Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

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.

[Extracorporeal cardiopulmonary resuscitation-An orientation]

Both in-hospital and out-of-hospital cardiac arrests are associated with a high mortality. In the past survival advantages for patients could be achieved by optimizing the chain of rescue and postresuscitation treatment; however, for patients with refractory cardiac arrest, there have so far been few promising treatment options. For selected patients with refractory cardiac arrest who do not achieve return of spontaneous circulation with conventional cardiopulmonary resuscitation (CPR), extracorporeal (e)CPR using venoarterial extracorporeal membrane oxygenation is an option to improve the probability of survival. This article describes the technical features, important aspects of treatment, and the current data situation on eCPR in patients with in-hospital or out-of-hospital cardiac arrest.

Impella and venoarterial extracorporeal membrane oxygenation in cardiogenic shock complicating acute myocardial infarction

AIMS

This study aimed to give contemporary insight into the use of Impella and venoarterial extracorporeal membrane oxygenation (VA-ECMO) in acute myocardial infarction-related cardiogenic shock (AMICS) and into associated outcomes, adverse events, and resource demands.

METHODS AND RESULTS

This nationwide observational cohort study describes all AMICS patients treated with Impella (ABIOMED, Danvers, MA, USA) and/or VA-ECMO in 2020-2021. Impella and/or VA-ECMO were used in 20% of all AMICS cases (n = 4088). Impella patients were older (34% vs. 13% >75 years, p < 0.001) and less frequently presented after an out-of-hospital cardiac arrest (18% vs. 40%, p < 0.001). In-hospital mortality was lower in the Impella versus VA-ECMO cohort (61% vs. 67%, p = 0.001). Adverse events occurred less frequently in Impella-supported patients: acute haemorrhagic anaemia (36% vs. 68%, p < 0.001), cerebrovascular accidents (4% vs. 11%, p < 0.001), thromboembolisms of the extremities (5% vs. 8%, p < 0.001), systemic inflammatory response syndrome (21% vs. 25%, p = 0.004), acute kidney injury (44% vs. 53%, p < 0.001), and acute liver failure (7% vs. 12%, p < 0.001). Impella patients were discharged home directly more often (20% vs. 11%, p < 0.001) whereas VA-ECMO patients were more often discharged to another care facility (22% vs. 19%, p = 0.031). Impella patients had shorter hospital stays and lower hospital costs.

CONCLUSION

This is the largest, most recent European cohort study describing outcomes, adverse events, and resource demands based on claims data in patients with Impella and/or VA-ECMO. Overall, adverse event rates and resource consumption were high. Given the current lack of beneficial evidence, our study reinforces the need for prospectively established, high-quality evidence to guide clinical decision-making.

Hospital-administered ECPR for out-of-hospital cardiac arrest: an observational cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment method for refractory out-of-hospital cardiac arrest (OHCA) requiring a complex chain of care.

METHODS

All cases of OHCA between 1 January 2016 and 31 December 2021 in the Helsinki University Hospital catchment area in which the ECPR protocol was activated were included in the study. The protocol involved patient transport from the emergency site with ongoing mechanical cardiopulmonary resuscitation (CPR) directly to the cardiac catheterisation laboratory where the implementation of extracorporeal membrane oxygenation (ECMO) was considered. Cases of hypothermic cardiac arrest were excluded. The main outcomes were the number of ECPR protocol activations, duration of prehospital and in-hospital time intervals, and whether the ECPR candidates were treated using ECMO or not.

RESULTS

The prehospital ECPR protocol was activated in 73 cases of normothermic OHCA. The mean patient age (SD) was 54 (±11) years and 67 (91.8%) of them were male. The arrest was witnessed in 67 (91.8%) and initial rhythm was shockable in 61 (83.6%) cases. The median ambulance response time (IQR) was 9 (7-11) min. All patients received mechanical CPR, epinephrine and/or amiodarone. Seventy (95.9%) patients were endotracheally intubated. The median (IQR) highest prehospital end-tidal CO2 was 5.5 (4.0-6.9) kPa.A total of 37 (50.7%) patients were treated with venoarterial ECMO within a median (IQR) of 84 (71-105) min after the arrest. Thirteen (35.1%) of them survived to discharge and 11 (29.7%) with a cerebral performance category (CPC) 1-2. In those ECPR candidates who did not receive ECMO, 8 (22.2%) received permanent return of spontaneuous circulation during transport or immediately after hospital arrival and 6 (16.7%) survived to discharge with a CPC 1-2.

