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DeMasi S, Donohue M, Merck L, Mosier J. Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: Lessons learned from recent clinical trials. J Am Coll Emerg Physicians Open 2024; 5:e13129. [PMID: 38434097 PMCID: PMC10904351 DOI: 10.1002/emp2.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/05/2024] Open
Abstract
Cardiac arrest is a leading contributor to morbidity and mortality in the United States. Survival has been historically dependent on high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. However, a large percentage of patients remain in refractory cardiac arrest despite adherence to structured advanced cardiac life support algorithms in which these factors are emphasized. Veno-arterial extracorporeal membrane oxygenation is becoming an increasingly used rescue therapy for patients in refractory cardiac arrest to restore oxygen delivery by extracorporeal CPR (ECPR). Recently published clinical trials have provided new insights into ECPR for patients who sustain an outside hospital cardiac arrest (OHCA). In this narrative review, we summarize the rationale for, results of, and remaining questions from these recently published clinical trials. The existing observational data combined with the latest clinical trials suggest ECPR improves mortality in patients in refractory arrest. However, a mixed methods trial is essential to understand the complexity, context, and effectiveness of implementing an ECPR program.
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Affiliation(s)
- Stephanie DeMasi
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Megan Donohue
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lisa Merck
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Jarrod Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and SleepDepartment of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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Demers SP, Cournoyer A, Dagher O, Noly PE, Ducharme A, Ly H, Albert M, Serri K, Cavayas YA, Ben Ali W, Lamarche Y. Impact of clinical variables on outcomes in refractory cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation. Front Cardiovasc Med 2024; 10:1315548. [PMID: 38250030 PMCID: PMC10799334 DOI: 10.3389/fcvm.2023.1315548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024] Open
Abstract
Background In the past two decades, extracorporeal resuscitation (ECPR) has been increasingly used in the management of refractory cardiac arrest (CA) patients. Decision algorithms have been used to guide the care such patients, but the effectiveness of such decision-making tools is not well described. The aim of this study was to compare the rate of survival with a good neurologic outcome of patients treated with ECPR meeting all criteria of a clinical decision-making tool for the initiation of ECPR to those for whom ECPR was implemented outside of the algorithm. Methods All patients who underwent E-CPR between January 2014 and December 2021 at the Montreal Heart Institute were included in this retrospective analysis. We dichotomized the cohort according to adherence or non-adherence with the ECPR decision-making tool, which included the following criteria: age ≤65 years, initial shockable rhythm, no-flow time <5 min, serum lactate <13 mmol/L. Patients were included in the "IN" group when they met all criteria of the decision-making tool and in the "OUT" group when at least one criterion was not met. Main outcomes and measures The primary outcome was survival with intact neurological status at 30 days, defined by a Cerebral Performance Category (CPC) Scale 1 and 2. Results A total of 41 patients (IN group, n = 11; OUT group, n = 30) were included. A total of 4 (36%) patients met the primary outcome in the IN group and 7 (23%) in the OUT group [odds ratio (OR): 1.88 (95% CI, 0.42-8.34); P = 0.45]. However, survival with a favorable outcome decreased steadily with 2 or more deviations from the decision-making tool [2 deviations: 1 (11%); 3 deviations: 0 (0%)]. Conclusion and relevance Most patients supported with ECPR fell outside of the criteria encompassed in a clinical decision-making tool, which highlights the challenge of optimal selection of ECPR candidates. Survival rate with a good neurologic outcome did not differ between the IN and OUT groups. However, survival with favorable outcome decreased steadily after one deviation from the decision-making tool. More studies are needed to help select proper candidates with refractory CA patients for ECPR.
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Affiliation(s)
- Simon-Pierre Demers
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
| | - Alexis Cournoyer
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Emergency Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Olina Dagher
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Pierre-Emmanuel Noly
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Anique Ducharme
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Hung Ly
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Martin Albert
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
| | - Karim Serri
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
| | - Yiorgos Alexandros Cavayas
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
| | - Walid Ben Ali
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Yoan Lamarche
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
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Olson T, Anders M, Burgman C, Stephens A, Bastero P. Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience. Front Med (Lausanne) 2022; 9:935424. [PMID: 36479094 PMCID: PMC9720280 DOI: 10.3389/fmed.2022.935424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/04/2022] [Indexed: 09/19/2023] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.
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Affiliation(s)
- Taylor Olson
- Pediatric Critical Care Medicine, Children's National Hospital, Washington, DC, United States
| | - Marc Anders
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Pediatric Critical Care Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Cole Burgman
- ECMO, Texas Children's Hospital, Houston, TX, United States
| | - Adam Stephens
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Congenital Heart Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Patricia Bastero
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Pediatric Critical Care Medicine, Texas Children's Hospital, Houston, TX, United States
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Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis. ASAIO J 2021; 68:987-995. [PMID: 34860714 DOI: 10.1097/mat.0000000000001613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (β = 0.02, 95% CI: 0.007-0.02; p = 0.0004).
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Pozzi M, Grinberg D, Armoiry X, Flagiello M, Hayek A, Ferraris A, Koffel C, Fellahi JL, Jacquet-Lagrèze M, Obadia JF. Impact of a Modified Institutional Protocol on Outcomes After Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-Of-Hospital Cardiac Arrest. J Cardiothorac Vasc Anesth 2021; 36:1670-1677. [PMID: 34130897 DOI: 10.1053/j.jvca.2021.05.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To analyze the impact of the modification of the authors' institutional protocol on outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). DESIGN An observational analysis. The protocol complied with national recommendations. A further eligibility criterion was added since January 2015: the presence of sustained shockable rhythm at extracorporeal life support (ECLS) implantation. To assess the impact of this change, patients were divided into two groups: (1) from January 2010 to December 2014 (group A) and (2) from January 2015 to December 2019 (group B). The primary endpoint was survival to hospital discharge with good neurologic outcome. Predictors of survival were searched with multivariate analyses. SETTING University hospital. PARTICIPANTS Adult patients supported with ECPR for refractory OHCA. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From January 2010 to December 2019, 85 patients had ECLS for OHCA (group A, n = 68, 80%; group B, n = 17, 20%). The mean age was 42.4 years, 78.8% were male. The rate of implantation of ECLS was significantly lower in group B (p = 0.01). Mortality during ECLS support was significantly lower (58.8 v 86.8%; p = 0.008), and the weaning rate was significantly higher (41.2 v 13.2%; p = 0.008) in group B. Survival to discharge with good neurologic outcome was significantly improved (23.5 v 4.4%; p = 0.027) in group B. A sustained shockable rhythm was the only independent predictor of survival to hospital discharge with good neurologic outcome. CONCLUSIONS The modification of the authors' institutional protocol throughout the further criterion of sustained shockable rhythm yielded a favorable impact on outcomes after ECPR for OHCA.
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Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France.
| | - Daniel Grinberg
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Xavier Armoiry
- University of Lyon, School of Pharmacy (ISPB) / UMR CNRS 5510 MATEIS / "Edouard Herriot" Hospital, Pharmacy Department, Lyon, France
| | - Michele Flagiello
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Ahmad Hayek
- Department of Cardiology, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Arnaud Ferraris
- Department of Anaesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Catherine Koffel
- Department of Anaesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean Luc Fellahi
- Department of Anaesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | | | - Jean Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
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Brain Injury and Neurologic Outcome in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 48:e611-e619. [PMID: 32332280 DOI: 10.1097/ccm.0000000000004377] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation has shown survival benefit in select patients with refractory cardiac arrest but there is insufficient data on the frequency of different types of brain injury. We aimed to systematically review the prevalence, predictors of and survival from neurologic complications in patients who have undergone extracorporeal cardiopulmonary resuscitation. DATA SOURCES MEDLINE (PubMed) and six other databases (EMBASE, Cochrane Library, CINAHL Plus, Web of Science, and Scopus) from inception to August 2019. STUDY SELECTION Randomized controlled trials and observational studies in patients greater than 18 years old. DATA EXTRACTION Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for randomized controlled trials, the Newcastle-Ottawa Scale for cohort and case-control studies, and the Murad tool for case series. Random-effects meta-analyses were used to pool data. DATA SYNTHESIS The 78 studies included in our analysis encompassed 50,049 patients, of which 6,261 (12.5%) received extracorporeal cardiopulmonary resuscitation. Among extracorporeal cardiopulmonary resuscitation patients, the median age was 56 years (interquartile range, 52-59 yr), 3,933 were male (63%), 3,019 had out-of-hospital cardiac arrest (48%), and 2,289 had initial shockable heart rhythm (37%). The most common etiology of cardiac arrest was acute coronary syndrome (n = 1,657, 50% of reported). The median extracorporeal cardiopulmonary resuscitation duration was 3.2 days (interquartile range, 2.1-4.9 d). Overall, 27% (95% CI, 0.17-0.39%) had at least one neurologic complication, 23% (95% CI, 0.14-0.32%) hypoxic-ischemic brain injury, 6% (95% CI, 0.02-0.11%) ischemic stroke, 6% (95% CI, 0.01-0.16%) seizures, and 4% (95% CI, 0.01-0.1%) intracerebral hemorrhage. Seventeen percent (95% CI, 0.12-0.23%) developed brain death. The overall survival rate after extracorporeal cardiopulmonary resuscitation was 29% (95% CI, 0.26-0.33%) and good neurologic outcome was achieved in 24% (95% CI, 0.21-0.28%). CONCLUSIONS One in four patients developed acute brain injury after extracorporeal cardiopulmonary resuscitation and the most common type was hypoxic-ischemic brain injury. One in four extracorporeal cardiopulmonary resuscitation patients achieved good neurologic outcome. Further research on assessing predictors of extracorporeal cardiopulmonary resuscitation-associated brain injury is necessary.
