Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Extracorporeal Cardiopulmonary Resuscitation for Amniotic Fluid Embolism: Review and Case Report

ABSTRACT

Amniotic fluid embolism (AFE) is a rare, sudden, and catastrophic complication of pregnancy that can result in cardiopulmonary arrest, potentially leading to death. The pathophysiology of an AFE includes an inflammatory and coagulopathic response due to fetal materials entering maternal circulation with the hallmark triad of symptoms: acute respiratory distress, cardiovascular collapse, and coagulopathy. Management of AFE should include high-quality cardiopulmonary resuscitation, immediate delivery of the fetus if applicable, early intubation to provide adequate oxygenation and ventilation, fluid volume resuscitation, and ongoing evaluation of coagulopathy. Priorities include thromoboelastography interpretation if available, control of hemorrhage and coagulopathy with blood component therapy, and cardiovascular support through inotropes and vasopressor administration. More recent approaches include implementing the A-OK (atropine, ondansetron, and ketorolac) protocol for suspected AFE protocol, extracorporeal cardiopulmonary resuscitation (ECPR), and extracorporeal membrane oxygenation (ECMO) therapies to increase survival and decrease complications. Venoarterial ECMO is the highest form of life support that provides support in patients with pulmonary and cardiac failure. ECPR is the application of Venoarterial ECMO during cardiopulmonary resuscitation in cases where the cause of arrest is believed to be reversible. Early implementation of ECPR during the acute phase of AFE can provide support for end-organ perfusion in place of the weakened and recovering heart while optimizing oxygenation, making venoarterial ECMO an ideal adjunctive therapy. Because of the rarity of AFE, many obstetrical teams may have limited prior experience in managing these catastrophic cases; however, with ongoing education and simulation, teams can be better prepared in the recognition and management of these life-threatening events.

Key performance indicators in extracorporeal membrane oxygenation (ECMO): protocol for a systematic review

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is an intervention used in critically ill patients with severe cardiopulmonary failure that is expensive and resource intensive and requires specialised care. There remains a significant practice variation in its application. This systematic review will assess the evidence for key performance indicators (KPIs) in ECMO.

METHODS AND ANALYSIS

We will search Ovid MEDLINE, Ovid EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and databases from the National Information Center of Health Services Research and Health Care Technology, for studies involving KPIs in ECMO. We will rate methodological quality using the Newcastle-Ottawa Quality Assessment Scale. Randomized controlled trials (RCTs) will be evaluated with the Cochrane Risk of Bias tool, and qualitative studies will be evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN checklist). Grey literature sources will be searched for technical reports, practice guidelines and conference proceedings. We will identify relevant organisations, industry leaders and non-profit organisations that represent key opinion leads in the use of ECMO. We will search the Agency of Healthcare Research and Quality National Quality Measures Clearinghouse for ECMO-related KPIs. Studies will be included if they contain quality measures that occur in critically ill patients and are associated with ECMO. The analysis will be primarily descriptive. Each KPI will be evaluated for importance, scientific acceptability, utility and feasibility using the four criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, KPIs will be evaluated for their potential operational characteristics, their potential to be integrated into electronic medical records and their affordability, if applicable.

ETHICS AND DISSEMINATION

Ethical approval is not required as no primary data will be collected. Findings will be published in a peer-reviewed journal and presented at academic.

PROSPERO REGISTRATION NUMBER

9 August 2022. CRD42022349910.

Expedited transport versus continued on-scene resuscitation for refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis

Background

The benefit of rapid transport from the scene to definitive in-hospital care versus extended on-scene resuscitation in out-of-Hospital Cardiac Arrest (OHCA) is uncertain.

Aim

To assess the use of expedited transport from the scene of OHCA compared with more extended on-scene resuscitation of out-of-hospital cardiac arrest in adults.

Methods

A systematic search of the literature was conducted using MEDLINE, Embase, and SCOPUS. Randomised control trials (RCTs) and observational studies were included. Studies reporting transport timing for OHCA patients with outcome data on survival were identified and reviewed. Two investigators assessed studies identified by screening for relevance and assessed bias using the ROBINS-I tool. Studies with non-dichotomous timing data or an absence of comparator group(s) were excluded. Outcomes of interest included survival and favourable neurological outcome. Survival to discharge and favourable neurological outcome were meta-analysed using a random-effects model.

Results

Nine studies (eight cohort studies, one RCT) met eligibility criteria and were considered suitable for meta-analysis. On pooled analysis, expedited (or earlier) transfer was not predictive of survival to discharge (odds ratio [OR] 1.16, 95% confidence interval [CI] 0.53 to 2.53, I2 = 99%, p = 0. 65) or favorable neurological outcome (OR 1.06, 95% CI 0.48 to 2.37, I2 = 99%, p = 0.85). The certainty of evidence across studies was assessed as very low with a moderate risk of bias. Region of publication was noted to be a major contributor to the significant heterogeneity observed amongst included studies.

Conclusions

There is inconclusive evidence to support or refute the use of expedited transport of refractory OHCA.

Extracorporeal membrane oxygenation for cardiac arrest: what, when, why, and how

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) facilitated resuscitation was first described in the 1960s, but only recently garnered increased attention with large observational studies and randomized trials evaluating its use.

AREAS COVERED

In this comprehensive review of extracorporeal cardiopulmonary resuscitation (ECPR), we report the history of resuscitative ECMO, terminology, circuit configuration and cannulation considerations, complications, selection criteria, implementation and management, and important considerations for the provider. We review the relevant guidelines, different approaches to cannulation, postresuscitation management, and expected outcomes, including neurologic, cardiac, and hospital survival. Finally, we advocate for the participation in national/international Registries in order to facilitate continuous quality improvement and support scientific discovery in this evolving area.

EXPERT OPINION

ECPR is the most disruptive technology in cardiac arrest resuscitation since high-quality CPR itself. ECPR has demonstrated that it can provide up to 30% increased odds of survival for refractory cardiac arrest, in tightly restricted systems and for select patients. It is also clear, though, from recent trials that ECPR will not confer this high survival when implemented in less tightly protocoled settings and within lower volume environments. Over the next 10 years, ECPR research will explore the optimal initiation thresholds, best practices for implementation, and postresuscitation care.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest - current status

PURPOSE OF REVIEW

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging treatment for refractory cardiac arrest. In recent years, several randomized controlled trials have been published that aimed to address the efficacy and effectiveness of ECPR for out-of-hospital cardiac arrest (OHCA). Despite the lack of high-quality evidence concerning clinical effectiveness and cost-effectiveness, ECPR is increasingly implemented throughout the world. In this review, we aim to provide an overview of the current status of ECPR for OHCA.

