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Baker E, Lee G. The science of reperfusion injury post cardiac arrest--Implications for emergency nurses. Int Emerg Nurs 2015; 24:66-70. [PMID: 26385262 DOI: 10.1016/j.ienj.2015.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Abstract
Survival following cardiac arrest in the developed world remains below 10%. In those who survive the initial cardiac arrest, prognosis remains poor due to the onset of multi-organ failure with both significant cardiac and neurological dysfunction. Nurses have demonstrated good understanding of cardiac arrest/post arrest guidelines and have good technical skills but deficits remain in their understanding of pathophysiological processes involved in post cardiac arrest syndromes. This article aims to provide an overview of these pathophysiological processes involved in the post cardiac arrest phase, potential treatment options and the nursing interventions that may be required within the emergency department setting. This article will focus emergency nurses to become more involved in patient management at this critical phase of treatment and highlight potential early signs of deterioration. Although return of spontaneous circulation (ROSC) is crucial in the process of recovery from cardiac arrest, it is only the first of many complex stages. Given the complexity of post cardiac arrest syndrome and its impact on the patient, healthcare professionals need to understand the cellular changes associated with reperfusion injuries in order to improve outcomes. It is only through effective nursing care and medical management that improved outcomes will become more common in the future.
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Affiliation(s)
- Edward Baker
- Emergency Department, King's College Hospital NHS Trust, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Geraldine Lee
- King's College London, James Clerk Maxwell Building, 57, Waterloo Road, Waterloo, London SW1 8WA, United Kingdom
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Bergan HA, Halvorsen PS, Skulstad H, Edvardsen T, Fosse E, Bugge JF. Successful ECMO-cardiopulmonary resuscitation with the associated post-arrest cardiac dysfunction as demonstrated by MRI. Intensive Care Med Exp 2015; 3:61. [PMID: 26335546 PMCID: PMC4558998 DOI: 10.1186/s40635-015-0061-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 08/18/2015] [Indexed: 11/28/2022] Open
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (ECMO-CPR) is a life-saving rescue for selected patients when standard cardiopulmonary resuscitation fails. The use is increasing although the treatment modality is not fully established. Resuscitated patients typically develop a detrimental early post-arrest cardiac dysfunction that also deserves main emphasis. The present study investigates an ECMO-CPR strategy in pigs and assesses early post-arrest left ventricular function in detail. We hypothesised that a significant dysfunction could be demonstrated with this model using magnetic resonance imaging (MRI), not previously used early post-arrest. Methods In eight anaesthetised pigs, a 15-min ventricular fibrillation was resuscitated by an ECMO-CPR strategy of 150-min veno-arterial ECMO aiming at high blood flow rate and pharmacologically sustained aortic blood pressure and pulse pressure of 50 and 15 mmHg, respectively. Pre-arrest cardiac MRI and haemodynamic measurements of left ventricular function were compared to measurements performed 300-min post-arrest. Results All animals were successfully resuscitated, weaned from the ECMO circuit, and haemodynamically stabilised post-arrest. Cardiac output was maintained by an increased heart rate post-arrest, but left ventricular ejection fraction and stroke volume were decreased by approximately 50 %. Systolic circumferential strain and mitral annular plane systolic excursion as well as the left ventricular wall thickening were reduced by approximately 50–70 % post-arrest. The diastolic function variables measured were unchanged. Conclusions The present animal study demonstrates a successful ECMO-CPR strategy resuscitating long-lasting cardiac arrest with adequate post-arrest haemodynamic stability. The associated severe systolic left ventricular dysfunction could be charted in detail by MRI, a valuable tool for future cardiac outcome assessments in resuscitation research. Trial registration Institutional protocol number: FOTS 4611/13. Electronic supplementary material The online version of this article (doi:10.1186/s40635-015-0061-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harald Arne Bergan
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Nydalen, Oslo, N-0424, Norway,
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Abrams D, Brodie D. Novel Uses of Extracorporeal Membrane Oxygenation in Adults. Clin Chest Med 2015; 36:373-84. [DOI: 10.1016/j.ccm.2015.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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204
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Jung C, Janssen K, Kaluza M, Fuernau G, Poerner TC, Fritzenwanger M, Pfeifer R, Thiele H, Figulla HR. Outcome predictors in cardiopulmonary resuscitation facilitated by extracorporeal membrane oxygenation. Clin Res Cardiol 2015; 105:196-205. [PMID: 26303097 DOI: 10.1007/s00392-015-0906-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Cardiac arrest is the major cause of sudden death in developed countries. Extracorporeal cardiopulmonary resuscitation (ECPR) employs extracorporeal membrane oxygenation (ECMO) in patients without return of spontaneous circulation (ROSC) by conventional cardiopulmonary resuscitation (CPR). Aim of the current study was to assess short- and long-term outcome in patients treated with ECPR in our tertiary center and to identify predictors of outcome. METHODS We retrospectively collected data of all patients treated with ECPR at our institution from 2002 to 2013. Outcome was assessed according to patient records; good neurological outcome was defined as cerebral performance category 1 or 2. Quality of life data was collected using EQ-5 questionnaire. Uni- and multivariate analysis was applied to identify predictors of outcome. RESULTS One-hundred and seventeen patients were included into the study. Weaning from ECMO was successful in 61 (52 %) patients. Thirty-day survival endpoint was achieved by 27 (23 %) patients. Good neurological outcome was present in 17 (15 %) patients. Multivariate analysis revealed baseline serum lactate as the strongest predictor of outcome, whereas age and out-of-hospital CPR did not predict outcome. The optimal lactate cut-off to discriminate outcome was determined at 4.6 mmol/l [HR 3.55 (2.29-5.49), p < 0.001, log-rank test]. CONCLUSION ECPR represents a treatment option in patients without ROSC after conventional CPR rescuing 15 % of patients with good neurological outcome. Serum lactate may play a crucial role in patient selection for ECPR.
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Affiliation(s)
- Christian Jung
- Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Erlanger Allee 101, 0774, Jena, Germany.
| | - Kyra Janssen
- Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Erlanger Allee 101, 0774, Jena, Germany.
| | - Mirko Kaluza
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
| | - Georg Fuernau
- Clinic for Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Lübeck, Germany.
| | - Tudor Constantin Poerner
- Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Erlanger Allee 101, 0774, Jena, Germany.
| | - Michael Fritzenwanger
- Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Erlanger Allee 101, 0774, Jena, Germany.
| | - Ruediger Pfeifer
- Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Erlanger Allee 101, 0774, Jena, Germany.
| | - Holger Thiele
- Clinic for Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Lübeck, Germany.
| | - Hans Reiner Figulla
- Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Erlanger Allee 101, 0774, Jena, Germany.