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A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation. MEMBRANES 2021; 11:membranes11040251. [PMID: 33808419 PMCID: PMC8065680 DOI: 10.3390/membranes11040251] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 01/28/2023]
Abstract
Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage of packed red cell transfusions. Predefined search criteria were used to identify journal articles reporting transfusion practice in ECMO by interrogating EMBASE and Medline databases and following the PRISMA statement. Results: Out of 1579 abstracts screened, articles reporting ECMO usage in a minimum of 10 adult patients were included. Full texts of 331 articles were obtained, and 54 were included in the final analysis. All studies were observational (2 were designed prospectively, and two were multicentre). A total of 3808 patients were reported (range 10–517). Mean exposure to ECMO was 8.2 days (95% confidence interval (CI) 7.0–9.4). A median of 5.6% was not transfused (interquartile range (IQR) 0–11.3%, 19 studies). The mean red cell transfusion per ECMO run was 17.7 units (CI 14.2–21.2, from 52 studies) or 2.60 units per day (CI 1.93–3.27, from 49 studies). The median survival to discharge was 50.8% (IQR 40.0–64.9%). Conclusion: Current evidence on transfusion practice in ECMO is mainly drawn from single-centre observational trials and varies widely. The need for transfusions is highly variable. Confounding factors influencing transfusion practice need to be identified in prospective multicentre studies to mitigate potential harmful effects and generate hypotheses for interventional trials.
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Miraglia D, Ayala JE. Extracorporeal cardiopulmonary resuscitation for adults with shock-refractory cardiac arrest. J Am Coll Emerg Physicians Open 2021; 2:e12361. [PMID: 33506232 PMCID: PMC7813516 DOI: 10.1002/emp2.12361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/28/2020] [Accepted: 12/23/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation has increasingly emerged as a feasible treatment to mitigate the progressive multiorgan dysfunction that occurs during cardiac arrest, in support of further resuscitation efforts. OBJECTIVES Because the recent systematic review commissioned in 2018 by the International Liaison Committee on Resuscitation Advanced Life Support task did not include studies without a control group, our objective was to conduct a review incorporating these studies to increase available evidence supporting the use of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest patients, while waiting for high-quality evidence from randomized controlled trials (RCTs). METHODS MEDLINE, Embase, and Science Citation Index (Web of Science) were searched for eligible studies from database inception to July 20, 2020. The population of interest was adult patients who had suffered cardiac arrest in any setting. We included all cohort studies with 1 exposure/1 group and descriptive studies (ie, case series studies). We excluded RCTs, non-RCTs, and observational analytic studies with a control group. Outcomes included short-term survival and favorable neurological outcome. Short-term outcomes (ie, hospital discharge, 30 days, and 1 month) were combined into a single category. RESULTS Our searches of databases and other sources yielded a total of 4302 citations. Sixty-two eligible studies were included (including a combined total of 3638 participants). Six studies were of in-hospital cardiac arrest, 34 studies were of out-of-hospital cardiac arrest, and 22 studies included both in-hospital and out-of-hospital cardiac arrest. Seven hundred and sixty-eight patients of 3352 (23%) had short-term survival; whereas, 602 of 3366 (18%) survived with favorable neurological outcome, defined as a cerebral performance category score of 1 or 2. CONCLUSIONS Current clinical evidence is mostly drawn from observational studies, with their potential for confounding selection bias. Although studies without controls cannot supplant case-control or cohort studies, several ECPR studies without a control group show successful resuscitation with impressive results that may provide valuable information to inform a comparison.
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Affiliation(s)
- Dennis Miraglia
- Department of Emergency MedicineSan Francisco HospitalSan JuanPuerto RicoUSA
| | - Jonathan E. Ayala
- Department of Emergency MedicineGood Samaritan HospitalAguadillaPuerto RicoUSA
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10
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Roach C, Tainter CR, Sell RE, Wardi G. Resuscitating Resuscitation: Advanced Therapies for Resistant Ventricular Dysrhythmias. J Emerg Med 2020; 60:331-341. [PMID: 33339645 DOI: 10.1016/j.jemermed.2020.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND More than 640,000 combined in-hospital and out-of-hospital cardiac arrests occur annually in the United States. However, survival rates and meaningful neurologic recovery remain poor. Although "shockable" rhythms (i.e., ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have the best outcomes, many of these ventricular dysrhythmias fail to return to a perfusing rhythm (resistant VF/VT), or recur shortly after they are resolved (recurrent VF/VT). OBJECTIVE This review discusses 4 emerging therapies in the emergency department for treating these resistant or recurrent ventricular dysrhythmias: beta-blocker therapy, dual simultaneous external defibrillation, stellate ganglion blockade, and extracorporeal cardiopulmonary resuscitation. We discuss the underlying physiology of each therapy, review relevant literature, describe when these approaches should be considered, and provide evidence-based recommendations for these techniques. DISCUSSION Esmolol may mitigate some of epinephrine's negative effects when used during resuscitation, improving both postresuscitation cardiac function and long-term survival. Dual simultaneous external defibrillation targets the region of the heart where ventricular fibrillation typically resumes and may apply a more efficient defibrillation across the heart, leading to higher rates of successful defibrillation. Stellate ganglion blocks, recently described in the emergency medicine literature, have been used to treat patients with recurrent VF/VT, resulting in significant dysrhythmia suppression. Finally, extracorporeal cardiopulmonary resuscitation is used to provide cardiopulmonary support while clinicians correct reversible causes of arrest, potentially resulting in improved survival and good neurologic functional outcomes. CONCLUSION These emerging therapies do not represent standard practice; however, they may be considered in the appropriate clinical scenario when standard therapies are exhausted without success.
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Affiliation(s)
- Colin Roach
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christopher R Tainter
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, California
| | - Rebecca E Sell
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California, San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, California
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11
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Miraglia D, Miguel LA, Alonso W. Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resusc Plus 2020; 4:100045. [PMID: 34223320 PMCID: PMC8244502 DOI: 10.1016/j.resplu.2020.100045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used as extracorporeal cardiopulmonary resuscitation (ECPR) to support further resuscitation efforts in patients with cardiac arrest, yet its clinical effectiveness remains uncertain. OBJECTIVES This study reviews the role of ECPR in contemporary resuscitation care compared to no ECPR and/or standard care, e.g. conventional CPR, and quantitatively summarize the rates of long-term neurologically intact survival after adult in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). METHODS We searched the following databases on January 31 st, 2020: CENTRAL, MEDLINE, Embase, and Web of Science. We followed PRISMA guidelines and used PICO format to summarize the research questions. Risk of bias was assessed using the ROBINS-I tool. Pooled risk ratios (RRs) for each outcome of interest were calculated. Quality of evidence was evaluated according to GRADE guidelines. RESULTS Six cohort studies were included, totaling 1750 patients. Of these, 530 (30.3%) received the intervention, and 91 (17.2%) survived with long-term neurologically intact survival. ECPR compared to no ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest in any setting (risk ratio [RR] 3.11, 95% confidence interval [CI] 2.06-4.69; p < 0.00001) (GRADE: Very low quality). Similar results were found for long-term neurologically intact survival after IHCA (RR 3.21, 95% CI 1.74-5.94; p < 0.0002) (GRADE: Very low quality) and OHCA (RR 3.11, 95% CI 1.50-6.47; p < 0.002) (GRADE: Very low quality). Long-term time frames for neurologically intact survival (three months to two years) were combined into a single category, defined a priori as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1 or 2. CONCLUSIONS VA-ECMO used as ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest. Future evidence from randomized trials is very likely to have an important impact on the estimated effect of this intervention and will further define optimal clinical practice. Review registration: PROSPERO CRD42020171945.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Lourdes A. Miguel
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Wilfredo Alonso
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
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12
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Gravesteijn BY, Schluep M, Disli M, Garkhail P, Dos Reis Miranda D, Stolker RJ, Endeman H, Hoeks SE. Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis. Crit Care 2020; 24:505. [PMID: 32807207 PMCID: PMC7430015 DOI: 10.1186/s13054-020-03201-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/26/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is a major adverse event with a high mortality rate if not treated appropriately. Extracorporeal cardiopulmonary resuscitation (ECPR), as adjunct to conventional cardiopulmonary resuscitation (CCPR), is a promising technique for IHCA treatment. Evidence pertaining to neurological outcomes after ECPR is still scarce. METHODS We performed a comprehensive systematic search of all studies up to December 20, 2019. Our primary outcome was neurological outcome after ECPR at any moment after hospital discharge, defined by the Cerebral Performance Category (CPC) score. A score of 1 or 2 was defined as favourable outcome. Our secondary outcome was post-discharge mortality. A fixed-effects meta-analysis was performed. RESULTS Our search yielded 1215 results, of which 19 studies were included in this systematic review. The average survival rate was 30% (95% CI 28-33%, I2 = 0%, p = 0.24). In the surviving patients, the pooled percentage of favourable neurological outcome was 84% (95% CI 80-88%, I2 = 24%, p = 0.90). CONCLUSION ECPR as treatment for in-hospital cardiac arrest is associated with a large proportion of patients with good neurological outcome. The large proportion of favourable outcome could potentially be explained by the selection of patients for treatment using ECPR. Moreover, survival is higher than described in the conventional CPR literature. As indications for ECPR might extend to older or more fragile patient populations in the future, research should focus on increasing survival, while maintaining optimal neurological outcome.
