title: Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).
abstract: BACKGROUND
  Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia.
  
  
  METHODS
  The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24h in the intensive care unit.
  
  
  RESULTS
  There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients.
  
  
  CONCLUSIONS
  A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.
authors.affiliation: Baker IDI Heart and Diabetes Research Institute, Australia; University of Washington, United States; St. Paul's Hospital, Vancouver, Canada.
authors.forename: Dion
authors.initials: D
authors.lastname: Stub
authors.affiliation: Alfred Hospital, Australia; Monash University, Australia; Ambulance Victoria, Australia. Electronic address: s.bernard@alfred.org.au.
authors.forename: Stephen
authors.initials: S
authors.lastname: Bernard
authors.affiliation: Alfred Hospital, Australia.
authors.forename: Vincent
authors.initials: V
authors.lastname: Pellegrino
authors.affiliation: Monash University, Australia; Ambulance Victoria, Australia; University of Western Australia, Australia.
authors.forename: Karen
authors.initials: K
authors.lastname: Smith
authors.affiliation: Ambulance Victoria, Australia.
authors.forename: Tony
authors.initials: T
authors.lastname: Walker
authors.affiliation: Alfred Hospital, Australia.
authors.forename: Jayne
authors.initials: J
authors.lastname: Sheldrake
authors.affiliation: Alfred Hospital, Australia.
authors.forename: Lisen
authors.initials: L
authors.lastname: Hockings
authors.affiliation: Alfred Hospital, Australia; Monash University, Australia; Baker IDI Heart and Diabetes Research Institute, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Shaw
authors.affiliation: Alfred Hospital, Australia; Monash University, Australia; Baker IDI Heart and Diabetes Research Institute, Australia.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Duffy
authors.affiliation: Alfred Hospital, Australia; Monash University, Australia.
authors.forename: Aidan
authors.initials: A
authors.lastname: Burrell
authors.affiliation: Alfred Hospital, Australia; Monash University, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Cameron
authors.affiliation: Alfred Hospital, Australia.
authors.forename: De Villiers
authors.initials: de V
authors.lastname: Smit
authors.affiliation: Alfred Hospital, Australia; Monash University, Australia; Baker IDI Heart and Diabetes Research Institute, Australia.
authors.forename: David M
authors.initials: DM
authors.lastname: Kaye
mesh_terms: D000328:Adult; D016887:Cardiopulmonary Resuscitation / Q000379:methods*; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D008875:Middle Aged; D015425:Myocardial Reperfusion; D058687:Out-of-Hospital Cardiac Arrest / Q000628:therapy*; D011446:Prospective Studies
keywords: Cardiac arrest; Extracorporeal membrane oxygenation; Resuscitation