The Bottom Line - January 1, 2015
"Authors' Conclusions
- A protocol involving ECMO-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate
Strengths
- The results for this study are impressive. It is difficult not to take notice of survival rates with CPC 1-2 of 54% in a group of patients with prolonged periods of cardiac arrest
- Protocolised resuscitation therapy driven by clinical teams and with engagement of pre-hospital Emergency Medical Services sounds sensible and based on this data correlates to important outcome benefits
- The manufacturers of Autopulse donated their device. They had no input into study preparation, analysis, results or publication. This is an example of a good collaboration between clinical research and industry support
- Historically, pre hospital Emergency Medical Services were authorised to cease resuscitation after 30 minutes of CPR unless compelling reasons to continue such as hypothermia were present. 5 patients therefore survived with good neurological recovery who would have otherwise been pronounced dead
Weaknesses
- This is a pilot observational study. It included very small numbers of selected patients in a single and specialist ECMO center. The authors clearly acknowledge this limitation
- The patients in the OHCA group had defined inclusion criteria including a time stipulated for refractory cardiac arrest (>30 minutes). The IHCA group did not and were a very selective cohort. In one patient, the time from collapse to initiation of ECMO was 27 minutes (impressive!). Whether these patients may have had equivalent outcomes with conventional treatment is unknown. Certainly comparison with historical studies dramatically favours the CHEER protocol in these small numbers
The Bottom Line
- The CHEER protocol has been shown to improve survival with favourable neurological outcome following cardiac arrest compared with historical data. It works and works very well in this experienced ECMO centre, with engagement of pre-hospital services and as part of a bundle. A multi-centre RCT is now required to determine if these impressive results can be replicated."
http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=2469070912831268058