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Affiliation(s)
- Benjamin Yaël Gravesteijn
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - Marc Schluep
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | - Maksud Disli
- Erasmus University Medical Centre School of Medicine, Rotterdam, The Netherlands
| | - Prakriti Garkhail
- Erasmus University Medical Centre School of Medicine, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robert-Jan Stolker
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sanne Elisabeth Hoeks
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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13
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Miraglia D, Miguel LA, Alonso W. Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: systematic review and meta-analysis of propensity score-matched cohort studies. J Am Coll Emerg Physicians Open 2020; 1:342-361. [PMID: 33000057 PMCID: PMC7493557 DOI: 10.1002/emp2.12091] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In this systematic review and meta-analysis of propensity score-matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30-day and long-term favorable neurological outcomes and survival in patients resuscitated from in- and out-of-hospital cardiac arrest. METHODS We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Six cohort studies using propensity score-matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30-day and long-term favorable neurological outcome in adults compared to CCPR for in- and out-of-hospital cardiac arrest (RR = 2.02, 95% CI = 1.29-3.16; I2 = 20%, P = 0.002; very low-quality evidence) and (RR = 2.86, 95% CI = 1.64-5.01; I2 = 0%, P = 0.0002; moderate-quality evidence), respectively. When we analyzed in- and out-of-hospital cardiac arrest separately, ECPR was likely associated with improved 30-day favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.18, 95% CI = 1.24-3.81; I2 = 9%, P = 0.006; very low-quality evidence), but not for out-of-hospital cardiac arrest (RR = 2.61, 95% CI = 0.56-12.20; I2 = 59%, P = 0.22; very low-quality evidence). ECPR was also likely associated with improved long-term favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.50, 95% CI = 1.33-4.71; I2 = 0%, P = 0.005; moderate-quality evidence) and out-of-hospital cardiac arrest (RR = 4.64, 95% CI = 1.41-15.25; I2 = 0%, P = 0.01; moderate-quality evidence). CONCLUSIONS Our analysis suggests that VA-ECMO used as ECPR may improve long-term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well-designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Lourdes A Miguel
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Wilfredo Alonso
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
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14
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Koen 'J, Nathanaël T, Philippe D. A systematic review of current ECPR protocols. A step towards standardisation. Resusc Plus 2020; 3:100018. [PMID: 34223301 PMCID: PMC8244348 DOI: 10.1016/j.resplu.2020.100018] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/25/2022] Open
Abstract
Aim Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Our goal was to identify the best protocol for survival with good neurological outcome through the evaluation of current inclusion criteria, exclusion criteria, cannulation strategies and additional therapeutic measures. Methods A systematic literature search was used to identify eligible publications from PubMed, Embase, Web of Science and Cochrane for articles published from 29 June 2009 until 29 June 2019. Results The selection process led to a total of 24 eligible articles, considering 1723 patients in total. A good neurological outcome at hospital discharge was found in 21.3% of all patients. The most consistent criterion for inclusion was refractory cardiac arrest (RCA), used in 21/25 (84%) of the protocols. The preferred cannulation method was the percutaneous Seldinger technique (44%). Conclusion ECPR is a feasible option for cardiac arrest and should already be considered in an early stage of CPR. One of the key findings is that time-to-ECPR seems to be correlated with good neurological survival. An important contributing factor is the definition of RCA. Protocols defining RCA as >10 min had a mean good neurological survival of 26.7%. Protocols with a higher cut-off, between 15 and 30 min, had a mean good neurological survival of 14.5%. Another factor contributing to the time-to-ECPR is the preferred access technique. A percutaneous Seldinger technique combined with ultrasonography and fluoroscopic guidance leads to a reduced cannulation time and complication rate. Conclusive research around prehospital cannulation still needs to be conducted.
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Affiliation(s)
- 't Joncke Koen
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium.,KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Thelinge Nathanaël
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium.,KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Dewolf Philippe
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium.,KULeuven, Department of Public Health and Primary Care, Leuven, Belgium.,KULeuven, Faculty of Medicine, Leuven, Belgium
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15
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Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Adult Patients. J Am Heart Assoc 2020; 9:e015291. [PMID: 32204668 PMCID: PMC7428656 DOI: 10.1161/jaha.119.015291] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out-of-hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra-aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.
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Affiliation(s)
- Akihiko Inoue
- Department of Emergency, Disaster and Critical Care MedicineFaculty of MedicineKagawa UniversityKagawaJapan
- Department of Emergency and Critical Care MedicineHyogo Emergency Medical CenterKagawaJapan
| | - Toru Hifumi
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalTokyoJapan
| | | | - Yasuhiro Kuroda
- Department of Emergency, Disaster and Critical Care MedicineFaculty of MedicineKagawa UniversityKagawaJapan
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16
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Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study. Intensive Care Med 2020; 46:973-982. [DOI: 10.1007/s00134-020-05926-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/08/2020] [Indexed: 11/26/2022]
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17
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Chen X, Zhen Z, Na J, Wang Q, Gao L, Yuan Y. Associations of therapeutic hypothermia with clinical outcomes in patients receiving ECPR after cardiac arrest: systematic review with meta-analysis. Scand J Trauma Resusc Emerg Med 2020; 28:3. [PMID: 31937354 PMCID: PMC6961259 DOI: 10.1186/s13049-019-0698-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia has been recommended for eligible patients after cardiac arrest (CA) in order to improve outcomes. Up to now, several comparative observational studies have evaluated the combined use of extracorporeal cardiopulmonary resuscitation (ECPR) and therapeutic hypothermia in adult patients with CA. However, the effects of therapeutic hypothermia in adult CA patients receiving ECPR are inconsistent. METHODS Relevant studies in English databases (PubMed, ISI web of science, OVID, and Embase) were systematically searched up to September 2019. Odds ratios (ORs) from eligible studies were extracted and pooled to summarize the associations of therapeutic hypothermia with favorable neurological outcomes and survival in adult CA patients receiving ECPR. RESULTS 13 articles were included in the present meta-analysis study. There were nine studies with a total of 806 cases reporting the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Pooling analysis suggested that therapeutic hypothermia was significantly associated with favorable neurological outcomes in overall (N = 9, OR = 3.507, 95%CI = 2.194-5.607, P < 0.001, fixed-effects model) and in all subgroups according to control type, regions, sample size, CA location, ORs obtained methods, follow-up period, and modified Newcastle Ottawa Scale (mNOS) scores. There were nine studies with a total of 806 cases assessing the association of therapeutic hypothermia with survival in CA patients receiving ECPR. After pooling the ORs, therapeutic hypothermia was found to be significantly associated with survival in overall (N = 9, OR = 2.540, 95%CI = 1.245-5.180, P = 0.010, random-effects model) and in some subgroups. Publication bias was found when evaluating the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Additional trim-and-fill analysis estimated four "missing" studies, which adjusted the effect size to 2.800 (95%CI = 1.842-4.526, P < 0.001, fixed-effects model) for neurological outcomes. CONCLUSIONS Therapeutic hypothermia may be associated with favorable neurological outcomes and survival in adult CA patients undergoing ECPR. However, the result should be treated carefully because it is a synthesis of low-level evidence and other limitations exist in present study. It is necessary to perform randomized controlled trials to validate our result before considering the result in clinical practices.