CONCLUSIONS

Half of the ECPR protocol activations did not lead to ECMO treatment. However, every fourth ECPR candidate and every third patient who received ECMO-facilitated resuscitation at the hospital survived with a good neurological outcome.

The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients-A Literature Review

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

Case Report: Correlation between pulmonary capillary wedge pressure and left-ventricular diastolic pressure during treatment with veno-arterial extracorporeal membrane oxygenation

Background

Pulmonary capillary wedge pressure (PCWP) is often used as a surrogate for left-ventricular end-diastolic pressure in patients (LVEDP) who are on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support for cardiogenic shock and cardiac arrest. However, the correlation between PCWP and LVEDP is not clear in the setting of V-A ECMO usage. We sought to evaluate this correlation in this case series.

Methods

Patients were referred to our cardiac catheterization laboratory for invasive hemodynamic studies to assess their readiness for VA-ECMO decannulation. All patients underwent simultaneous left and right heart catheterization. Using standard techniques, we measured PCWP and LVEDP simultaneously. Continuous variables were reported as medians with interquartile ranges. The correlation between PCWP and LVEDP was evaluated using simple linear regression and reported as R2.

Results

Four patients underwent invasive hemodynamic studies 4 (2.5, 7) days after VA-ECMO cannulation. All four patients had suffered in-hospital cardiac arrest and had been put on VA-ECMO. At the baseline level of VA-ECMO flow of 4.1 (3.8, 4.4) L/min, the median LVEDP and PCWP were 6 (4, 7.5) mmHg and 12 (6.5, 16) mmHg, respectively. At the lowest level of VA-ECMO flow of 1.9 (1.6, 2.0) L/min, the median LVEDP and PCWP was 13.5 (8.5, 16) mmHg and 15 (13, 18) mmHg, respectively. There was a poor correlation between the simultaneously measured PCWP and LVEDP (R2 = 0.03, p = 0.66).

Conclusions

The PCWP may not correlate well with LVEDP in patients treated with VA-ECMO, particularly at high levels of VA-ECMO support.

Out-of-hospital cardiac arrest treated with prehospital double sequential external defibrillation during eCPR in refractory VF - a case report

BACKGROUND

Double sequential external defibrillation (DSED) has demonstrated increased survival with good neurological outcome in a recent randomized controlled trial. DSED has not been studied in patients with extracorporeal cardiopulmonary resuscitation (eCPR).

CASE

We present the first case of prehospital eCPR with ongoing refractory ventricular fibrillation (VF), terminated by DSED. After six shocks, return of spontaneous circulation was initially achieved; however, the patient went into recurrent VF. ECPR was performed prehospital, with VF still refractory after three more shocks. DSED successfully terminated VF and showed a further increase in etCO2 and near-infrared spectroscopy cerebral oximetry values.

CONCLUSION

DSED can be a sufficient strategy for patients in refractory VF while on eCPR and should be evaluated in further studies.

Long-term prognostic significance of gasping in out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: a post hoc analysis of a multi-center prospective cohort study

BACKGROUND

Gasping during resuscitation has been reported as a favorable factor for out-of-hospital cardiac arrest. We examined whether gasping during resuscitation is independently associated with favorable neurological outcomes in patients with refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) undergoing extracorporeal cardiopulmonary resuscitation ECPR.

METHODS

Data from a 2014 study on advanced cardiac life support for ventricular fibrillation with extracorporeal circulation in Japan (SAVE-J), which examined the efficacy of ECPR for refractory VF/pVT, were analyzed. The primary endpoint was survival with a 6-month favorable neurological outcome in patients who underwent ECPR with or without gasping during resuscitation. Multivariate logistic regression analysis was performed to evaluate the association between gasping and outcomes.

RESULTS

Of the 454 patients included in the SAVE-J study, data from 212 patients were analyzed in this study after excluding those with missing information and those who did not undergo ECPR. Gasping has been observed in 47 patients during resuscitation; 11 (23.4%) had a favorable neurological outcome at 6 months. Multivariate logistic regression analysis showed that gasping during resuscitation was independently associated with a favorable neurological outcome (odds ratio [OR], 10.58 [95% confidence interval (CI) 3.22-34.74]). The adjusted OR for gasping during emergency medical service transport and on arrival at the hospital was 27.44 (95% CI 5.65-133.41).

