INCLUSION Criteria

Usual criteria

Overview

Inclusion criteria have been agreed upon to guide the clinician at the bedside to apply intensive care resources prudently and include patients who are thought to have improved chances of survival with ECPR. ECPR programs MUST prospectively quantify outcome and process metrics and undergo constant review to address application of ECPR with low survival outcomes (<10%).

OUTCOME METRIC

• CPC 1/2 Survival to Hospital Discharge
  • 40% IHCA
  • 20% OHCA

PROCESS METRICS

• Decision to ECMO Commencement Time: <30min
• Failed cannulation: <5%
• Annual ECLS Staff Participation in ECPR Simulation Training: >90%

General Inclusion criteria

*Does not apply to accidental hypothermia ** ROSC <20min is considered continuous cardiac arrest; ROSC >20min is considered as separate arrests, the longer cardiac arrest time is taken

* only OHCA, local experience Victorian ambulance and The Alfred ECPR program

* Only OHCA, local experience Victorian ambulance and The Alfred ECPR program

Additional factors

Factors that may also form part of the decision making at the bedside and favour inclusion

• Signs of life such as movements, breathing effort, gasping
• Any ROSC period during the arrest (only ROSC for 20min or greater would be considered separate arrest episodes)

Factors at the bedside that almost certainly favour exclusion

• Age >65
• End-tidal CO₂ less than 10 mmHg
• Femoral cannulation impossible (e.g. iliacofemoral occlusion / occluded IVC filter / severe peripheral vascular disease)
• Known aortic regurgitation > mild
• Presence of pericardial effusion or tamponade with suspected aortic dissection

Explanation

Age of patient – commonly available; if not available an approximate age may be used or alternatively “Time only” criterion

Call time – this is the activation time for the ambulance and reliably recorded

Cardiac arrest time

• Starts with ambulance call time (most reliable) if arrested on EMS arrival
• If arrest witnessed by ambulance, take recorded time
• ROSC for less than 20min is considered continuous cardiac arrest
• If ROSC >20min take longest cardiac arrest as the reference time

Witnessed arrest – visual or acoustic witness is included e.g. heard thud from collapse impact, heard to be gasping

Shockable rhythm – this refers to initial rhythm, irrespective of subsequent rhythms or rhythm on arrival to the ED

Bystander CPR – as judged by the ambulance whether performed or not. No CPR for greater than 5 min also considered no bystander CPR

End-stage disease includes

• Severe disability impairing activities of daily living
• End-stage organ disease – cardiac, liver, lung, renal
• Other life-limiting diseases e.g. malignancy, terminal illness
• Advanced healthcare directive

Special circumstances

Include arrests in the cath lab, accidental hypothermia and selected toxicology cases

Cardiac arrest in the Cath Lab

ONLY patients who fulfill the following are considered for ECPR

ALL Prerequisites + ALL Minimum Criteria

Prerequisite – ALL required

• Considered suitable for ECPR by the interventional cardiologist
• Early cardiac arrest (<20 min)
• Without significant peripheral mottling/ lactate rise (>10 mmol/L)

*Only for patients in cardiac catheter lab with all prerequisites fulfilled

For patients in cardiogenic shock, principally the same criteria apply if shock is not expected to imminently reverse with the interventional procedure.

Decision making process regarding urgent ECMO initiation in the cath lab

Suitability for ECPR in the cath lab in the event of a cardiac arrest should be determined by the procedural cardiologist prior to commencing the cardiac procedure, based on their personal opinion but only if the minimal criteria are also met. Ideally this decision will be documented in a visible location and be part of the pre-procedural time out. If the patient is ineligible for ECMO initiation by not fulfilling ALL minimum criteria, but the procedural cardiologist considers them appropriate, the patient should be discussed with the ECMO ICU consultant prior to the cath lab procedure commencing.

ECMO cannulation should only be performed by ICU and cardiology consultants credentialed by Alfred Health.

Accidental hypothermia

Hypothermia in response to environmental conditions represents an exception. The usual Inclusion Criteria do not apply and the condition is generally considered favourable. Hypothermic cardiac arrests are uncommon in the Australian setting. The factors included in the HOPE score, a predictive outcome tool, are listed below. It should not replace but may assist the clinical decision process.

• Patient age, gender
• Hypothermia with asphyxia (head fully covered by water or snow) AND in cardiac arrest at extrication vs without asphyxia (immersion, outdoor or indoor cold exposure) – better outcomes without asphyxia
• Serum potassium (hyperkalaemia has a high negative predictive value – no survivor in literature >12 mmol/L) marker for cell death/hypoxia before cooling occured
• CPR duration
• Core body temperature (cooler patients have a higher likelihood of survival)

Other exceptions

Other exceptions included selected toxicology cases where prolonged CPR times have yielded survival even without ECMO.