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Affiliation(s)
- Xi Chen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Zhen Zhen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Jia Na
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Qin Wang
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Lu Gao
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Yue Yuan
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
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18
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Pozzi M, Armoiry X, Achana F, Koffel C, Pavlakovic I, Lavigne F, Fellahi JL, Obadia JF. Extracorporeal Life Support for Refractory Cardiac Arrest: A 10-Year Comparative Analysis. Ann Thorac Surg 2019; 107:809-816. [DOI: 10.1016/j.athoracsur.2018.09.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Patricio D, Peluso L, Brasseur A, Lheureux O, Belliato M, Vincent JL, Creteur J, Taccone FS. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:27. [PMID: 30691512 PMCID: PMC6348681 DOI: 10.1186/s13054-019-2320-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/11/2019] [Indexed: 11/10/2022]
Abstract
Background The potential benefit of extracorporeal cardiopulmonary resuscitation (ECPR) compared to conventional CPR (CCPR) for patients with refractory cardiac arrest (CA) remains unclear. Methods This study is a retrospective analysis of a prospective database of CA patients, which includes all consecutive adult patients admitted to the Department of Intensive Care after CA between January 2012 and December 2017. The decision to initiate ECPR was made by the attending physician and ECPR performed by the ECPR team, which is composed of ICU physicians. A propensity score was derived using a logistic regression model, including characteristics that varied between groups with a p < 0.10 and were potentially related to outcome. Primary outcomes were survival to ICU discharge and favorable 3-month neurologic outcome, assessed by a Cerebral Performance Category (CPC) score of 1–2. Results From a total of 635 patients with CA during the study period (ECPR, n = 112), 80 ECPR patients were matched to 80 CCPR patients. The time from arrest to termination of CPR (i.e., return of spontaneous circulation [ROSC], extracorporeal membrane oxygenation [ECMO] initiation, or death) was 54 ± 22 and 54 ± 19 min in the ECPR and CCPR groups, respectively. ROSC rates were 77/80 (96%) for ECPR and 30/80 (38%) for CCPR (p < 0.001). Survival to ICU discharge was 18/80 (23%) vs. 14/80 (18%) in the ECPR and CCPR groups, respectively (p = 0.42). At 3 months, 17/80 (21%) ECPR patients and 9/80 (11%) CCPR patients had a favorable outcome (p = 0.11). Cox regression analysis stratified by matched pairs showed a significantly higher neurologic outcome rate in the ECPR group than in the CCPR group (log-rank test p = 0.003). Conclusions ECPR after CA may be associated with improved long-term neurological outcome.
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Affiliation(s)
- Daniel Patricio
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Alexandre Brasseur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Olivier Lheureux
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Abstract
High-quality cardiopulmonary resuscitation, in particular chest compressions, is a key aspect of out-of-hospital cardiac arrest (OHCA) resuscitation. Manual chest compressions remain the standard of care; however, the extrication and transport of patients with OHCA undermine the quality of manual chest compressions and risk the safety of paramedics. Therefore, in circumstances whereby high-quality manual chest compressions are difficult or unsafe, paramedics should consider using a mechanical device. By combining high-quality manual chest compressions and judicious application of mechanical chest compressions, emergency medical service agencies can optimize paramedic safety and patient outcomes.
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Affiliation(s)
- Kylie Dyson
- Centre for Research and Evaluation, Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia; Cardiology Department, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia; Cardiology Department, Western Health, Gordon Street, Footscray, VIC 3011, Australia; Medical Directorate, Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia; Medical Directorate, Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, McMahons Road, Frankston, VIC 3199, Australia
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21
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Beyea MM, Tillmann BW, Iansavichene AE, Randhawa VK, Van Aarsen K, Nagpal AD. Neurologic outcomes after extracorporeal membrane oxygenation assisted CPR for resuscitation of out-of-hospital cardiac arrest patients: A systematic review. Resuscitation 2018; 130:146-158. [PMID: 30017957 DOI: 10.1016/j.resuscitation.2018.07.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation-assisted CPR (ECPR) is an evolving adjunct for resuscitation of OHCA patients. The primary objective of this systematic review was to assess survival-to-hospital discharge with good neurologic recovery after OHCA among patients treated with ECPR compared to conventional CPR (CCPR). METHODS A systematic search of MEDLINE® and EMBASE® electronic databases was performed from inception until July 2016 to identify studies reporting ECPR use in adults with OHCA and survival outcomes. RESULTS Of the 1512 citations identified, 75 studies met our inclusion criteria (63 case series and 12 cohort studies). Among case series, 0 to 71.4% of patients treated with ECPR survived to discharge with a good neurologic outcome. Subgroup analysis of the cohort studies demonstrated survival-to-hospital discharge with good neurologic recovery in the ECPR group ranging from 8.3 to 41.6% compared to 1.5 to 9.1% in the CCPR group. Five cohort studies adjusted for confounders, 3 of which demonstrated significantly increased adjusted odds ratios of survival among the ECPR-treated patients. Due to significant heterogeneity (I2 = 63%, p = 0.03), pooling of outcomes and a meta-analysis were not conducted. CONCLUSION Although a trend towards improved survival with good neurologic outcome was reported in controlled, low-risk of bias cohort studies, a preponderance of low quality evidence may ascribe an optimistic effect size of ECPR on survival among OHCA patients. Our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. In this state of equipoise, high quality RCT data is urgently needed.
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Affiliation(s)
- Michael M Beyea
- Division of Emergency Medicine, London Health Sciences Centre, Western University, London, ON, Canada; Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
| | - Bourke W Tillmann
- Department of Critical Care Medicine, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Alla E Iansavichene
- Health Science Library, London Health Sciences Centre, Victoria Campus, London, ON, Canada
| | - Varinder K Randhawa
- Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kristine Van Aarsen
- Division of Emergency Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - A Dave Nagpal
- Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada
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Extracorporeal Life Support Increases Survival After Prolonged Ventricular Fibrillation Cardiac Arrest in the Rat. Shock 2018; 48:674-680. [PMID: 28562481 PMCID: PMC5586591 DOI: 10.1097/shk.0000000000000909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Extracorporeal life support (ECLS) for cardiopulmonary resuscitation (CPR) may increase end organ perfusion and thus survival when conventional CPR fails. The aim was to investigate, if after ventricular fibrillation cardiac arrest in rodents ECLS improves outcome compared with conventional CPR. Methods: In 24 adult male Sprague–Dawley rats (460–510 g) resuscitation was started after 10 min of no-flow with ECLS (consisting of an open reservoir, roller pump, and membrane oxygenator, connected to cannulas in the jugular vein and femoral artery, n = 8) or CPR (mechanical chest compressions plus ventilations, n = 8) and compared with a sham group (n = 8). After return of spontaneous circulation (ROSC), all rats were maintained at 33°C for 12 h. Survival to 14 days, neurologic deficit scores and overall performance categories were assessed. Results: ECLS leads to sustained ROSC in 8 of 8 (100%) and neurological intact survival to 14 days in 7 of 8 rats (88%), compared with 5 of 8 (63%) and 1 of 8 CPR rats. The median survival time was 14 days (IQR: 14–14) in the ECLS and 1 day (IQR: 0 to 5) for the CPR group (P = 0.004). Conclusion: In a rat model of prolonged ventricular fibrillation cardiac arrest, ECLS with mild hypothermia produces 100% resuscitability and 88% long-term survival, significantly better than conventional CPR.