CONCLUSIONS

Gasping during resuscitation is a favorable factor in patients with refractory VF/pVT. Patients with refractory VF/pVT with continuously preserved gasping during EMS transportation to the hospital are expected to have more favorable outcomes.

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.

Transfusion of red blood cells in venoarterial extracorporeal membrane oxygenation: A multicenter retrospective observational cohort study

BACKGROUND

Evidence-based recommendations for transfusion in patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) are scarce. The current literature is limited to single-center studies with small sample sizes, therefore complicating generalizability. This study aims to create an overview of red blood cell (RBC) transfusion in VA ECMO patients.

METHODS

This international mixed-method study combined a survey with a retrospective observational study in 16 centers. The survey inventoried local transfusion guidelines. Additionally, retrospective data of all adult patients with a VA ECMO run >24 h (January 2018 until July 2019) was collected of patient, ECMO, outcome, and daily transfusion parameters. All patients that received VA ECMO for primary cardiac support were included, including surgical (i.e., post-cardiotomy) and non-surgical (i.e., myocardial infarction) indications. The primary outcome was the number of RBC transfusions per day and in total. Univariable logistic regressions and a generalized linear mixed model (GLMM) were performed to assess factors associated with RBC transfusion.

RESULTS

Out of 419 patients, 374 (89%) received one or more RBC transfusions. During a median ECMO run of 5 days (1st-3rd quartile 3-8), patients received a median total of eight RBC units (1st-3rd quartile 3-17). A lower hemoglobin (Hb) prior to ECMO, longer ECMO-run duration, and hemorrhage were associated with RBC transfusion. After correcting for duration and hemorrhage using a GLMM, a different transfusion trend was found among the regimens. No unadjusted differences were found in overall survival between either transfusion status or the different regimens, which remained after adjustment for potential confounders.

CONCLUSION

RBC transfusion in patients on VA ECMO is very common. The sum of RBC transfusions increases rapidly after ECMO initiation, and is dependent on the Hb threshold applied. This study supports the rationale for prospective studies focusing on indications and thresholds for RBC transfusion.

Clinical Features and Outcomes Among Patients With Refractory Out-of-Hospital Cardiac Arrest and an Initial Shockable Rhythm

BACKGROUND

Clinical features among patients with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia are not well-characterized.

METHODS

We compared clinical characteristics and coronary angiographic findings between patients with refractory OHCA (incessant ventricular fibrillation/pulseless ventricular tachycardia after ≥3 direct-current shocks) and those without refractory OHCA.

RESULTS

Between 2014 and 2018, a total of 204 patients with ventricular fibrillation/pulseless ventricular tachycardia OHCA (median age 62; males 78%) were divided into groups with (36%, 74/204) and without refractory arrest (64%, 130/204). Refractory OHCA patients had longer cardiopulmonary resuscitation (23 versus 15 minutes), more frequently required ≥450 mg amiodarone (34% versus 3.8%), and had cardiogenic shock (80% versus 55%) necessitating higher adrenaline dose (4.0 versus 1.0 mg) and higher rates of mechanical ventilation (92% versus 74%; all P<0.01). Of 167 patients (82%) selected for coronary angiography, 33% (n=55) had refractory OHCA (P=0.035). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA patients frequently had acute coronary occlusion (64% versus 47%), especially left circumflex (20% versus 6.4%) and graft vessel (7.3% versus 0.9%; all P<0.05) compared with those without refractory OHCA. Refractory OHCA group had higher in-hospital mortality (45% versus 30%, P=0.036) and greater new requirement for dialysis (18% versus 6.3%, P=0.011). After adjustment, refractory OHCA was associated with over 2-fold higher odds of in-hospital mortality (odds ratio, 2.28 [95% CI, 1.06-4.89]; P=0.034).

CONCLUSIONS

Refractory ventricular fibrillation/pulseless ventricular tachycardia OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion, and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.

