A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis

Extracorporeal cardiopulmonary resuscitation: is it futile?

PURPOSE OF REVIEW

Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment modality used to restore end-organ perfusion in the setting of refractory cardiac arrest in patients receiving cardiopulmonary resuscitation (CPR). Despite advances in medicine, survival from cardiac arrest remains low with conventional CPR. The body of literature relating to ECPR is limited to retrospective studies and case series, with data that are inconsistent. Routine use of ECPR is not currently endorsed by the American Heart Association.

RECENT FINDINGS

In several single-center retrospective studies, ECPR was associated with a higher level of return of spontaneous circulation and survival to hospital discharge, when compared with conventional CPR. However, data from larger population-based registry studies have not reproduced these findings. Implementation of ECPR is a complex endeavor that requires specialized, multidisciplinary expertise to be successful.

SUMMARY

ECPR may be considered as an adjunct to CPR in cases of refractory cardiac arrest. The success of ECPR relies on specialized expertise, thoughtful patient selection, and timely initiation.

The impact of on-site cardiac rhythm on mortality in patients supported with extracorporeal cardiopulmonary resuscitation: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used in patients with out-of-hospital or in-hospital cardiac arrest in whom conventional cardiopulmonary resuscitation remains unsuccessful. The aim of this study was to analyze the impact of initial cardiac rhythm-detected on-site of the cardiac arrest-on mortality.

METHODS

We performed a retrospective cohort study of patients who received ECPR in our tertiary care cardiac arrest center. Patients were divided into three groups depending on their cardiac rhythm: shockable rhythm, pulseless electrical activity, and asystole. The primary endpoint was mortality within the first 7 days after ECPR deployment. Secondary endpoints were mortality within 28 days and the impact of pre-ECPR potassium, serum lactate, pH, and pCO₂ on mortality. The association of the initial cardiac rhythm and the location of arrhythmia detection (patient monitored in hospital [category: monitored], not monitored but hospitalized [in-hospital], not monitored, not hospitalized [out-of hospital]) with the primary and secondary outcome was examined by means of univariable and multivariable logistic regression.

RESULTS

Sixty-five patients could be included in the final analysis. Thirty-two patients (49.2%, 95%CI 36.6%-61.9%) died within the first 7 days. In terms of 7-day-mortality patients differed in the initial cardiac rhythm (p = 0.040) and with respect to the location of arrhythmia detection (p = 0.002). Shockable cardiac rhythm (crude OR 0.21; 95%CI 0.03-0.98) and pulseless electrical activity (0.13; 0.02-0.61) as the initial rhythm on-site showed better odds for survival compared to asystole. However, this association did neither persist in adjusted analysis nor pairwise comparison.

DISCUSSION

The study could not demonstrate a better outcome with shockable rhythm after ECPR. More homogeneous and adequately powered cohorts are needed to better understand the impact of cardiac rhythm on patient outcomes after ECPR.

Outcomes of patients with refractory out-of-hospital cardiac arrest transported to an ECMO centre compared with transport to non-ECMO centres

Objective: To compare the outcomes of patients with refractory out-of-hospital cardiac arrest (OHCA) transported to a hospital that provides extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) with patients transported to hospitals without ECPR capability. Design, setting: Retrospective review of patient care records in a pre-hospital and hospital setting. Participants: Adult patients with OHCA who left the scene and arrived with cardiopulmonary resuscitation in progress at 16 hospitals in Melbourne, Australia, between January 2016 and December 2019. Intervention: For selected patients transported to the ECPR centre, initiation of ECMO. Main outcome measures: Survival to hospital discharge and 12-month quality of life. Results: There were 223 eligible patients during the study period. Of 49 patients transported to the ECPR centre, 23 were commenced on ECMO. Of these, survival to hospital with good neurological recovery (Cerebral Performance Category [CPC] score 1/2) occurred in 4/23 patients. Four other patients developed return of spontaneous circulation in the ECPR centre before cannulation of whom one survived, giving overall good functional outcome at 12 months survival of 5/49 (10.2%). There were 174 patients transported to the 15 non-ECPR centres and 3/174 (2%) had good functional outcome at 12 months. After adjustment for baseline differences, the odds ratio for good neurological outcome after transport to an ECPR centre compared with a non-ECPR centre was 4.63 (95% CI, 0.97-22.11; P = 0.055). Conclusion: The survival rate of patients with refractory OHCA transported to an ECPR centre remains low. Outcomes in larger cities might be improved with shorter scene times and additional ECPR centres that would provide for earlier initiation of ECMO.

Extracorporeal life support in adult patients with out-of-hospital cardiac arrest

The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.

Extracorporeal cardiopulmonary resuscitation for an out-of-hospital cardiac arrest

Extra corporeal membrane oxygenation (ECMO) for refractory out-of-hospital cardiac arrest (OHCA) has been shown to improve outcome in many Western countries. There are no reports of ECMO being used to support OHCA in India till date. We report a case of a young man who developed cardiac arrest (CA) while driving and was given bystander cardiac massage. He was brought to tertiary care center where an ECMO was utilized for refractory CA. The patient subsequently underwent emergency coronary artery stenting and was weaned off ECMO and ventilation. We discuss the case and highlight the role of bystander cardiopulmonary resuscitation.

Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis

The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (β = 0.02, 95% CI: 0.007-0.02; p = 0.0004).

Current interventional therapies in acute pulmonary embolism

Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality. The management of PE is currently evolving given the development of new technologies and team-based approaches. This document will focus on risk stratification of PEs, review of the current interventional therapies, the role of clinical endpoints to assess the effectiveness of different interventional therapies, and the role for mechanical circulatory support in the complex management of this disease.