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Tanguay-Rioux X, Grunau B, Neumar R, Tallon J, Boone R, Christenson J. Is initial rhythm in OHCA a predictor of preceding no flow time? Implications for bystander response and ECPR candidacy evaluation. Resuscitation 2018; 128:88-92. [PMID: 29738800 DOI: 10.1016/j.resuscitation.2018.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/11/2018] [Accepted: 05/04/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Shockable cardiac rhythms are associated with improved outcomes among out-of-hospital cardiac arrests (OHCA). Initial cardiac rhythm may also be predictive of a short preceding no-flow duration. We examined the relationship between no-flow duration and initial cardiac rhythm, which may demonstrate the urgency in rescuer response and assist with candidacy evaluation for extracorporeal-cardiopulmonary resuscitation (ECPR). METHODS We examined consecutive adult OHCA's identified by a prospective registry in British Columbia (2005-2016). We included those with witnessed OHCA but no bystander CPR. The variable of interest was no-flow duration, defined as time from 9-1-1 call to EMS arrival. We fit an adjusted logistic regression model to estimate the association of no-flow duration and initial cardiac rhythm. Among those with shockable initial rhythms, we calculated the cumulative proportion with no-flow durations under incremental time cut-offs. RESULTS Of 26 621 EMS-treated OHCA's, 2532 were included. Overall survival was 13.8%, and 34% had initial shockable rhythms. The probability of having an initial shockable rhythm decreased with increasing no-flow durations (adjusted OR 0.88 per minute, 95% CI 0.85-0.91). Among those found with initial shockable rhythms, 94% (95% CI 92-96%) had a no-flow time under 10 min. CONCLUSION The odds of a shockable initial rhythm declined with each additional minute of no-flow time, highlighting the importance of early access to defibrillation. Among those with initial shockable rhythms, the preceding no-flow duration was highly likely to be under 10 min, which may inform decisions about ECPR candidacy among select patients with unwitnessed arrests.
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Affiliation(s)
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Canada; St. Paul's Hospital, Vancouver, B.C., Canada
| | - Robert Neumar
- Department of Emergency Medicine and Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - John Tallon
- Department of Emergency Medicine, University of British Columbia, Canada; British Columbia Emergency Health Services, Vancouver, B.C., Canada
| | - Robert Boone
- St. Paul's Hospital, Vancouver, B.C., Canada; Division of Cardiology, University of British Columbia, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Canada; St. Paul's Hospital, Vancouver, B.C., Canada
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Warenits AM, Sterz F, Schober A, Ettl F, Magnet IAM, Högler S, Teubenbacher U, Grassmann D, Wagner M, Janata A, Weihs W. Reduction of Serious Adverse Events Demanding Study Exclusion in Model Development: Extracorporeal Life Support Resuscitation of Ventricular Fibrillation Cardiac Arrest in Rats. Shock 2018; 46:704-712. [PMID: 27392153 DOI: 10.1097/shk.0000000000000672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Extracorporeal life support is a promising concept for selected patients in refractory cardiogenic shock and for advanced life support of persistent ventricular fibrillation cardiac arrest. Animal models of ventricular fibrillation cardiac arrest could help to investigate new treatment strategies for successful resuscitation. Associated procedural pitfalls in establishing a rat model of extracorporeal life support resuscitation need to be replaced, refined, reduced, and reported.Anesthetized male Sprague-Dawley rats (350-600 g) (n = 126) underwent cardiac arrest induced with a pacing catheter placed into the right ventricle via a jugular cannula. Rats were resuscitated with extracorporeal life support, mechanical ventilation, defibrillation, and medication. Catheter and cannula explantation was performed if restoration of spontaneous circulation was achieved. All observed serious adverse events (SAEs) occurring in each of the experimental phases were analyzed.Restoration of spontaneous circulation could be achieved in 68 of 126 rats (54%); SAEs were observed in 76 (60%) experiments. Experimental procedures related SAEs were 62 (82%) and avoidable human errors were 14 (18%). The most common serious adverse events were caused by insertion or explantation of the venous bypass cannula and resulted in lethal bleeding, cannula dislocation, or air embolism.Establishing an extracorporeal life support model in rats has confronted us with technical challenges. Even advancements in small animal critical care management over the years delivered by an experienced team and technical modifications were not able to totally avoid such serious adverse events. Replacement, refinement, and reduction reports of serious adverse events demanding study exclusions to avoid animal resources are missing and are presented hereby.
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Affiliation(s)
- Alexandra-Maria Warenits
- *Department of Emergency Medicine, Medical University of Vienna, Wien, Austria †Department of Biomedical Research, Medical University of Vienna, Wien, Austria ‡Department of Pathobiology, University of Veterinary Medicine Vienna, Wien, Austria §II. Med. Department Cardiology, Hanusch Hospital, Wien, Austria
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Jevdjic J, Zunic F, Milosevic B. New Therapeutic Concepts in Post-Resuscitation Care. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2017. [DOI: 10.1515/sjecr-2016-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
After the return of spontaneous circulation (ROSC), as a result of global ischaemia due to cardiac arrest followed by reperfusion, a condition develops called post-cardiac arrest syndrome. It manifests, alongside the pathology that caused the cardiac arrest, as a systemic inflammatory response, including severe cardio-circulatory and neurological dysfunction, leading to a fatal outcome. Th e aim of post-resuscitation care is to reduce the consequences of circulatory arrest, reperfusion, and the inflammatory response of the body on vital organ functions. The basis of post-resuscitation care comprises application of therapeutic hypothermia and early coronary angiography with PCI. However, after the initial enthusiasm, the validity of applying these aggressive methods in all comatose post-cardiac arrest patients was questioned. Currently, instead of therapeutic hypothermia, a strategy of maintaining a targeted body temperature, usually 36 °C, is being applied because there is no clear evidence of benefit for maintaining a lower body temperature in relation to the outcome. Additionally, patients with an obvious cardiac aetiology of cardiac arrest do not undergo early coronarography unless there is a clear indication of coronary artery occlusion. In the post-resuscitation period, the maintenance of adequate ventilation, maintaining levels of oxygen and carbon dioxide in the normal range, haemodynamic stability, control of blood glucose and electrolytes, and epileptic attack prevention are all strongly recommended measures. Th ere is no evidence to suggest that the application of the so-called neuroprotective agents affects the outcome of cardiac arrest.
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Affiliation(s)
- Jasna Jevdjic
- Department for anesthesia and ranimation, Clinical Centre Kragujevac, Kragujevac , Serbia
- Faculty of Medical Sciences, Kragujevac , Serbia
| | - Filip Zunic
- Department for anesthesia and ranimation, Clinical Centre Kragujevac, Kragujevac , Serbia
- Faculty of Medical Sciences, Kragujevac , Serbia
| | - Bojan Milosevic
- Clinic for Chirurgy, Clinical Centre Kragujevac, Kragujevac , Serbia
- Faculty of Medical Sciences, Kragujevac , Serbia
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Abstract
Cardiogenic shock is an acute emergency, which is classically managed by medical support with inotropes or vasopressors and frequently requires invasive ventilation. However, both catecholamines and ventilation are associated with a worse prognosis, and many patients deteriorate despite all efforts. Mechanical circulatory support is increasingly considered to allow for recovery or to bridge until making a decision or definite treatment. Of all devices, extracorporeal membrane oxygenation (ECMO) is the most widely used. Here we review features and strategical considerations for the use of ECMO in cardiogenic shock and cardiac arrest.
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Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study. Resuscitation 2017; 119:56-62. [PMID: 28789990 DOI: 10.1016/j.resuscitation.2017.08.003] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/02/2017] [Indexed: 11/12/2022]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging therapy for refractory cardiac arrest. The purpose of this study was to analyze and report characteristics and outcomes of adult patients treated with ECPR after out-of-hospital cardiac arrest (OHCA) in a large international registry. METHODS The Extracorporeal Life Support Organization's Extracorporeal Life Support Registry was queried for adult cardiac arrests with arrest location of "EMT Transport" or "Outside Hospital." RESULTS From 2010-2016, 217 cases of ECPR following OHCA were reported in Europe (47%), Asia-Pacific (29%), and North America (24%). The median age was 52 years (IQR 45-62, range 18-87); 73% were male. The median duration of ECPR was 47h (IQR 17-94, range 0-711). Reported complications included hemorrhage (31.3%), limb complications (11.1%), circuit complications (8.8%), infection (7.4%), and seizures (5.5%). The rate of percutaneous coronary intervention (PCI) was higher in Europe (35.6%) and Asia-Pacific (25.8%) than North America (9.4%; p<0.01). Survival to hospital discharge was 27.6% (95% CI 22.1-34.0%), and male gender was independently associated with mortality (adjusted odds ratio 2.1 [95% CI 1.1-4.2], p<0.05). Survival did not differ by region, race, age, or year. Brain death was reported in 16.6% [95% CI 12.2-22.1%]; organ donation rate was not reported. CONCLUSION This international analysis of ECPR for refractory OHCA reveals a survival rate of 27.6%, demonstrates association of male gender with mortality, and highlights regional differences in PCI utilization. These results will help inform implementation and research of this potentially life-saving strategy for refractory OHCA.