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Kim KI, Lee HS, Kim HS, Ha SO, Lee WY, Park SJ, Lee SH, Lee TH, Seo JY, Choi HH, Park KT, Han SJ, Hong KS, Hwang SM, Lee JJ. The pre-ECMO simplified acute physiology score II as a predictor for mortality in patients with initiation ECMO support at the emergency department for acute circulatory and/or respiratory failure: a retrospective study. Scand J Trauma Resusc Emerg Med 2015; 23:59. [PMID: 26283075 PMCID: PMC4538750 DOI: 10.1186/s13049-015-0135-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022] Open
Abstract
Background In the emergency department (ED), extracorporeal membrane oxygenation (ECMO) can be used as a rescue treatment modality for patients with refractory circulatory and/or respiratory failure. Serious consideration must be given to the indication, and the PRESERVE and RESP scores for mortality have been investigated. However these scores were validated to predict survival in patients who received mainly veno-venous (VV) ECMO in the intensive care unit. The aim of the present study was to investigate the factors that predicted the outcomes for patients who received mixed mode (veno-arterial [VA] and VV) ECMO support in the ED. Methods This single center retrospective study included 65 patients who received ECMO support at the ED for circulatory or respiratory failure between January 2009 and December 2013. Pre-ECMO SAPS II and other variables were evaluated and compared for predicting mortality. Results Fifty-four percent of patients received ECMO-cardiopulmonary resuscitation (E-CPR), 31 % received VA and V-AV ECMO, and 15 % received VV ECMO. The 28-day and 60-month mortality rates were 52 % and 63 %. In the multivariate analysis, only the pre-ECMO Simplified Acute Physiology Score II (SAPS II) (odd ratio: 1.189, 95 % confidence interval: 1.032–1.370, p = 0.016) could predict the 28-day mortality. The area under the receiver operating characteristic curve and the optimal cutoff value for pre-ECMO SAPS II in predicting 28-day mortality was 0.852 (95 % CI: 0.753–0.951, p < 0.001) and 80 (sensitivity of 97.1 % and specificity of 71.0 %), respectively. Validation of the 80 cutoff value revealed a statistically significant difference for the 28-day and 60-month mortality rates in the overall, E-CPR, and VA groups (28-day: p < 0.001, p = 0.004, p = 0.005; 60-month: p < 0.001, p = 0.004, p = 0.020). In the Kaplan-Meier analysis, the 28-day and 60-month survival rates were lower among the patients with a pre-ECMO SAPS II of ≤80, compared to those with a score of >80 (both, p < 0.001). Conclusion The pre-ECMO SAPS II could be helpful for identifying patients with refractory acute circulatory and/or respiratory failure who will respond to ECMO support in the ED.
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Affiliation(s)
- Kun Il Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Donan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Donan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Hyoung Soo Kim
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University, Chuncheon, South Korea.
| | - Won Yong Lee
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sang Jun Park
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sun Hee Lee
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Tae Hun Lee
- Division of Cardiology, Department of Internal Medicine, Hallym University, Chuncheon, South Korea.
| | - Jeong Yeol Seo
- Division of Cardiology, Department of Internal Medicine, Hallym University, Chuncheon, South Korea.
| | - Hyun Hee Choi
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Kyu Tae Park
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Sang Jin Han
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Kyung Soon Hong
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Sung Mi Hwang
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Jae Jun Lee
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
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Pichler P, Antretter H, Dünser M, Eschertzhuber S, Gottardi R, Heinz G, Pölzl G, Pretsch I, Rajek A, Wasler A, Zimpfer D, Geppert A. Positionspapier der Österreichischen Kardiologischen Gesellschaft zum Einsatz der extrakorporalen Membranoxygenation (ECMO) bei Erwachsenen kardiologischen Patienten. Med Klin Intensivmed Notfmed 2015. [DOI: 10.1007/s00063-015-0052-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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207
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Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis 2015; 7:E166-76. [PMID: 26380745 PMCID: PMC4522501 DOI: 10.3978/j.issn.2072-1439.2015.07.17] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 06/15/2015] [Indexed: 12/14/2022]
Abstract
Extra Corporeal Membrane Oxygenation (ECMO) indications and usage has strikingly progressed over the last 20 years; it has become essential tool in the care of adults and children with severe cardiac and pulmonary dysfunction refractory to conventional management. In this article we will provide a review of ECMO development, clinical indications, patients' management, options and cannulations techniques, complications, outcomes, and the appropriate strategy of organ management while on ECMO.
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Affiliation(s)
- George Makdisi
- Indiana University School of Medicine & Indiana University Health, Indianapolis, IN 46202, USA
| | - I-Wen Wang
- Indiana University School of Medicine & Indiana University Health, Indianapolis, IN 46202, USA
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208
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Bednarczyk JM, Singal RK. Functional outcomes after resuscitative extracorporeal membrane oxygenation for cardiac arrest: The patients speak for themselves. J Thorac Cardiovasc Surg 2015; 150:955-6. [PMID: 26190657 DOI: 10.1016/j.jtcvs.2015.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph M Bednarczyk
- Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Rohit K Singal
- Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Surgical Heart Failure Program, Section of Cardiac Surgery, Department of Surgery, University of Manitoba, St Boniface General Hospital, Winnipeg, Manitoba, Canada
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209
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Choudhri O, Shah A, Basarab-Tung J, Jaffe RA, Steinberg GK. Extracorporeal membrane oxygenation for cardiac arrest during moyamoya cerebral revascularization surgery: case report. J Neurosurg 2015; 123:693-8. [PMID: 26052804 DOI: 10.3171/2014.11.jns141054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the case of a 51-year-old man with bilateral moyamoya disease and prior strokes who developed an asystolic cardiac arrest while undergoing revascularization surgery under mild hypothermia. The patient was successfully treated with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) after manual cardiopulmonary resuscitation (CPR) was unsuccessful for 45 minutes. ECMO is a cardiopulmonary support system that is indicated for respiratory failure in pediatric and adult patients. It is increasingly being used as an extension to mechanical CPR for patients who have suffered cardiac arrest if the underlying cause of cardiac arrest is thought to be reversible. Identifying which patients should be placed on emergency ECMO after cardiac arrest is controversial given its high morbidity and mortality. ECMO in neurosurgical settings has associated risks of intracranial hemorrhage and neurological compromise, while resource utilization is paramount given the high costs of this treatment. This paper is significant because it describes the use of ECMO in an unindicated setting. Limited data are available for ECMO usage after cardiac arrest with baseline cerebral ischemia. Furthermore, this paper raises important considerations for extracorporeal CPR use in a patient who had recently undergone craniotomy. The patient in this report remained on ECMO for 48 hours, after which he was successfully weaned. He developed a pericardial effusion and compartment syndrome from the ECMO but made a complete neurological recovery. Use of ECMO emergently in an appropriately chosen neurosurgical patient is safe, even in the setting of baseline cerebral ischemia and recent craniotomy.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery and Stanford Stroke Center, and
| | - Aatman Shah
- Department of Neurosurgery and Stanford Stroke Center, and
| | - Jennifer Basarab-Tung
- Department of Anesthesiology, Stanford University School of Medicine, Stanford California
| | - Richard A Jaffe
- Department of Neurosurgery and Stanford Stroke Center, and.,Department of Anesthesiology, Stanford University School of Medicine, Stanford California
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Abstract
Cardiogenic shock is the leading cause of morbidity and mortality in patients presenting with acute coronary syndrome. Although early reperfusion strategies are essential to the management of these critically ill patients, additional treatment plans are often needed to stabilize and treat the patient before reperfusion may be possible. This article discusses pharmacologic and surgical interventions, their indications and contraindications, management strategies, and treatment algorithms.
