The goal of the clinical trial is to learn if early extracorporeal life support ( ECLS ) will save more out-of-hospital cardiac arrest ( OHCA ) patients with good neurological outcome. It will also learn if emergency ECLS is safe in the OHCA rescue. Researchers aim to investigate if emergency total ECLS is better than standard advanced cardiac life support ( ACLS ) first, followed by bailout ECMO if required, for survival with favorable neurological outcome in OHCA patients. Participants meeting criteria of OHCA with witness, bystander CPR, shockable initial rhythm with repeated defibrillation, and transport time less than 30 min will be compared between total ECLS versus standard ACLS first with bailout ECMO protocols. All participants will receive emergency interventional coronary revascularization , intensive care unit therapy , cardiac ward care and up to 180 days of clinical follow up after survival .
Out-of-hospital cardiac arrest ( OHCA ) is a highly lethal emergency, unless return of spontaneous circulation ( ROSC ) is timely achieved by efficient and effective resuscitation. Nevertheless, despite advanced cardiopulmonary resuscitation ( CPR ) with mechanical chest compression, assisted ventilation and automatic external defibrillation, the survival of OHCA patients remains below 10%. Extracorporeal membranous oxygenation ( ECMO ) facilitated life support ( ECLS ) could help hemodynamic stability and improve significantly the survival of refractory OHCA to 25-40 %. On the other hand, the precise role and timing of the ECLS during the emergency management of OHCA remains largely unestablished. In the present study, we hypothesized that emergency total ECLS is superior to standard ACLS with ECMO bailout for survival with favorable neurological outcome in refractory out-of-hospital cardiac arrest. All OHCA patients meeting the including criteria, i.e. age 18-75 years, witnessed cardiac arrest with bystander CPR, initial shockable rhythm as ventricular fibrillation or pulseless ventricular tachycardia ( VF/pVT ), repeated defibrillation shocks and escorted transportation within 30 minutes from 119 call to arriving emergency department ( ED ) in the hospital would be recruited. Eligible patients will be consecutively randomized at ED in 1:1 ratio, stratified by hospitals, into emergency total ECLS group and standard ACLS with ECMO bailout group. Informed consent is waived in the life-threatening emergency condition. For emergency total ECLS group, OHCA patients will receive early implantation and initiation of ECMO circulation within 15 minutes after randomization or up to 45 minutes after 119 call. For standard ACLS with ECMO bailout group, OHCA patients will receive standard ACLS for at least 45 minutes after collapse or 119 call or at least 15 minutes after ED arrival before calling for bailout ECMO if required. Following return of spontaneous systemic circulation (ROSC) or depending on ECMO circulation, both groups would be transferred to brain and chest computer tomography screening, emergency coronary revascularization intervention and subsequent intensive cardiac care with targeted hypothermia management. Survivals will be treated with guideline directed medical therapy for reduced ejection fraction heart failure and/or implantable cardioverter-defibrillator implantation for prevention of recurrent VT/VF in wards. All survivals will be followed up for medical and neurological status at 30 days, 90 days and 180 days after discharge. Primary endpoint is survival with favorable neurological outcome at 30 days. Secondary endpoints are survival to discharge with favorable neurological outcome, survival with favorable neurological outcome at 180 days, total duration of cardiopulmonary resuscitation ( CPR ), total duration of mechanical ventilation, total duration of intensive care unit stay, total duration of hospitalization. Safety endpoints will be incidence of serious adverse events related to prolonged CPR, prolonged ischemia, and ECMO systemic perfusion and coronary reperfusion. The number of subjects to be enrolled according to the primary endpoint of 30 days survival with favorable neurological outcome. With a power of 80%, accepting the level of statistical significance at alpha= 0.05 and based on two-sided Chi-Square test, we estimated 166 participants per arm are needed. This is based on the 30% success rate and 15% success rate of 30-day survival with good neurological outcome of emergency total ECLS intervention and standard ACLS with bailout ECMO (if required) intervention, according to previous trials, plus a 10% drop out rate. Based on two-tailed test, p less than 0.05 is considered statistical significance. If interim analysis is deemed necessary, the significance level will be adjusted accordingly using Bonferroni method. Because of no interim analysis and no stopping point in ITT protocol, there is no criteria for premature termination of the trial. The missing data of the primary and secondary efficacy outcomes will be considered as failure for ITT analysis. Last observations carry forward method will be adapted for the missing data of repeated measurements. The data record will be monitored and audited by the Institutional Review Board of the TMU Shuangho hospital as well as the Data and Safety Monitoring Plan committee.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
332
ECMO supported life support for cardiopulmonary resuscitation in refractory OHCA
Standard ACLS in cardioplumonary resuscitation of refractory OHCA
Shuang Ho Hospital
New Taipei, Taiwan, Taiwan
The rate of survival with favorable neurological outcome ( modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) at 30 days after discharge from hospital, in percentage
After survival discharge from hospital, clinical followup at out-patient clinic or by visual phone interview is conducted to assess medical health status as well as neurological status of the patients at 30 days after discharge from hospital. Survival with favorable neurological outcome ( i.e. modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) is to be measured as percentage of all randomized patients fulfilling inclusion criteria and without any exclusion criteria.