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Affiliation(s)
- Nathan L Haas
- University of Michigan, Department of Emergency Medicine, 1500 East Medical Center Drive, B1-380 Taubman Center, SPC 5305, Ann Arbor, MI, 48109, United States.
| | - Ryan A Coute
- Kansas City University of Medicine and Biosciences, 1750 Independence Ave, Kansas City, MO, 64106, United States
| | - Cindy H Hsu
- Department of Emergency Medicine, Division of Emergency Critical Care, Department of Surgery, Division of Acute Care Surgery, Michigan Center for Integrative Research in Critical Care, University of Michigan, NCRC B026-319N, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, United States
| | - James A Cranford
- University of Michigan, Department of Psychiatry, 4250 Plymouth Rd., Ann Arbor, MI, 48105, United States
| | - Robert W Neumar
- University of Michigan, Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, 1500 E. Medical Center Drive, TC B1220, Ann Arbor, MI, 48109-5301, United States
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Reynolds JC, Grunau BE, Elmer J, Rittenberger JC, Sawyer KN, Kurz MC, Singer B, Proudfoot A, Callaway CW. Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation 2017; 117:24-31. [DOI: 10.1016/j.resuscitation.2017.05.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 11/15/2022]
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Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, Citerio G. Organ donation in cardiac arrest patients treated with extracorporeal CPR: A single centre observational study. Resuscitation 2017; 118:133-139. [PMID: 28596083 DOI: 10.1016/j.resuscitation.2017.06.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/22/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
Abstract
AIM OF THE STUDY In a consecutive cohort of cardiac arrest (CA) treated with extracorporeal cardiopulmonary resuscitation (eCPR), we describe the incidence of brain death (BD), the eligibility for organ donation and the short-term follow-up of the transplanted organs. METHODS All refractory in- and out-of-hospital CA admitted to our Cardiac Intensive Care Unit between January 2011 and September 2016 treated with eCPR were enrolled in the study. RESULTS 112 CA patients received eCPR. 82 (73.2%) died in hospital, 25 BD (22.3%) and 57 for other causes (50.9%). At the time of first neurological evaluation after rewarming, variables related to evolution to BD were a lower GCS (3 [3-3] vs. 8 [3-11], p<0.001), a higher level of neuron specific enolase (269.3±49.4 vs. 55.2±37.2ng/ml, p<0.001), a higher presence of EEG indices of poor outcome (84% vs. 15%, p<0.001), absence of brainstem reflexes (p<0.001), absence of bilateral N20 SSEPS waves (66.7% vs. 3.7%, p<0.001). None of BD patients present a normal CT scan (at 2.5±2days), with 85% prevalence of diffuse hypoxic injury and a mean grey/white matter ratio of 1.1±0.1. Rate of donation in BD patients was 56%, with 39 donated organs: 23 kidneys, 12 livers, and 4 lungs. 89.74% of the transplanted organs reached an early good functional recovery. CONCLUSION In refractory CA patients treated with eCPR, the prevalence of BD is high. This population has a high potential for considering organ donation. Donated organs have a good outcome.
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Affiliation(s)
| | - Anna Coppo
- Cardiac Intensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy
| | - Alessia Vargiolu
- Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy
| | - Jacopo Villa
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Matteo Rota
- Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy
| | - Leonello Avalli
- Cardiac Intensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy.
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30
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Sunde K, Callaway CW. Extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest - to whom and when, that's the difficult question! Acta Anaesthesiol Scand 2017; 61:369-371. [PMID: 28251604 DOI: 10.1111/aas.12873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- K. Sunde
- Department of Anaesthesiology; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - C. W. Callaway
- Department of Emergency Medicine; University of Pittsburgh; Pittsburgh PA USA
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31
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Callaway CW, Sunde K. Extracorporeal cardiopulmonary resuscitation probably good, but adoption should not be too fast and furious! Emerg Med J 2017; 34:275-276. [PMID: 28259845 DOI: 10.1136/emermed-2016-206442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 01/15/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Kjetil Sunde
- Department of Anesthesiology, Division of Emergencies and Critical Care, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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32
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Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: A multicentre experience. Int J Cardiol 2017; 231:131-136. [DOI: 10.1016/j.ijcard.2016.12.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/01/2016] [Indexed: 11/21/2022]
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33
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Debaty G, Babaz V, Durand M, Gaide-Chevronnay L, Fournel E, Blancher M, Bouvaist H, Chavanon O, Maignan M, Bouzat P, Albaladejo P, Labarère J. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation 2017; 112:1-10. [DOI: 10.1016/j.resuscitation.2016.12.011] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 11/07/2016] [Accepted: 12/04/2016] [Indexed: 12/29/2022]
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34
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Orrego R, Díaz R. REANIMACIÓN CARDIOPULMONAR EXTRACORPÓREA: LA ÚLTIMA FRONTERA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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35
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Fjølner J, Greisen J, Jørgensen MRS, Terkelsen CJ, Ilkjaer LB, Hansen TM, Eiskjaer H, Christensen S, Gjedsted J. Extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest in a Danish health region. Acta Anaesthesiol Scand 2017; 61:176-185. [PMID: 27935015 DOI: 10.1111/aas.12843] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 11/06/2016] [Accepted: 11/11/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Extracorporeal Cardiopulmonary Resuscitation (ECPR) has emerged as a feasible rescue therapy for refractory, normothermic out-of-hospital cardiac arrest (OHCA). Reported survival rates vary and comparison between studies is hampered by heterogeneous study populations, differences in bystander intervention and in pre-hospital emergency service organisation. We aimed to describe the first experiences, treatment details, complications and outcome with ECPR for OHCA in a Danish health region. METHODS Retrospective study of adult patients admitted at Aarhus University Hospital, Denmark between 1 January 2011 and 1 July 2015 with witnessed, refractory, normothermic OHCA treated with ECPR. OHCA was managed with pre-hospital advanced airway management and mechanical chest compression during transport. Relevant pre-hospital and in-hospital data were collected with special focus on low-flow time and ECPR duration. Survival to hospital discharge with Cerebral Performance Category (CPC) of 1 and 2 at hospital discharge was the primary endpoint. RESULTS Twenty-one patients were included. Median pre-hospital low-flow time was 54 min [range 5-100] and median total low-flow time was 121 min [range 55-192]. Seven patients survived (33%). Survivors had a CPC score of 1 or 2 at hospital discharge. Five survivors had a shockable initial rhythm. In all survivors coronary occlusion was the presumed cause of cardiac arrest. CONCLUSION Extracorporeal cardiopulmonary resuscitation is feasible as a rescue therapy in normothermic refractory OHCA in highly selected patients. Low-flow time was longer than previously reported. Survival with favourable neurological outcome is possible despite prolonged low-flow duration.
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Affiliation(s)
- J. Fjølner
- Department of Anaesthesia and Intensive Care; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus N Denmark
| | - J. Greisen
- Department of Anaesthesia and Intensive Care; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus N Denmark
| | - M. R. S. Jørgensen
- Department of Anaesthesia and Intensive Care; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
| | - C. J. Terkelsen
- Department of Cardiology; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus N Denmark
| | - L. B. Ilkjaer
- Department of Cardiothoracic and Vascular Surgery; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
| | - T. M. Hansen
- Danish Air Ambulance; Department of Pre-hospital Medical Services; Aarhus N Denmark
| | - H. Eiskjaer
- Department of Cardiology; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus N Denmark
| | - S. Christensen
- Department of Anaesthesia and Intensive Care; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus N Denmark
| | - J. Gjedsted
- Department of Anaesthesia and Intensive Care; Head & Heart Centre; Aarhus University Hospital; Aarhus N Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus N Denmark
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Park DW, Egi M, Nishimura M, Chang Y, Suh GY, Lim CM, Kim JY, Tada K, Matsuo K, Takeda S, Tsuruta R, Yokoyama T, Kim SO, Koh Y. The Association of Fever with Total Mechanical Ventilation Time in Critically Ill Patients. J Korean Med Sci 2016; 31:2033-2041. [PMID: 27822946 PMCID: PMC5102871 DOI: 10.3346/jkms.2016.31.12.2033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/06/2016] [Indexed: 01/30/2023] Open
Abstract
This research aims to investigate the impact of fever on total mechanical ventilation time (TVT) in critically ill patients. Subgroup analysis was conducted using a previous prospective, multicenter observational study. We included mechanically ventilated patients for more than 24 hours from 10 Korean and 15 Japanese intensive care units (ICU), and recorded maximal body temperature under the support of mechanical ventilation (MAX(MV)). To assess the independent association of MAX(MV) with TVT, we used propensity-matched analysis in a total of 769 survived patients with medical or surgical admission, separately. Together with multiple linear regression analysis to evaluate the association between the severity of fever and TVT, the effect of MAX(MV) on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAX(MV) ≥ 37.5°C was significantly associated with longer mean TVT by 5.4 days in medical admission, and by 1.2 days in surgical admission, compared to those with MAX(MV) of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAX(MV) of 37.5°C to 38.4°C, 38.5°C to 39.4°C, and ≥ 39.5°C) sustained a significantly longer duration of TVT than those with normal range of MAX(MV) in both categories of ICU admission. A significant association between MAX(MV) and mechanical ventilator-free days was also observed in all enrolled subjects. Fever may be a detrimental factor to prolong TVT in mechanically ventilated patients. These findings suggest that fever in mechanically ventilated patients might be associated with worse mechanical ventilation outcome.
