Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states

Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part 1)

AIM OF THE REVIEW

To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome.

METHODS

Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment.

RESULTS

The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology.

CONCLUSIONS

A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable.

[Percutaneous extracorporeal life support in acute severe hemodynamic collapses: single centre experience in 100 consecutive patients]

BACKGROUND

Extracorporeal life support (ECLS) is a circulatory assistance device that is increasingly used in adults undergoing cardiopulmonary arrest (CPA) or hemodynamic collapse when conventional therapies fail.

OBJECTIVES

To assess the feasibility and outcomes of 100 consecutive arteriovenous percutaneous ECLS procedures at the Grenoble University Hospital between January 2002 and September 2007.

METHODS

Monocentric descriptive registry with one-year prospective follow-up.

RESULTS

An ECLS device was successfully used in 93% of patients. Its indication was cardiogenic shock in 50% of the cases, CPA in 38% of the cases and unsuccessful weaning of cardiopulmonary bypass (CPB) after cardiothoracic surgery in 12% of the cases. Direct complications of ECLS were observed in 56% of patients, the most frequent being hemorrhage at the intravenous puncture site requiring red blood cell transfusions (26%), and lower limb ischemia (19%). Weaning from ECLS was achieved in 33 patients (44% cardiogenic shocks, 13% CPAs, 50% CPB weaning failures) and 20 patients were discharged from the hospital (26% cardiogenic shocks, 10.5% CPAs and 25% CPB weaning failures). All are still living without any serious sequelae (mean follow-up period of 16.8 months).

CONCLUSION

The use of ECLS in CPA patients, especially with cardiogenic shock, is feasible with satisfactory survival rates, given the extreme severity of their initial state.

The approach to delayed resuscitation in paediatric cardiac arrest: A survey of paediatric intensivists in Canada

AIM

To determine how long a period of having had no cardiopulmonary-resuscitation (CPR) (delay time) is considered to result in subsequent futile efforts at resuscitation.

METHODS

In 2007 a survey was mailed to all 77 paediatric intensivists in Canada. Three scenarios of witnessed cardiac arrest were presented: out-of-hospital, in-hospital, and in-hospital with extracorporeal-CPR (E-CPR). Each scenario asked what delay time would make attempts at resuscitation futile for survival to hospital discharge, and for survival to hospital discharge in a better than vegetative state. Comparisons of median [inter-quartile range] used Wilcoxon-signed-rank or Friedman tests with Bonferroni corrections.

RESULTS

The response rate was 49/77 (64%). The delay time was significantly different between rhythms within all scenarios (p<.001); and was significantly shorter for survival than for better than vegetative survival (p<.006) except when E-CPR was to be used. The delay time was not significantly different between the in-hospital and out-of-hospital scenario with the same rhythms (p>.01). The delay time was significantly shorter in scenarios with asystole versus pulseless electrical activity with (p=.010) or without (p<.001) an arterial line with absent pulsation. In out-of-hospital arrest, the delay time for survival varied from 15 [10-20]min for asystole to 20 [15-20]min for pulseless electrical activity. In in-hospital scenarios, the delay time for survival varied from 10 [10-20]min for asystole, to 15 [10-20]min for most other rhythms.

CONCLUSION

A delay time of 15 [10-20] (range 5-30)min was considered futile for survival. This has implications for pronouncing death in donation after cardiac death.

Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke

AIM OF THE REVIEW

To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome.

METHODS

Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment.

RESULTS

The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology.

CONCLUSIONS

A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.

Extracorporeal membrane oxygenation rescue for cardiopulmonary resuscitation in pediatric patients

OBJECTIVE

To describe survival and neurologic outcome and identify the factors associated with survival among pediatric patients following extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest.

DESIGN

Retrospective study.

SETTING

A university-affiliated tertiary care hospital.

PATIENTS

Eligible patients were < or = 18 yrs of age and received extracorporeal membrane oxygenation during active cardiopulmonary resuscitation for in-hospital cardiac arrest.

INTERVENTIONS

Extracorporeal membrane oxygenation (ECMO) during active cardiopulmonary resuscitation.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was survival to hospital discharge. The secondary outcome was neurologic status after ECPR at hospital discharge and late follow-up. Good neurologic outcome was defined as Pediatric Cerebral Performance Categories 1, 2, and 3. Continuous variables were expressed as medians (interquartile range). We prospectively defined the early cohort (January 1999 to December 2001) and late cohort (January 2002 to January 2006) and compared the survival rates. We identified 27 ECPR events. The survival rate to hospital discharge was 41% (11 of 27). The nonsurvivors had higher pre-cardiopulmonary resuscitation serum lactate levels (14 [10.2-19.6] mmol/L vs. 8.5 [4.4-12.6] mmol/L, p < .01), longer durations of cardiopulmonary resuscitation (60 [37-81] mins vs. 45 [25-50] mins, p < .05) with longer activating time for ECMO (12.5 [7.5-33.8] mins vs. 5 [0-10] mins, p < .01), and more renal failure after ECPR (68% [11 of 16] vs. 9% [1 of 11], p < .01). The survival rate of the late cohort was better than that of the early cohort (58% [11 of 19] vs. 0% [0 of 8], p < .05). By exact multiple logistic regression analysis, the early cohort and renal failure after ECPR were two independent risk factors for mortality. Among the 11 survivors, ten had good neurologic outcomes.

CONCLUSIONS

ECPR successfully rescued some pediatric patients who failed rescue with conventional in-hospital CPR. Good neurologic outcomes were achieved in the majority of the survivors. Early cohort and post-ECPR renal failure were associated with mortality.

Clinical review: aggressive management and extracorporeal support for drug-induced cardiotoxicity

Poisoning may induce failure in multiple organs, leading to death. Supportive treatments and supplementation of failing organs are usually efficient. In contrast, the usefulness of cardiopulmonary bypass in drug-induced shock remains a matter of debate. The majority of deaths results from poisoning with membrane stabilising agents and calcium channel blockers. There is a need for more aggressive treatment in patients not responding to conventional treatments. The development of new antidotes is limited. In contrast, experimental studies support the hypothesis that cardiopulmonary bypass is life-saving. A review of the literature shows that cardiopulmonary bypass of the poisoned heart is feasible. The largest experience has resulted from the use of peripheral cardiopulmonary bypass. However, a literature review does not allow any conclusions regarding the efficiency and indications for this invasive method. Indeed, the majority of reports are single cases, with only one series of seven patients. Appealing results suggest that further studies are needed. Determination of prognostic factors predictive of refractoriness to conventional treatment for cardiotoxic poisonings is mandatory. These prognostic factors are specific for a toxicant or a class of toxicants. Knowledge of them will result in clarification of the indications for cardiopulmonary bypass in poisonings.

(Uncontrolled) donation after cardiac determination of death: a note of caution

In this short article, we articulate a position that organ recovery from uncontrolled DCD (uDCD)--primarily patients who have suffered a cardiac arrest--is unlikely to result in a significant number of organs, and this small gain must be balanced against significant risk of unduly influencing resuscitation provider decision-making, and jeopardizing public trust in the propriety of organ donation and transplantation.