RECENT FINDINGS

Randomized controlled trials showed diverging results, largely due to differences in selection criteria and study design. Single-center studies, performed in centers with extraordinary expertise and dedication consistently achieve a low-flow time of around 60 min, but such achievements are rarely reproduced outside these centers. Strict patient selection can improve outcome but simultaneously limits the caseload. Preliminary data suggest that outcome may also be improved by avoiding hyperoxia postresuscitation.

SUMMARY

The potential of ECPR to increase survival in selected patients in highly dedicated systems seems to be proven, the question remains whether ECPR for OHCA can be widely implemented successfully and can develop into a sustainable, commonplace resource-effective treatment.

Successful Prehospital Extracorporeal Cardiopulmonary Resuscitation: A Comprehensive Case Report and Analysis of the Current Experience and Knowledge

This case report describes a prehospital extracorporeal cardiopulmonary resuscitation (ECPR) in a female patient who suffered a sudden cardiac arrest while shopping in a supermarket. The success of this intervention marks the first of its kind in our institution and highlights the potential of prehospital application of extracorporeal membrane oxygenation (ECMO) systems in life-threatening scenarios. Despite the complicated challenges faced in this case, the patient exhibited a favorable neurological outcome. This case underscores the potential of prehospital ECMO in cardiac arrest scenarios and the benefits of a coordinated, multidisciplinary approach. As prehospital ECMO evolves, it offers hope for saving lives in critical situations where rapid intervention is essential.

In-hospital extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest: an analysis by time-dependent propensity score matching using a nationwide database in Japan

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has been proposed as a rescue therapy for patients with refractory cardiac arrest. This study aimed to evaluate the association between ECPR and clinical outcomes among patients with out-of-hospital cardiac arrest (OHCA) using risk-set matching with a time-dependent propensity score.

METHODS

This was a secondary analysis of the JAAM-OHCA registry data, a nationwide multicenter prospective study of patients with OHCA, from June 2014 and December 2019, that included adults (≥ 18 years) with OHCA. Initial cardiac rhythm was classified as shockable and non-shockable. Patients who received ECPR were sequentially matched with the control, within the same time (minutes) based on time-dependent propensity scores calculated from potential confounders. The odds ratios with 95% confidence intervals (CI) for 30-day survival and 30-day favorable neurological outcomes were estimated for ECPR cases using a conditional logistic model.

RESULTS

Of 57,754 patients in the JAAM-OHCA registry, we selected 1826 patients with an initial shockable rhythm (treated with ECPR, n = 913 and control, n = 913) and a cohort of 740 patients with an initial non-shockable rhythm (treated with ECPR, n = 370 and control, n = 370). In these matched cohorts, the odds ratio for 30-day survival in the ECPR group was 1.76 [95%CI 1.38-2.25] for shockable rhythm and 5.37 [95%CI 2.53-11.43] for non-shockable rhythm, compared to controls. For favorable neurological outcomes, the odds ratio in the ECPR group was 1.11 [95%CI 0.82-1.49] for shockable rhythm and 4.25 [95%CI 1.43-12.63] for non-shockable rhythm, compared to controls.

CONCLUSION

ECPR was associated with increased 30-day survival in patients with OHCA with initial shockable and even non-shockable rhythms. Further research is warranted to investigate the reproducibility of the results and who is the best candidate for ECPR.

Intraoperative cardiac arrest caused by unexpected vasospastic angina requiring prolonged resuscitation using extracorporeal membrane oxygenation: a case report

BACKGROUND

Vasospastic angina (VSA) occurring during surgery is rare but can lead to sudden intraoperative cardiac arrest.

CASE PRESENTATION

A 77-year-old man with hypertension, and no history of coronary artery disease, displayed an abrupt ST-segment elevation on the electrocardiogram (ECG) during laparoscopic inguinal hernia surgery under general anesthesia. Subsequently, ventricular fibrillation (VF) occurred, with a finding suggesting ischemic myocardial contracture by transesophageal echocardiography. VF was refractory to cardiopulmonary resuscitation (CPR), and veno-arterial extracorporeal membrane oxygenation (VA ECMO) was introduced. Spontaneous circulation resumed 77 min post-cardiac arrest. VSA was confirmed through the patient's clinical course and coronary angiography. Subsequently, VA ECMO was terminated, and the patient was discharged uneventfully.

CONCLUSIONS

Extracorporeal CPR may be a valuable alternative to extended resuscitation for refractory ventricular arrhythmias by VSA.

Indications for Cardiac Catheterization and Percutaneous Coronary Intervention in Patients with Resuscitated Out-of-Hospital Cardiac Arrest

PURPOSE OF REVIEW

The role of emergent cardiac catheterization after resuscitated out-of-hospital cardiac arrest (OHCA) has evolved based on recent randomized evidence. This review aims to discuss the latest evidence and current indications for emergent coronary angiography (CAG) and mechanical circulatory support (MCS) use following OHCA.

RECENT FINDINGS

In contrast to previous observational data, recent RCTs evaluating early CAG in resuscitated OHCA patients without ST elevation have uniformly demonstrated a lack of benefit in terms of survival or neurological outcome. There is currently no randomized evidence supporting MCS use specifically in patients with resuscitated OHCA and cardiogenic shock. Urgent CAG should be considered in all patients with ST elevation, recurrent electrical or hemodynamic instability, those who are awake following resuscitated OHCA, and those receiving extracorporeal cardiopulmonary resuscitation (ECPR). Recent evidence suggests that CAG may be safely delayed in hemodynamically stable patients without ST-segment elevation following resuscitated OHCA.

Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis

BACKGROUND

Although outcomes of patients after cardiac arrest remain poor, studies have suggested that extracorporeal cardiopulmonary resuscitation (ECPR) might improve survival and neurological outcomes. We aimed to investigate any potential benefits of using ECPR over conventional cardiopulmonary resuscitation (CCPR) in patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA).