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Affiliation(s)
- Joshua B Moskovitz
- Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Hempstead, NY 11030, USA.
| | - Zachary D Levy
- Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Hempstead, NY 11030, USA
| | - Todd L Slesinger
- Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Hempstead, NY 11030, USA
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211
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Palatinus JA, Lieber SB, Joyce KE, Richards JB. Extracorporeal Membrane Oxygenation Support for Hypokalemia-induced Cardiac Arrest: A Case Report and Review of the Literature. J Emerg Med 2015; 49:159-64. [PMID: 26004853 DOI: 10.1016/j.jemermed.2015.02.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypokalemia is a reversible cause of cardiac arrest in patients presenting to the emergency department (ED). Extracorporeal membrane oxygenation (ECMO) is an established technology for cardiopulmonary support with emerging roles in resuscitation. Here, we review the literature of hypokalemic-induced cardiac arrests and discuss one such case successfully managed with ECMO. CASE REPORT A 23-year-old Central American man who presented to a community ED under federal custody with several days of nausea and vomiting was found to have a serum potassium level of 1.5 mEq/L. Repeat serum potassium level was 1.1 mEq/L upon arrival to our facility. Within 2 h of arrival, despite electrolyte repletion, he suffered cardiac arrest. Advanced cardiac life support was performed for 45 min. ECMO was initiated while active chest compressions were performed. After aggressive potassium repletion, return of spontaneous circulation was achieved and ECMO was eventually discontinued. Further investigation ultimately confirmed the presence of a potassium-wasting nephropathy, for which the patient had been treated with chronic potassium supplementation prior to entering federal custody. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO is a well-established modality for cardiopulmonary support, with an emerging role for patients in undifferentiated cardiac arrest presenting to the ED. There is a growing interest in the utility of ECMO in these circumstances. This report highlights hypokalemia as an important cause of cardiac arrest, reviews the treatment and causes of hypokalemia, and demonstrates a potential role for ECMO as a critical temporizing measure to provide time for potassium repletion.
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Affiliation(s)
- Joseph A Palatinus
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sarah B Lieber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Katherine E Joyce
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jeremy B Richards
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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212
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Abstract
PURPOSE OF REVIEW To examine the utility and technical challenges of applying veno-arterial extracorporeal membrane oxygenation for acute cardiovascular failure in adults with acute and chronic causes of heart failure. RECENT FINDINGS The role of mechanical circulatory support in acute cardiovascular continues to evolve as technology and clinical experience develop. There is increasing interest in the role of veno-arterial extracorporeal membrane oxygenation as a bridging therapy and as an adjunct to conventional cardiopulmonary resuscitation. SUMMARY Veno-arterial extracorporeal membrane oxygenation is an expensive, complex, resource intensive support. It is essential that its future use be guided by evidence obtained from centres that have demonstrated timely, safe support.
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213
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Díez F, Sousa I, Juárez M, Díez-Villanueva P, Elízaga J, Fernández-Avilés F. Resucitación cardiopulmonar mediante ECMO percutáneo: una nueva herramienta en el laboratorio de hemodinámica. Med Intensiva 2015; 39:251-3. [DOI: 10.1016/j.medin.2014.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/05/2014] [Accepted: 04/04/2014] [Indexed: 11/29/2022]
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Wally D, Velik-Salchner C. [Near-infrared spectroscopy during cardiopulmonary resuscitation and mechanical circulatory support: From the operating room to the intensive care unit]. Med Klin Intensivmed Notfmed 2015; 110:621-30. [PMID: 25917180 DOI: 10.1007/s00063-015-0012-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Near infrared spectroscopy (NIRS) allows continuous measurement of cerebral regional oxygen saturation (rSO2). It is a weighted saturation value derived from approximately 70-75 % venous, 20-25 % arterial and 2.5-5 % capillary blood. In contrast to pulse oximetry, NIRS is independent of pulsatile flow. Therefore, it is also applicable during extracorporeal circulation, cardiopulmonary resuscitation (CPR), and hypothermia. OBJECTIVES The purpose of this work is to describe the application of cerebral and somatic NIRS in cardiology and cardiac surgery patients in the operation room, during and after CPR, and during the intensive care unit stay. MATERIALS AND METHODS This article is based on peer-reviewed literature from PubMed. RESULTS Interventions based on decline of cerebral NIRS values during on-pump cardiac surgery can reduce major organ morbidity and mortality; however, the appearance of a postoperative cognitive dysfunction is scarcely influenced. Persisting of low cerebral oximetry values during resuscitation is a marker for not achieving return of spontaneous circulation under normothermia. NIRS is an additional method for monitoring that can be used during extracorporeal circulation. CONCLUSION NIRS is a rapidly available, user-friendly, and noninvasive method for continuous measurement of rSO2. NIRS provides additional information about tissue oxygenation especially during resuscitation and extracorporeal circulatory assist support. Recommendations concerning the use of NIRS for standard monitoring during resuscitation and mechanical circulatory support are not currently available. Further studies are required to show if use of NIRS can reduce pulse control and hands-off times during resuscitation and if use of NIRS can improve outcome after CPR and mechanical circulatory support.