Targeted high mean arterial pressure aggravates cerebral hemodynamics after extracorporeal resuscitation in swine

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (E-CPR) is used for the treatment of refractory cardiac arrest. However, the optimal target to reach for mean arterial pressure (MAP) remains to be determined. We hypothesized that MAP levels critically modify cerebral hemodynamics during E-CPR and tested two distinct targets (65-75 vs 80-90 mmHg) in a porcine model.

METHODS

Pigs were submitted to 15 min of untreated ventricular fibrillation followed by 30 min of E-CPR. Defibrillations were then delivered until return of spontaneous circulation (ROSC). Extracorporeal circulation was initially set to an average flow of 40 ml/kg/min. The dose of epinephrine was set to reach a standard or a high MAP target level (65-75 vs 80-90 mmHg, respectively). Animals were followed during 120-min after ROSC.

RESULTS

Six animals were included in both groups. During E-CPR, high MAP improved carotid blood flow as compared to standard MAP. After ROSC, this was conversely decreased in high versus standard MAP, while intra-cranial pressure was superior. The pressure reactivity index (PRx), which is the correlation coefficient between arterial blood pressure and intracranial pressure, also demonstrated inverted patterns of alteration according to MAP levels during E-CPR and after ROSC. In standard-MAP, PRx was transiently positive during E-CPR before returning to negative values after ROSC, demonstrating a reversible alteration of cerebral autoregulation during E-CPR. In high-MAP, PRx was negative during E-CPR but became sustainably positive after ROSC, demonstrating a prolonged alteration in cerebral autoregulation after ROSC. It was associated with a significant decrease in cerebral oxygen consumption in high- versus standard-MAP after ROSC.

CONCLUSIONS

During early E-CPR, MAP target above 80 mmHg is associated with higher carotid blood flow and improved cerebral autoregulation. This pattern is inverted after ROSC with a better hemodynamic status with standard versus high-MAP.

Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock

The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.

Extracorporeal Cardiopulmonary Resuscitation and Survival After Refractory Cardiac Arrest: Is ECPR Beneficial?

The level of evidence of expert recommendations for starting extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) is low. Therefore, we reported our experience in the field to identify factors associated with hospital mortality. We conducted a retrospective cohort study of all consecutive patients treated with ECPR for refractory cardiac arrest without return to spontaneous circulation, regardless of cause, at the Caen University Hospital. Factors associated with hospital mortality were analyzed. Eighty-six patients (i.e., 35 OHCA and 51 IHCA) were included. The overall hospital mortality rate was 81% (i.e., 91% and 75% in the OHCA and IHCA groups, respectively). Factors independently associated with mortality were: sex, age > 44 years, and time from collapse until extracorporeal life support (ECLS) initiation. Interestingly, no-shockable rhythm was not associated with mortality. The receiver operating characteristic-area under the curve values of pH value (0.75 [0.60-0.90]) and time from collapse until ECLS initiation over 61 minutes (0.87 [0.76-0.98]) or 74 minutes (0.90 [0.80-1.00]) for predicting hospital mortality showed good discrimination performance. No-shockable rhythm should not be considered a formal exclusion criterion for ECPR. Time from collapse until ECPR initiation is the cornerstone of success of an ECPR strategy in refractory cardiac arrest.

Unité mobile d’assistance circulatoire et respiratoire de l’enfant et du nouveau-né : une revue narrative

Les unités mobiles d’assistance circulatoire et respiratoire de l’enfant et du nouveau-né se sont développées au cours des dix dernières années. En effet, la mise en place d’une suppléance extracorporelle respiratoire ou circulatoire nécessite une équipe expérimentée et n’est pas disponible dans tous les centres hospitaliers pédiatriques. Or, les enfants atteints d’une défaillance circulatoire ou respiratoire réfractaire ne sont, pour la plupart, pas déplaçables vers une unité délivrant ce type de traitement de sauvetage. Les unités mobiles ont donc pour objectif de mettre à disposition ces technologies d’exception sur l’ensemble du territoire afin de garantir une égalité d’accès aux soins. Cependant, la haute technicité de ces thérapeutiques nécessite une équipe entraînée sachant poser et régler une assistance extracorporelle, prendre en charge un patient en défaillance respiratoire et/ou hémodynamique réfractaire et aguerrie à ces transports à haut risque. Le territoire français était jusqu’en 2014 très mal couvert par les unités mobiles pédiatriques et néonatales. Depuis, la création de plusieurs unités a permis une couverture totale du territoire. L’objectif de cette revue narrative sur les unités mobiles pédiatriques et néonatales est de résumer les différentes modalités de suppléance respiratoire et hémodynamique extracorporelle, d’en illustrer leurs différentes missions et leurs modalités de fonctionnement. Nous finirons par une description de leur efficacité en termes de survie et de survenue d’incidents en cours de transport.

[Extracorporeal cardiopulmonary resuscitation for treatment of out-of-hospital cardiac arrest]

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) affects ca. 75,000 people each year in Germany and is associated with a limited prognosis and a high mortality. Extracorporeal cardiopulmonary resuscitation (eCPR) using arteriovenous extracorporeal membrane oxygenation (av-ECMO) systems is an additional option for treatment, which is increasingly more widespread and since 2020 anchored in the guideline algorithm.