METHODS

In this systematic review and meta-analysis, we searched MEDLINE via PubMed, Embase, and Scopus from Jan 1, 2000, to April 1, 2023, for randomised controlled trials and propensity-score matched studies. We included studies comparing ECPR with CCPR in adults (aged ≥18 years) with OHCA and IHCA. We extracted data from published reports using a prespecified data extraction form. We did random-effects (Mantel-Haenszel) meta-analyses and rated the certainty of evidence using the Grading of Recommendations, Assessments, Developments, and Evaluations (GRADE) approach. We rated the risk of bias of randomised controlled trials using the Cochrane risk-of-bias 2.0 tool, and that of observational studies using the Newcastle-Ottawa Scale. The primary outcome was in-hospital mortality. Secondary outcomes included complications during extracorporeal membrane oxygenation, short-term (from hospital discharge to 30 days after cardiac arrest) and long-term (≥90 days after cardiac arrest) survival with favourable neurological outcomes (defined as cerebral performance category scores 1 or 2), and survival at 30 days, 3 months, 6 months, and 1 year after cardiac arrest. We also did trial sequential analyses to evaluate the required information sizes in the meta-analyses to detect clinically relevant reductions in mortality.

FINDINGS

We included 11 studies (4595 patients receiving ECPR and 4597 patients receiving CCPR) in the meta-analysis. ECPR was associated with a significant reduction in overall in-hospital mortality (OR 0·67, 95% CI 0·51-0·87; p=0·0034; high certainty), without evidence of publication bias (pegger=0·19); the trial sequential analysis was concordant with the meta-analysis. When considering IHCA only, in-hospital mortality was lower in patients receiving ECPR than in those receiving CCPR (0·42, 0·25-0·70; p=0·0009), whereas when considering OHCA only, no differences were found (0·76, 0·54-1·07; p=0·12). Centre volume (ie, the number of ECPR runs done per year in each centre) was associated with reductions in odds of mortality (regression coefficient per doubling of centre volume -0·17, 95% CI -0·32 to -0·017; p=0·030). ECPR was also associated with an increased rate of short-term (OR 1·65, 95% CI 1·02-2·68; p=0·042; moderate certainty) and long-term (2·04, 1·41-2·94; p=0·0001; high certainty) survival with favourable neurological outcomes. Additionally, patients receiving ECPR had increased survival at 30-day (OR 1·45, 95% CI 1·08-1·96; p=0·015), 3-month (3·98, 1·12-14·16; p=0·033), 6-month (1·87, 1·36-2·57; p=0·0001), and 1-year (1·72, 1·52-1·95; p<0·0001) follow-ups.

INTERPRETATION

Compared with CCPR, ECPR reduced in-hospital mortality and improved long-term neurological outcomes and post-arrest survival, particularly in patients with IHCA. These findings suggest that ECPR could be considered for eligible patients with IHCA, although further research into patients with OHCA is warranted.

FUNDING

None.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A meta-analysis of randomized controlled trials

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (ECPR) is a resuscitation method for patients with refractory out-of-hospital cardiac arrest (OHCA). However, evidence from randomized controlled trials (RCTs) is lacking.

METHODS

We searched several electronic databases until March 2023 for RCTs comparing ECPR with conventional CPR in OHCA patients. RevMan 5.4 was used to pool risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

A total of four RCTs were included. The results of our meta-analysis showed no statistically significant benefit of ECPR regarding mid-term survival (RR 1.21; 95% CI 0.64 to 2.28; I2 = 48%; p = .55). We found a significant improvement with ECPR in mid-term favorable neurological outcome (RR 1.59; 95% CI 1.09 to 2.33; I2 = 0%; p = .02). There was no significant difference between ECPR and conventional CPR in long-term survival (RR 1.32; 95% CI 0.18 to 9.50; I2 = 64%; p = .79), and long-term favorable neurological outcome (RR 1.47; 95% CI 0.89 to 2.43; I2 = 25%; p = .13). There was an increased incidence of adverse events in the ECPR group (RR 3.22; 95% CI 1.18 to 8.80; I2 = 63%; p = .02).

CONCLUSION

ECPR in OHCA patients was not associated with improved survival or long-term favorable neurological outcome but did improve favorable neurological outcome in the mid-term. However, these results are likely underpowered due to the small number of available RCTs. Large-scale confirmatory RCTs are needed to provide definitive conclusions.

[Extracorporeal cardiopulmonary resuscitation-When the heart no longer functions]

Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for restoring blood circulation in patients with refractory circulatory failure. While conventional resuscitation measures are being continued, venoarterial extracorporeal membrane oxygenation (VA ECMO) is established in patients with cardiac arrest. This bypass can compensate for the functions of the heart and lungs until recovery of organ function. The benefit of ECPR compared to conventional resuscitation appears to be evident, especially after a prolonged resuscitation period; however, in three prospective randomized controlled studies an advantage has not yet been conclusively proven for widespread use in clinical routine. ECPR systems are complex and resource-intensive and should therefore be limited to specialized centers where sufficient numbers of patients are treated to ensure a high level of expertise in the teams.

Diabetes mellitus is associated with 90-day mortality in old critically ill COVID-19 patients: a multicenter prospective observational cohort study

BACKGROUND

Several studies have found an association between diabetes mellitus, disease severity and outcome in COVID-19 patients. Old critically ill patients are particularly at risk. This study aimed to investigate the impact of diabetes mellitus on 90-day mortality in a high-risk cohort of critically ill patients over 70 years of age.

METHODS

This multicentre international prospective cohort study was performed in 151 ICUs across 26 countries. We included patients ≥ 70 years of age with a confirmed SARS-CoV-2 infection admitted to the intensive care unit from 19th March 2020 through 15th July 2021. Patients were categorized into two groups according to the presence of diabetes mellitus. Primary outcome was 90-day mortality. Kaplan-Meier overall survival curves until day 90 were analysed and compared using the log-rank test. Mixed-effect Weibull regression models were computed to investigate the influence of diabetes mellitus on 90-day mortality.

RESULTS

This study included 3420 patients with a median age of 76 years were included. Among these, 37.3% (n = 1277) had a history of diabetes mellitus. Patients with diabetes showed higher rates of frailty (32% vs. 18%) and several comorbidities including chronic heart failure (20% vs. 11%), hypertension (79% vs. 59%) and chronic kidney disease (25% vs. 11%), but not of pulmonary comorbidities (22% vs. 22%). The 90-day mortality was significantly higher in patients with diabetes than those without diabetes (64% vs. 56%, p < 0.001). The association of diabetes and 90-day mortality remained significant (HR 1.18 [1.06-1.31], p = 0.003) after adjustment for age, sex, SOFA-score and other comorbidities in a Weibull regression analysis.

