Modeling Hospital-Wide Extracorporeal Cardiopulmonary Resuscitation: Pros and Cons

Abstract

Background: We aimed to analyze the potential benefits of implementing a hospital-wide extracorporeal cardiopulmonary resuscitation (ECPR) protocol. Methods: We analyzed in-hospital cardiac arrests in a large, academic hospital for two consecutive years. For this model, we assumed that ECPR would be started in all adults, with no upper age limit, who have a full code status. We excluded codes lastingminutes, arrests with asystole as an initial rhythm, and patients with hemorrhagic shock or who coded due to new stroke (contraindications for anticoagulation). We calculated how many extra lives could be saved per year if ECPR was initiated during each code meeting these criteria. Results: During two consecutive years, a total of 710 in-hospital cardiac arrests occurred. We excluded 91 codes due to bleeding or new stroke, 96 cases with asystole as an initial rhythm, and 206 codes lasting less than 15 minutes. In the remaining 317 codes, ECPR could have been used. In 229 cases out of 317, patients survived conventional CPR, so ECPR would be futile. Out of remaining 88 codes, only 38 (3.5%) were due to reversible cardiac or non-cardiac emergencies and resulted in death. They could have favorable outcomes if ECPR was used. Using the Extracorporeal Life Support Organization data, survival to discharge after ECPR is about 30%. So, we estimate that 13 patients (1.2%) could have been saved in 2 years, or ~7 patients per year. Considering 317 veno-arterial extracorporeal membrane oxygenation (VA ECMO) initiations, the ratio would be 24.4 VA ECMO initiations per one life saved. Conclusion: An implementation of a hospital-wide ECPR could change outcomes from unfavorable to favorable in 1.2% of patients, at the cost of initiation of 24.4 VA ECMO initiations per one life saved.