Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

Extracorporeal-CPR Versus Conventional-CPR for Adult Patients in Out of Hospital Cardiac Arrest- Systematic Review and Meta-Analysis

OBJECTIVE

Extracorporeal cardiopulmonary resuscitation (ECPR) utilizes veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in cardiac arrest patients to reduce the risk of mortality and multiorgan dysfunction from systemic hypoperfusion. We aimed to compare clinical outcomes of patients receiving ECPR versus conventional cardiopulmonary resuscitation (CCPR) for refractory cardiac arrest.

DATA SOURCES

This was a systematic review and meta-analysis. A librarian searched the main databases, Ovid MEDLINE (including epub ahead of print, in-process & other non-indexed citations), Ovid EMBASE and Ovid Cochrane Central Register of Controlled Trials from inception through July 2024.

STUDY SELECTION

We included randomized controlled trials and observational studies that compared the outcomes of ECPR to CCPR in cardiac arrest patients. Primary outcomes were neurological sequelae and survival.

DATA EXTRACTION

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers independently screened articles, extracted data on selected articles and performed risk of bias assessments using ROBINS-I for non-randomized controlled trials and the revised Cochrane risk of bias tool for randomized controlled trials with disagreements settled by a third independent reviewer.

DATA SYNTHESIS

Out of 3458 studies identified and screened, 28 studies including 304,360 cardiac arrest patients met eligibility criteria and were included. Survival at hospital discharge was 20% for ECPR versus 3.3% for CCPR (OR 0.48 [CI 0.27, 0.84]). Favorable neurological outcome at hospital discharge was 11.8% for ECPR versus 1.9% for CCPR (OR 0.41 [CI 0.17, 1.01]). Complications from bleeding were ten times higher in the ECPR group (35.3% vs 3.7%; OR 0.08 [0.03, 0.24]).

CONCLUSIONS

ECPR appeared to be superior to CCPR for improved neurological outcome and survival in cardiac arrest patients, although bleeding was increased. There was large heterogeneity in the included studies and outcomes reported. Future prospective studies may improve the identification of subgroups of patients that will benefit most from ECPR.Systematic review and meta-analysis registration: PROSPERO - CRD42023394128.

ECPR for cardiac arrest caused by abnormal uterine bleeding and coronary vasospasm: a case report

Introduction

Cardiac arrest during pregnancy is receiving increasing attention. However, there are few reports on cardiac arrest in nonpregnant women caused by abnormal uterine bleeding (AUB). We report a case in which extracorporeal cardiopulmonary resuscitation (ECPR) was used in a patient with cardiac arrest caused by AUB and coronary vasospasm.

Patient presentation

A 52-year-old female patient presented to the emergency department because of sudden chest pain, with a history of hypertension, coronary heart disease and AUB for more than half a month. At the initial stage of admission, cardiac arrest occurred after the ECG demonstrated ST-segment elevation in leads II, III and a VF. ECPR was started after traditional cardiopulmonary resuscitation, and coronary angiography was performed with the support of extracorporeal membrane oxygenation (ECMO). The left and right coronary arteries were slender and narrow, which was relieved after the injection of 100 µg nitroglycerine through the left coronary artery. After performing a coronary angiogram, the patient was given long-acting nitrates and calcium channel blockers orally, and her chest pain did not reoccur. The patient was weaned from ECMO support after 4 days.

Conclusion

This clinical case highlights the challenges that clinicians face in accurately diagnosing and possibly treating AUB and coronary vasospasm-induced acute myocardial infarction because of its rare occurrence and serious adverse events. ECPR can effectively improve the success rate of cardiopulmonary resuscitation.

The impact of door to extracorporeal cardiopulmonary resuscitation time on mortality and neurological outcomes among out-of-hospital cardiac arrest acute myocardial infarction patients treated by primary percutaneous coronary intervention

Background

Few previous studies evaluated the impact of time from the hospital arrival to the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) (door to ECPR time) on outcomes among out-of-hospital cardiac arrest (OHCA) acute myocardial infarction (MI) patients.

Methods

50 patients with OHCA who received both ECPR and percutaneous coronary intervention (PCI) at Cardiovascular Division, NHO Osaka National Hospital were analyzed. Patients were divided into 2 groups according to the median of door to ECPR time. The primary outcome was all-cause death. Survival analyses were conducted to compare all-cause mortality at 90 days between 2 groups. Neurological outcome at 30 days was also compared between 2 groups using the Cerebral Performance Category (CPC).