METHODS

A selective search of the literature was carried out in PubMed and Embase focusing on studies that investigated eCPR for OHCA. Furthermore, clinical studies on this topic that are currently recruiting and running are summarized.

RESULTS

The available data on the benefits of eCPR for OHCA are mostly based on retrospective cohort studies. A survival advantage and an advantage in the neurological outcome could be derived from these data for selected patients treated with eCPR vs. conventionally resuscitated patients (CPR). This effect could be confirmed by two current randomized controlled studies. Studies which are currently running are investigating if out-of-hospital ECMO cannulation at the earliest time possible at the site of OHCA of patients could be associated with a better survival.

CONCLUSION

Despite a current scarcity of data, a survival advantage for eCPR treatment in selected OHCA patients must be assumed. If this can be substantiated by other high-quality studies, it seems to be indicated to evaluate if and to what extent resource-intensive eCPR programs can be comprehensively established.

Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism

AIM OF THE STUDY

Extracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). We sought to analyze use and outcome of ECMO with or without adjunctive treatment strategies in patients with acute PE.

METHODS

We retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) undergoing ECMO in Germany between 2005 and 2018.

RESULTS

At total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Cardiac arrest requiring cardiopulmonary resuscitation was present in 77,196 (6.5%) patients. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority of patients received thrombolysis and VA-ECMO (n = 165; 0.2%), embolectomy and VA-ECMO (n = 385; 0.5%) or VA-ECMOalone (n = 588; 0.8%). A multivariable logistic regression analysis indicated the lowest risk for in-hospital death in patients who received embolectomy in combination with VA-ECMO (OR, 0.50 [95% CI, 0.41-0.61], p < 0.001), thrombolysis and VA-ECMO (0.60 [0.43-0.85], p = 0.003) or VA-ECMO alone (0.68 [0.57-0.82], p < 0.001) compared to thrombolysis alone (1.04 [0.99-1.01], p = 0.116).

CONCLUSION

Our findings suggest that the use of VA-ECMO alone or as part of a multi-pronged reperfusion approach including embolectomy or thrombolysis might offer survival advantages compared to thrombolysis alone in patients with PE deteriorating to cardiac arrest.

Femoral vascular access for endovascular resuscitation

ABSTRACT

Endovascular resuscitation is an emerging area in the resuscitation of both severe traumatic hemorrhage and nontraumatic cardiac arrest. Vascular access is the critical first procedural step that must be accomplished to initiate endovascular resuscitation. The endovascular interventions presently available and emerging are routinely or potentially performed via the femoral vessels. This may require either femoral arterial access alone or access to both the femoral artery and vein. The time-critical nature of resuscitation necessitates that medical specialists performing endovascular resuscitation be well-trained in vascular access techniques. Keen knowledge of femoral vascular anatomy and skill with vascular access techniques are required to meet the needs of critically ill patients for whom endovascular resuscitation can prove lifesaving. This review article addresses the critical importance of femoral vascular access in endovascular resuscitation, focusing on the pertinent femoral vascular anatomy and technical aspects of ultrasound-guided percutaneous vascular access and femoral vessel cutdown that may prove helpful for successful endovascular resuscitation.

The impact of selection criteria and study design on reported survival outcomes in extracorporeal oxygenation cardiopulmonary resuscitation (ECPR): a systematic review and meta-analysis

Background

The use of extracorporeal membrane oxygenation (ECMO) during cardiac arrest (ECPR) has increased exponentially. However, reported outcomes vary considerably due to differing study designs and selection criteria. This review assessed the impact of pre-defined selection criteria on ECPR survival.

Methods

Systematic review applying PRISMA guidelines. We searched Medline, Embase, and Evidence-Based Medicine Reviews for RCTs and observational studies published from January 2000 to June 2021. Adult patients (> 12 years) receiving ECPR were included. Two investigators reviewed and extracted data on study design, number and type of inclusion criteria. Study quality was assessed using the Newcastle–Ottawa Scale (NOS). Outcomes included overall and neurologically favourable survival. Meta-analysis and meta-regression were performed.

Results

67 studies were included: 14 prospective and 53 retrospective. No RCTs were identified at time of search. The number of inclusion criteria to select ECPR patients (p = 0.292) and study design (p = 0.962) was not associated with higher favourable neurological survival. However, amongst prospective studies, increased number of inclusion criteria was associated with improved outcomes in both OHCA and IHCA cohorts. (β = 0.12, p = 0.026) and arrest to ECMO flow time was predictive of survival. (β = -0.023, p < 0.001).

Conclusions

Prospective studies showed number of selection criteria and, in particular, arrest to ECMO time were associated with significant improved survival. Well-designed prospective studies assessing the relative importance of criteria as well as larger efficacy studies are required to ensure appropriate application of what is a costly intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00956-5.

The effect of the localisation of an underlying ST-elevation myocardial infarction on the VF-waveform: A multi-centre cardiac arrest study

INTRODUCTION

In cardiac arrest, ventricular fibrillation (VF) waveform characteristics such as amplitude spectrum area (AMSA) are studied to identify an underlying myocardial infarction (MI). Observational studies report lower AMSA-values in patients with than without underlying MI. Moreover, experimental studies with 12-lead ECG-recordings show lowest VF-characteristics when the MI-localisation matches the ECG-recording direction. However, out-of-hospital cardiac arrest (OHCA)-studies with defibrillator-derived VF-recordings are lacking.

METHODS

Multi-centre (Amsterdam/Nijmegen, the Netherlands) cohort-study on the association between AMSA, ST-elevation MI (STEMI) and its localisation. AMSA was calculated from defibrillator pad-ECG recordings (proxy for lead II, inferior vantage point); STEMI-localisation was determined using ECG/angiography/autopsy findings.