Time frame: From randomization to 30 days after survival discharge from hospital
Total duration of cardioplumonary resuscitation from on-site CPR by EMS till the stable ROSC or initiation of ECMO life support or the decease of the subject at emergency department up to 30 days after randomization, in minutes
total duration of standard cardiopulmonary resuscitation ( CPR ) is counted from the start of on-site CPR by emergency medical service ( EMS ) till the stable return of spontaneous circulation ( ROSC ) or initiation of ECMO life support or the decease of the subject at emergency department ( ED ) up to 30 days after randomization. The measure is in minutes.
Time frame: From the start of on-site CPR by EMS till the return of stable ROSC or the initiation of ECMO life support or the decease of the subject at the emergency department up to 30 days after randomization, in minutes
The rate of survival with favorable neurological outcome ( modified Rankin score less than 3 or CPC scale 1 or 2 ) from the date of randomization to the date of discharge from hospital up to 180 days after randomization, in percentage
At discharge from hospital, patient status is assessed as survival or mortality. The rate of survival with favorable neurological outcome ( modified Rankin score \<3 or CPC scale 1 or 2 ) is counted from the date of randomization to the date of discharge from hospital up to 180 days after randomization. The rate of survival is measured as percentage of total randomization number.
Time frame: From the date of randomization to the date of discharge from hospital up to 180 days after randomization, in percentage.
The rate of survival with favorable outcomes ( modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) at 90 days after discharge from hospital, in percentage
After patients survived and discharged from hospital, clinical followup at out-patient clinic or by visual phone interview is conducted to assess medical health as well as neurological status at 90 days after discharge. The rate of survival with favorable neurological outcome ( i.e. modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) is measured as percentage of all randomized patients fulfilling inclusion criteria and without any exclusion criteria.
Time frame: From the date of randomization to 90 days after survival discharge from hospital
The rate of survival with favorable outcomes ( modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) at 180 days, in percentage
After patients discharged from hospital, clinical followup at out-patient clinic or by visual phone interview is conducted to assess medical health as well as neurological status at 180 days after discharge. The rate of survival with favorable neurological outcome ( i.e. modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) is measured as percentage of all enrolled patients fulfilling inclusion criteria and without any exclusion criteria.
Time frame: From enrollment to the end of treatment at 180 days
total duration of mechanical ventilation from randomization to discharge from hospital or up to 180 days after randomization , in days
The total duration of assisted mechanical ventilation by volume cycle or pressure cycled artificial ventilators from randomization at the emergency department to discharge from hospital or up to 180 days after randomization, measured in days.
Time frame: From randomization at the emergency department to discharge from hospital or up to 180 days after randomization
total duration of stay in intensive care ward from randomization to discharge from hospital or up to 180 days after randomization , in days
The total duration of stay in intensive care ward from randomization to discharge from hospital or up to 180 days after randomization. The intensive care ward is to provide cardiovascular hemodynamic support, assisted mechanical ventilation, targeted temperature therapy ( if needed ) and infection control, whenever needed. The measure is in days.
Time frame: From the date of randomization to the date of discharge from hospital or up to 180 days after randomization
total duration of hospitalization from the date of randomization to the date of discharge or up to 180 days after randomization , in days
total duration of stay in the hospital from the date randomization at emergency department to the date discharge from hospital or up to 180 days after randomization, survived or deceased. The measure in in days.
Time frame: From the date of randomization to the date of discharge from hospital or up to 180 days after randomization, survived or deceased.
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