Results

The multivariable Cox proportional-hazards model showed that all-cause mortality at 90 days was significantly higher among patients with door to ECPR time ≥ 25 min compared with those with door to ECPR time < 25 min (adjusted hazard ratio [HR]: 3.14; 95 % confidence interval [CI]: 1.21-8.18). The proportion of patients with CPC at 30 days ≤ 2 was significantly higher among patients with shorter door to ECPR time (P = 0.048).

Conclusion

Among patients with OHCA due to acute MI who received ECPR and PCI, the shorter door to ECPR time was associated with the lower mortality and favorable neurological outcomes.

Out-of-Hospital Cardiac Arrest Outcomes After Ventricular Fibrillation

INTRODUCTION

 This study is a retrospective review of patients who sustained out-of-hospital cardiac arrest due to ventricular fibrillation. The data were analyzed to decipher predictors of good outcomes as the overall survival rate in the county is significantly higher than the national average.

METHODS

The inclusion criteria for the study comprised all patients over the age of 18 for whom a call was made for unresponsiveness. Data for this project included all cardiac arrests due to ventricular fibrillation in the calendar year 2022.  Results: A total of 80 patients sustained cardiac arrest due to ventricular fibrillation. The age range was 27-80 years old. The study has 71% White, 19% African American, 8.7% Hispanic, and 1% other populations. Ninety-five percent received epinephrine, 89% utilized an advanced airway, 60% underwent hypothermia protocol, 24% utilized an AED device, and 14% used a mechanical CPR device. Seventy-six percent were pronounced dead in the ER or the hospital, and 19% survived to discharge. In the survivor population, CPR was initiated in 13 minutes or less and defibrillation occurred in 23 minutes or less. While none of the variables achieved statistical significance, epinephrine use showed a trend toward statistical significance for the outcome of sustained return of spontaneous circulation (ROSC) with a p-value of 0.05346.

CONCLUSION

Nineteen percent of patients survived out-of-hospital cardiac arrests in the Polk County hospital system. This is significantly higher than the national average. This likely reflects the emphasis on high-quality CPR and active on-scene management, as no individual variable was statistically significant.

Acute kidney injury as a prognostic predictor of in-hospital mortality and neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly being applied to patients with refractory cardiac arrest, but the survival rate to hospital discharge is only approximately 29%. Because ECPR requires intensive resources, it is important to predict outcomes. We therefore investigated the prognostic association between acute kidney injury (AKI) and ECPR to confirm the performance of AKI as a prognostic predictor of in-hospital mortality and neurological outcomes in ECPR.

METHODS

We conducted a retrospective observational study on patients undergoing ECPR for cardiac etiology at Chonnam National University Hospital from 2015 to 2021. The group diagnosed with AKI in any KDIGO category within the first 48 h after ECPR was compared to that without AKI, and the primary outcome of the study was in-hospital mortality.

RESULTS

Of 138 enrolled patients, 83 were studied. Hospital mortality occurred in 49 patients (59%), and 55 (66.3%) showed poor neurological outcomes. The AKI group displayed significantly elevated in-hospital mortality (77.8% vs 24.1%) and poor neurological outcomes (81.5% vs 37.9%) compared to the non-AKI group (p < 0.001). Regression analysis showed that AKI was associated with significantly higher rates of both in-hospital mortality (odds ratio (OR) range 10.75-12.88) and neurologic outcomes (OR range 5.9-6.22).

CONCLUSIONS

There was a significant association of AKI with both in-hospital mortality and poor neurologic outcome in patients after ECPR, and AKI can be used as an early prognostic predictor in these patients.

Comparison of prognosis between extracorporeal CPR and conventional CPR for patients in cardiac arrest: a systematic review and meta-analysis

AIM

Compared to the conventional cardiopulmonary resuscitation (CCPR), potential benefits of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest (CA) are still controversial. We aimed to determine whether ECPR can improve the prognosis of CA patients compared with CCPR.

METHODS

We systematically searched PubMed, EMBASE, and Cochrane Library from database's inception to July 2023 to identify randomized controlled trials (RCTs) or cohort studies that compared ECPR with CCPR in adults (aged ≥ 16 years) with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). This meta-analysis was performed using a random-effects model. Two researchers independently reviewed the relevance of the study, extracted data, and evaluated the quality of the included literature. The primary outcome was short-term (from hospital discharge to one month after cardiac arrest) and long-term (≥ 90 days after cardiac arrest) survival with favorable neurological status (defined as cerebral performance category scores 1 or 2). Secondary outcomes included survival at 1 months, 3-6 months, and 1 year after cardiac arrest.