RESULTS

We studied AMSA-values in 754 OHCA-patients. There were statistically significant differences between no STEMI, anterior STEMI and inferior STEMI (Nijmegen: no STEMI 13.0mVHz [7.9-18.6], anterior STEMI 7.5mVHz [5.6-13.8], inferior STEMI 7.5mVHz [5.4-11.8], p = 0.006. Amsterdam: 11.7mVHz [5.0-21.9], 9.6mVHz [4.6-17.2], and 6.9mVHz [3.2-16.0], respectively, p = 0.001). Univariate analyses showed significantly lower AMSA-values in inferior STEMI vs. no STEMI; there was no significant difference between anterior and no STEMI. After correction for confounders, adjusted absolute AMSA-values were numerically lowest for inferior STEMI in both cohorts, and the relative differences in AMSA between inferior and no STEMI was 1.4-1.7 times larger than between anterior and no STEMI.

CONCLUSION

This multi-centre VF-waveform OHCA-study showed significantly lower AMSA in case of underlying STEMI, with a more pronounced difference for inferior than for anterior STEMI. Confirmative studies on the impact of STEMI-localisation on the VF-waveform are warranted, and might contribute to earlier diagnosis of STEMI during VF.

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.

Severe Myocardial Dysfunction after Non-Ischemic Cardiac Arrest: Effectiveness of Percutaneous Assist Devices

Introduction: Despite the improvements in standardized cardiopulmonary resuscitation, survival remains low, mainly due to initial myocardial dysfunction and hemodynamic instability. Our goal was to compare the efficacy of two left ventricular assist devices on resuscitation and hemodynamic supply in a porcine model of ventricular fibrillation (VF) cardiac arrest. Methods: Seventeen anaesthetized pigs had 12 min of untreated VF followed by 6 min of chest compression and boluses of epinephrine. Next, a first defibrillation was attempted and pigs were randomized to any of the three groups: control (n = 5), implantation of an percutaneous left ventricular assist device (Impella, n = 5) or extracorporeal membrane oxygenation (ECMO, n = 7). Hemodynamic and myocardial functions were evaluated invasively at baseline, at return of spontaneous circulation (ROSC), after 10–30–60–120–240 min post-resuscitation. The primary endpoint was the rate of ROSC. Results: Only one of 5 pigs in the control group, 5 of 5 pigs in the Impella group, and 5 of 7 pigs in the ECMO group had ROSC (p < 0.05). Left ventricular ejection fraction at 240 min post-resuscitation was 37.5 ± 6.2% in the ECMO group vs. 23 ± 3% in the Impella group (p = 0.06). No significant difference in hemodynamic parameters was observed between the two ventricular assist devices. Conclusion: Early mechanical circulatory support appeared to improve resuscitation rates in a shockable rhythm model of cardiac arrest. This approach appears promising and should be further evaluated.

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.

Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study

Background

Mechanical circulatory support (MCS) with either extracorporeal membrane oxygenation or Impella has shown potential as a salvage therapy for patients with refractory out-of-hospital cardiac arrest (OHCA). The objective of this study was to describe the gradual implementation, survival and adherence to the national consensus with respect to use of MCS for OHCA in Denmark, and to identify factors associated with outcome.

Methods

This retrospective, observational cohort study included patients receiving MCS for OHCA at all tertiary cardiac arrest centers (n = 4) in Denmark between July 2011 and December 2020. Logistic regression and Kaplan–Meier survival analysis were used to determine association with outcome. Outcome was presented as survival to hospital discharge with good neurological outcome, 30-day survival and predictors of 30-day mortality.

Results

A total of 259 patients were included in the study. Thirty-day survival was 26%. Sixty-five (25%) survived to hospital discharge and a good neurological outcome (Glasgow–Pittsburgh Cerebral Performance Categories 1–2) was observed in 94% of these patients. Strict adherence to the national consensus showed a 30-day survival rate of 30% compared with 22% in patients violating one or more criteria. Adding criteria to the national consensus such as signs of life during cardiopulmonary resuscitation (CPR), pre-hospital low-flow < 100 min, pH > 6.8 and lactate < 15 mmol/L increased the survival rate to 48%, but would exclude 58% of the survivors from the current cohort. Logistic regression identified asystole (RR 1.36, 95% CI 1.18–1.57), pulseless electrical activity (RR 1.20, 95% CI 1.03–1.41), initial pH < 6.8 (RR 1.28, 95% CI 1.12–1.46) and lactate levels > 15 mmol/L (RR 1.16, 95% CI 1.16–1.53) as factors associated with increased risk of 30-day mortality. Patients presenting signs of life during CPR had reduced risk of 30-day mortality (RR 0.63, 95% CI 0.52–0.76).

Conclusions

A high survival rate with a good neurological outcome was observed in this Danish population of patients treated with MCS for OHCA. Stringent patient selection for MCS may produce higher survival rates but potentially withholds life-saving treatment in a significant proportion of survivors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03606-5.

Optimizing hemodynamic function during cardiopulmonary resuscitation

PURPOSE OF REVIEW

The purpose of this narrative review is to provide an update on hemodynamics during cardiopulmonary resuscitation (CPR) and to describe emerging therapies to optimize perfusion.