CONCLUSION

Diabetes mellitus was a relevant risk factor for 90-day mortality in old critically ill patients with COVID-19.

STUDY REGISTRATION

NCT04321265, registered March 19th, 2020.

Time-saving effect of real-time ultrasound-guided cannulation for extracorporeal cardiopulmonary resuscitation: A multicenter retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR), a bridge to treatments for cardiac arrest patients, can be technically challenging and requires expertise. While ultrasound guidance is frequently used for vascular access, its effects on cannulation time in patients treated with ECPR are poorly defined. We hypothesized that real-time ultrasound guidance would contribute to faster and safer cannulation for ECPR.

METHODS

This nationwide, multicenter, retrospective study analyzed data from 36 Japanese institutions. Patients who were over age 18 years and underwent ECPR between January 1, 2013, and December 31, 2018, were included. Patients who underwent open surgical vascular access were excluded. Cannulation time and outcomes of patients who underwent real-time ultrasound-guided cannulation (i.e., ultrasound-guided group) were compared to those cannulated without the use of real-time ultrasound guidance (control group) using propensity score matching analysis.

RESULTS

The ultrasound-guided group comprised 510 cases, whereas the control group comprised 941 cases. Of those, 443 propensity score-matched pairs were evaluated. Cannulation time in the ultrasound-guided group was 2.5 minutes shorter than in the control group [difference, -2.5 minutes; 95% Confidence interval (CI), -3.7 to -1.3, p < 0.001]. The incidence of catheter-related complications and the incidence of the poor neurological outcomes (Cerebral Performance Category ≥3) did not differ between groups [Odds ratio (OR), 1.51; 95% CI, 0.64-3.74; OR, 1.08; 95% CI, 0.83-1.59].

CONCLUSION

Real-time ultrasound-guided cannulation was associated with shorter cannulation time of ECPR.

Outcome assessment for out-of-hospital cardiac arrest patients in Singapore and Japan with initial shockable rhythm

BACKGROUND

Singapore and Osaka in Japan have comparable population sizes and prehospital management; however, the frequency of ECPR differs greatly for out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Given this disparity, we hypothesized that the outcomes among the OHCA patients with initial shockable rhythm in Singapore were different from those in Osaka. The aim of this study was to evaluate the outcomes of OHCA patients with initial shockable rhythm in Singapore compared to the expected outcomes derived from Osaka data using machine learning-based prediction models.

METHODS

This was a secondary analysis of two OHCA databases: the Singapore PAROS database (SG-PAROS) and the Osaka-CRITICAL database from Osaka, Japan. This study included adult (18-74 years) OHCA patients with initial shockable rhythm. A machine learning-based prediction model was derived and validated using data from the Osaka-CRITICAL database (derivation data 2012-2017, validation data 2018-2019), and applied to the SG-PAROS database (2010-2016 data), to predict the risk-adjusted probability of favorable neurological outcomes. The observed and expected outcomes were compared using the observed-expected ratio (OE ratio) with 95% confidence intervals (CI).

RESULTS

From the SG-PAROS database, 1,789 patients were included in the analysis. For OHCA patients who achieved return of spontaneous circulation (ROSC) on hospital arrival, the observed favorable neurological outcome was at the same level as expected (OE ratio: 0.905 [95%CI: 0.784-1.036]). On the other hand, for those who had continued cardiac arrest on hospital arrival, the outcomes were lower than expected (shockable rhythm on hospital arrival, OE ratio: 0.369 [95%CI: 0.258-0.499], and nonshockable rhythm, OE ratio: 0.137 [95%CI: 0.065-0.235]).

CONCLUSION

This observational study found that the outcomes for patients with initial shockable rhythm but who did not obtain ROSC on hospital arrival in Singapore were lower than expected from Osaka. We hypothesize this is mainly due to differences in the use of ECPR.

Interactions between extracorporeal support and the cardiopulmonary system

This review describes the intricate physiological interactions involved in the application of extracorporeal therapy, with specific focus on cardiopulmonary relationships. Extracorporeal therapy significantly influences cardiovascular and pulmonary physiology, highlighting the necessity for clinicians to understand these interactions for improved patient care. Veno-arterial extracorporeal membrane oxygenation (veno-arterial ECMO) unloads the right ventricle and increases left ventricular (LV) afterload, potentially exacerbating LV failure and pulmonary edema. Veno-venous (VV) ECMO presents different challenges, where optimal device and ventilator settings remain unknown. Influences on right heart function and native gas exchange as well as end-expiratory lung volumes are important concepts that should be incorporated into daily practice. Future studies should not be limited to large clinical trials focused on mortality but rather address physiological questions to advance the understanding of extracorporeal therapies. This includes exploring optimal device and ventilator settings in VV ECMO, standardizing cardiopulmonary function monitoring strategies, and developing better strategies for device management throughout their use. In this regard, small human or animal studies and computational physiological modeling may contribute valuable insights into optimizing the management of extracorporeal therapies.

Percutaneous cannulation is associated with lower rate of severe neurological complication in femoro-femoral ECPR: results from the Extracorporeal Life Support Organization Registry

BACKGROUND

Percutaneous cannulation is now accepted as the first-line strategy for extracorporeal cardiopulmonary resuscitation (ECPR) in adults. However, previous studies comparing percutaneous cannulation to surgical cannulation have been limited by small sample size and single-center settings. This study aimed to compare in-hospital outcomes in cardiac arrest (CA) patients who received femoro-femoral ECPR with percutaneous vs surgical cannulation.

METHODS

Adults with refractory CA treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral ECPR between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was severe neurological complication. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes.

RESULTS

Among 3575 patients meeting study inclusion, 2749 (77%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 18% to 89% over the study period (p < 0.001 for trend). Severe neurological complication (13% vs 19%; p < 0.001) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rate of severe neurological complication (odds ratio [OR] 0.62; 95% CI 0.46-0.83; p = 0.002), similar rates of in-hospital mortality (OR 0.93; 95% CI 0.73-1.17; p = 0.522), limb ischemia (OR 0.84; 95% CI 0.58-1.20; p = 0.341) and cannulation site bleeding (OR 0.90; 95% CI 0.66-1.22; p = 0.471). The comparison of outcomes provided similar results across different levels of center percutaneous experience or center ECPR volume.

CONCLUSIONS

Among adults receiving ECPR, percutaneous cannulation was associated with probable lower rate of severe neurological complication, and similar rates of in-hospital mortality, limb ischemia and cannulation site bleeding.