RESULTS

The meta-analysis included 3 RCTs and 14 cohort studies involving 167,728 patients. We found that ECPR can significantly improve good neurological prognosis (RR 1.82, 95%CI 1.42-2.34, I2 = 41%) and survival rate (RR 1.51, 95%CI 1.20-1.89, I2 = 62%). In addition, the results showed that ECPR had different effects on favorable neurological status in patients with OHCA (short-term: RR 1.50, 95%CI 0.98- 2.29, I2 = 55%; long-term: RR 1.95, 95% CI 1.06-3.59, I2 = 11%). However, ECPR had significantly better effects on neurological status than CCPR in patients with IHCA (short-term: RR 2.18, 95%CI 1.24- 3.81, I2 = 9%; long-term: RR 2.17, 95% CI 1.19-3.94, I2 = 0%).

CONCLUSIONS

This meta-analysis indicated that ECPR had significantly better effects on good neurological prognosis and survival rate than CCPR, especially in patients with IHCA. However, more high-quality studies are needed to explore the role of ECPR in patients with OHCA.

Implementing enhanced extracorporeal membrane oxygenation for CPR (ECPR) in the emergency department

Refractory out-of-hospital cardiac arrest (OHCA) has a very poor prognosis, with survival rates at around 10%. Extracorporeal membrane oxygenation (ECMO) for patients in refractory arrest, known as ECPR, aims to provide perfusion to the patient whilst the underlying cause of arrest can be addressed. ECPR use has increased substantially, with varying survival rates to hospital discharge. The best outcomes for ECPR occur when the time from cardiac arrest to implementation of ECPR is minimised. To reduce this time, systems must be in place to identify the correct patient, expedite transfer to hospital, facilitate rapid cannulation and ECMO circuit flows. We describe the process of activation of ECPR, patient selection, and the steps that emergency department clinicians can utilise to facilitate timely cannulation to ensure the best outcomes for patients in refractory cardiac arrest. With these processes in place our survival to hospital discharge for OHCA patients is 35%, with most patients having a good neurological function.

Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation

BACKGROUND

Epinephrine is recommended without an apparent ceiling dosage during cardiac arrest. However, excessive alpha- and beta-adrenergic stimulation may contribute to unnecessarily high aortic afterload, promote post-arrest myocardial dysfunction, and result in cerebral microvascular insufficiency in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

This was a retrospective cohort study of adults (≥ 18 years) who received ECPR at large academic ECMO center from 2018 to 2022. Patients were grouped based on the amount of epinephrine given during cardiac arrest into low (≤ 3 mg) and high (> 3 mg) groups. The primary endpoint was neurologic outcome at hospital discharge, defined by cerebral performance category (CPC). Multivariable logistic regression was used to assess the relationship between cumulative epinephrine dosage during arrest and neurologic outcome.

RESULTS

Among 51 included ECPR cases, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during arrest was 6.2 mg but ranged from 0 to 24 mg. There were 18 patients in the low-dose (≤ 3 mg) and 25 patients in the high-dose (> 3 mg) epinephrine groups. Favorable neurologic outcome at discharge was significantly greater in the low-dose (55%) compared to the high-dose (24%) group (p = 0.025). After adjusting for age, those who received higher doses of epinephrine during the arrest were more likely to have unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3, 18.0, p = 0.017).

CONCLUSION

After adjusting for age, cumulative epinephrine doses above 3 mg during cardiac arrest may be associated with unfavorable neurologic outcomes after ECPR and require further investigation.

Temporal trends in the incidence and outcomes of shock-refractory ventricular fibrillation out-of-hospital cardiac arrest

Aim

We aimed to describe trends in the incidence and outcomes of refractory ventricular fibrillation (RVF) compared to non-refractory ventricular fibrillation (non-RVF) in out-of-hospital cardiac arrest (OHCA).

Methods

Between 2010 and 2019, we included all OHCA cases involving adults ≥ 16 years old with an initial shockable rhythm and who received an attempted resuscitation by Emergency Medical Services (EMS) or a bystander shock prior to EMS arrival in Victoria, Australia. Trends in incidence and survival outcomes over the study period were examined. Adjusted logistic regression analyses were conducted to examine factors associated with RVF, as well as the association of RVF on survival to hospital discharge. RVF refers to patients receiving three or more consecutive shocks without a return of spontaneous circulation (ROSC).