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Affiliation(s)
- D Wally
- Universitätsklinik für Anästhesie und Intensivmedizin, Department für Operative Medizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Corinna Velik-Salchner
- Universitätsklinik für Anästhesie und Intensivmedizin, Department für Operative Medizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
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Patel JK, Schoenfeld E, Parnia S, Singer AJ, Edelman N. Venoarterial Extracorporeal Membrane Oxygenation in Adults With Cardiac Arrest. J Intensive Care Med 2015; 31:359-68. [PMID: 25922385 DOI: 10.1177/0885066615583651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 03/13/2015] [Indexed: 11/15/2022]
Abstract
Cardiac arrest (CA) is a major cause of morbidity and mortality worldwide. Despite the use of conventional cardiopulmonary resuscitation (CPR), rates of return of spontaneous circulation and survival with minimal neurologic impairment remain low. Utilization of venoarterial extracorporeal membrane oxygenation (ECMO) for CA in adults is steadily increasing. Propensity-matched cohort studies have reported outcomes associated with ECMO use to be superior to that of conventional CPR alone in in-hospital patients with CA. In this review, we discuss the mechanism, indications, complications, and evidence for ECMO in CA in adults.
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Affiliation(s)
- Jignesh K Patel
- Division of Pulmonary and Critical Care, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Elinor Schoenfeld
- Department of Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Sam Parnia
- Division of Pulmonary and Critical Care, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Norman Edelman
- Division of Pulmonary and Critical Care, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
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216
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Schaheen BW, Thiele RH, Isbell JM. Extracorporeal life support for adult cardiopulmonary failure. Best Pract Res Clin Anaesthesiol 2015; 29:229-39. [PMID: 26060032 DOI: 10.1016/j.bpa.2015.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 01/19/2023]
Abstract
The use of extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO), as it is also known, has rapidly expanded over the past decade. The increase in ECMO use is a consequence of multiple factors including significant advancements in extracorporeal technology, the emergence of data supporting its use, and a growing number of potential clinical applications. This review focuses on the various modes of ECLS as well as the clinical indications and available evidence for the use of extracorporeal support.
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Affiliation(s)
- Basil W Schaheen
- General Surgery, University of Virginia, P.O. Box 800681, Charlottesville, VA 22908, USA.
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908-0710, USA.
| | - James M Isbell
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, P.O. Box 800679, Charlottesville, VA 22908, USA.
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Pichler P, Antretter H, Dünser M, Eschertzhuber S, Gottardi R, Heinz G, Pölzl G, Pretsch I, Rajek A, Wasler A, Zimpfer D, Geppert A. [Use of ECMO in adult patients with cardiogenic shock: a position paper of the Austrian Society of Cardiology]. Wien Klin Wochenschr 2015; 127:169-84. [PMID: 25821055 DOI: 10.1007/s00508-015-0743-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/19/2015] [Indexed: 11/29/2022]
Abstract
The use of ECMO to stabilize critically ill patients with severely depressed cardiac function and hemodynamics increased in the last years due to broader availability, better performance and easier implantation of the devices. The present guidelines of the Austrian Society of Cardiology focus on the use of ECMO in adult non-operated patients with cardiac diseases. Not only indications and contraindications are highlighted, but also the equally important issues of monitoring, complication management, measures during implantation and operation, and weaning of the devices are treated in detail. Thereby the present guidelines aim to optimize the use of ECMO in the individual centers, and aim to help current non-ECMO centers in developing a local ECMO-program or to contact ECMO-centers for discussion of individual patients.
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Affiliation(s)
- Philipp Pichler
- Universitätsklinik für Innere Medizin II, Abteilung für Kardiologie, Medizinische Universität Wien, Wien, Österreich
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Ryu JA, Cho YH, Sung K, Choi SH, Yang JH, Choi JH, Lee DS, Yang JH. Predictors of neurological outcomes after successful extracorporeal cardiopulmonary resuscitation. BMC Anesthesiol 2015; 15:26. [PMID: 25774089 PMCID: PMC4358703 DOI: 10.1186/s12871-015-0002-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 02/10/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) refers to use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary arrest. Although ECPR can increase survival rates after cardiac arrest, it can also result in poor post-resuscitation neurological status. Thus, we investigated predictors of good neurological outcomes after successful ECPR. METHODS A total of 227 patients underwent ECPR from May 2004 to June 2013 at Samsung Medical Center. Successful ECPR was defined as survival more than 24 hours after ECPR. Neurological outcomes were assessed at discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified as good and CPC 3 to 5 were classified as poor neurological outcomes. Excluded were 22 patients who did not survive more than 24 hours after ECPR and 90 patients who died from unknown causes or causes other than brain death or whose neurological status could not be assessed at discharge. Multiple logistic regression analysis was used to identify independent predictors of neurological outcomes. RESULTS Included were 115 patients with a mean age of 58 (range 45-66) years and 80 men (70%). Cardiopulmonary resuscitation (CPR) was performed at non-hospital sites for 19 (17%) patients and bystander CPR was performed in 9 of 19 cases (47%). Cardiac etiology was verified in 74 (64%) patients and therapeutic hypothermia was performed in 9 patients (8%); 68 (59%) had good neurological outcomes and 47 (41%) did not and 24 patients died from brain death. Neurological outcomes were affected by hemoglobin levels before ECMO (P = 0.02), serum lactic acid (P < 0.001) before ECMO insertion, and interval from cardiac arrest to ECMO (P = 0.04). CONCLUSIONS Low hemoglobin or high serum lactic acid levels before ECMO, and prolonged interval from cardiac arrest to ECMO predicted poor neurological outcomes after successful ECPR. Early institution of ECMO and a low threshold for blood transfusion might improve neurological outcomes for patients who survive ECPR.
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Affiliation(s)
- Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae-Sang Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Nouveautés dans les indications de l’ECMO veino-artérielle périphérique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW To discuss the role of extracorporeal membrane oxygenation (ECMO) in patients with cardiac arrest. RECENT FINDINGS Return to spontaneous circulation dramatically decreases with the duration of cardiopulmonary resuscitation (CPR). In this context, it has been proposed to implement venoarterial ECMO in order to assist CPR (ECPR) both in inhospital cardiac arrest (IHCA) and in out-of-hospital cardiac arrest (OHCA). SUMMARY This review highlights that ECPR is feasible for both IHCA and OHCA. In the recent series, the outcome of ECPR in IHCA is satisfactory, with survival rates good with neurologic outcome reaching the 40-50% range. All series converge in highlighting that time from cardiac arrest to ECMO flow is a critical determinant of outcome, with survival rates of 50% when initiated within 30 min of IHCA, 30% between 30 and 60 min, and 18% after 60 min. Results of ECPR in OHCA are more challenging. Recent series suggest that good outcome can be obtained in 15-20% of the patients, provided that time from arrest to ECMO is shorter than 60 min. Duration of cardiac arrest seems to be more important than location of cardiac arrest. ECPR thus seems to be a valuable option in selected cases.
