluoroscopy-compatible gurney on arrival to ED o Prioritization of vascular access for iSTAT measurement of serum lactate o Run final Refractory Arrest protocol checklist with paramedic and cannulating MD o Ensures that cath lab is activated (immediately after decision made to cannulate for

ECMO) o Supervise endotracheal intubation, if not done pre-hospital o Supervise resuscitative efforts with goal MAP >55 mmHg o Delegate procedures to qualified stabilization room staff members (R radial arterial

line, IJ central venous line, etc).

• ECMO RN SPECIALIST o Proceeds to the ED stabilization room with primed ECMO circuit and ECMO cart o Ensures that patient is transferred to fluoroscopy-compatible gurney on arrival to ED o Prioritization of iSTAT measurement of serum lactate o Verifies eligibility for refractory arrest protocol with ED and cannulating physicians o Lays out equipment on sterile table o Is the primary resource for cannula selection and equipment o First assist for the cannulating physician if needed (when there are 2 ECMO

specialists present)

• CANNULATING MD o Ensures that patient meets criteria for ECMO and runs final checklist with EM

attending physician and ECMO RN specialist o Responsible for sterile prep and draping of bilateral inguinal areas for access,

including application of sterile sheet o Percutaneous access with ultrasound or re-wire sheath access in femoral artery and

vein, verify wire position with fluoroscopy o Ensures that 5000 units of heparin is administered o V-A ECMO cannulation (15-17 Fr arterial, depending on patient stature; 25 Fr

venous) o Supervise initiation of V-A ECMO support


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o Coordinate hemodynamic management with EM Faculty while patient remains in stabilization bay (achieve MAP >50-55 mmHg, right radial arterial line, etc., prior to transport)

• EM ‘PIT BOSS’ – G3 Resident o U/S guided right CFV S-MAK introducer and venous blood specific for iSTAT lactate o Sterile prep and drape o U/S guided left CFA S-MAK introducer if cannulating MD not yet present o Right upper extremity arterial line for monitoring and ABGs

• EM FACULTY 2 o Crowd control in stabilization room (quiet environment, no gallery) o Supervises SMAK placement in common femoral vessels (if done by G3) o TEE for monitoring o Ensures that cath lab is activated (backup to Team Leader [faculty #1]) o Coordinate with additional consulting services, if needed

• EM NURSE 1 & 2 o Establish cardiorespiratory monitoring and measure core temperature o Prepare heparin 5000 units IV bolus, to be given with cannulation o Transfer EMS pads to the ED defibrillator o Patient weight for drug dosing o Medication administration (e.g. sedatives, paralytics, calcium, sodium bicarbonate) o Prepare norepinephrine infusion at 0.1 mcg/kg/min o Prepare 2 liters of normal saline

• PERFUSIONIST (IF PRESENT) o Assist the ECMO nurse specialist and cannulating physician and serve as a double-

check on safety and sterility of the procedure


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11. CARDIAC ARREST MANAGEMENT

Prehospital Resuscitation

Cardiac arrest protocol as approved by the EMS Medical Director should be followed.

• For Hennepin EMS, this includes active compression-decompression (ACD) manual CPR and placement of an advanced airway with ventilation delivered through an impedance threshold device (ITD)

• Vascular access and medication management per protocol

• Paramedics should assess for Refractory Arrest inclusion criteria, and once accepted by medical control, early transport should be pursued if ROSC is not sustained after defibrillation attempt and an IV/IO anti-arrhythmic bolus

• Mechanical LUCAS CPR is used during transport

• Sodium bicarbonate 100 mEq (2 amps) IV/IO given empirically en route

Emergency Department Resuscitation

Continued cardiac resuscitation should proceed as directed by the Team Leader, with the following priorities:

• De-prioritize further epinephrine or defibrillation attempts

• Early definitive airway management

• CPR with minimal interruption, as guided by peripheral pulses and resuscitative transesophageal ultrasound

• Ensure patient is supine on the gurney (remove any devices from underneath the patient besides LUCAS backboard)

• Vascular access in common femoral artery and vein during CPR (using US guidance)

• Right upper extremity arterial catheter (in preparation for monitoring during V-A ECMO)


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12. INITATION OF E-CPR

• Bolus heparin 5,000 U intravenously

• Arterial cannulation o Must use fluoroscopy, ultrasound, or radiograph to demonstrate arterial wire position

prior to serial dilation o 15 Fr cannula preferred, 17 Fr cannula acceptable for patients with larger body

surface area

• Venous cannulation o Must use fluoroscopy or ultrasound to visualize the guidewire WITHIN the IVC o Continuous imaging recommended while advancing cannula into position o 25 Fr long cannula with tip ideally within the low right atrium

• Establish the extracorporeal circuit o The sterile tubing tray from the primed HLS kit will be placed on top of the

