Jonathan Chen

Jonathan completes his general medicine and intensive care medicine training this year, having graduated from Otago in 2008. He believes strongly in equity of access to healthcare for all New Zealanders, having completed his basic training the the regions. Outside of work, he loves spending time with his wife and 2 daughters, watching cricket, wine tasting, beer drinking and cooking.

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An Australasian First: Management of Accidental Hypothermic Cardiac Arrest (AHCA) with Veno-Arterial Extra-Corporeal Membranous Oxygenation (VA-ECMO)​

Case:
A 38-year old woman, wearing a life-jacket, was swamped due to a fishing boat motor failure. There was no history of submersion, although it is likely there was aspiration and ingestion of sea water. She was rescued after 90-120 minutes in the water.
She was profoundly hypothermic but breathing spontaneously with a GCS of 9. During helicopter loading, she became unresponsive and pulseless, requiring 3 minutes of CPR before return of spontaneous circulation. Twenty minutes prior to arrival at our institution, she arrested again necessitating CPR within the helicopter. On arrival, she was found to be in VF. Advanced life support was performed. Initial blood gas demonstrated a pH of 6.65, lactate 23.0 and K+ of 6.8. Her temperature was <28°C. She was immediately referred for consideration of urgent VA-ECMO. Asystole developed fifteen minutes after arrival. 

Trans-oesophageal echocardiography-guided peripheral ECMO cannulation was performed. Time from CPR until establishment of ECMO flow was 65 minutes. Early during the rewarming phase, she developed VF and was successfully defibrillated into sinus rhythm. 
Recovery was complicated by myocardial stunning and poor lung compliance. However, steady improvement allowed successful decannulation from ECMO 44 hours after its initiation with subsequent extubation then discharge from hospital 6 days following presentation. Her Montreal Cognitive Assessment prior to discharge was 22/30.
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Discussion:
Extracorporeal cardiopulmonary resuscitation (E-CPR) is increasingly utilised with some impressive neurologically-intact survival data1.  Consequently, there has been a 10-fold increase in worldwide E-CPR recipients between 2003-20142. Benefits in accidental hypothermic cardiac arrest (AHCA) are dual, with simultaneous restoration of cardiac and cerebral perfusion, and circulatory rewarming. Internationally, there have been neurologically intact survivors with time from AHCA until institution of extracorporeal circulation of up to 292 minutes3. A national ECMO retrieval service is operated by the Cardiovascular Intensive Care Unit (CVICU) at Auckland City Hospital.

Conclusion:
Patients with refractory AHCA anywhere in NZ could be salvaged with E-CPR.

Practise Point:
Consultation with the national ECMO retrieval service should occur early for all cases of AHCA, regardless of location.

References:

1. Stub et al., 'Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial)', Resuscitation, Volume 86, p88 - 94.
2. Richardson et al., 'ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years', Resuscitation. Volume 112, p34-40.
3. Hilmo, Naesheim and Gilbert, '“Nobody is dead until warm and dead”: Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas – A retrospective study from northern Norway', Resuscitation, Volume 85, p1204–1211.