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Tsukahara K, Toida C, Muguruma T. Current experience and limitations of extracorporeal cardiopulmonary resuscitation for cardiac arrest in children: a single-center retrospective study. J Intensive Care 2014; 2:68. [PMID: 25705425 PMCID: PMC4336122 DOI: 10.1186/s40560-014-0068-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 12/10/2014] [Indexed: 11/24/2022] Open
Abstract
Background There are few reports detailing the importance of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac arrest in Japan. We investigated the status and issues surrounding extracorporeal cardiopulmonary resuscitation (ECPR) at our institution. Methods Patients aged <15 years who underwent ECPR between April 1, 2003 and March 31, 2012 were eligible. The characteristics, cannulation site, durations of cardiopulmonary resuscitation (CPR), cannulation procedure, and ECMO, and neurologic outcomes were retrospectively reviewed. A favorable neurologic outcome was defined as Pediatric Cerebral Performance Categories 1 and 2. Results A total of 21 ECPR events were identified. The median CPR and cannulation durations were 60 and 25 min, respectively. Central and peripheral access sites were employed in 15 and six cases, respectively. Five of the 21 patients (24%) were successfully weaned from ECMO and three of the 21 (14%) survived. Two of the three survivors had a favorable neurologic outcome. Conclusions The mortality of patients undergoing ECPR at our institution was low. However, about 10% of all patients had a favorable neurologic outcome, which suggests that ECPR may be effective in pediatric cardiac arrest patients.
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Affiliation(s)
- Kohei Tsukahara
- Division of Critical Care Medicine, National Medical Center for Children and Mothers, 2-10-1 Okura, 157-0074 Setagaya-ku, Tokyo Japan ; Advanced emergency and critical care center, Okayama University Hospital, 2-5-1 Shikadacho, 700-8558 Kitaku, Okayama Japan
| | - Chiaki Toida
- Division of Critical Care Medicine, National Medical Center for Children and Mothers, 2-10-1 Okura, 157-0074 Setagaya-ku, Tokyo Japan
| | - Takashi Muguruma
- Division of Critical Care Medicine, National Medical Center for Children and Mothers, 2-10-1 Okura, 157-0074 Setagaya-ku, Tokyo Japan
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Murphy DA, Hockings LE, Andrews RK, Aubron C, Gardiner EE, Pellegrino VA, Davis AK. Extracorporeal membrane oxygenation-hemostatic complications. Transfus Med Rev 2014; 29:90-101. [PMID: 25595476 DOI: 10.1016/j.tmrv.2014.12.001] [Citation(s) in RCA: 252] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/19/2014] [Accepted: 12/03/2014] [Indexed: 12/17/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) support for cardiac and respiratory failure has increased in recent years. Improvements in ECMO oxygenator and pump technologies have aided this increase in utilization. Additionally, reports of successful outcomes in supporting patients with respiratory failure during the 2009 H1N1 pandemic and reports of ECMO during cardiopulmonary resuscitation have led to increased uptake of ECMO. Patients requiring ECMO are a heterogenous group of critically ill patients with cardiac and respiratory failure. Bleeding and thrombotic complications remain a leading cause of morbidity and mortality in patients on ECMO. In this review, we describe the mechanisms and management of hemostatic, thrombotic and hemolytic complications during ECMO support.
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Affiliation(s)
- Deirdre A Murphy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia.
| | - Lisen E Hockings
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
| | - Robert K Andrews
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Cecile Aubron
- ANZIC Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Vincent A Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
| | - Amanda K Davis
- Department of Haematology, Alfred Hospital Melbourne, Australia
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Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: A Canadian observational experience. Resuscitation 2014; 85:1713-9. [DOI: 10.1016/j.resuscitation.2014.09.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/12/2014] [Accepted: 09/25/2014] [Indexed: 11/21/2022]
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224
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Parnia S. Death and consciousness--an overview of the mental and cognitive experience of death. Ann N Y Acad Sci 2014; 1330:75-93. [DOI: 10.1111/nyas.12582] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Sam Parnia
- The State University of New York at Stony Brook; Stony Brook New York
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Kim J, Yin T, Yin M, Zhang W, Shinozaki K, Selak MA, Pappan KL, Lampe JW, Becker LB. Examination of physiological function and biochemical disorders in a rat model of prolonged asphyxia-induced cardiac arrest followed by cardio pulmonary bypass resuscitation. PLoS One 2014; 9:e112012. [PMID: 25383962 PMCID: PMC4226499 DOI: 10.1371/journal.pone.0112012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/11/2014] [Indexed: 11/18/2022] Open
Abstract
Background Cardiac arrest induces whole body ischemia, which causes damage to multiple organs particularly the heart and the brain. There is clinical and preclinical evidence that neurological injury is responsible for high mortality and morbidity of patients even after successful cardiopulmonary resuscitation. A better understanding of the metabolic alterations in the brain during ischemia will enable the development of better targeted resuscitation protocols that repair the ischemic damage and minimize the additional damage caused by reperfusion. Method A validated whole body model of rodent arrest followed by resuscitation was utilized; animals were randomized into three groups: control, 30 minute asphyxial arrest, or 30 minutes asphyxial arrest followed by 60 min cardiopulmonary bypass (CPB) resuscitation. Blood gases and hemodynamics were monitored during the procedures. An untargeted metabolic survey of heart and brain tissues following cardiac arrest and after CPB resuscitation was conducted to better define the alterations associated with each condition. Results After 30 min cardiac arrest and 60 min CPB, the rats exhibited no observable brain function and weakened heart function in a physiological assessment. Heart and brain tissues harvested following 30 min ischemia had significant changes in the concentration of metabolites in lipid and carbohydrate metabolism. In addition, the brain had increased lysophospholipid content. CPB resuscitation significantly normalized metabolite concentrations in the heart tissue, but not in the brain tissue. Conclusion The observation that metabolic alterations are seen primarily during cardiac arrest suggests that the events of ischemia are the major cause of neurological damage in our rat model of asphyxia-CPB resuscitation. Impaired glycolysis and increased lysophospholipids observed only in the brain suggest that altered energy metabolism and phospholipid degradation may be a central mechanism in unresuscitatable brain damage.