Results

Of the 57,749 OHCA attended by EMS, 7,267 met the inclusion criteria. Of these, 4,168 (57.4%) were non-RVF and 3,099 (42.6%) were RVF. The incidence of RVF decreased significantly from 7.7 per 100,000 population in 2010 to 5.6 per 100,000 population in 2019 (p-trend = 0.01). Survival to hospital discharge increased significantly for both the RVF and non-RVF groups (26% vs 41% in 2010 to 31% vs 53% in 2019, p-trend = 0.004 for RVF; and p-trend = 0.01 for non-RVF). Compared to non-RVF, RVF was associated with reduced odds of survival to hospital discharge (Odds Ratio = 0.503 [95% confidence interval 0.448 - 0.565]). Factors associated with a lower likelihood of RVF and improved survival to hospital discharge included being witnessed to arrest by EMS, receiving bystander defibrillation and bystander cardiopulmonary resuscitation (CPR).

Conclusion

The incidence of RVF is declining, and survival rates are improving. Early treatment of VF patients with bystander CPR and defibrillation is likely to reduce RVF incidence.

Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: Lessons learned from recent clinical trials

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.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

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.

Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study

Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.

How effective is extracorporeal life support for patients with out-of-hospital cardiac arrest initiated at the emergency department? A systematic review and meta-analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is commonly initiated for adults experiencing cardiac arrest within the cardiac catheterization lab or the intensive care unit. However, the potential benefit of ECPR for these patients in the emergency department (ED) remains undocumented. This study aims to assess the benefit of ECPR initiated in the ED for patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a systematic review and meta-analysis of studies comparing ECPR initiated in the ED versus conventional CPR. Relevant articles were identified by searching several databases including PubMed, EMBASE, Web of Science, and Cochrane collaborations up to July 31, 2022. Pooled estimates were calculated using the inverse variance heterogeneity method, while heterogeneity was evaluated using Q and I2 statistics. The risk of bias in included studies was evaluated using validated bias assessment tools. The primary outcome was a favorable neurological outcome at hospital discharge, and the secondary outcome was survival to hospital discharge or 30-day survival. Sensitivity analyses were performed to explore the benefits of ED-initiated ECPR in studies utilizing propensity score (PPS) analysis. Publication bias was assessed using Doi plots and the Luis Furuya-Kanamori (LFK) index.

RESULTS

The meta-analysis included a total of eight studies comprising 51,173 patients. ED-initiated ECPR may not be associated with a significant increase in favorable neurological outcomes (odds ratio [OR] 1.43, 95% confidence interval [CI] 0.30-6.70, I2 = 96%). However, this intervention may be linked to improved survival to hospital discharge (OR 3.34, 95% CI 2.23-5.01, I2 = 17%). Notably, when analyzing only PPS data, ED-initiated ECPR demonstrated efficacy for both favorable neurological outcomes (OR 1.89, 95% CI 1.26-2.83, I2 = 21%) and survival to hospital discharge (OR 3.37, 95% CI 1.52-7.49, I2 = 57%). Publication bias was detected for primary (LFK index 2.50) and secondary (LFK index 2.14) outcomes.

CONCLUSION

The results of this study indicate that ED-initiated ECPR may not offer significant benefits in terms of favorable neurological outcomes for OHCA patients. However, it may be associated with increased survival to hospital discharge. Future studies should prioritize randomized trials with larger sample sizes and strive for homogeneity in patient populations to obtain more robust evidence in this area.

Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis

BACKGROUND

Although outcomes of patients after cardiac arrest remain poor, studies have suggested that extracorporeal cardiopulmonary resuscitation (ECPR) might improve survival and neurological outcomes. We aimed to investigate any potential benefits of using ECPR over conventional cardiopulmonary resuscitation (CCPR) in patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA).