Extracorporeal Membrane Oxygenation (VA-ECMO) in Management of Cardiogenic Shock

Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.

In-Hospital Cardiac Arrest

This article reviews the epidemiology and management of in-hospital cardiac arrest.

Investigating the outcomes of cardiopulmonary resuscitation and factors affecting it: A cross-sectional study at Dr. Moaven Hospital, Sahneh City from 2014 to 2021

Background and Aims

Cardiopulmonary resuscitation (CPR) is referred to an attempt to maintain the respiratory system and blood circulation active to oxygenate the body's important organs until the heart and blood circulation system return to normal. CPR results are influenced by a variety of circumstances and factors. The purpose of this study was to look into the outcomes of CPR and the factors that influence them at the Dr. Moaven Hospital in Sahneh.

Methods

This cross-sectional descriptive study was carried out retrospectively from the start of 2014 to the start of 2021. Kermanshah University of Medical Sciences provides hospitals with a two-page form for data collection. After entering the data into SPSS24, descriptive and inferential statistical tests were applied to analyze the results.

Results

Out of 497 patients who referred to Dr. Moaven Hospital in Sahne City, 280 were men and 217 were women, with a resuscitation success rate of 22.5% in men and 23.5% in women. CPR was conducted on 63.2% of patients in the emergency department, with 22.2% of them having successful CPR. The existence of the underlying disease had a statistically significant link with the outcomes of CPR (p = 0.007). The most prevalent cause for visit was cardiorespiratory arrest (30.6%), and there was no statistically significant difference between the diagnostic and reason for visit and the outcome of resuscitation, according to the χ 2 test.

Conclusion

According to the findings of this study, increasing age and duration of CPR, the existence of underlying diseases, and the absence of shockable rhythms all reduce the likelihood of success in CPR.

Resuscitation Strategies for Maximizing Survival

There is no single resuscitation strategy that will uniformly improve cardiac arrest outcomes. Traditional vital signs cannot be relied on in cardiac arrest, and the use of continuous capnography, regional cerebral tissue oxygenation, and continuous arterial monitoring are options for use early defibrillation are critical elements of resuscitation. Cardio-cerebral perfusion may be improved with the use of active compression-decompression CPR, an impedance threshold device, and head-up CPR. In refractory shockable arrest, if ECPR is not an option, consider changing defibrillator pad placement and/or double defibrillation, additional medication options, and possibly stellate ganglion block.

Development of the Modern Cardiothoracic Intensive Care Unit and Current Management

The modern cardiothoracic intensive care unit (CTICU) developed as a result of advances in critical care, cardiology, and cardiac surgery. Patients undergoing cardiac surgery today are sicker, frailer, and have more complex cardiac and noncardiac morbidities. CTICU providers need to understand postoperative implications of different surgical procedures, complications that can occur in CTICU patients, resuscitation protocols for cardiac arrest, and diagnostic and therapeutic interventions such as transesophageal echocardiography and mechanical circulatory support. Optimum CTICU care requires a multidisciplinary team with collaboration between cardiac surgeons and critical care physicians with training and experience in the care of CTICU patients.

Long-term survival, functional capacity and quality of life after refractory out-of-hospital cardiac arrest treated with mechanical circulatory support

Introduction

Studies on long-term outcomes after refractory out-of-hospital cardiac arrest (OHCA) treated with mechanical circulatory support (MCS) are limited. This study aimed to evaluate long-term neurologically intact survival, functional capacity and quality of life after refractory OHCA treated with MCS.

Methods

This was a follow-up study of survivors after refractory OHCA treated with MCS. Follow-up examinations comprised clinical assessment with transthoracic echocardiography and cardiopulmonary exercise test (CPX). Neurological and cognitive screening was evaluated with the Cerebral Performance Category (CPC) and Montreal Cognitive Assessment (MoCA test). A good neurological outcome was defined as CPC 1 or CPC 2. Health-related quality of life was measured by questionnaires (Short Form-36 (SF-36)).

Results

A total of 101 patients with refractory OHCA were treated with MCS at Aarhus University Hospital between 2015 and 2019. The total low-flow time was median 105 min [IQR, 94-123] minutes. The hospital discharge rate was 27%. At a mean follow-up time of 4.8 years ± 1.6 (range 2.8-6.1 years), 21 patients remained alive of whom 15 consented to participate in the present study. Good neurological outcome with CPC 1-2 was found in 93% (14/15) patients. No severe cognitive function was discovered; mean MoCA score of 26.4 ± 3.1. Functional capacity examined by CPX showed acceptable VO2 max values (23.9 ± 6.3 mL/kg/min). Mean SF-36 scores revealed an overall high level of quality of life in long-term survivors.

Conclusions

Long-term survival with a good neurological outcome with functional recovery was high in patients with refractory OHCA treated with MCS. These patients may expect a reasonable quality of life after discharge despite prolonged resuscitation.

What is the potential benefit of pre-hospital extracorporeal cardiopulmonary resuscitation for patients with an out-of-hospital cardiac arrest? A predictive modelling study

AIM

In this predictive modelling study we aimed to investigate how many patients with an out-of-hospital cardiac arrest (OHCA) would benefit from pre-hospital as opposed to in-hospital initiation of extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

A temporal spatial analysis of Utstein data was performed for all adult patients with a non-traumatic OHCA attended by three emergency medical services (EMS) covering the north of the Netherlands during a one-year period. Patients were considered potentially eligible for ECPR if they had a witnessed arrest with immediate bystander CPR, an initial shockable rhythm (or signs of life during resuscitation) and could be presented in an ECPR-centre within 45 minutes of the arrest. Endpoint of interest was defined as the hypothetical number of ECPR eligible patients after 10, 15 and 20 minutes of conventional CPR and upon (hypothetical) arrival in an ECPR-centre as a fraction of the total number of OHCA patients attended by EMS.

RESULTS

During the study period 622 OHCA patients were attended, of which 200 (32%) met ECPR eligibility criteria upon EMS arrival. The optimal transition point between conventional CPR and ECPR was found to be after 15 minutes. Hypothetical intra-arrest transport of all patients in whom no return of spontaneous circulation (ROSC) was obtained after that point (n=84) would have yielded 16/622 (2.5%) patients being potentially ECPR eligible upon hospital arrival (average low-flow time 52 minutes), whereas on-scene initiation of ECPR would have resulted in 84/622 (13.5%) potential candidates (average estimated low-flow time 24 minutes before cannulation).