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Affiliation(s)
- Junhwan Kim
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Tai Yin
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Ming Yin
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Wei Zhang
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Koichiro Shinozaki
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Mary A. Selak
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kirk L. Pappan
- Metabolon Inc., Durham, North Carolina, United States of America
| | - Joshua W. Lampe
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lance B. Becker
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Hsu J, Wang CH, Huang SC, Yu HY, Chi NH, Wu IH, Chan CY, Chang CI, Wang SS, Chen YS. Clinical Applications of Extracorporeal Membranous Oxygenation: A Mini-Review. ACTA CARDIOLOGICA SINICA 2014; 30:507-13. [PMID: 27122828 DOI: 10.6515/acs20140821a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
UNLABELLED The clinical usage of extracorporeal membranous oxygenation began more than 40 years ago. Although the indications for its use have expanded over the years, it has been challenging to conduct randomized controlled trials to prove that extracorporeal membranous oxygenation is more effective than traditional approaches. Through a review of retrospective reports and data from registries, we attempted to evaluate the appropriateness of its application for acute respiratory distress syndrome, cardiopulmonary resuscitation, postcardiotomy cardiogenic shock, and sepsis. Our investigation revealed that using extracorporeal membranous oxygenation when readily available is appropriate for all patients with cardiopulmonary resuscitation or postcardiotomy cardiogenic shock, and for selected patients with acute respiratory distress syndrome or sepsis. KEY WORDS Acute respiratory distress syndrome; Cardiopulmonary resuscitation; Extracorporeal membranous oxygenation; Postcardiotomy cardiogenic shock; Sepsis.
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Affiliation(s)
- Jiun Hsu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Yunlin Branch, Douliou City, Yunlin County
| | - Chih-Hsien Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shu-Chien Huang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Hsi-Yu Yu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei; ; Department of Cardiovascular Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, Taiwan
| | - Nai-Hsin Chi
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - I-Hui Wu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Chih-Yang Chan
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Chung-I Chang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shoei-Shen Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Yih-Sharng Chen
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
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Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L, Shaw J, Duffy SJ, Burrell A, Cameron P, Smit DV, Kaye DM. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2014; 86:88-94. [PMID: 25281189 DOI: 10.1016/j.resuscitation.2014.09.010] [Citation(s) in RCA: 421] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 08/22/2014] [Accepted: 09/11/2014] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia. METHODS The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24h in the intensive care unit. RESULTS There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients. CONCLUSIONS A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.
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Affiliation(s)
- Dion Stub
- Baker IDI Heart and Diabetes Research Institute, Australia; University of Washington, United States; St. Paul's Hospital, Vancouver, Canada
| | - Stephen Bernard
- Alfred Hospital, Australia; Monash University, Australia; Ambulance Victoria, Australia.
| | | | - Karen Smith
- Monash University, Australia; Ambulance Victoria, Australia; University of Western Australia, Australia
| | | | | | | | - James Shaw
- Alfred Hospital, Australia; Monash University, Australia; Baker IDI Heart and Diabetes Research Institute, Australia
| | - Stephen J Duffy
- Alfred Hospital, Australia; Monash University, Australia; Baker IDI Heart and Diabetes Research Institute, Australia
| | - Aidan Burrell
- Alfred Hospital, Australia; Monash University, Australia
| | - Peter Cameron
- Alfred Hospital, Australia; Monash University, Australia
| | | | - David M Kaye
- Alfred Hospital, Australia; Monash University, Australia; Baker IDI Heart and Diabetes Research Institute, Australia
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Kim SJ, Jung JS, Park JH, Park JS, Hong YS, Lee SW. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:535. [PMID: 25255842 PMCID: PMC4189722 DOI: 10.1186/s13054-014-0535-8] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 09/08/2014] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Prolonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR. METHODS This study is a retrospective analysis based on a prospective cohort. We included patients ≥ 18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group. RESULTS Of 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥ 21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥ 60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome. CONCLUSIONS ECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥ 21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.
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Ventetuolo CE, Muratore CS. Extracorporeal life support in critically ill adults. Am J Respir Crit Care Med 2014; 190:497-508. [PMID: 25046529 PMCID: PMC4214087 DOI: 10.1164/rccm.201404-0736ci] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/13/2014] [Indexed: 12/18/2022] Open
Abstract
Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.
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Affiliation(s)
- Corey E. Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep, Rhode Island Hospital, Departments of Medicine and Health Services, Policy, and Practice, and
| | - Christopher S. Muratore
- Division of Pediatric Surgery, Hasbro Children’s Hospital, Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
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Wang CH, Chou NK, Becker LB, Lin JW, Yu HY, Chi NH, Hunag SC, Ko WJ, Wang SS, Tseng LJ, Lin MH, Wu IH, Ma MHM, Chen YS. Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – A comparison with that for extracorporeal rescue for in-hospital cardiac arrest. Resuscitation 2014; 85:1219-24. [DOI: 10.1016/j.resuscitation.2014.06.022] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/13/2014] [Indexed: 10/25/2022]
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Abstract
The role for temporary and durable mechanical circulatory support is rapidly expanding. As the use of these technologies continues to grow, the emergency physician has an increasing opportunity to participate in the advancement of these potentially life-saving technologies. This review discusses the current role of the intra-aortic balloon pump in cardiogenic shock, describes the complications and management strategies for the critically ill patient with a left ventricular assist device, and explores the emerging role of ECMO in the emergency department for patients presenting in refractory cardiogenic shock and cardiac arrest.