Cardiohelp unit by the ECMO RN specialist o The cannulating MD will clamp tubing inside of the sterile tray to exclude the priming

system, then take the closed loop out of the tray and brings it to the sterile field o An assistant will cut the tubing distal to the clamps o The cannulating MD will de-air the lines, briefly bleed (i.e. “flash”) the cannulas, and

connect tubing to cannulas using underwater seal

• Establish VA ECMO flow o Pump to 1,000 RPM before unclamping to prevent backflow o Ensure FDO2 1.0 and sweep gas flow 1 L/min o Unclamp venous and arterial lines o Increase RPM over 1-2 minutes targeting goal ECMO blood flow of 3-4 L/min o Monitor line pressures (Pvenous between -80 and -20 mmHg; Parterial <300 mmHg)

13. MAINTENANCE ON V-A ECMO

Mechanical CPR (e.g. LUCAS) should be stopped when VA ECMO blood flow has reached target (> 3 L/min) x 2 minutes and there is evidence of adequate peripheral perfusion (MAP > 50 mm Hg, normalization of SpO2). The following tasks should be strongly considered before transport to the cath lab:

• Crystalloid bolus 2 liters IV/IO

• Norepinephrine infusion at 0.1 mcg/kg/min

• Monitor perfusion: invasive BP via arterial line and tissue oximetry (StO2) probes on the bilateral forehead and lower legs


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14. PATIENT TRANSPORT

The patient should be accompanied by the cannulating physician (if not the interventional cardiologist), ICU fellow, ED RN, ECMO RN specialist, and respiratory therapist to the cath lab. The cannulating MD will provide a face to face sign out to the interventional cardiologist. If the patient achieves adequate hemodynamics to support recovery (defined further below) following angiography +/- (PCI), the patient will be met in the ICU by the critical care attending physician and fellow for a face-to-face sign-out from the interventional MD and/or ECMO cannulating physician. Standard procedures for in-hospital transfer of an ECMO patient should be followed at all times.

15. PROGNOSTICATION

Adequate hemodynamics to support recovery For this refractory arrest protocol, adequate hemodynamics implies adequate perfusion (as measured by MAP) to minimize ongoing tissue ischemia, as well as organized electrical activity of the heart at 60 minutes after arrival in the cardiac catheterization lab, if no reversible cause identified (or 90 minutes if PCI was performed).

• Organized electrical activity is defined as lack of persistent VF or refractory VT for at least 15 consecutive minutes after the following have been addressed: o Completion of treatment for reversible cause of VF/VT arrest (e.g. PCI of infarct

artery) o At least two anti-arrhythmic medications (e.g. amiodarone + lidocaine) o At least five attempts at defibrillation

• Adequate perfusion to minimize ischemia is defined as: o MAP >55 mmHg, regardless of organized cardiac contractility (organized

cardiac contractility on admission to the MICU is preferred, but not required) o Organized cardiac contractility (preferred but not required) is defined as:

▪ Spontaneous: pulse pressure >10 mmHg with ≥3 L/min of ECMO flow ▪ Assisted: pulse pressure >10 mmHg and/or demonstrable aortic valve

opening on echocardiography4 with turn-down of ECMO flow to 1 L/min ▪ TTE-assisted: demonstrable aortic valve opening on TTE without pulse

pressure >10 mmHg after ECMO turn down to 1L flow + dobutamine and/or

norepinephrine infusion for 10 minutes

4 The cardiac sonographer should be called when the patient arrives in the cath lab


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▪ IABP-assisted: Any valve opening with addition of IABP,

dobutamine/norepinephrine, and reduction in ECMO flow, regardless of pulse

pressure

• IABP placement is recommended for any patient who has undergone PCI if pulse pressure less than 20 mmHg or if there is evidence of hypoxemia on ABG sent from right upper extremity arterial line

• If the patient does not achieve adequate hemodynamics (MAP >55 mmHg and organized electrical activity for at least 15 minutes) to support recovery, despite cath lab interventions, while on VA ECMO support, two attending physicians (typically the ECMO cannulator and on-call non-interventional cardiologist) should agree that continued VA ECMO support and hospital admission would be non-beneficial and therefore not warranted. In this case, the team will cease resuscitative efforts, discontinue V-A ECMO, declare death, and a physician will notify the next of kin.

• A 6F or greater distal perfusion catheter (DPC) should be placed ipsilateral to the arterial cannula prior to transfer to the MICU

o 6 Fr Arrow braided sheaths preferred due to resistance to kinking

o Vascular ultrasound is available for DPC placement

o If DPC placement cannot be successfully completed after 15-20 minutes despite

multiple attempts, it is acceptable to defer DPC placement to the bedside in the

MICU (at the discretion of the interventional cardiologist).

o If DPC placement is deferred to MICU, it is the responsibility of the interventional

cardiologist to place the DPC at the bedside or to contact vascular surgery to

arrange placement.