RECENT FINDINGS

Cadaver studies have shown large inter-individual variations in blood distribution and anatomical placement of the heart during chest compressions. Using advanced CT techniques the studies have demonstrated atrial and slight right ventricular compression, but no direct compression of the left ventricle. A hemodynamic-directed CPR strategy may overcome this by allowing individualized hand-placement, drug dosing, and compression rate and depth. Through animal studies and one clinical before-and-after study head-up CPR has shown promising results as a potential strategy to improve cerebral perfusion. Two studies have demonstrated that placement of an endovascular balloon occlusion in the aorta (REBOA) can be performed during ongoing CPR.

SUMMARY

Modern imaging techniques may help increase our understanding on the mechanism of forward flow during CPR. This could provide new information on how to optimize perfusion. Head-up CPR and the use of REBOA during CPR are novel methods that might improve cerebral perfusion during CPR; both techniques do, however, still await clinical testing.

Transportation during and after cardiac arrest: who, when, how and where?

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

RECENT FINDINGS

We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

SUMMARY

There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

Beyond Extracorporeal Cardiopulmonary Resuscitation: Systems of Care Supporting Cardiac Arrest Patients

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability in the United States. Cardiac arrest centers (CAC) are necessary for the management of these critically ill and complex post arrest patients due to their specialized services and provider expertise. We report the case of a patient with OHCA and the systems of care involved in his resuscitation and recovery. Case Report: Emergency medical services attended a 39-year-old male with ongoing bystander cardiopulmonary resuscitation (CPR) after a witnessed collapse. Despite receiving appropriate advanced cardiac life support, including three defibrillations, he remained in refractory ventricular fibrillation. A prehospital physician identified him as an extracorporeal cardiopulmonary resuscitation (ECPR) candidate due to his age, witnessed arrest, refractory rhythm, and functional status. He was expedited to a CAC but no longer qualified for ECPR due to the time limit. He was resuscitated by the multiple teams activated prior to his arrival. He eventually had sustained return of circulation, was taken to the catheterization lab for emergent percutaneous coronary intervention, and recovered with a good neurologic outcome. Conclusion: Cardiac arrest centers may be capable of advanced interventions including ECPR. However, the systems of care offered by these centers is itself a lifesaving intervention. As this case highlights, despite not receiving the specified intervention (ECPR) the systems of care required to offer such a resource led to this favorable outcome.

Balanced Biventricular Assist Versus Extracorporeal Membrane Oxygenation in Cardiac Arrest

Mechanical assist devices in refractory cardiac arrest are increasingly employed. We compared the hemodynamics and organ perfusion during cardiac arrest with either veno-arterial extracorporeal membrane oxygenation (ECMO) or biventricular assisted circulation combining left- and right-sided impeller devices (BiPella) in an acute experimental setting. Twenty pigs were randomized in two equal groups receiving circulatory support either by ECMO or by BiPella during 40 minutes of ventricular fibrillation (VF) followed by three attempts of cardioversion, and if successful, 60 minute observation with spontaneous, unsupported circulation. Hemodynamic variables were continuously recorded. Tissue perfusion was evaluated by fluorescent microsphere injections. Cardiac function was visualized by intracardiac echocardiography. During VF device output, carotid flow, kidney perfusion, mean aortic pressure (AOPmean), and mean left ventricular pressure (LVPmean) were all significantly higher in the ECMO group, and serum-lactate values were lower compared with the BiPella group. No difference in myocardial or cerebral perfusion was observed between groups. In 15 animals with sustained cardiac function for 60 minutes after return of spontaneous circulation, left ventricular subendocardial blood flow rate averaged 0.59 ± 0.05 ml/min/gm during VF compared with 0.31 ± 0.07 ml/min/gm in five animals with circulatory collapse (p = 0.005). Corresponding values for the midmyocardium was 0.91 ± 0.06 vs. 0.65 ± 0.15 ml/min/gm (p = 0.085). Both BiPella and ECMO could sustain vital organ function. ECMO provided a more optimal systemic circulatory support related to near physiologic output. Myocardial tissue perfusion and sustained cardiac function were related to coronary perfusion pressure during VF, irrespective of mode of circulatory support.

State-of-the-Art Review-Endovascular Resuscitation

ABSTRACT

The emerging concept of endovascular resuscitation applies catheter-based techniques in the management of patients in shock to manipulate physiology, optimize hemodynamics, and bridge to definitive care. These interventions hope to address an unmet need in the care of severely injured patients, or those with refractory non-traumatic cardiac arrest, who were previously deemed non-survivable. These evolving techniques include Resuscitative Endovascular Balloon Occlusion of Aorta, Selective Aortic Arch Perfusion, and Extracorporeal Membrane Oxygenation and there is a growing literature base behind them. This review presents the up-to-date techniques and interventions, along with their application, evidence base, and controversy within the new era of endovascular resuscitation.

Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization

DISCLAIMER

Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: first results and outcomes of a newly established ECPR program in a large population area

OBJECTIVES

Out-of-hospital cardiac arrest (OHCA) is associated with excessively high mortality rates. Recent studies suggest benefits from extracorporeal cardiopulmonary resuscitation (ECPR) performed in selected patients. We sought to present the first results from our interdisciplinary ECPR program with a particular focus on early outcomes and potential risk factors associated with in-hospital mortality.

METHODS

Between January 2016 and December 2019, 44 patients who underwent ECPR selected according to our institutional ECPR protocol were retrospectively analyzed regarding pre-hospital, in-hospital, and early outcome parameters. Patients were divided into survivors (S) and non-survivors (NS). Statistical analysis of risk factors regarding in-hospital mortality of the patient cohort analyzed was performed.