METHODS

In this systematic review and meta-analysis, we searched MEDLINE via PubMed, Embase, and Scopus from Jan 1, 2000, to April 1, 2023, for randomised controlled trials and propensity-score matched studies. We included studies comparing ECPR with CCPR in adults (aged ≥18 years) with OHCA and IHCA. We extracted data from published reports using a prespecified data extraction form. We did random-effects (Mantel-Haenszel) meta-analyses and rated the certainty of evidence using the Grading of Recommendations, Assessments, Developments, and Evaluations (GRADE) approach. We rated the risk of bias of randomised controlled trials using the Cochrane risk-of-bias 2.0 tool, and that of observational studies using the Newcastle-Ottawa Scale. The primary outcome was in-hospital mortality. Secondary outcomes included complications during extracorporeal membrane oxygenation, short-term (from hospital discharge to 30 days after cardiac arrest) and long-term (≥90 days after cardiac arrest) survival with favourable neurological outcomes (defined as cerebral performance category scores 1 or 2), and survival at 30 days, 3 months, 6 months, and 1 year after cardiac arrest. We also did trial sequential analyses to evaluate the required information sizes in the meta-analyses to detect clinically relevant reductions in mortality.

FINDINGS

We included 11 studies (4595 patients receiving ECPR and 4597 patients receiving CCPR) in the meta-analysis. ECPR was associated with a significant reduction in overall in-hospital mortality (OR 0·67, 95% CI 0·51-0·87; p=0·0034; high certainty), without evidence of publication bias (pegger=0·19); the trial sequential analysis was concordant with the meta-analysis. When considering IHCA only, in-hospital mortality was lower in patients receiving ECPR than in those receiving CCPR (0·42, 0·25-0·70; p=0·0009), whereas when considering OHCA only, no differences were found (0·76, 0·54-1·07; p=0·12). Centre volume (ie, the number of ECPR runs done per year in each centre) was associated with reductions in odds of mortality (regression coefficient per doubling of centre volume -0·17, 95% CI -0·32 to -0·017; p=0·030). ECPR was also associated with an increased rate of short-term (OR 1·65, 95% CI 1·02-2·68; p=0·042; moderate certainty) and long-term (2·04, 1·41-2·94; p=0·0001; high certainty) survival with favourable neurological outcomes. Additionally, patients receiving ECPR had increased survival at 30-day (OR 1·45, 95% CI 1·08-1·96; p=0·015), 3-month (3·98, 1·12-14·16; p=0·033), 6-month (1·87, 1·36-2·57; p=0·0001), and 1-year (1·72, 1·52-1·95; p<0·0001) follow-ups.

INTERPRETATION

Compared with CCPR, ECPR reduced in-hospital mortality and improved long-term neurological outcomes and post-arrest survival, particularly in patients with IHCA. These findings suggest that ECPR could be considered for eligible patients with IHCA, although further research into patients with OHCA is warranted.

FUNDING

None.

Refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta-analysis of randomized trials

BACKGROUND

In adults with refractory out-of-hospital cardiac arrest, when conventional cardiopulmonary resuscitation (CPR) alone does not achieve return of spontaneous circulation, extracorporeal CPR is attempted to restore perfusion and improve outcomes. Considering the contrasting findings of recent studies, we conducted a meta-analysis of randomized controlled trials to ascertain the effect of extracorporeal CPR on survival and neurological outcome.

METHODS

Pubmed via MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched up to February 3, 2023, for randomized controlled trials comparing extracorporeal CPR versus conventional CPR in adults with refractory out-of-hospital cardiac arrest. Survival with a favorable neurological outcome at the longest follow-up available was the primary outcome.

RESULTS

Among four randomized controlled trials included, extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome at the longest follow-up available for all rhythms (59/220 [27%] vs. 39/213 [18%]; OR = 1.72; 95% CI, 1.09-2.70; p = 0.02; I²  = 26%; number needed to treat of 9), for initial shockable rhythms only (55/164 [34%] vs. 38/165 [23%]; OR = 1.90; 95% CI, 1.16-3.13; p = 0.01; I²  = 23%; number needed to treat of 7), and at hospital discharge or 30 days (55/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13-2.92; p = 0.01; I²  = 0.0%). Overall survival at the longest follow-up available was similar (61/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13-2.92; p = 0.59; I²  = 58%).

CONCLUSIONS

Extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome in adults with refractory out-of-hospital cardiac arrest, especially when the initial rhythm was shockable.

REVIEW REGISTRATION

PROSPERO CRD42023396482.

Role of ECMO in E-CPR

Extracorporeal cardiopulmonary resuscitation (ECPR) is the implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a patient who experienced a sudden and unexpected pulseless condition attributable to cessation of cardiac mechanical activity. The aim of ECPR is to provide adequate perfusion to the end organs when the potentially “reversible” conditions were managed. ECPRs are mostly done in tertiary care center in India. There is little scope for out of hospital arrest as poor quality of CPR and response time exists with lack of awareness about ECPR, which hinders its wider usage even in IHCA. Emergency department doctors need to be involved to counsel, recognize candidates activate, and initiate ECPR.