Patient-centered weaning from venoarterial extracorporeal membrane oxygenation: "A practice-oriented narrative review of literature"

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used in cardiogenic shock for rapid stabilization and bridging towards recovery, long-term mechanical circulatory support or transplant. Although technological advances have instigated its widespread use, the complex, long-lasting ECMO care creates a significant strain on hospital staff and resources. Therefore, optimal clinical management including timely decisions on ECMO removal and further therapy are pivotal, yet require a well-structured weaning approach. Although dedicated guidelines are lacking, a variety of weaning protocols have distillated echocardiographic and hemodynamic predictors for successful weaning. Nevertheless, a strikingly high mortality up to 70% after initial successful weaning raises concerns about the validity of current weaning strategies. Here, we plead for a patient-tailored approach including a bailout strategy when weaning fails. This should account not only for left- but also right ventricular function and interdependence, as well as the temporal course of cardiac recovery in function of extracorporeal support. Patients with a high risk of weaning failure should be identified early, enabling timely transportation to an advanced heart failure center. This review summarizes predictors of successful weaning and discusses all relevant elements for a structured weaning approach with a central role for patient-specific clinical considerations and echocardiography.

Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized clinical trials

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (ECPR) is currently recommended as a rescue therapy for selected patients in refractory out-of-hospital cardiac arrest (OHCA). However, there is conflicting evidence regarding its effect on survival and neurological outcomes. We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) to evaluate whether ECPR is superior to standard CPR in refractory OHCA.

METHODS

We performed a systematic search of electronic databases (PubMed, CENTRAL, and Scopus) until March 2023. Studies were eligible if they a) were RCTs, and b) compared ECPR vs. standard CPR for OHCA. Outcomes were defined as survival with a favorable neurological status (cerebral performance category 1 or 2) at both the shortest follow-up and at 6 months, and in-hospital mortality. Meta-analyses using a random-effects model were undertaken.

RESULTS

Three RCTs, with a total of four hundred and eighteen patients, were included. Compared with standard CPR, ECPR was associated with a non-statistically significant higher rate of survival with a favorable neurological outcome at the shortest follow-up (26.4% vs. 17.2%; RR 1.47 [95% CI 0.91-2.40], P = 0.12) and at 6 months (28.3% vs. 18.6%; RR 1.48 [95% CI 0.88-2.49], P = 0.14). The mean absolute rate of in-hospital mortality was not significantly lower in the ECPR group (RR 0.89 [95% CI 0.74-1.07], P = 0.23).

CONCLUSION

ECPR was not associated with a significant improvement in survival with favorable neurologic outcomes in refractory OHCA patients. Nevertheless, these results constitute the rationale for a well-conducted, large-scale RCT, aiming to clarify the effectiveness of ECPR compared to standard CPR.

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.

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.

Extracorporeal membrane oxygenation for critically ill adults

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) may provide benefit in certain populations of adults, including those with severe cardiac failure, severe respiratory failure, and cardiac arrest. However, it is also associated with serious short- and long-term complications, and there remains a lack of high-quality evidence to guide practice. Recently several large randomized controlled trials (RCTs) have been published, therefore, we undertook an update of our previous systematic review published in 2014.

OBJECTIVES

To evaluate whether venovenous (VV), venoarterial (VA), or ECMO cardiopulmonary resuscitation (ECPR) improve mortality compared to conventional cardiopulmonary support in critically ill adults.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was March 2022. The search was limited to English language only.

SELECTION CRITERIA

We included RCTs, quasi-RCTs, and cluster-RCTs that compared VV ECMO, VA ECMO or ECPR to conventional support in critically ill adults.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. all-cause mortality at day 90 to one year. Our secondary outcomes were 2. length of hospital stay, 3. survival to discharge, 4. disability, 5. adverse outcomes/safety events, 6. health-related quality of life, 7. longer-term health status, and 8. cost-effectiveness. We used GRADE to assess certainty of evidence.

MAIN RESULTS

Five RCTs met our inclusion criteria, with four new studies being added to the original review (total 757 participants). Two studies were of VV ECMO (429 participants), one VA ECMO (41 participants), and two ECPR (285 participants). Four RCTs had a low risk of bias and one was unclear, and the overall certainty of the results (GRADE score) was moderate, reduced primarily due to indirectness of the study populations and interventions. ECMO was associated with a reduction in 90-day to one-year mortality compared to conventional treatment (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.70 to 0.92; P = 0.002, I2 = 11%). This finding remained stable after performing a sensitivity analysis by removing the single trial with an uncertain risk of bias. Subgroup analyses did not reveal a significant subgroup effect across VV, VA, or ECPR modes (P = 0.73). Four studies reported an increased risk of major hemorrhage with ECMO (RR 3.32, 95% CI 1.90 to 5.82; P < 0.001), while two studies reported no difference in favorable neurologic outcome (RR 2.83, 95% CI 0.36 to 22.42; P = 0.32). Other secondary outcomes were not consistently reported across the studies.