RESULTS

The mean age of the population was 53 ± 12 years, with most patients being male (n = 40). The leading cause of cardiac arrest (CA) was myocardial infarction (n = 24, 55%). The median hospital stay was 1 (1;13) day. Twenty-three percent of patients (n = 10) were discharged from hospital including eight patients (18%) with CPC 1-2. Survivors showed a trend toward shorter pre-hospital CPR duration (60 (59;60) min (S) vs 60 (55;90) min (NS), p = 0.07).

CONCLUSION

Establishing ECPR programs in large population areas offers the option to improve survival rates for OHCA patients. Stringent compliance of institutional criteria (mainly age, witnessed arrest, and time of pre-hospital resuscitation) and providing ECPR to strictly selected patients seems to be a vital factor for such programs' success. Pre-clinical settings and therapeutic measures must be adjusted in this regard to improve outcomes for this highly demanding patient cohort.

Prognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest

PURPOSE

Prognostication of refractory out-of-hospital cardiac arrest (OHCA) is essential for selecting the population that may benefit from extracorporeal cardiopulmonary resuscitation (ECPR). We aimed to examine the prognostic value of signs of life before or throughout conventional CPR for individuals undergoing ECPR for refractory OHCA.

METHODS

Pooling the original data from three cohort studies, we estimated the prevalence of signs of life, for individuals with refractory OHCA resuscitated with ECPR. We performed multivariable logistic regression to examine the independent associations between the occurrence of signs of life and 30-day survival with a CPC score ≤ 2.

RESULTS

The analytical sample consisted of 434 ECPR recipients. The prevalence of any sign of life was 61%, including pupillary light reaction (48%), gasping (32%), or increased level of consciousness (13%). Thirty-day survival with favorable neurological outcome was 15% (63/434). In multivariable analysis, the adjusted odds ratios of 30-day survival with favorable neurological outcome were 7.35 (95% confidence interval [CI], 2.71-19.97), 5.86 (95% CI, 2.28-15.06), 4.79 (95% CI, 2.16-10.63), and 1.75 (95% CI, 0.95-3.21) for any sign of life, pupillary light reaction, increased level of consciousness, and gasping, respectively.

CONCLUSION

The assessment of signs of life before or throughout CPR substantially improves the accuracy of a multivariable prognostic model in predicting 30-day survival with favorable neurological outcome. The lack of any sign of life might obviate the provision of ECPR for patients without shockable cardiac rhythm.

Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol

AIM

To compare the outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) fulfilling the criteria for extracorporeal cardiopulmonary resuscitation (ECPR) before and after implementation of an ECPR protocol, whether the patient received ECPR or not.

METHODS

We compared cardiac arrest registry data before (2014-2015) and after (2016-2019) implementation of the ECPR protocol. The ECPR criteria were presumed cardiac origin, witnessed arrest with ventricular fibrillation, bystander CPR, age 18-65, advanced life support (ALS) within 15 min and ALS > 10 min without return of spontaneous circulation (ROSC). The primary outcome was 30-day survival; the secondary outcomes were sustained ROSC, neurological outcome and the proportion of patients transported with ongoing ALS.

RESULTS

There were 1086 and 3135 patients in the pre- and post-implementation sample; 48 (4%) and 100 (3%) met the ECPR criteria, respectively. Of these, 21 (44%) vs. 37 (37%) were alive after 30 days, p = 0.4, and 30 (63%) vs. 50 (50%) achieved sustained ROSC, p = 0.2. All survivors in the pre-implementation sample had cerebral performance category 1-2 vs. 30 (81%) in the post-implementation sample, p = 0.03. Of the patients fulfilling the ECPR criteria, 7 (15%) and 26 (26%), p = 0.1, were transported with ongoing ALS in the pre- and post-implementation sample, respectively.

CONCLUSIONS

There were no differences in 30-day survival or prehospital ROSC in patients with refractory OHCA before and after initiation of an ECPR protocol.

A review of ECMO for cardiac arrest

Cardiac arrest is an important public health concern, affecting an estimated 356,500 people in the out-of-hospital setting and 209,000 people in the in-hospital setting each year. The causes of cardiac arrest include acute coronary syndromes, pulmonary embolism, dyskalemia, respiratory failure, hypovolemia, sepsis, and poisoning among many others. In order to tackle the enormous issue of high mortality among sufferers of cardiac arrest, ongoing research has been seeking improved treatment protocols and novel therapies. One of the mechanical devices that has been increasingly utilized for cardiac arrest is venoarterial extracorporeal membrane oxygenation (VA-ECMO). Presently there is only one published randomized controlled trial examining the use of VA-ECMO as part of cardiopulmonary resuscitation (CPR), a process referred to as extracorporeal cardiopulmonary resuscitation (ECPR). Recently there has been significant progress in providing ECPR for refractory cardiac arrest patients. This narrative review seeks to outline the use of ECPR for both in-hospital and out-of-hospital cardiac arrest, as well as provide information on the expected outcomes associated with its use.

ECMO in Cardiac Arrest: A Narrative Review of the Literature

Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.

Extracorporeal cardiopulmonary resuscitation for adults with shock-refractory cardiac arrest

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation has increasingly emerged as a feasible treatment to mitigate the progressive multiorgan dysfunction that occurs during cardiac arrest, in support of further resuscitation efforts.

OBJECTIVES

Because the recent systematic review commissioned in 2018 by the International Liaison Committee on Resuscitation Advanced Life Support task did not include studies without a control group, our objective was to conduct a review incorporating these studies to increase available evidence supporting the use of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest patients, while waiting for high-quality evidence from randomized controlled trials (RCTs).