• If not present on arrival to the cath lab, right radial arterial line should be placed before

transfer to the MICU to allow monitoring for differential hypoxemia.

ICU neuro-protection and prognostication

• Targeted temperature management, initially using the ECMO heater/cooler, should be maintained for 24 hours at 33.5 °C, followed by 36 °C for an additional 48 hours.

• After rewarming and cessation of sedatives and analgesics, the neurocritical care service should be consulted as appropriate

• The decision about duration of supportive care must be individualized to the patient’s circumstance, however, in most cases, withdrawal of life-sustaining therapy in the setting of severe anoxic encephalopathy should not occur before 5 days following initiation of the Refractory Arrest protocol. There is a growing experience around delayed myocardial or cerebral recovery (up to a week or more) after ECMO initiation

• Brain death determination should follow the institutional policy, with clinical exams followed by a confirmatory test (apnea test or brain perfusion scan). If the patient is unable to wean from ECMO due to hemodynamic instability or severe respiratory failure,


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the brain perfusion scan is the preferred confirmatory test. There are case series describing approaches to apnea testing during ECMO support (see references).

16. ECMO WEANING

Weaning from VA ECMO should commence in the ICU when there are signs of myocardial recovery. Weaning trials should follow standard practices for VA ECMO. This includes multidisciplinary morning rounds at 09:00 attended by the MICU physician and cardiology co-managing physician, among others, with support from a cardiac sonographer to document cardiac performance during the structured weaning trial (~30 minutes, see ECMO manual for details).

17. TRANSFER TO ADVANCED HEART FAILURE CENTER

VA ECMO patients should be considered for transfer to an advanced heart failure center for consideration of LVAD or orthotopic heart transplantation if they meet either of the following triggers:

• Discovery of underlying severe heart disease (e.g. LVEF <30%, pulmonary arterial hypertension, severe valvular disease) expected to inhibit cardiac recovery

• Lack of cardiac recovery after E-CPR, as manifest by inability to wean inotropes and/or lack of improvement in EF or VTI on daily weaning trial echo

Early and frequent communication between the consulting HCMC cardiologist and the advanced heart failure cardiologist is appropriate if there is no evidence of cardiac recovery after the initial 24-48 hours in the ICU. The decision to transfer requires consensus among the ICU physician, the co-managing cardiologist, and the advanced heart failure cardiologist.


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18. REFERENCES

The Alfred Hospital E-CPR guideline, Melbourne, Australia accessed on April 6, 2017 at: http://www.alfredicu.org.au/assets/Documents/ICUGuidelines/ECMO/ECMOCPRGuideline2012draft6.pdf Fagnoul D, Combes A, De Backer D. Extracorporeal cardiopulmonary resuscitation. Current Opinion in Critical Care 2014;20:259-65. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2014:1-7. Fair J, Tonna J, Ockerse P, et al. Emergency physician-performed transesophageal echocardiography for extracorporeal life support vascular cannula placement. Am J Emerg Med 2016;34:1637-9. Giani M, Scaravilli V, Colombo SM, et al. Apnea test during brain death assessment in mechanically ventilated and ECMO patients. Intensive Care Med 2016;42:72-81. Yannopoulos D, Bartos JA, Raveendran G, et al. Coronary Artery Disease in Patients With Out-of-Hospital Refractory Ventricular Fibrillation Cardiac Arrest. J Am Coll Cardiol 2017;70:1109-1117

19. CONTRIBUTORS

Primary Authors Date Department

Matt Prekker, MD 3/2/21 ECMO Medical Director

Beth Heather, RN ECMO Program Coordinator

Contributing Authors Department

Michele LeClaire, MD PCCM; Critical Care Ring Director

Gautam Shroff, MD Cardiology; CV Service Line Director

Lou Kohl, MD Cardiology; Assoc. ECMO Medical Director

Nick Simpson, MD EM / EMS; Assoc. ECMO Medical Director

Michelle Carlson, MD Cardiology; Assoc. ECMO Medical Director

http://www.alfredicu.org.au/assets/Documents/ICU-Guidelines/ECMO/ECMOCPRGuideline2012draft6.pdf

http://www.alfredicu.org.au/assets/Documents/ICU-Guidelines/ECMO/ECMOCPRGuideline2012draft6.pdf

https://www.ncbi.nlm.nih.gov/pubmed/28838358

https://www.ncbi.nlm.nih.gov/pubmed/28838358


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20. APPENDICES APPENDIX 1. Emergency Department Checklist for Refractory Arrest Protocol Candidate


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APPENDIX 2. Reference Card: Initial Vascular Access Using Micropuncture Kit (4F SMAK)


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APPENDIX 3. Working With Family of E-CPR Patient Prior to ICU Admission