AUTHORS' CONCLUSIONS

In this updated systematic review, which included four additional RCTs, we found that ECMO was associated with a reduction in day-90 to one-year all-cause mortality, as well as three times increased risk of bleeding. However, the certainty of this result was only low to moderate, limited by a low number of small trials, clinical heterogeneity, and indirectness across studies.

Current animal models of extracorporeal cardiopulmonary resuscitation: A scoping review

Aim

Animal models of Extracorporeal Cardiopulmonary Resuscitation (ECPR) focusing on neurological outcomes are required to further the development of this potentially life-saving technology. The aim of this review is to summarize current animal models of ECPR.

Methods

A comprehensive database search of PubMed, EMBASE, and Web of Science was undertaken. Full-text publications describing animal models of ECPR between January 1, 2000, and June 30, 2022, were identified and included in the review. Data describing the conduct of the animal models of ECPR, measured variables, and outcomes were extracted according to pre-defined definitions.

Results

The search strategy yielded 805 unique reports of which 37 studies were included in the final analysis. Most studies (95%) described using a pig model of ECPR with the remainder (5%) describing a rat model. The most common method for induction of cardiac arrest was a fatal ventricular arrhythmia through electrical stimulation (70%). 10 studies reported neurological assessment of animals using physical examination, serum biomarkers, or electrophysiological findings, however, only two studies described a multimodal assessment. No studies reported the use of brain imaging as part of the neurological assessment. Return of spontaneous circulation was the most reported primary outcome, and no studies described the neurological status of the animal as the primary outcome.

Conclusion

Current animal models of ECPR do not describe clinically relevant neurological outcomes after cardiac arrest. Further work is needed to develop models that more accurately mimic clinical scenarios and can test innovations that can be translated to the application of ECPR in clinical medicine.

Extracorporeal membrane oxygenation and Extracorporeal Membrane Oxygenation Cardiopulmonary Resusciation (ECPR) research priorities in Australia: A clinician survey

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) for cardiorespiratory failure and during cardiopulmonary resuscitation has increased significantly and is resource intensive. High-quality evidence to guide management of patients on ECMO is limited.

OBJECTIVES

The objective of this study was to determine the research priorities of clinicians for ECMO and Extracorporeal Membrane Oxygenation Cardiopulmonary Resusciation (ECPR) in Australia and New Zealand.

METHODS

A prospective, binational survey of clinicians was conducted in May 2022.

RESULTS

There were 133 respondents; 110 (84%) worked at an Australian ECMO centre; 28 (21%) were emergency, 45 (34%) were intensive care, and 41 (31%) were nursing clinicians. All aspects of ECMO care were identified by respondents as being important for further research; however, appropriate patient selection and determining long-term outcomes were ranked the highest. While most believed ECMO was efficacious, they felt that there was insufficient evidence to determine cost-effectiveness. There was uncertainty of the best model of ECPR provision. Equipoise exists for randomised studies into anticoagulation, blood product usage, and ECPR.

CONCLUSIONS

This survey found strong support amongst clinicians for further research into the optimal use of ECMO and ECPR and provides a frame work for prioritising future clinical trials and research agendas.

Advances in the Management of Cardiogenic Shock

OBJECTIVES

To review a contemporary approach to the management of patients with cardiogenic shock (CS).

DATA SOURCES

We reviewed salient medical literature regarding CS.

STUDY SELECTION

We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials.

DATA EXTRACTION

We extracted salient study results and scientific statement recommendations regarding the management of CS.

DATA SYNTHESIS

Professional society recommendations were integrated with evaluated studies.

CONCLUSIONS

CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.

Non-Occlusive Mesenteric Ischemia in Cardiac Arrest Patients

Non-occlusive mesenteric ischemia (NOMI) is a severe complication in patients after cardiac arrest (CA). The diagnosis is complicated, the treatment options are limited. Given the susceptibility of enterocytes to ischemia, the incidence and severity of NOMI in the post-resuscitation period may reflect the intensity and duration of both ischemia and subsequent reperfusion injury. NOMI is considered to be associated with adverse neurological outcomes in CA patients. Therefore, NOMI should not only be regarded as a post-resuscitation complication but also as one of the prognostic markers in CA patients.This paper summarizes current knowledge on NOMI's pathophysiology, diagnosis, treatment, and prognostic significance in CA patients.