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Affiliation(s)
- John C Greenwood
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA.
| | - Daniel L Herr
- Critical Care Service, Cardiac Surgery ICU, Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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Abrams D, Combes A, Brodie D. Extracorporeal Membrane Oxygenation in Cardiopulmonary Disease in Adults. J Am Coll Cardiol 2014; 63:2769-78. [DOI: 10.1016/j.jacc.2014.03.046] [Citation(s) in RCA: 316] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 02/25/2014] [Accepted: 03/04/2014] [Indexed: 12/17/2022]
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Park TK, Yang JH, Choi SH, Song YB, Hahn JY, Choi JH, Sung K, Lee YT, Gwon HC, Lee SH. Clinical outcomes of patients with acute myocardial infarction complicated by severe refractory cardiogenic shock assisted with percutaneous cardiopulmonary support. Yonsei Med J 2014; 55:920-7. [PMID: 24954319 PMCID: PMC4075395 DOI: 10.3349/ymj.2014.55.4.920] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Limited data are available on the role of percutaneous cardiopulmonary support (PCPS) for the treatment of acute myocardial infarction (AMI) patients with cardiogenic shock. We investigated the clinical outcomes and predictors of in-hospital mortality after PCPS in patients with AMI complicated by severe refractory cardiogenic shock. MATERIALS AND METHODS From January 2004 to December 2011, we analyzed data from 96 consecutive AMI patients with cardiogenic shock assisted by a PCPS system. The primary outcome was in-hospital mortality. The predictors of in-hospital mortality were determined by a Cox proportional-hazards model. RESULTS In-hospital mortality occurred in 51 (53.1%) patients and 58 (60.4%) patients were able to be weaned from PCPS. Cardiopulmonary resuscitation (CPR) was performed in 61 (63.5%) patients before PCPS initiation. On multivariate analysis, age≥67 years [adjusted hazard ratio (HR), 4.74; 95% confidence interval (CI), 2.27-9.93; p<0.001], CPR (adjusted HR, 2.32; 95% CI, 1.11-4.85; p=0.03), lactate clearance for 48 hours<70% (adjusted HR, 2.50; 95% CI, 1.04-6.05; p=0.041), and unsuccessful revascularization (adjusted HR, 3.57; 95% CI, 1.85-6.90; p=0.002) were independent predictors of in-hospital mortality after PCPS in patients with AMI complicated by cardiogenic shock. CONCLUSION In spite of PCPS management, AMI patients complicated by severe refractory cardiogenic shock demonstrated high mortality. Older age, CPR, lower lactate clearance for 48 hours, and unsuccessful revascularization were independent predictors of in-hospital mortality.
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Affiliation(s)
- Taek Kyu Park
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Division of Cardiology, Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hoon Lee
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Pediatric and neonatal extracorporeal membrane oxygenation: does center volume impact mortality?*. Crit Care Med 2014; 42:512-9. [PMID: 24164955 DOI: 10.1097/01.ccm.0000435674.83682.96] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation, an accepted rescue therapy for refractory cardiopulmonary failure, requires a complex multidisciplinary approach and advanced technology. Little is known about the relationship between a center's case volume and patient mortality. The purpose of this study was to analyze the relationship between hospital extracorporeal membrane oxygenation annual volume and in-hospital mortality and assess if a minimum hospital volume could be recommended. DESIGN Retrospective cohort study. SETTING A retrospective cohort admitted to children's hospitals in the Pediatric Health Information System database from 2004 to 2011 supported with extracorporeal membrane oxygenation was identified. Indications were assigned based on patient age (neonatal vs pediatric), diagnosis, and procedure codes. Average hospital annual volume was defined as 0-19, 20-49, or greater than or equal to 50 cases per year. Maximum likelihood estimates were used to assess minimum annual case volume. PATIENTS A total of 7,322 pediatric patients aged 0-18 were supported with extracorporeal membrane oxygenation and had an indication assigned. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Average hospital extracorporeal membrane oxygenation volume ranged from 1 to 58 cases per year. Overall mortality was 43% but differed significantly by indication. After adjustment for case-mix, complexity of cardiac surgery, and year of treatment, patients treated at medium-volume centers (odds ratio, 0.86; 95% CI, 0.75-0.98) and high-volume centers (odds ratio, 0.75; 95% CI, 0.63-0.89) had significantly lower odds of death compared with those treated at low-volume centers. The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22-28). CONCLUSIONS Pediatric centers with low extracorporeal membrane oxygenation average annual case volume had significantly higher mortality and a minimum volume of 22 cases per year was associated with improved mortality. We suggest that this threshold should be evaluated by additional study.
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Esper SA, Levy JH, Waters JH, Welsby IJ. Extracorporeal Membrane Oxygenation in the Adult. Anesth Analg 2014; 118:731-43. [DOI: 10.1213/ane.0000000000000115] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bernat JL, Bleck TP, Blosser SA, Bratton SL, Capron AM, Cornell D, DeVita MA, Fulda GJ, Glazier AK, Gries CJ, Mathur M, Nakagawa TA, Shemie SD. Circulatory Death Determination in Uncontrolled Organ Donors: A Panel Viewpoint. Ann Emerg Med 2014; 63:384-90. [DOI: 10.1016/j.annemergmed.2013.05.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/15/2013] [Accepted: 05/23/2013] [Indexed: 11/30/2022]
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Extracorporeal Membrane Oxygenation Strategy in Cardiac Arrest. Resuscitation 2014. [DOI: 10.1007/978-88-470-5507-0_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Massetti M, Gaudino M, De Paulis S, Scapigliati A, Cavaliere F. Extracorporeal membrane oxygenation for resuscitation and cardiac arrest management. Heart Fail Clin 2013; 10:S85-93. [PMID: 24262356 DOI: 10.1016/j.hfc.2013.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This article reviews the potential application of extracorporeal membrane oxygenation (ECMO) technology to cardiopulmonary resuscitation for in and out-of-hospital cardiac arrest and discusses the current evidence on the subject. The possible strategies for organ protection during ECMO and the concept of ECMO networks are also reviewed.
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Affiliation(s)
- Massimo Massetti
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, Catholic University, L.go Gemelli 1, 00168 Rome, Italy
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Shin TG, Jo IJ, Sim MS, Song YB, Yang JH, Hahn JY, Choi SH, Gwon HC, Jeon ES, Sung K, Lee YT, Choi JH. Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation. Int J Cardiol 2013; 168:3424-30. [DOI: 10.1016/j.ijcard.2013.04.183] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 02/07/2013] [Accepted: 04/19/2013] [Indexed: 01/31/2023]
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Roussel A, Al-Attar N, Alkhoder S, Radu C, Raffoul R, Alshammari M, Montravers P, Wolff M, Nataf P. Outcomes of percutaneous femoral cannulation for venoarterial extracorporeal membrane oxygenation support. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:111-4. [PMID: 24062897 DOI: 10.1177/2048872612449417] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 05/02/2012] [Indexed: 12/18/2022]
Abstract
INTRODUCTION We report and examine the outcomes of emergency venoarterial extracorporeal membrane oxygenation (ECMO) support initiated via percutaneous cannulation of the femoral vessels. PATIENTS AND METHODS Fifteen patients undergoing percutaneous venoarterial ECMO under emergency circumstances between January 2009 and July 2011 were identified. The implantation technique employed the Seldinger's technique for both arterial and venous cannulae. Whenever possible antegrade perfusion of the ipsilateral lower limb was performed through percutaneous catheterization of the superficial femoral artery (SFA). RESULTS ECMO support was indicated mainly for cardiac arrest (n=9, 60%) or cardiogenic shock (n=4, 27%), while two (13%) patients required ECMO support for acute respiratory failure. In five (33%) patients, ECMO was implanted during cardiopulmonary resuscitation manoeuvres. ECMO support was maintained for a mean of 4.9 days. Eight patients (53%) were successfully weaned from the device. Thirty-day mortality was 53%. Seven patients (47%) suffered early complications, namely two wound infections, one thrombosis of the venous cannula, one erroneous implantation of the arterial cannula into the femoral vein, one local dissection of the femoral artery, one retroperitoneal bleeding and one acute limb ischaemia. No long-term vascular complications were noted. CONCLUSION Percutaneous femoral cannulation for ECMO support remains a prompt approach for establishing extracorporeal circulatory support in acute cardiopulmonary failure when conditions for performing femoral vessel cut down are not optimal. However, vascular complications are frequent and carry a significant morbidity and mortality.
