EDECMO 15: The CHEER Trial & Part 2 of our Interview with Dr. Stephen Bernard

What this episode covers

In this episode Zack and Joe discuss the CHEER Trial (mechanical CPR, Hypothermia, ECMO, and Early Revascularization) and follow up with Dr. Stephen Bernard with a few more questions about ECMO at the Alfred. Just days after we published our initial interview With Dr. Stephen Bernard from the Alfred Hospital in Melbourne, Australia, the CHEER Trial was published. Background: Recently, we reviewed two big papers in the ECPR (Extracorporeal Cardiopulmonary Resuscitation) World: 1.) The Chen Trial (Lancet 2008): a large prospective observational study of in-house arreest (IHCA), out of Taiwan, that showed 32.6% (ECPR) benefit vs. 17% (non-ECPR); and 2.) The Save-J Trial (Resuscitation 2014): a large prospective observational study of Out-of-Hospital cardiac arrest (OHCA) that showed a 11.2% (ECPR) benefit vs. 2.6% (non-ECPR). Indeed these numbers are impressive! We all know that we need a randomized, controlled trial (RCT) but until then the guys at the Alfred Hospital in Melbourne, Australia decided to up the ante and published the initial findings of this pilot study. That study was called CHEER. This amounts to a hyper-aggressive, bundled protocol that begins on the street (EMS) and ends in the cath lab, whereafter world-class critical care has resulted in some remarkable initial numbers. CHEER (mechanical CPR, Hypothermia, ECMO, & Early Revascularization) This is a single-center, prospective, pilot study that was done over 32 months. The primary outcome measure was short and long-term outcomes at CPC 1 or 2 (excellent neurologic outcome). The guys down-under generated inclusion criteria to capture the most salvageable patients who suffered out-of-hospital cardiac arrest (OHCA), combined those with in-hospital cardiac arrest (IHCA) patients and applied the CHEER algorithm: * CPR (using the Zoll Autopulse) * Hypothermia (initiated intra-arrest with iced saline) * ECMO (cannulation in the ED by intensivists) * Early Revascularization (aka a trip to the cath lab) Zoll Autopulse (TM) And all this was begun in the prehospital setting. Since the EMS system in their neighborhood is a single-provider system, they were able to get support from Zoll Pharmaceuticals to supply all of their rigs with their mechanical chest compression device - the Zoll Autopulse . Patients who met inclusion criteria were met by EMS, put on the Autopulse, and transported to the Alfred. EMS also began intra-arrest cooling by rapid infusion of iced saline at 30cc/kg. On arrival to their Emergency Department, intensivists met the patient and began the cannulation process. Once on ECMO the patients were immediately brought to the cath lab for revascularization. IHCA patients received the identical protocol, obviously minus the limo ride to the hospital. In 2014 this amounts to a super-aggressive bundle therapy that just makes us salivate over here in the US. Initiating intra-arrest cooling and mechanical chest compressions in the pre-hospital setting is formidable goal for us. Their results: 26 patients were entered into the protocol (11 with OHCA, 15 with IHCA).

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