ECPR Survivor Estimates: a simulation-based approach to comparing ECPR delivery strategies

Abstract

Objective The number of out-of-hospital cardiac arrest (OHCA) patients who may benefit from prehospital extracorporeal cardiopulmonary resuscitation (ECPR) is yet to be elucidated. Patient eligibility is determined both by case characteristics and physical proximity to an ECPR service. We applied accessibility principles to historical cardiac arrest data, to identify the number of patients who would have been eligible for prehospital ECPR in Sydney, Australia, and the potential survival benefit had prehospital ECPR been available. METHODS The New South Wales cardiac arrest registry between January 2017 to June 2021 included 39,387 cardiac arrests. We retrospectively defined two groups: 1) possible ECPR eligible arrests that would have triggered activation of a team, and 2) ECPR eligible arrests, those arrests that met ECPR inclusion criteria and remained refractory. Transport accessibility modelling was used to ascertain the number of arrests that would have been served by a hypothetical prehospital service and the potential survival benefit. RESULTS There were 699 arrests screened as possibly ECPR eligible in the Sydney metropolitan area, 488 of whom were subsequently confirmed as ECPR eligible refractory OHCA. Of these, 38% (n =185) received intra-arrest transfer to hospital, with 37% (n = 180) arriving within 60 minutes. Using spatial and transport modelling, a prehospital team located at an optimal location could establish 437 (90%) patients onto ECMO within 60 minutes, with an estimated survival of 48% (IQR 38-57). Based on existing survival curves, compared to conventional CPR, an optimally located prehospital ECPR service has the potential to save one additional life for every 3.0 patients. CONCLUSIONS A significant number of historical OHCA patients could have benefited from prehospital ECPR, with a potential survival benefit above conventional CPR.