CONCLUSION

Even in healthcare systems with relatively short transport distances to hospital, consideration should be given to pre-hospital initiation of ECPR for OHCA as it shortens low-flow time and increases the number of potentially eligible patients.

Left-ventricular unloading in extracorporeal cardiopulmonary resuscitation due to acute myocardial infarction - A multicenter study

BACKGROUND

Guidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI).

METHODS

This study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed.

RESULTS

95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31-0.91], P = 0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50-1.95], P < 0.001) and ICU LOS (IRR 1.81 [95% CI 1.57-2.08], P < 0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading.

CONCLUSIONS

LV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes.

Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations

Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals' wishes.

Management of Intraoperative Cardiac Arrest

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.

Clinician Perspectives on Cannulation for Extracorporeal Cardiopulmonary Resuscitation: A Mixed Methods Analysis

Out-of-hospital cardiac arrest is a leading cause of mortality with survival rates of less than 10%. In selected patients, survival may be improved via timely application of extracorporeal cardiopulmonary resuscitation (ECPR). However, ECPR is a complex and resource intensive intervention with a high risk of complications that impair widespread clinical adoption. This study employed a mixed approach of qualitative interview analysis embedded with quantitative data collection to uncover the major hurdles faced by clinicians during ECPR initiation. We conducted semi-structured interviews with eight ECPR intensive care specialists with 2-10 years of experience working at a large, tertiary ECPR center in Australia. Clinicians identified dilation as the most time-consuming step, followed by draping, and decision-making during extracorporeal membrane oxygenation patient selection. The most challenging step was the decision-making for patient selection, followed by dilation and imaging. These findings uncovered key barriers to ECPR, and identified priority areas for further research and clinical training. Major logistical hindrances will require well-defined protocols and improved clinical training. Engineering innovations in the identified areas may improve the delivery of ECPR, making it simpler and faster to deliver.

The center for the treatment of sudden cardiac death: the results of five years of work

The objective was to summarize the Center's experience in the treatment of sudden cardiac death and to assess the prospects of using venoarterial extracorporeal membrane oxygenation (VA ECMO) in the complex of extended cardiopulmonary resuscitation (CPR).

Materials and methods.  109 patients aged 52.6±1.5 years, delivered  to the hospital  by emergency  medical teams with a background of ongoing cardiopulmonary resuscitation.

Results. In the majority of cases (78), extended resuscitation measures were ineffective, ECMO was not used due to inadequate technology connection criteria. In 15 cases, primary stabilization without ECMO was achieved, and these patients were transferred for further treatment to intensive care unit (ICU), 8 of them died later. Extracorporeal cardiopulmonary resuscitation (ECPR) was used in 16 cases, in 6 cases, patients were decannulated after cardiac recovery; also, ECMO was used postmortem 15 times to preserve donor organs. The overall survival rate among the delivered to the Center was 7.5%. We found out the correlation between the duration of the prehospital period and survival rate (time to hospital admission in survivors was 42.7±9.6 min versus 64.31±3.13 min in the deceased). The association between pH (AUC ROC 0.728) on admission and favorable outcome was found to be more reliable than EtCO2 (0.266) and blood lactate  (0.387).

Conclusion. The creation of centers for the treatment of patients with refractory circulatory arrest seems reasonable on the basis of level 3 hospitals with the possibility  of using X-ray surgical methods  of treatment. The widespread  introduction of ECPR should be accompanied  by the change of CPR  algorithms  in the prehospital period. The effectiveness of ECPR is determined by mandatory strict  adherence  to the connection criteria, which can be revised as experience accumulates.

Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM)

AIMS

International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe.

METHODS AND RESULTS

A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions.

CONCLUSION

Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.

Integral assessment of gas exchange during veno-arterial ECMO: accuracy and precision of a modified Fick principle in a porcine model

Assessment of native cardiac output during extracorporeal circulation is challenging. We assessed a modified Fick principle under conditions such as dead space and shunt in 13 anesthetized swine undergoing centrally cannulated veno-arterial extracorporeal membrane oxygenation (V-A ECMO, 308 measurement periods) therapy. We assumed that the ratio of carbon dioxide elimination (V̇co₂) or oxygen uptake (V̇o₂) between the membrane and native lung corresponds to the ratio of respective blood flows. Unequal ventilation/perfusion (V̇/Q̇) ratios were corrected towards unity. Pulmonary blood flow was calculated and compared to an ultrasonic flow probe on the pulmonary artery with a bias of 99 mL/min (limits of agreement -542 to 741 mL/min) with blood content V̇o₂ and no-shunt, no-dead space conditions, which showed good trending ability (least significant change from 82 to 129 mL). Shunt conditions led to underestimation of native pulmonary blood flow (bias -395, limits of agreement -1,290 to 500 mL/min). Bias and trending further depended on the gas (O₂, CO₂) and measurement approach (blood content vs. gas phase). Measurements in the gas phase increased the bias (253 [LoA -1,357 to 1,863 mL/min] for expired V̇o₂ bias 482 [LoA -760 to 1,724 mL/min] for expired V̇co₂) and could be improved by correction of V̇/Q̇ inequalities. Our results show that common assumptions of the Fick principle in two competing circulations give results with adequate accuracy and may offer a clinically applicable tool. Precision depends on specific conditions. This highlights the complexity of gas exchange in membrane lungs and may further deepen the understanding of V-A ECMO.

ECPR successfully used in 5.5-hour cardiac arrest caused by peripartum cardiomyopathy: a case report and minireview

Background

Cardiac arrest (CA) caused by peripartum cardiomyopathy (PPCM) is a catastrophic disease that can lead to a high mortality rate in young women. Cardiopulmonary resuscitation (CPR) is the initial first aid measure to be taken and unfortunately, does not always lead to the restoration of spontaneous circulation (ROSC). We shared a rare successful case of extracorporeal cardiopulmonary oxygenation-assisted resuscitation (ECPR) in a patient with CA for up to 5.5 hours due to PPCM.