METHODS

MEDLINE, Embase, and Science Citation Index (Web of Science) were searched for eligible studies from database inception to July 20, 2020. The population of interest was adult patients who had suffered cardiac arrest in any setting. We included all cohort studies with 1 exposure/1 group and descriptive studies (ie, case series studies). We excluded RCTs, non-RCTs, and observational analytic studies with a control group. Outcomes included short-term survival and favorable neurological outcome. Short-term outcomes (ie, hospital discharge, 30 days, and 1 month) were combined into a single category.

RESULTS

Our searches of databases and other sources yielded a total of 4302 citations. Sixty-two eligible studies were included (including a combined total of 3638 participants). Six studies were of in-hospital cardiac arrest, 34 studies were of out-of-hospital cardiac arrest, and 22 studies included both in-hospital and out-of-hospital cardiac arrest. Seven hundred and sixty-eight patients of 3352 (23%) had short-term survival; whereas, 602 of 3366 (18%) survived with favorable neurological outcome, defined as a cerebral performance category score of 1 or 2.

CONCLUSIONS

Current clinical evidence is mostly drawn from observational studies, with their potential for confounding selection bias. Although studies without controls cannot supplant case-control or cohort studies, several ECPR studies without a control group show successful resuscitation with impressive results that may provide valuable information to inform a comparison.

Impella CP Implantation during Cardiopulmonary Resuscitation for Cardiac Arrest: A Multicenter Experience

BACKGROUND

Impella CP is a left ventricular pump which may serve as a circulatory support during cardiopulmonary resuscitation (CPR) for cardiac arrest (CA). Nevertheless, the survival rate and factors associated with survival in patients undergoing Impella insertion during CPR for CA are unknown.

METHODS

We performed a retrospective multicenter international registry of patients undergoing Impella insertion during on-going CPR for in- or out-of-hospital CA. We recorded immediate and 30-day survival with and without neurologic impairment using the cerebral performance category score and evaluated the factors associated with survival.

RESULTS

Thirty-five patients had an Impella CP implanted during CPR for CA. Refractory ventricular arrhythmias were the most frequent initial rhythm (65.7%). In total, 65.7% of patients immediately survived. At 30 days, 45.7% of patients were still alive. The 30-day survival rate without neurological impairment was 37.1%. In univariate analysis, survival was associated with both an age < 75 years and a time from arrest to CPR ≤ 5 min (p = 0.035 and p = 0.008, respectively).

CONCLUSIONS

In our multicenter registry, Impella CP insertion during ongoing CPR for CA was associated with a 37.1% rate of 30-day survival without neurological impairment. The factors associated with survival were a young age and a time from arrest to CPR ≤ 5 min.

First Description of a Helicopter-Borne ECPR Team for Remote Refractory Out-of-Hospital Cardiac Arrest

Introduction: Access time to extracorporeal cardiopulmonary resuscitation (ECPR) refractory out of hospital cardiac arrest (OHCA) is a crucial factor. In our region, some patients are not eligible to this treatment due to the impossibility to reach the hospital with reasonable delay (ideally 60 min). In order to increase accessibility for patients far from ECPR centers, we developed a helicopter-borne ECPR-team which is sent out to the patient for ECPR implementation on the scene of the OHCA.Methods: We conducted a retrospective monocentric study to evaluate this strategy. The team is triggered by the local emergency medical service and heliborne on the site of the OHCA. All consecutive patients implemented with ECPR by our heliborne ECPR team from January 2014 to December 2017 were included. We analyzed usual CA characteristics, different times (no-flow, low-flow, time between OHCA and dispatch…), and patient outcome.Results: During this 4-year study period, 33 patients were included. Mean age was 43.9 years. Mean distance from the ECPR-team base to OHCA location was 41 km. Mean low-flow time was 110 minutes. Five patients survived with good neurological outcome; 6 patients developed brain death and became organ donors.Conclusion: These results show the possibility to make ECPR accessible for patients far from ECPR centers. Survival rate is non negligible, especially in the absence of therapeutic alternative. An earlier trigger of the ECPR-team could reduce the low-flow time and probably increase survival. This strategy improves equity of access to ECPR and needs to be confirmed by further studies.

Assessing need for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest using Power BI for data visualisation

OBJECTIVE

To estimate the number of patients in refractory out-of-hospital cardiac arrest (OHCA) potentially suitable for transport to an extracorporeal cardiopulmonary resuscitation (ECPR)-capable hospital in Brisbane, Queensland, Australia, based on outcome predictors for ECPR, ambulance geolocation and patient data.

METHODS

A retrospective cohort study was performed using data from all patients in OHCA attended by Queensland Ambulance Service between 1 January 2014 and 31 December 2018. The number of refractory arrest patients who could potentially be transferred to an ECPR-capable centre within 45 min of the time of arrest was modelled using theoretical on-scene treatment times.

RESULTS

Of 25 518 ambulance-attended OHCA in Queensland during the study period, 540 (2%) patients met criteria of refractory arrest for study inclusion. Further age and arrest rhythm criteria for transport to an ECPR-capable hospital were met in 253 (47%) study patients, an average of 51 patients per year. In 2018, 72 patients met study criteria for transport to an ECPR-capable centre. Based on theoretical on-scene treatment times of 12 and 20 min, in 2018 only 14 (19%) and 11 (15%) patients respectively would potentially arrive at an ECPR-capable hospital within accepted timeframes for ECPR.