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Affiliation(s)
- Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Masaji Nishimura
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Yeol Kim
- Department of Pulmonary and Critical Care Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Keiichi Tada
- Department of Anesthesiology and Intensive Care Medicine, Hiroshima City Hospital, Hiroshima, Japan
| | - Koichi Matsuo
- Division of Intensive Care Unit, New Tokyo Hospital, Tokyo, Japan
| | - Shinhiro Takeda
- Division of Intensive and Coronary Care Unit, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Takeshi Yokoyama
- Intensive Care Unit, Department of Anesthesiology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Seon Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Lazzeri C, Valente S, Peris A, Gensini GF. Editor’s Choice-Extracorporeal life support for out-of-hospital cardiac arrest: Part of a treatment bundle. EUROPEAN HEART JOURNAL: ACUTE CARDIOVASCULAR CARE 2016; 5:512-521. [DOI: 10.1177/2048872615585517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Serafina Valente
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Adriano Peris
- Anesthesia and Intensive Unit of Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Gian Franco Gensini
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Italy
- Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, Fondazione Don Carlo Gnocchi IRCCS, Italy
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Benedek T, Popovici MM, Glogar D. Extracorporeal Life Support and New Therapeutic Strategies for Cardiac Arrest Caused by Acute Myocardial Infarction - a Critical Approach for a Critical Condition. ACTA ACUST UNITED AC 2016; 2:164-174. [PMID: 29967856 DOI: 10.1515/jccm-2016-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/20/2016] [Indexed: 12/14/2022]
Abstract
This review summarizes the most recent developments in providing advanced supportive measures for cardiopulmonary resuscitation, and the results obtained using these new therapies in patients with cardiac arrest caused by acute myocardial infarction (AMI). Also detailed are new approaches such as extracorporeal cardiopulmonary resuscitation (ECPR), intra-arrest percutaneous coronary intervention, or the regional models for systems of care aiming to reduce the critical times from cardiac arrest to initiation of ECPR and coronary revascularization.
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Affiliation(s)
- Theodora Benedek
- University of Medicine and Pharmacy Tirgu Mures, Clinic of Cardiology, Tirgu Mures, Romania
| | - Monica Marton Popovici
- Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, USA
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Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest—An ethical analysis of an unresolved clinical dilemma. Resuscitation 2016; 108:87-94. [DOI: 10.1016/j.resuscitation.2016.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 11/23/2022]
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Singal RK, Singal D, Bednarczyk J, Lamarche Y, Singh G, Rao V, Kanji HD, Arora RC, Manji RA, Fan E, Nagpal AD. Current and Future Status of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest. Can J Cardiol 2016; 33:51-60. [PMID: 28024556 DOI: 10.1016/j.cjca.2016.10.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 01/06/2023] Open
Abstract
Numerous series, propensity-matched trials, and meta-analyses suggest that appropriate use of extracorporeal cardiopulmonary resuscitation (E-CPR) for in-hospital cardiac arrest (IHCA) can be lifesaving. Even with an antecedent cardiopulmonary resuscitation (CPR) duration in excess of 45 minutes, 30-day survival with favourable neurologic outcome using E-CPR is approximately 35%-45%. Survival may be related to age, duration of CPR, or etiology. Associated complications include sepsis, renal failure, limb and neurologic complications, hemorrhage, and thrombosis. However, methodological biases-including small sample size, selection bias, publication bias, and inability to control for confounders-in these series prevent definitive conclusions. As such, the 2015 American Heart Association Advanced Cardiac Life Support guidelines update recommended E-CPR as a Level of Evidence IIb recommendation in appropriate cases. The absence of high-quality evidence presents an opportunity for clinician/scientists to generate practice-defining data through collaborative investigation and prospective trials. A multidisciplinary dialogue is required to standardize the field and promote multicentre investigation of E-CPR with data sharing and the development of a foundation for high-quality trials. The objectives of this review are to (1) provide an overview of the strengths and limitations of currently available studies investigating the use of E-CPR in patients with IHCA and highlight knowledge gaps; (2) create a framework for the standardization of terminology, clinical practice, data collection, and investigation of E-CPR for patients with IHCA that will help ensure congruence in future work in this area; and (3) propose suggestions to guide future research by the cardiovascular community to advance this important field.
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Affiliation(s)
- Rohit K Singal
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Deepa Singal
- Department of Community Health Sciences, Max Rady College of Medicine, Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph Bednarczyk
- Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute and Department of Critical Care, Hôpital du Sacré Coeur de Montréal, Université de Montréal, Québec, Canada
| | - Gurmeet Singh
- Departments of Critical Care Medicine and Surgery, Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hussein D Kanji
- Division of Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - A Dave Nagpal
- London Health Sciences Centre/Western University, London Ontario, Canada
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Sandroni C, D'Arrigo S, Callaway CW, Cariou A, Dragancea I, Taccone FS, Antonelli M. The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis. Intensive Care Med 2016; 42:1661-1671. [PMID: 27699457 PMCID: PMC5069310 DOI: 10.1007/s00134-016-4549-3] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/11/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The occurrence of brain death in patients with hypoxic-ischaemic brain injury after resuscitation from cardiac arrest creates opportunities for organ donation. However, its prevalence is currently unknown. METHODS Systematic review. MEDLINE via PubMed, ISI Web of Science and the Cochrane Database of Systematic Reviews were searched for eligible studies (2002-2016). The prevalence of brain death in adult patients resuscitated from cardiac arrest and the rate of organ donation among brain dead patients were summarised using a random effect model with double-arcsine transformation. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. RESULTS 26 studies [16 on conventional cardiopulmonary resuscitation (c-CPR), 10 on extracorporeal CPR (e-CPR)] included a total of 23,388 patients, 1830 of whom developed brain death at a mean time of 3.2 ± 0.4 days after recovery of circulation. The overall prevalence of brain death among patients who died before hospital discharge was 12.6 [10.2-15.2] %. Prevalence was significantly higher in e-CPR vs. c-CPR patients (27.9 [19.7-36.6] vs. 8.3 [6.5-10.4] %; p < 0.0001). The overall rate of organ donation among brain dead patients was 41.8 [20.2-51.0] % (9/26 studies, 1264 patients; range 0-100 %). The QOE was very low for both outcomes. CONCLUSIONS In patients with hypoxic-ischaemic brain injury following CPR, more than 10 % of deaths were due to brain death. More than 40 % of brain-dead patients could donate organs. Patients who are unconscious after resuscitation from cardiac arrest, especially when resuscitated using e-CPR, should be carefully screened for signs of brain death.
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Affiliation(s)
- Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Sonia D'Arrigo
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alain Cariou
- Medical ICU, Cochin Hospital (AP-HP) Paris Descartes University, Paris, France
| | - Irina Dragancea
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF, Gunnerson KJ, Weng C, McKellar S. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation 2016; 107:38-46. [PMID: 27523953 PMCID: PMC5475402 DOI: 10.1016/j.resuscitation.2016.07.237] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/12/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 3C127, Salt Lake City, UT 84132, United States; Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States.
| | - Nicholas J Johnson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA 98195-6522, United States.
| | - John Greenwood
- Department of Emergency Medicine, Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, United States.
| | - David F Gaieski
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, 1025 Walnut Street, 300 College Building, Philadelphia, PA 19107, United States.
| | - Zachary Shinar
- Department of Emergency Medicine, Sharpe Memorial Hospital, 7901 Frost Street, San Diego, CA 92123, United States.
| | - Joseph M Bellezo
- Department of Emergency Medicine, Emergency Department ECMO Services, Department of Emergency Medicine, Sharpe Memorial Hospital, 7901 Frost Street, San Diego, CA 92123, United States.
| | - Lance Becker
- Hofstra Northwell School of Medicine, Chairman of Emergency Medicine at Long Island Jewish Medical Center & North Shore University Hospital, 270-05 76th Ave., New Hyde Park, NY 11040, United States.
| | - Atman P Shah
- Section of Cardiology, Adult Cardiac Catheterization Laboratory, The University of Chicago, 5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, United States.
| | - Scott T Youngquist
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States; Salt Lake City Fire Department, 475 300 E, Salt Lake City, UT 84111, United States.
| | - Michael P Mallin
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States.
| | - James Franklin Fair
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States.