Case Description

A previously healthy 31-year-old woman at 34 weeks of gestation was admitted to the emergency department with fever and arrhythmia. Two days later, the patient had postpartum CA. She underwent CPR for up to 5 hours before receiving V-A extracorporeal membrane oxygenation (ECMO) support and eventually regained spontaneous circulation after half an hour. Based on the clinical manifestations, the patient was diagnosed with PPCM and received treatment. The patient was successfully removed from ECMO after 9 days. The patient experienced ECMO-related complications, including thrombocytopenia and intracranial hemorrhage (ICH). Although treatment was difficult, the patient was discharged after 2 months without any neurological complications. We followed up for 1 year and the patient was able to work normally as a teacher. In our mini-review, we found that the success rate of ECPR in perinatal CA was high, and ECPR is worthy of promotion and application.

Conclusions

As an advanced life support method, ECPR can save patients undergoing postpartum CA. However, effective CPR and avoidance of ICH are necessary for the recovery of brain function.

Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest

BACKGROUND

eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR.

METHODS

The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome.

RESULTS

From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs.

CONCLUSION

We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.

Regulation of the p53‑mediated ferroptosis signaling pathway in cerebral ischemia stroke (Review)

Stroke is one of the most threatening diseases worldwide, particularly in countries with larger populations; it is associated with high morbidity, mortality and disability rates. As a result, extensive research efforts are being made to address these issues. Stroke can include either hemorrhagic stroke (blood vessel ruptures) or ischemic stroke (blockage of an artery). Whilst the incidence of stroke is higher in the elderly population (≥65), it is also increasing in the younger population. Ischemic stroke accounts for ~85% of all stroke cases. The pathogenesis of cerebral ischemic injury can include inflammation, excitotoxic injury, mitochondrial dysfunction, oxidative stress, ion imbalance and increased vascular permeability. All of the aforementioned processes have been extensively studied, providing insights into the disease. Other clinical consequences observed include brain edema, nerve injury, inflammation, motor deficits and cognitive impairment, which not only cause disabilities obstructing daily life but also increase the mortality rates. Ferroptosis is a type of cell death that is characterized by iron accumulation and increased lipid peroxidation in cells. In particular, ferroptosis has been previously implicated in ischemia-reperfusion injury in the central nervous system. It has also been identified as a mechanism involved in cerebral ischemic injury. The tumor suppressor p53 has been reported to modulate the ferroptotic signaling pathway, which both positively and negatively affects the prognosis of cerebral ischemia injury. The present review summarizes the recent findings on the molecular mechanisms of ferroptosis under the regulation of p53 underlying cerebral ischemia injury. Understanding of the p53/ferroptosis signaling pathway may provide insights into developing methods for improving the diagnosis, treatment and even prevention of stroke.

The interplay between left ventricular diastolic and right ventricular dysfunction: challenges in the interpretation of critical care echocardiography studies

BACKGROUND

Sepsis is a leading cause of death and it is characterized not only by profound vasoplegia but also by myocardial dysfunction. Critical care echocardiography is the preferred modality for the initial assessment of the cause of shock. Moreover, it can be extremely helpful in the identification of progressing myocardial dysfunction during the course of sepsis, also known as septic cardiomyopathy.

MAIN BODY

One of the issues in the identification of septic cardiomyopathy is that it can be manifest with different clinical phenotypes, from overt biventricular dysfunction to isolated left ventricular (LV) systolic and/or diastolic dysfunction, from right ventricular (RV) systolic dysfunction to RV failure and dilatation. However, the commonly used echocardiography parameters for the assessment of LV and/or RV function are not always entirely reliable. Indeed, these are influenced by variable preload and afterload conditions imposed by critical illness such as fluid shifts, sedation level and mechanical ventilation with positive pressure.

CONCLUSIONS

Strain echocardiography is a promising tool for the early identification of myocardial dysfunction in the context of sepsis. Studies reporting data on strain echocardiography should be particularly detailed in order to increase the reproducibility of results and to favor comparison with future studies.

Regional Cerebral Oxygen Saturation to Predict Favorable Outcome in Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the role of regional cerebral oxygen saturation (rSO₂) in predicting survival and neurologic outcomes after extracorporeal cardiopulmonary resuscitation (ECPR).

DESIGN

The study authors performed a systematic review and meta-analysis of all available literature.

SETTING

The authors searched relevant databases (Pubmed, Medline, Embase) for studies measuring precannulation rSO₂ in patients undergoing ECPR and reporting mortality and/or neurologic outcomes.

PARTICIPANTS

The authors included both in-hospital and out-of-hospital cardiac arrest patients receiving ECPR. They identified 3 observational studies, including 245 adult patients.

INTERVENTIONS

The authors compared patients with a low precannulation rSO₂ (≤15% or 16%) versus patients with a high (>15% or 16%) precannulation rSO₂. In addition, the authors carried out subgroup analyses on out-of-hospital cardiac arrest (OHCA) patients.

MEASUREMENTS AND MAIN RESULTS

A high precannulation rSO₂ was associated with an overall reduced risk of mortality in ECPR recipients (98 out of 151 patients [64.9%] in the high rSO₂ group, v 87 out of 94 patients [92.5%] in the low rSO₂ group, risk differences [RD] -0.30; 95% CI -0.47 to -0.14), and in OHCA (78 out of 121 patients [64.5%] v 82 out of 89 patients [92.1%], RD 0.30; 95% CI -0.48 to -0.12). A high precannulation rSO₂ also was associated with a significantly better neurologic outcome in the overall population (42 out of 151 patients [27.8%] v 2 out of 94 patients [2.12%], RD 0.22; 95% CI 0.13-0.31), and in OHCA patients (33 out of 121 patients [27.3%] v 2 out of 89 patients [2.25%] RD 0.21; 95% CI 0.11-0.30).

CONCLUSIONS

A low rSO₂ before starting ECPR could be a predictor of mortality and survival with poor neurologic outcomes.

External validation of the TiPS65 score for predicting good neurological outcomes in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation

AIM

Estimating prognosis of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) is essential for selecting candidates. The TiPS65 score can predict neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated with ECPR. We aimed to perform an external validation of this score.

METHODS

Data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentred, nationwide, prospectively registered database, were analysed. All adult patients with OHCA and shockable rhythm and treated with ECPR between January 2018 to December 2019 were included. In the TiPS65 score, age, call-to-hospital arrival time, initial cardiac rhythm at hospital arrival, and initial pH value were used as predictors. The primary outcome was 30-day survival with favourable neurological outcomes (Cerebral Performance Category 1 or 2). Discrimination, using the C-statistic, and predictive performances of each score, such as sensitivity and specificity, were investigated.