CONCLUSIONS

Retrospective data collected from existing ambulance databases can be used to model patient suitability for ECPR. Relatively few patients with refractory OHCA in Queensland, Australia, could be attended and transported to an ECPR-capable centre within clinically acceptable timeframes. Further studies of the transport logistics and economic implications of providing ECPR services for OHCA are required to better inform decisions around this intervention.

Prehospital extracorporeal cardiopulmonary resuscitation for cardiac arrest patients in rural areas: a case report of two patients

Background

The prognosis of out-of-hospital cardiac arrest remains poor, especially for cardiopulmonary arrest patients in rural areas with longer transport duration to hospitals.

Case Presentation

In June 2016, we began providing prehospital extracorporeal life support using a mobile operating room for emergency surgery. We report two patients who survived after receiving prehospital extracorporeal cardiopulmonary resuscitation and were discharged. A patient with cardiopulmonary arrest from accidental hypothermia due to drowning survived with good neurological outcomes after on-site extracorporeal cardiopulmonary resuscitation immediately after rescue. The other patient who survived experienced cardiopulmonary arrest at his workplace, which was approximately 90 min from the center. Prehospital extracorporeal cardiopulmonary resuscitation shortened the cardiopulmonary arrest time by an estimated 30 min, and the patient survived until the hospital.

Conclusion

Prehospital extracorporeal cardiopulmonary resuscitation has the potential to save lives in rural areas by reducing low-flow time.

Shorter Interval from Witnessed Out-Of-Hospital Cardiac Arrest to Reaching the Target Temperature Could Improve Neurological Outcomes After Extracorporeal Cardiopulmonary Resuscitation with Target Temperature Management: A Retrospective Analysis of a Japanese Nationwide Multicenter Observational Registry

Extracorporeal cardiopulmonary resuscitation (ECPR) with extracorporeal membrane oxygenation is a more promising treatment for out-of-hospital cardiac arrest (OHCA) than conventional cardiopulmonary resuscitation (CCPR). However, previous studies that compared ECPR and CCPR included mixed groups of patients with or without target temperature management (TTM). In this study, we compared the neurological outcomes of OHCA between ECPR and CCPR with TTM in all patients. We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. Witnessed adult cases of cardiogenic OHCA treated with TTM were eligible for this study. We used univariate and multivariable analyses in all eligible patients to compare the neurological outcomes after ECPR or CCPR. We also conducted propensity score analyses of all patients and according to the interval from witnessed OHCA to reaching the target temperature (IWT) of ≤600, ≤480, ≤360, ≤240, and ≤120 minutes. We analyzed 1146 cases. The propensity score analysis did not show a significant difference in favorable neurological outcomes (defined as a Glasgow-Pittsburgh Cerebral Performance Category of 1-2 at 1 month after collapse) between EPCR and CCPR (odds ratio: OR 4.683 [95% confidence interval: CI 0.859-25.535], p = 0.747). However, ECPR was associated with more favorable neurological outcomes in patients with IWT of ≤600 minutes (OR 7.089 [95% CI 1.091-46.061], p = 0.406), ≤480 minutes (OR 10.492 [95% CI 1.534-71.773], p = 0.0168), ≤360 minutes (OR 17.573 [95% CI 2.486-124.233], p = 0.0042), ≤240 minutes (OR 38.908 [95% CI 5.045-300.089], p = 0.0005), and ≤120 minutes (OR 200.390 [95% CI 23.730-1692.211], p < 0.001). This study revealed significant differences in the neurological outcomes between ECPR and CCPR in patients with TTM whose IWT was ≤600 minutes.

[Extracorporeal cardiopulmonary resuscitation (eCPR) for out-of-hospital cardiac arrest (OHCA) : Retrospective analysis of a load and go strategy under the aspect of golden hour of eCPR]

BACKGROUND

Survival rates after an out-of-hospital cardiac arrest (OHCA) remain low. Extracorporeal cardiopulmonary resuscitation (eCPR) has been introduced as an attempt to increase survival in selected patients and observational studies have shown promising results. Nevertheless, inclusion criteria and timing of eCPR remain undefined.

OBJECTIVE

The current study analyzed a load and go strategy with respect to the golden hour of eCPR as a cut-off time for survival and favorable neurological outcome.

MATERIAL AND METHODS

This retrospective cohort study included 32 patients who underwent eCPR treatment due to an OHCA between January 2017 and September 2019. Routinely taken patient demographic data (age, BMI, sex) were analyzed. The main focus was set on processing times in the preclinical and clinical setting. Time intervals including OHCA until ambulance arrival, time on scene, transportation times and door to eCPR were extracted from emergency medical service (EMS) and resuscitation protocols. Low-flow times, survival and neurological outcome were analyzed.

RESULTS

The use of eCPR in OHCA was associated with survival to hospital discharge in 28% and a good neurological outcome in 19% of the cases. Both groups (survivor and nonsurvivor) did not differ in patient demographics except for age. Survivors were significantly younger (47 (30-60) vs. 59 (50-68) years, p = 0.035). Processing times as well as low-flow times were not significantly different (OHCA-eCPR survivor 64 (50-87) vs. non-survivor 74 (51-85) min; p-value 0.64); however, median low-flow times were outside the golden hour of eCPR (69 (52-86)).

CONCLUSION

Despite low-flow times of more than 60 min, eCPR was associated with survival in 28% after OHCA. Hence, exceeding the golden hour of eCPR cannot act as a definitive exclusion criterion for eCPR.