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A comprehensive regional clinical and educational ECPR protocol decreases time to ECMO in patients with refractory out-of-hospital cardiac arrest

  • Brian Grunau (a1) (a2) (a3), Sarah Carrier (a1), Jamil Bashir (a1) (a4), William Dick (a2) (a5), Luke Harris (a1), Robert Boone (a1) (a6), Dan Kalla (a1) (a2), Frank Scheuermeyer (a1) (a2), Brian Twaites (a5), Ron Straight (a5), James Abel (a1) (a4), Ken McDonald (a1) (a7), Ruth MacRedmond (a1) (a8), David Agulnik (a1) (a2) (a5), Joe Finkler (a1) (a2), Jeanne MacLeod (a1) (a2), Jim Christenson (a1) (a2) and Anson Cheung (a1) (a6)...

Abstract

Objective

Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival for refractory out-of-hospital cardiac arrest (OHCA). We developed a prehospital, emergency department (ED), and hospital-based clinical and educational protocol to improve the key variable of time-to-ECPR (TTE).

Methods

In a single urban health region we involved key prehospital, clinical, and administrative stakeholders over a 2-year period, to develop a regional ECPR program with destination to a single urban tertiary care hospital. We developed clear and reproducible inclusion criteria and processes, including measures of program efficiency. We conducted seminars and teaching modules to paramedics and hospital-based clinicians including monthly simulator sessions, and performed detailed reviews of each treated case in the form of report cards. In this before-and-after study we compared patients with ECPR attempted prior to, and after, protocol implementation. The primary outcome was TTE, defined as the time of initial professional CPR to establishment of extracorporeal circulation. We compared the median TTE for patients in the two groups using the Wilcoxon signed rank test.

Results

Four patients were identified prior to the protocol and managed in an ad hoc basis; for nine patients the protocol was utilized. Overall favourable neurological outcomes among ECPR-treated patients were 27%. The median TTE was 136 minutes (IQR 98 - 196) in the pre-protocol group, and 60 minutes (IQR 49 - 81) minutes in the protocol group (p=0.0165).

Conclusion

An organized clinical and educational protocol to initiate ECPR for patients with OHCA is feasible and significantly reduces the key benchmark of time-to-ECPR flows.

Objectif

L’oxygénation par circulation extracorporelle (OCEC) en cours de réanimation cardiorespiratoire (RCR) peut améliorer la survie dans les cas d’arrêt cardiaque extrahospitalier (ACEH) réfractaire. Aussi avons-nous élaboré un protocole clinique et éducatif reposant sur le milieu préhospitalier, le service des urgences et le milieu hospitalier afin d’améliorer la principale variable temporelle liée à la RCR+OCEC.

Méthode

Des représentants importants des milieux préhospitalier, clinique et administratif ont travaillé, sur une période de deux ans, à l’élaboration d’un programme de RCR+OCEC dans une région sanitaire urbaine en vue du transport de malades vers un seul centre hospitalier de soins tertiaires, situé en ville. Ont été établis des critères d’inclusion et des processus précis et reproductibles, y compris des mesures d’efficacité du programme. Nous avons tenu des séminaires, préparé des modules d’enseignement à l’intention des ambulanciers paramédicaux et des cliniciens hospitaliers, organisé des séances mensuelles de formation par simulation, et procédé, sous forme de fiche, à l’examen détaillé de chacun des cas traités. Dans cette étude de type avant-après, il y a eu comparaison des patients soumis à des tentatives de RCR+OCEC avant et après la mise en œuvre du protocole. Le principal critère d’évaluation consistait en la mesure du temps écoulé avant la RCR+OCEC, défini comme le temps passé depuis le début des manœuvres de RCR par des professionnels jusqu’à l’établissement de la circulation extracorporelle. Nous avons comparé le temps médian écoulé avant la RCR+OCEC dans les deux groupes de patients à l’aide du test de Wilcoxon pour observations appariées.

Résultats

Quatre patients ont été retenus avant la mise en œuvre du protocole et pris en considération de façon ponctuelle, tandis que neuf autres patients ont été soumis au protocole. La proportion de résultats neurologiques favorables chez les patients traités par la RCR+OCEC a atteint, dans l’ensemble, 27%. Le temps médian écoulé avant la RCR+OCEC était de 136 minutes (écart interquartile [EIQ] : 98-196) dans le groupe antérieur à la mise en œuvre du protocole et de 60 minutes (EIQ : 49 - 81) dans le groupe soumis au protocole (p=0,0165).

Conclusion

Les résultats de l’étude montrent qu’il est possible d’élaborer un protocole clinique et éducatif sur la pratique de la RCR+OCEC chez les patients victimes d’un ACEH, et que celui-ci permet de réduire considérablement la principale valeur de référence liée au temps écoulé avant la RCR+OCEC.

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Copyright

Corresponding author

Correspondence to: Dr. Brian Grunau, 1081 Burrard Street, Vancouver, BC V6Z 1Y6; Email: Brian.Grunau2@vch.ca

References

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