Both decreased and increased grey-to-white matter attenuation ratio in the putamen and caudate on early head computed tomography differentiate patients with favorable and unfavorable outcomes after prolonged cardiac arrest-secondary analysis of the Prague OHCA study

Background

Neurological damage remains the leading cause of death in cardiac arrest victims with early neuroprognostication being the cornerstone of the decision-making process to continue or discontinue advanced treatments. In this study, we aimed to find markers of favorable and unfavorable outcome on early brain computed tomography (CT) in patients after prolonged out-of-hospital cardiac arrest (OHCA) treated both by conventional and extracorporeal cardiopulmonary resuscitation (ECPR).

Methods

In a secondary analysis of the Prague OHCA study, patients who underwent brain CT within 36 hours after cardiac arrest were identified. Qualitative findings (brain edema, hemorrhage) and quantitative measurements [attenuation of grey matter structures and grey-to-white matter attenuation ratio (GWR)] between patients with cerebral performance category (CPC) of 1-2 (favorable outcome) and 3-5 (unfavorable outcome) within 180 days after the event were compared.

Results

In 45 eligible patients, intracranial edema (n=16, 50%) was present in patients with CPC 3-5 only (n=32, 71%). Attenuation of brain structures and GWR did not differ between patients with favorable and unfavorable outcomes. However, the GWR in the caudate and putamen of most CPC 1-2 patients was within a narrow range of values (1.18 to 1.30 and 1.20 to 1.33) that separated patients with CPC 1-2 from CPC 3-5 with a sensitivity of 78% and 66% a specificity of 85% and 100%, and area under the curve （AUC） of 0.86 (P=0.0001) and 0.77 (P=0.0053), respectively. Patients treated by ECPR had lower attenuation in the centrum semiovale (28.3±2.7) compared to those who were not (31.0±2.8, P=0.003). The most common causes of death in CPC 3-5 patients were brain death in 13 (41%) patients, multiorgan failure in 12 (38%), and cardiac rearrest in 4 (13%).

Conclusions

Both decreased and increased grey-to-white matter differentiation in the putamen and caudate on early non-contrast brain CT after prolonged OHCA indicate poor neurological outcome within 180 days after cardiac arrest.

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.

Pulmonary embolism-related refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: Prague OHCA study post hoc analysis

AIMS

Refractory out-of-hospital cardiac arrest (r-OHCA) in patients with pulmonary embolism (PE) is associated with poor outcomes. The role of extracorporeal cardiopulmonary resuscitation (ECPR) in this patient group is uncertain. This study aims to analyse clinical course, outcomes, and the effect of an invasive procedure, including ECPR, in a randomized population.

METHODS AND RESULTS

A post hoc analysis of a randomized controlled trial (Prague OHCA study) was conducted to evaluate the effect of ECPR vs. a standard approach in r-OHCA. A subgroup of patients with PE-related r-OHCA was identified, and procedural and outcome characteristics, including favourable neurological survival, organ donation, and complications, were compared to patients without PE. Pulmonary embolism was identified as a cause of r-OHCA in 24 of 256 (9.4%) enrolled patients. Patients with PE were more likely to be women [12/24 (50%) vs. 32/232 (13.8%); P < 0.001] and presented more frequently with an initial non-shockable rhythm [23/24 (95.8%) vs. 77/232 (33.2%); P < 0.001], as well as more severe acidosis at admission [median pH (interquartile range); 6.83 (6.75-6.88) vs. 6.98 (6.82-7.14); P < 0.001]. Their favourable 180-day neurological survival was significantly lower [2/24 (8.3%) vs. 66/232 (28.4%); P = 0.049], but the proportion of accepted organ donors was higher (16.7 vs. 4.7%, P = 0.04).

CONCLUSION

Refractory out-of-hospital cardiac arrest due to PE has a different presentation and inferior outcomes compared to other causes but may represent an important source of organ donations. The ECPR method did not improve patient outcomes.

Extracorporeal cardiopulmonary resuscitation for refractory OHCA: lessons from three randomized controlled trials-the trialists' view

Extracorporeal cardiopulmonary resuscitation is a promising treatment for refractory out-of-hospital cardiac arrest. Three recent randomized trials (ARREST trial, Prague OHCA study, and INCEPTION trial) that addressed the clinical benefit of extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest yielded seemingly diverging results. The evidence for extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest, derived from three recent randomized controlled trials, is not contradictory but rather complementary. Excellent results can be achieved with a very high level of dedication, provided that strict selection criteria are applied. However, pragmatic implementation of extracorporeal cardiopulmonary resuscitation does not necessarily lead to improved outcome of refractory out-of-hospital cardiac arrest. Centres that are performing extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest or aspire to do so should critically evaluate whether they are able to meet the pre-requisites that are needed to conduct an effective extracorporeal cardiopulmonary resuscitation programme.