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The cool bypass toward life: hypothermic extracorporeal membrane oxygenation after cardiac arrest. Crit Care Med 2013; 41:2248-50. [PMID: 23979381 DOI: 10.1097/ccm.0b013e31828ce8a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Müller T, Lubnow M. The future of E-CPR: a joint venture. Resuscitation 2013; 84:1463-4. [PMID: 23954661 DOI: 10.1016/j.resuscitation.2013.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/08/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Thomas Müller
- Department of Medicine II, University Medical Centre, Regensburg, Germany.
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Lazzeri C, Sori A, Bernardo P, Picariello C, Gensini GF, Valente S. In-hospital refractory cardiac arrest treated with extracorporeal membrane oxygenation: A tertiary single center experience. ACTA ACUST UNITED AC 2013; 15:47-51. [DOI: 10.3109/17482941.2013.796385] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Skhirtladze-Dworschak K, Dworschak M. Cerebral oximetry and cardiac arrest. Semin Cardiothorac Vasc Anesth 2013; 17:269-75. [PMID: 23782549 DOI: 10.1177/1089253213492861] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cerebral oximetry is a Food and Drug Administration-approved technology that allows monitoring of brain oxygen saturation in accessible superficial brain cortex regions, which are amongst the most vulnerable in regard to ischemic or hypoxic injury. Since most oxygen in the area of interest is located in the venous compartment, the determined regional brain oxygen saturation approximately reflects the local balance between oxygen delivery and oxygen consumption. Major systemic alterations in blood oxygen content and oxygen delivery will be accompanied by corresponding changes in regional brain saturation. This systematic review, which is based on a Medline search, focuses on the characteristic changes in regional cerebral oxygen saturation that occur, when global oxygen supply to the brain ceases. It further highlights the potential application of cerebral oximetry in the management of cardiac arrest victims, the predictability of clinical outcome after global cerebral ischemia, and it also indicates possible potentials for the management of cerebral reperfusion after having instituted return of spontaneous circulation.
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Abstract
OBJECTIVES The purpose of this review was to provide a systematic review of the literature regarding the use of extracorporeal life support (ECLS) in various specialized conditions, as part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support. DATA SOURCES MEDLINE and PubMed. STUDY SELECTION Searches for published abstracts and articles were conducted using the following MeSH terms: extracorporeal life support, extracorporeal membrane oxygenation, or mechanical support, and pediatric or children. DATA EXTRACTION Abstracts of all articles including case reports were reviewed; the full article was reviewed if the abstract indicated that it focused on extracorporeal life support for conditions other than primary respiratory disease or persistent pulmonary hypertension of the newborn and described outcomes such as survival to hospital discharge. Studies with potential overlapping patients were highlighted in the review process and summary results. DATA SYNTHESIS Classification of recommendations and level of evidence are expressed in the American College of Cardiology Foundation/American Heart Association format. CONCLUSIONS The majority of specialized situations where extracorporeal life support is used fall into the category of class II-III evidence. Class I indications for extracorporeal life support in the pediatric population include myocarditis and in the context of acute interventions in the cardiac catheterization laboratory.
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Hollenberg J, Svensson L, Rosenqvist M. Out-of-hospital cardiac arrest: 10 years of progress in research and treatment. J Intern Med 2013; 273:572-83. [PMID: 23480824 DOI: 10.1111/joim.12064] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Cardiac disease is the most common cause of mortality in Western countries, with most deaths due to out-of-hospital cardiac arrest (OHCA). In Sweden, 5000-10 000 OHCAs occur annually. During the last decade, the time from cardiac arrest to start of cardiopulmonary resuscitation (CPR) and defibrillation has increased, whereas survival has remained unchanged or even increased. Resuscitation of OHCA patients is based on the 'chain-of-survival' concept, including early (i) access, (ii) CPR, (iii) defibrillation, (iv) advanced cardiac life support and (v) post-resuscitation care. Regarding early access, agonal breathing, telephone-guided CPR and the use of 'track and trigger systems' to detect deterioration in patients' condition prior to an arrest are all important. The use of compression-only CPR by bystanders as an alternative to standard CPR in OHCA has been debated. Based on recent findings, guidelines recommend telephone-guided chest compression-only CPR for untrained rescuers, but trained personnel are still advised to give standard CPR with both compressions and ventilation, and the method of choice for this large group remains unclear and demands for a randomized study. Data have shown the benefit of public access defibrillation for dispatched rescuers (e.g. police and fire fighters) but data are not as strong for the use of automated defibrillators (AEDs) by trained or untrained rescuers. Postresuscitation, use of therapeutic hypothermia, the importance of specific prognostic survival factors in the intensive care unit and the widespread use of percutaneous coronary intervention have all been considered. Despite progress in research and improved treatment regimens, most patients do not survive OHCA. Particular areas of interest for improving survival include (i) identification of high-risk patients prior to their arrest (e.g. early warning symptoms and genes); (ii) increased use of bystander CPR training (e.g. in schools) and simplified CPR techniques; (iii) better identification of high-incidence sites and better recruitment of AEDs (via mobile phone solutions?); (iv) improved understanding of the use of therapeutic hypothermia; (v) determining which patients should undergo immediate coronary angiography on hospital admission; and (vi) clarifying the importance of extracorporeal membrane oxygenation during CPR.
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Affiliation(s)
- J Hollenberg
- Section of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
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