Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport

Cindy H Hsu; William J Meurer; Robert Domeier; Jennifer Fowler; Sage P Whitmore; Benjamin S Bassin; Kyle J Gunnerson; Jonathan W Haft; William R Lynch; Brahmajee K Nallamothu; Renee A Havey; Kelley M Kidwell; William C Stacey; Robert Silbergleit; Robert H Bartlett; Robert W Neumar

doi:10.1016/j.annemergmed.2020.11.011

Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport

Ann Emerg Med. 2021 Jul;78(1):92-101. doi: 10.1016/j.annemergmed.2020.11.011. Epub 2021 Feb 1.

Authors

Cindy H Hsu¹, William J Meurer², Robert Domeier³, Jennifer Fowler⁴, Sage P Whitmore⁴, Benjamin S Bassin⁵, Kyle J Gunnerson⁵, Jonathan W Haft⁶, William R Lynch⁶, Brahmajee K Nallamothu⁷, Renee A Havey⁴, Kelley M Kidwell⁸, William C Stacey⁹, Robert Silbergleit⁴, Robert H Bartlett¹⁰, Robert W Neumar¹¹

Affiliations

¹ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. Electronic address: hcindy@med.umich.edu.
² Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Neurology, University of Michigan Medical School, Ann Arbor, MI.
³ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Saint Joseph Hospital, University of Michigan Medical School, Ann Arbor, MI.
⁴ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI.
⁵ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI.
⁶ Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI.
⁷ Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI.
⁸ Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI.
⁹ Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI.
¹⁰ Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI.
¹¹ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI.

Abstract

Study objective: Outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest depend on time to therapy initiation. We hypothesize that it would be feasible to select refractory out-of-hospital cardiac arrest patients for expedited transport based on real-time estimates of the 911 call to the emergency department (ED) arrival interval, and for emergency physicians to rapidly initiate ECPR in eligible patients.

Methods: In a 2-tiered emergency medical service with an ECPR-capable primary destination hospital, adults with refractory shockable or witnessed out-of-hospital cardiac arrest were randomized 4:1 to expedited transport or standard care if the predicted 911 call to ED arrival interval was less than or equal to 30 minutes. The primary outcomes were the proportion of subjects with 911 call to ED arrival less than or equal to 30 minutes and ED arrival to ECPR flow less than or equal to 30 minutes.

Results: Of 151 out-of-hospital cardiac arrest 911 calls, 15 subjects (10%) were enrolled. Five of 12 subjects randomized to expedited transport had an ED arrival time of less than or equal to 30 minutes (overall mean 32.5 minutes [SD 7.1]), and 5 were eligible for and treated with ECPR. Three of 5 ECPR-treated subjects had flow initiated in less than or equal to 30 minutes of ED arrival (overall mean 32.4 minutes [SD 10.9]). No subject in either group survived with a good neurologic outcome.

Conclusion: The Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest trial did not meet predefined feasibility outcomes for selecting out-of-hospital cardiac arrest patients for expedited transport and initiating ECPR in the ED. Additional research is needed to improve the accuracy of predicting the 911 call to ED arrival interval, optimize patient selection, and reduce the ED arrival to ECPR flow interval.

Trial registration: ClinicalTrials.gov NCT03065647.

Publication types

Randomized Controlled Trial
Research Support, N.I.H., Extramural

MeSH terms

Cardiopulmonary Resuscitation / methods*
Emergency Medical Services*
Emergency Service, Hospital
Feasibility Studies
Female
Humans
Male
Michigan
Middle Aged
Out-of-Hospital Cardiac Arrest / therapy*
Time-to-Treatment

Associated data

ClinicalTrials.gov/NCT03065647

Abstract

Publication types

MeSH terms

Associated data

Grants and funding