Extracorporeal Life Support: Indications and Use in Severely Poisoned Patients

Extracorporeal cardio-pulmonary resuscitation in poisoning: A scoping review article

Background

Extracorporeal cardiopulmonary resuscitation (ECPR) represents last-line salvage therapy for poisoning-induced cardiac arrest but no review has focused on this specific area.

Objective

This scoping review sought to evaluate the survival outcomes and characteristics of published cases of ECPR for toxicological arrest, with the aim of highlighting the potential and limitations of ECPR in toxicology.Eligibility Criteria.We searched PubMed and Cochrane for eligible papers from database inception to October 1, 2022 using the keywords "toxicology", "ECLS" and "CPR". References of included publications were searched to identify additional relevant articles. Qualitative synthesis was used to summarize the evidence.

Results

85 articles were chosen: 15 case series, 58 individual cases and 12 other publications that were analyzed separately due to ambiguity. ECPR may improve survival outcomes in selected poisoned patients, although the extent of benefit is unclear. As ECPR for poisoning-induced arrest may have better prognosis compared to from other aetiologies, it is likely reasonable to apply ELSO ECPR consensus guideline recommendations to toxicological arrest.Out-of-hospital cardiac arrest alone may not be sufficient grounds to deny ECPR if effective resuscitation had been promptly instituted. Poisonings involving membrane-stabilizing agents and cardio-depressive drugs, and cardiac arrests with shockable rhythms appear to have better outcomes. ECPR may permit excellent neurologically-intact recovery despite prolonged low-flow time of up to four hours. Early ECLS activation and pre-emptive catheter placement can significantly shorten time-to-ECPR and possibly improve survival.

Conclusion

As effects of poisoning may be reversible, ECPR can potentially support poisoned patients through the critical peri-arrest state.

Extracorporeal Membrane Oxygenation for Pediatric Toxin Exposures: Review of the Extracorporeal Life Support Organization Registry

Evidence for the use of extracorporeal membrane oxygenation (ECMO) in children with refractory respiratory failure or shock following ingestion or toxin exposure, has been confined to single-center experiences, individual case reports, and extrapolated from adult cohorts; no pediatric multicenter cohorts exist. The objective of this retrospective review of the Extracorporeal Life Support Organization registry is to describe pediatric ECMO use following ingestion or toxin exposure, and define factors associated with mortality. Twenty-eight children between the ages of 30 days and 18 years met inclusion criteria between January 1, 2008 and December 31, 2017. The primary outcome measure was mortality before hospital discharge, which occurred in 32% of patients. Factors associated with in-hospital mortality included pre-ECMO use of inhaled nitric oxide (44.4% vs. 5.3%, p = 0.026), lower pre-ECMO arterial blood gas pH (6.97 [6.80-7.17] vs. 7.20 [7.15-7.32], p = 0.034), and higher pre-ECMO PaCO2 (79 [57-85] vs. 49 [38-63], p = 0.014). Receipt of inotropic support during ECMO was more common in nonsurvivors (66.7% vs. 21.1%, p = 0.035). Extracorporeal membrane oxygenation should be considered in the most severe pediatric toxin exposures as a bridge to recovery, providing time for both toxin elimination and end-organ recovery.