Potential Candidates for Emergency Department Initiated Extracorporeal Cardiopulmonary Resuscitation (ECPR) in a Canadian Institution

Introduction Out-of-hospital cardiac arrest (OHCA) patients experience poor survival. The use of extracorporeal membrane oxygenation (ECMO), a form of heart-lung bypass, in the setting of cardiac arrest, termed extracorporeal cardiopulmonary resuscitation (ECPR), has promise in improving survival with good neurologic outcomes. The study objective was to determine the number of potential annual ECPR candidates among the OHCA population in a health region within the Atlantic Canadian province of Nova Scotia. Methods A retrospective chart review was conducted over a five-year period: January 1st, 2012 to December 31st, 2016. Consecutive non-traumatic OHCA and emergency department (ED) cardiac arrests occurring in a pre-determined catchment area (20-minute transport to ECMO center) defined by a geographic bounding box were identified. Criteria for ECPR were developed to identify candidates for activation of a “Code ECPR”: (1) age 16-70, (2) witnessed arrest, (3) no flow duration (time to CPR, including bystander) <10 minutes, (4) resuscitation >10 minutes without return of spontaneous circulation (ROSC), (5) emergency medical service (EMS) transport to hospital <20 minutes, (6) no patient factors precluding ongoing resuscitation (do not resuscitate status (DNR), palliative care involvement, or metastatic cancer), and (7) initial rhythm not asystole. Candidates were stratified by initial rhythm. Candidates were considered ultimately ED ECPR eligible if they failed conventional treatment, defined by death or resuscitation >30 minutes. Clinical data related to candidacy was extracted by an electronic query from prehospital and ED electronic records and manual chart review by three researchers. Results Our search yielded 561 cases of EMS-treated OHCA or in-ED arrests. Of those 204/561 (36%; 95% CI 33-40%) met the criteria for activation of a “Code ECPR”. Ultimately 79/204 (34%; 95% CI 28-41%) of those who met activation criteria were considered ED ECPR eligible; which is 14% (95% CI 11-17%) of the total number of arrests-of the total number of arrests, the initial rhythms were pulseless electrical activity (PEA) 33/79 (42%; 95% CI 32-53%) and shockable 46/79 (58%; 95% CI 47-69%). Conclusion Of all cardiac arrests in the area surrounding our ECMO center, approximately 41 per year met the criteria for a Code ECPR activation, with 16 per year ultimately being eligible for ED ECPR. This annual estimate varies based on the inclusion of initial rhythm. This provides insight into both prehospital and hospital implications of an ED ECPR program and will help guide the establishment of a program within our Nova Scotian health region. This study also provides a framework for similar investigation at other institutions contemplating ED ECPR program implementation.