State of the art post-cardiac arrest care: evolution and future of post cardiac arrest care

Out-of-hospital cardiac arrest is a leading cause of mortality. In the pre-hospital setting, bystander response with cardiopulmonary resuscitation and the use of publicly available automated external defibrillators have been associated with improved survival. Early in-hospital treatment still focuses on emergency coronary angiography for selected patients. For patients remaining comatose, temperature control to avoid fever is still recommended, but former hypothermic targets have been abandoned. For patients without spontaneous awakening, the use of a multimodal prognostication model is key. After discharge, follow-up with screening for cognitive and emotional disabilities is recommended. There has been an incredible evolution of research on cardiac arrest. Two decades ago, the largest trials include a few hundred patients. Today, undergoing studies are planning to include 10-20 times as many patients, with improved methodology. This article describes the evolution and perspectives for the future in post-cardiac arrest care.

Interleukin-10: A Potential Pre-Cannulation Marker for Development of Acute Kidney Injury in Patients Receiving Veno-Arterial Extracorporeal Membrane Oxygenation

INTRODUCTION

Acute kidney injury (AKI) in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is associated with high mortality. The objective of this study was to investigate whether cytokine levels before the initiation of ECMO treatment could predict AKI. We also aimed to investigate the impact of AKI on 30-day and 1-year mortality.

METHODS

Serum cytokine levels were analyzed in 100 consecutive VA-ECMO-treated patients at pre-cannulation, at 48 h post-cannulation, and at 8 days. Clinical data to establish the incidence and outcome of AKI after the start of ECMO was retrieved from the local ECMO registry.

SETTING

The study was conducted at tertiary care, university hospital. Participants included 100 patients treated with VA-ECMO.

INTERVENTIONS

The blood samples for cytokine analysis were collected before VA-ECMO treatment, at 48 h after VA-ECMO treatment was started, and at 8 days.

RESULTS

Pre-cannulation serum IL-10 levels were significantly higher in patients who developed AKI (212 [38.9, 620.7]) versus those who did not (49.0 [11.9, 102.2]; p = 0.007), and the development of AKI can be predicted by pre-cannulation IL-10 levels (p = 0.025, OR = 1.2 [1.02-1.32]). The development of AKI during ECMO treatment is associated with increased 30-day mortality (p = 0.049) compared to patients who did not develop AKI and had a pre-cannulation estimated glomerular filtration rate ≥ 45 mL/min. The 1-year survival rate for patients with AKI who survived the first 30 days of ECMO treatment is comparable to that of patients without AKI.

CONCLUSION

Increased pre-cannulation IL-10 levels are associated with the development of AKI during VA-ECMO support. AKI is associated with increased 30-day mortality compared to patients with no AKI and better renal function. However, patients with AKI who survive the first 30 days have a 1-year survival rate similar to those without AKI.

Post-Cardiac Arrest Care

A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.

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.

Coronary angiography findings in resuscitated and refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

Coronary angiography (CAG) frequently reveals coronary artery disease (CAD) after out-of-hospital cardiac arrest (OHCA), but its use is not standardized and often reported in different subpopulations. This systematic review and meta-analysis accurately describes angiographic features in resuscitated and refractory OHCA.

METHODS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched up to October 31, 2022. Studies reporting coronary angiography findings after OHCA were considered eligible. The primary outcome was location and rate of coronary lesions. Coronary angiography findings with 95% confidence intervals were pooled with a meta-analysis of proportion.

RESULTS

128 studies (62,845 patients) were included. CAG, performed in 69% (63-75%) of patients, found a significant CAD in 75% (70-79%), a culprit lesion in 63% (59-66%), and a multivessel disease in 46% (41-51%). Compared to patients with return of spontaneous circulation, refractory OHCA was associated with more severe CAD due to a higher rate of left main involvement (17% [12-24%] vs 5.7% [3.1-10%]; p = 0.002) and acute occlusion of left anterior descending artery (27% [17-39%] vs 15% [13-18%]; p = 0.02). Nonshockable patients without ST-elevation were those receiving CAG less frequently, despite significant disease in 54% (31-76%). Left anterior descending artery was the most frequently involved (34% [30-39%]).