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, Michigan Center for Integrative Research In Critical Care (MCIRCC), University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109-5303, United States.
| | - Cindy Weng
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, United States.
| | - Stephen McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 3C127, Salt Lake City, UT 84132, United States.
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Blumenstein J, Leick J, Liebetrau C, Kempfert J, Gaede L, Groß S, Krug M, Berkowitsch A, Nef H, Rolf A, Arlt M, Walther T, Hamm CW, Möllmann H. Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:13-22. [DOI: 10.1177/2048872615612454] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jürgen Leick
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | | | - Joerg Kempfert
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Germany
| | - Luise Gaede
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | - Sebastian Groß
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | - Marcel Krug
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | | | - Holger Nef
- Justus Liebig University of Giessen, Department of Internal Medicine I, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
- Justus Liebig University of Giessen, Department of Internal Medicine I, Germany
| | - Matthias Arlt
- Department of Anesthesiology, Kerckhoff Heart and Thorax Center, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
- Justus Liebig University of Giessen, Department of Internal Medicine I, Germany
| | - Helge Möllmann
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
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Cirillo F, DeRobertis E, Hinkelbein J. Extracorporeal life support for refractory out-of-hospital cardiac arrest in adults. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2016. [DOI: 10.1016/j.tacc.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Thrombolytic-Enhanced Extracorporeal Cardiopulmonary Resuscitation After Prolonged Cardiac Arrest. Crit Care Med 2016; 44:e58-69. [PMID: 26488218 DOI: 10.1097/ccm.0000000000001305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate the effects of the combination of extracorporeal cardiopulmonary resuscitation and thrombolytic therapy on the recovery of vital organ function after prolonged cardiac arrest. DESIGN Laboratory investigation. SETTING University laboratory. SUBJECTS Pigs. INTERVENTIONS Animals underwent 30-minute untreated ventricular fibrillation cardiac arrest followed by extracorporeal cardiopulmonary resuscitation for 6 hours. Animals were allocated into two experimental groups: t-extracorporeal cardiopulmonary resuscitation (t-ECPR) group, which received streptokinase 1 million units, and control extracorporeal cardiopulmonary resuscitation (c-ECPR), which did not receive streptokinase. In both groups, the resuscitation protocol included the following physiologic targets: mean arterial pressure greater than 70 mm Hg, cerebral perfusion pressure greater than 50 mm Hg, PaO2 150 ± 50 torr (20 ± 7 kPa), PaCO2 40 ± 5 torr (5 ± 1 kPa), and core temperature 33°C ± 1°C. Defibrillation was attempted after 30 minutes of extracorporeal cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS A cardiac resuscitability score was assessed on the basis of success of defibrillation, return of spontaneous heart beat, weanability from extracorporeal cardiopulmonary resuscitation, and left ventricular systolic function after weaning. The addition of thrombolytic to extracorporeal cardiopulmonary resuscitation significantly improved cardiac resuscitability (3.7 ± 1.6 in t-ECPR vs 1.0 ± 1.5 in c-ECPR). Arterial lactate clearance was higher in t-ECPR than in c-ECPR (40% ± 15% vs 18% ± 21%). At the end of the experiment, the intracranial pressure was significantly higher in c-ECPR than in t-ECPR. Recovery of brain electrical activity, as assessed by quantitative analysis of electroencephalogram signal, and ischemic neuronal injury on histopathologic examination did not differ between groups. Animals in t-ECPR group did not have increased bleeding complications, including intracerebral hemorrhages. CONCLUSIONS In a porcine model of prolonged cardiac arrest, t-ECPR improved cardiac resuscitability and reduced brain edema, without increasing bleeding complications. However, early electroencephalogram recovery and ischemic neuronal injury were not improved.
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Voicu S, Baud FJ, Malissin I, Deye N, Bihry N, Vivien B, Brun PY, Sideris G, Henry P, Megarbane B. Can mortality due to circulatory failure in comatose out-of-hospital cardiac arrest patients be predicted on admission? A study in a retrospective derivation cohort validated in a prospective cohort. J Crit Care 2016; 32:56-62. [DOI: 10.1016/j.jcrc.2015.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 11/08/2015] [Accepted: 11/10/2015] [Indexed: 12/18/2022]
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Ortega-Deballon I, Hornby L, Shemie SD, Bhanji F, Guadagno E. Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes. Resuscitation 2016; 101:12-20. [DOI: 10.1016/j.resuscitation.2016.01.018] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/05/2015] [Accepted: 01/21/2016] [Indexed: 11/27/2022]
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Grunau B, Reynolds J, Scheuermeyer F, Stenstom R, Stub D, Pennington S, Cheskes S, Ramanathan K, Christenson J. Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital? PREHOSP EMERG CARE 2016; 20:615-22. [PMID: 27018764 DOI: 10.3109/10903127.2016.1149652] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Extracorporeal cardiopulmonary resuscitation (ECPR) may improve outcomes for refractory out-of-hospital cardiac arrest (OHCA). Transport of intra-arrest patients to hospital however, may decrease CPR quality, potentially reducing survival for those who would have achieved return-of-spontaneous-circulation (ROSC) with further on-scene resuscitation. We examined time-to-ROSC and patient outcomes for the optimal time to consider transport. METHODS From a prospective registry of consecutive adult non-traumatic OHCA's, we identified a hypothetical ECPR-eligible cohort of EMS-treated patients with age ≤ 65, witnessed arrest, and bystander CPR or EMS arrival < 10 minutes. We assessed the relationship between time-to-ROSC and survival, and constructed a ROC curve to illustrate the ability of a pulseless state to predict non-survival with conventional resuscitation. RESULTS Of 6,571 EMS-treated cases, 1,206 were included with 27% surviving. Increasing time-to-ROSC (per minute) was negatively associated with survival (adjusted OR 0.91; 95%CI 0.89-0.93%). The yield of survivors per minute of resuscitation increased from commencement and started to decline in the 8th minute. Fifty percent and 90% of survivors had achieved ROSC by 8.0 and 24 min, respectively, at which times the probability of survival for those with initial shockable rhythms was 31% and 10%, and for non-shockable rhythms was 5.2% and 1.6%. The ROC curve illustrated that the 16th minute of resuscitation maximized sensitivity and specificity (AUC = 0.87, 95% CI 0.85-0.89). CONCLUSION Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.
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Potential Candidates for a Structured Canadian ECPR Program for Out-of-Hospital Cardiac Arrest. CAN J EMERG MED 2016; 18:453-460. [PMID: 26940662 DOI: 10.1017/cem.2016.8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Extracorporeal cardiopulmonary resuscitation (ECPR), while resource-intensive, may improve outcomes in selected patients with refractory out-of-hospital cardiac arrest (OHCA). We sought to identify patients who fulfilled a set of ECPR criteria in order to estimate: (1) the proportion of patients with refractory cardiac arrest who may have benefited from ECPR; and (2) the outcomes achieved with conventional resuscitation. METHODS We performed a secondary analysis from a 52-month prospective registry of consecutive adult non-traumatic OHCA cases from a single urban Canadian health region serving one million patients. We developed a hypothetical ECPR-eligible cohort including adult patients <60 years of age with a witnessed OHCA, and either bystander CPR or EMS arrival within five minutes. The primary outcome was the proportion of ECPR-eligible patients who had refractory cardiac arrest, defined as termination of resuscitation pre-hospital or in the ED. The secondary outcome was the proportion of EPCR-eligible patients who survived to hospital discharge. RESULTS Of 1,644 EMS-treated OHCA, 168 (10.2%) fulfilled our ECPR criteria. Overall, 54/1644 (3.3%; 95% CI 2.4%-4.1%) who were ECPR-eligible had refractory cardiac arrest. Of ECPR-eligible patients, 114/168 (68%, 95% CI 61%-75%) survived to hospital admission, and 70/168 (42%; 95% CI 34-49%) survived to hospital discharge. CONCLUSION In our region, approximately 10% of EMS-treated cases of OHCA fulfilled our ECPR criteria, and approximately one-third of these (an average of 12 patients per year) were refractory to conventional resuscitation. The integration of an ECPR program into an existing high-performing system of care may have a small but clinically important effect on patient outcomes.
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Lee YH, Oh YT, Ahn HC, Kim HS, Han SJ, Lee JJ, Lee TH, Seo JY, Shin DH, Ha SO, Park SO. The prognostic value of the grey-to-white matter ratio in cardiac arrest patients treated with extracorporeal membrane oxygenation. Resuscitation 2016; 99:50-5. [DOI: 10.1016/j.resuscitation.2015.11.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 10/30/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
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