RESULTS

Of 590 included patients (517 [81.6%] men; median [interquartile range] age, 60 [50-69] years), 64 (10.8%) reported favourable neurological outcomes. The C-statistic of the TiPS65 score was 0.729 (95% confidence interval (CI): 0.672-0.786). When the cut-off of TiPS65 score was set to >1, the sensitivity and specificity were 0.906 (95%CI: 0.807-0.965) and 0.430 (95%CI: 0.387-0.473), respectively; conversely, when the cut-off was set to >3, they were 0.172 (95%CI: 0.089-0.287) and 0.971 (95%CI: 0.953-0.984), respectively.

CONCLUSIONS

The TiPS65 score shows reasonable discrimination and predictive performances. This score can be supportive in the decision-making process for the selection of eligible patients for ECPR in clinical settings.

Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review

Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.

The neuro-prognostic value of the ion shift index in cardiac arrest patients following extracorporeal cardiopulmonary resuscitation

BACKGROUND

The ion shift index (ISI) as a prognostic indicator that can show the severity of hypoxic-ischemic injury. We aimed to evaluate the performance of the ISI in predicting unfavorable neurological outcomes at hospital discharge in cardiac arrest (CA) patients following extracorporeal cardiopulmonary resuscitation (ECPR) and to compare its performance to other prognostic predictors.

METHODS

This was a retrospective observational study including adult CA patients treated with ECPR between January 2018 and December 2022 in a tertiary hospital. Data regarding clinical characteristics and laboratory parameters were collected from medical records. The ISI was determined based on the first available serum electrolyte levels after ECPR. The primary outcome was unfavorable neurological status at hospital discharge, defined as Cerebral Performance Categories 3-5. Comparisons of the characteristics between the two groups were made using the χ2 test for categorical variables and the t-test or non-parametric Mann-Whitney U-test for continuous variables, as appropriate. Correlation analysis was performed using Spearman's rank correlation coefficient. A two-tailed P-value <0.05 was considered statistically significant.

RESULTS

Among the 122 patients involved, 46 (37.7%) had out-of-hospital CA, and 88 had unfavorable neurological outcomes. The ISI was significantly higher in the unfavorable outcome group than in the favorable outcome group (3.74 [3.15-4.57] vs. 2.69 [2.51-3.07], P<0.001). A higher ISI level was independently related to unfavorable outcome (odds ratio=6.529, 95% confidence interval 2.239-19.044, P=0.001). An ISI level >3.12 predicted unfavorable outcomes with a sensitivity and specificity of 74.6% and 85.2%, respectively (P<0.001). The prognostic performance of ISI (area under the curve [AUC]=0.887) was similar to that of other predictors, such as gray-to-white matter ratio (AUC=0.850, P=0.433) and neuron-specific enolase (AUC=0.925, P=0.394).

CONCLUSION

ISI may be used as a prognostic biomarker to predict neurological outcomes in CA patients following ECPR.

Starting and Sustaining an Extracorporeal Membrane Oxygenation Program

The use of extracorporeal membrane oxygenation (ECMO) is growing rapidly in all patient populations, especially adults for both acute lung or heart failure. ECMO is a complex, high risk, resource-intense, expensive modality that requires appropriate planning, training, and management for successful outcomes. This article provides an optimal approach and the basic framework for initiating a new ECMO program, which can be tailored to meet local needs. Setting up a new ECMO program and sustaining it requires institutional commitment, physician champions, multidisciplinary team involvement, ongoing training, and education of the ECMO team personnel and a robust quality assurance program to minimize complications and improve outcomes.

Extracorporeal cardiopulmonary resuscitation for cardiac arrest: An updated systematic review

OBJECTIVES

To provide an updated systematic review on the use of extracorporeal cardiopulmonary resuscitation (ECPR) compared with manual or mechanical cardiopulmonary resuscitation during cardiac arrest.

METHODS

This was an update of a systematic review published in 2018. OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for randomized trials and observational studies between January 1, 2018, and June 21, 2022. The population included adults and children with out-of-hospital or in-hospital cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed bias. The certainty of evidence was evaluated using GRADE.

RESULTS

The search identified 3 trials, 27 observational studies, and 6 cost-effectiveness studies. All trials included adults with out-of-hospital cardiac arrest and were terminated before enrolling the intended number of subjects. One trial found a benefit of ECPR in survival and favorable neurological status, whereas two trials found no statistically significant differences in outcomes. There were 23 observational studies in adults with out-of-hospital cardiac arrest or in combination with in-hospital cardiac arrest, and 4 observational studies in children with in-hospital cardiac arrest. Results of individual studies were inconsistent, although many studies favored ECPR. The risk of bias was intermediate for trials and critical for observational studies. The certainty of evidence was very low to low. Study heterogeneity precluded meta-analyses. The cost-effectiveness varied depending on the setting and the analysis assumptions.

CONCLUSIONS

Recent randomized trials suggest potential benefit of ECPR, but the certainty of evidence remains low. It is unclear which patients might benefit from ECPR.

Prehospital Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the available published evidence of the effects of extracorporeal cardiopulmonary resuscitation (ECPR) in the prehospital setting on clinical outcomes in patients with out-of-hospital cardiac arrest.

DESIGN

A systematic review and meta-analysis designed according to the Preferred Reporting Items for Systematic Reviews an Meta-Analyses guidelines.

SETTING

In the prehospital setting.

PARTICIPANTS

All randomized control trials (RCTs) and observational trials using pre-hospital ECPR in adult patients (>17 years).

INTERVENTIONS

Prehospital ECPR.

MEASUREMENTS AND MAIN RESULTS

The study authors searched Medline, Embase, and PUBMED for all RCTs and observational trials. The studies were assessed for clinical, methodologic, and statistical heterogeneity. The primary outcome was survival at hospital discharge. The study outcomes were aggregated using random-effects meta-analysis of means or proportions as appropriate. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence. Four studies were included, with a total of 222 patients receiving prehospital ECPR (mean age = 51 years [95% CI 44-57], 81% of patients were male (CI 74-87), and 60% patients had a cardiac cause for their arrest (95% CI 43-76). Overall survival at discharge was 23.4% (95% CI 15.5-33.7; I² = 62%). The pooled low-flow time was 61.1 minutes (95% CI 45.2-77.0; I² = 97%). The quality of evidence was assessed to be low, and the overall risk of bias was assessed to be serious, with confounding being the primary source of bias.

CONCLUSION

No definitive conclusions can be made as to the efficacy of prehospital ECPR in refractory cardiac arrest. Higher quality evidence is required.