CONCLUSIONS

Patients with OHCA have a high prevalence of significant CAD caused by acute and treatable coronary lesions. Refractory OHCA was associated with more severe coronary lesions. CAD was also present in patients with nonshockable rhythm and without ST elevation. However, heterogeneity of studies and selection of patients undergoing CAG limit the certainty of findings.

Extracorporeal Membrane Oxygenation

The utilization of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support continues to increase globally, with > 190,000 ECMO cases reported to the international Extracorporeal Life Support Organization Registry. The present review aims to synthesize important contributions to the literature surrounding the management of mechanical ventilation, prone positioning, anticoagulation, bleeding complications, and neurologic outcomes for infants, children, and adults undergoing ECMO in 2022. Additionally, issues related to cardiac ECMO, Harlequin syndrome, and anticoagulation during ECMO will be discussed.

The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review

According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).

Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest

BACKGROUND

Out-of-hospital cardiac arrest due to shock-refractory ventricular fibrillation (VF) is associated with relatively poor survival. The ability to predict refractory VF (requiring ≥3 shocks) in advance of repeated shock failure could enable preemptive targeted interventions aimed at improving outcome, such as earlier administration of antiarrhythmics, reconsideration of epinephrine use or dosage, changes in shock delivery strategy, or expedited invasive treatments.

METHODS

We conducted a cohort study of VF out-of-hospital cardiac arrest to develop an ECG-based algorithm to predict patients with refractory VF. Patients with available defibrillator recordings were randomized 80%/20% into training/test groups. A random forest classifier applied to 3-s ECG segments immediately before and 1 minute after the initial shock during cardiopulmonary resuscitation was used to predict the need for ≥3 shocks based on singular value decompositions of ECG wavelet transforms. Performance was quantified by area under the receiver operating characteristic curve.

RESULTS

Of 1376 patients with VF out-of-hospital cardiac arrest, 311 (23%) were female, 864 (63%) experienced refractory VF, and 591 (43%) achieved functional neurological survival. Total shock count was associated with decreasing likelihood of functional neurological survival, with a relative risk of 0.95 (95% CI, 0.93-0.97) for each successive shock (P<0.001). In the 275 test patients, the area under the receiver operating characteristic curve for predicting refractory VF was 0.85 (95% CI, 0.79-0.89), with specificity of 91%, sensitivity of 63%, and a positive likelihood ratio of 6.7.

CONCLUSIONS

A machine learning algorithm using ECGs surrounding the initial shock predicts patients likely to experience refractory VF, and could enable rescuers to preemptively target interventions to potentially improve resuscitation outcome.

Extracorporeal membrane oxygenation-facilitated resuscitation in out-of-hospital cardiac arrest: a meta-analysis of randomized controlled trials

AIMS

It remains unclear whether extracorporeal cardiopulmonary resuscitation (ECPR) could improve neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) compared with conventional cardiopulmonary resuscitation (CCPR).

METHODS

We conducted a systemic search for randomized controlled trials (RCTs) comparing the efficacy of ECPR versus CCPR for OHCA until February 2023. The main end points were 6-month survival, and 6-month and short-term (in-hospital or 30-day) survival with favorable neurological outcome, defined as a Glasgow-Pittsburg cerebral performance category (CPC) score of 1 or 2.

RESULTS

We identified four RCTs including a total of 435 patients. In the included RCTs, the initial cardiac rhythms were ventricular fibrillation in most cases (75%). There was a tendency towards improved 6-month survival and 6-month survival with favorable neurological outcome in ECPR although it did not reach statistical significance [odds ratio (OR): 1.50; 95% confidence interval (CI): 0.67 to 3.36, I2  = 50%, and OR: 1.74; 95% CI: 0.86 to 3.51, I2  = 35%, respectively]. ECPR was associated with a significant improvement in short-term favorable neurological outcomes without heterogeneity (OR: 1.84; 95% CI: 1.14 to 2.99, I2  = 0%).

CONCLUSION

Our meta-analysis of RCTs revealed that there was a tendency towards better mid-term neurological outcomes in ECPR and that ECPR was associated with a significant improvement in short-term favorable neurological outcomes compared with CCPR.

Hospital ECMO capability is associated with survival in pediatric cardiac arrest

AIM

Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital's ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital.

METHODS

We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival.

RESULTS

We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support.

CONCLUSION

A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.