Resuscitation 85 (2014) 709–710
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Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
A bridge to life: ECPR who, when, where and why?
The outcome after out-of-hospital cardiac arrest (OHCA) remains poor. Even if rates of return of spontaneous circulation (ROSC) are as high as 50% depending on the country and the emergency medical system (EMS), rates of good neurological outcome (CPC 1 and 2) remain low. In subgroups such as witnessed cardiac arrest and shockable cardiac rhythms combined with high quality post resuscitation care (including use of therapeutic hypothermia (TH), normoxia, and early coronary reperfusion, and treatment of electrolyte disorders, seizures and pneumonia) rates of CPC 1 and 2 categories are as high as 25–30%.1 Many studies have dealt with the optimisation of the compression–ventilation ratio or compression depth and rate in cardiopulmonary resuscitation (CPR), fractional inspired oxygen, use of therapeutic hypothermia, vasopressors, thrombolysis, early percutaneous coronary intervention (PCI), supportive intensive care and ischaemia reperfusion treatment, and the reduction of no-flow time with bystander CPR, telephone CPR and early defibrillation (AEDs).2 Devices such as mechanical compression or impedance threshold valves have also been studied.3 Within the last few years there have been increasing numbers of reports on the use of emergency extracorporeal circulation for inhospital cardiac arrest (IHCA) for children and later for adults as a bridge to definitive therapy and to increase the time window for identification and treatment of a reversible underlying cause. Extracorporeal CPR (ECPR) generates a circulation to provide sufficient oxygen to the brain and other organs and controls reperfusion to minimise ischaemia reperfusion injury.4–6 Extracorporeal CPR for OHCA has produced promising results in specialised settings.7–9 In this issue, Sakamoto et al.10 from the SAVE-J study group in Japan report results of their prospective observational study on ECPR versus conventional CPR for patients with OHCA and no ROSC on arrival in the emergency department. During 3.5 years, 546 patients in 46 hospitals were screened for this study. The authors should be congratulated, as this is by far the biggest study evaluating ECPR in OHCA. Two hundred and sixty patients were treated in the ECPR group and 194 were treated in the non-ECPR group. Each hospital participating in the study chose whether to be in the ECPR or non-ECPR group. In the ECPR group, patients received significantly more mild therapeutic hypothermia (91.5% vs. 54.1%), were more commonly treated with an intra-aortic balloon pump (IABP) (92.7% vs. 62.2%) and had an overall better outcome (12.4% vs. 3.1%). The study has major limitations: the participating hospitals were not randomised inevitably causing significant bias. One must hypothesise that a hospital using ECPR is keen to prove an advantage for their preferred therapy. Use of TH and IABPs were significantly less in the non-ECPR group. Besides the selection bias http://dx.doi.org/10.1016/j.resuscitation.2014.03.315 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
of the centres, the difference in the post resuscitation care makes the two groups difficult to compare. As ECPR is not easy to establish, needs well trained personnel and is expensive, the following questions need to be raised: when, where, and why should ECPR be considered in patients with OHCA and who should be considered for such therapy. The mere existence of an extracorporeal membrane oxygenation (ECMO) device does not justify its use. So far there is no clear answer to the question ‘who’ should receive such a therapy. A strict protocol using inclusion and exclusion criteria is essential: is it age (