ARREST trial - early ECMO for refractory OHCA

[SpacemanSpifff]

Published recently in Lancet, presented at AHA ReSS today by the senior author, Yannopoulos (free PDF here).

Obviously the Minnesota system has been building towards this trial for years, with a ton of leg work obtaining institutional buy in and in the prehospital arena getting their EMS systems trained. Small trial (N=30), but huge effect size - survival to discharge in early ECMO arm >40% compared to 6% in standard ACLS group. Stopped early due to posterior Bayesian probability randomization design, which I can't pretend to totally understand...

Anyone have prehospital ECMO activations in place for favorable patients (young, witnessed, VF/VT, etc.)? Our system has a rough protocol in place, but we have only had 3-4 activations in the first 6 months in a major metropolitan area.

Plus their metrics are insane - mean time from 911 call to cannulation <60 min?! I definitely wonder if this is achievable in other systems.

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[Modanq]

Excellent study. We are already knee deep into our eCPR program both surgery and anesthesia/icu run. Mobile and eCPR

 

[WheezyBaby]

Didn't read the entire study yet, and skimmed the article for citation 10 that mentioned some more nitty gritty about their process, so maybe it's mentioned somewhere but I didn't see it. Who makes up the ECMO team and who's doing the actual cannulation?

 

[SpacemanSpifff]

Didn't read the entire study yet, and skimmed the article for citation 10 that mentioned some more nitty gritty about their process, so maybe it's mentioned somewhere but I didn't see it. Who makes up the ECMO team and who's doing the actual cannulation?

Here's an additional publication that describes the ground work and process that went into forming the entire system.

"Each mobile ECMO cannulation team consisted of three members: one senior cannulating physician, one sterile assistant, and one non-sterile assistant. Assistants were critical care-experienced paramedics/nurses or physicians. Ten physicians and 9 critical careexperienced paramedics/nurses from all four healthcare systems participated. Physicians performing the cannulations were specialized in interventional cardiology, emergency medicine, and critical care."

 

[Modanq]

I believe at UM they a mixture of Docs as listed above. But they do have a direct to cath lab pathway.
The main point is that this is no longer just CT surgeons but CCM, ER, Anesthesiology, IC, CT Surg, putting people on ECMO. As seen around the country. Most importantly, if you put them on ECMO you should take care of them afterwards. Thats huge in my opinion.

 

[lymphocyte]

Yannopoulos is a beast and has also done some interesting animal studies on sodium nitroprusside as opposed to adrenaline in cardiac arrest.

At the 30 minute mark of this video, he demonstrates an actual case. The systems level barriers to implementing this are massive, which is what makes the Minnesota system so impressive.

 

[SpacemanSpifff]

Yannopoulos is a beast and has also done some interesting animal studies on sodium nitroprusside as opposed to adrenaline in cardiac arrest.

At the 30 minute mark of this video, he demonstrates an actual case. The systems level barriers to implementing this are massive, which is what makes the Minnesota system so impressive.

Absolutely. It would have been very interesting to have been in on the meetings when the MRC was being formed. Navigating the amount of ego involved, figuring out the finances... I can’t imagine this happening in my practice environment currently.