The use of a heart-lung machine for resuscitation has no added value in the Netherlands. This is the conclusion of researchers from Maastricht UMC+ in NEJM.
To this end, Van de Poll and colleagues set up a multicenter study in which ten Dutch hospitals participated. ‘Virtually everyone in the Netherlands who works with ECMO has participated in the study.’ Between May 2017 and February 2021, they collectively included 134 patients who experienced out-of-hospital cardiac arrest. Based on randomization, 70 patients ended up in the ECMO group and 64 patients in the conventional resuscitation group. The researchers then determined how many people survived and were still able to function independently.
Labor intensive
‘Contrary to our expectations, ECMO does not appreciably increase the chance of a good outcome after cardiac arrest.’ After thirty days, fourteen patients (20%) in the ECMO group had the desired outcome, and ten patients (16%) in the conventional resuscitation group. ‘There is a real chance that this difference is due to chance. Otherwise, the difference is so small that it is irrelevant if you take cost-effectiveness and the efficient deployment of healthcare personnel into account.’
ECMO in CPR is labour-intensive. According to Van de Poll, this is a major problem with this technique. ‘You need a whole team, or rather a whole chain.’ This starts on the street. ‘The ambulance staff must recognize potential candidates for treatment. If it is not possible to get the circulation going with a heart massage and defibrillations, the ambulance must call the hospital quickly so that they can prepare everything there.’ The hospital needs four to six extra people on top of the resuscitation team. “These people all have to come to the emergency room or vascular room to have the procedure done. It’s a logistical challenge.’
inclusive criteria
According to Van de Poll, it is difficult to get enough routine in the procedure, because only six percent of people with cardiac arrest outside the hospital meet the inclusion criteria. To be eligible for ECMO, patients in the study had to be 18 to 70 years old, a witness had to have observed the cardiac arrest, and medical providers or an AED had to have diagnosed a ventricular arrhythmia. Patients whose circulation resumed within 15 minutes of cardiac arrest following resuscitation were excluded. This also applied to people with terminal heart failure, severe lung disease, metastatic cancer, suspected pregnancy, bypass surgery, or when caregivers couldn’t connect the heart-lung machine within an hour.
Investments out of proportion
Two previous studies on ECMO in resuscitation show conflicting results. An American study was terminated early due to the superiority of the procedure, while a Czech study was stopped because interim analyzes showed that the procedure was useless. According to Van de Poll, the situation in the American Arrest study is not comparable to the Dutch situation. ‘In Minneapolis – a city with a population of 3 million – four locations are ready to perform the procedure within ten minutes 24/7. To realize this, a private fund has made available 18 million dollars. It is not realistic to expect that we will be able to do this in the Netherlands, where we use our resources in a more balanced way.’
According to Van de Poll, the fact that the results in this Dutch study are disappointing does not mean that care providers should not use ECMO at all during resuscitation. ‘I am convinced that – also in our study – there are people who have survived thanks to ECMO.’ However, according to him, the investments in the researched method are not in proportion to the health gain. According to Van de Poll, the first figures of an incomplete cost-effectiveness analysis suggest that the costs per QALY (quality-adjusted life year) amount to approximately 200 thousand euros in the first year. ‘That is well above the threshold that we currently maintain in the Netherlands. It is likely that there will be more health gains to use this money elsewhere, and that also applies to healthcare staff. You also have to take into account the effort this takes.’
Trauma helicopters
“Our study does not exclude the possibility that ECMO with a different procedure may be effective in resuscitation.” A study is currently underway in which trauma helicopters connect ECMO on the spot, and in which the patient is therefore not first taken to the hospital. “Maybe this time saving will make a difference. Moreover, these are small teams, which will build up more routine with this procedure.’ In addition, Van de Poll and colleagues are still carrying out additional analyzes to see whether the method they are using is beneficial for a specific subgroup of patients.
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