Prehospital ABC (Age, Bystander and Cardiogram) scoring system to predict neurological outcomes of cardiopulmonary arrest on arrival: post hoc analysis of a multicentre prospective observational study

BACKGROUND

There is currently limited evidence to guide prehospital identification of patients with cardiopulmonary arrest on arrival (CPAOA) to hospital who have potentially favourable neurological function. This study aimed to develop a simple scoring system that can be determined at the contact point with emergency medical services to predict neurological outcomes.

METHODS

We analysed data from patients with CPAOA using a regional Japanese database (SOS-KANTO), from January 2012 to March 2013. Patients were randomly assigned into derivation and validation cohorts. Favourable neurological outcomes were defined as cerebral performance category 1 or 2. We developed a new scoring system using logistic regression analysis with the following predictors: age, no-flow time, initial cardiac rhythm and arrest place. The model was internally validated by assessing discrimination and calibration.

RESULTS

Among 4907 patients in the derivation cohort and 4908 patients in the validation cohort, the probabilities of favourable outcome were 0.9% and 0.8%, respectively. In the derivation cohort, age ≤70 years (OR 5.11; 95% CI 2.35 to 11.14), no-flow time ≤5 min (OR 4.06; 95% CI 2.06 to 8.01) and ventricular tachycardia or fibrillation as initial cardiac rhythm (OR 6.66; 95% CI 3.45 to 12.88) were identified as predictors of favourable outcome. The ABC score consisting of Age, information from Bystander and Cardiogram was created. The areas under the receiver operating characteristic curves of this score were 0.863 in the derivation and 0.885 in the validation cohorts. Positive likelihood ratios were 6.15 and 6.39 in patients with scores >2 points and were 11.06 and 17.75 in those with 3 points.

CONCLUSION

The ABC score showed good accuracy for predicting favourable neurological outcomes in patients with CPAOA. This simple scoring system could potentially be used to select patients for extracorporeal cardiopulmonary resuscitation and minimise low-flow time.

Analyzing willingness for extracorporeal cardiopulmonary resuscitation in refractory ventricular fibrillation

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia in out-of-hospital cardiac arrest has recently been recommended for selected patients with favorable prognostic features. We aimed to identify factors affecting the willingness of emergency physicians to implement extracorporeal cardiopulmonary resuscitation (ECPR). We conducted a factorial survey with nine experimental vignettes by combining three different scene time intervals and transportation time intervals. Emergency physicians reported willingness to implement ECPR (1-100 points). Respondent characteristics that could affect the willingness were studied. Multilevel analysis of vignettes and respondent factors was conducted using a mixed-effects regression model. We obtained 486 vignette responses from 54 emergency physicians. In the case of longer scene time intervals, there was a significant difference in the willingness scores at 9 and 12 min transportation time intervals. When the pre-hospital time interval was > 40 min, emergency physicians demonstrated lower willingness to implement ECPR. Clinical experience of 15-19 years showed a significant favorable effect on willingness to implement extracorporeal membrane oxygenation (ECMO). However, the mean willingness scores of EPs for ECMO implementation were more than 75 across all vignettes. In ECPR, the prehospital time interval is an important factor, and the willingness of emergency physicians to implement ECMO could be mutually affected by scene time intervals, transportation time intervals, and total prehospital time.

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: A modelling study

Background

Methods

Results

Conclusion

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience

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.

The first case series analysis on efficacy of esmolol injection for in-hospital cardiac arrest patients with refractory shockable rhythms in China

Background: This study assessed the effects of esmolol injection in patients with in-hospital cardiac arrest (IHCA) with refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT).

Methods: From January 2018 to December 2021, 29 patients with IHCA with refractory shockable rhythm were retrospectively reviewed. Esmolol was administered after advanced cardiovascular life support (ACLS)-directed procedures, and outcomes were assessed.

Results: Among the 29 cases, the rates of sustained return of spontaneous circulation (ROSC), 24-h ROSC, and 72-h ROSC were 79%, 62%, and 59%, respectively. Of those patients, 59% ultimately survived to discharge. Four patients with cardiac insufficiency died. The duration from CA to esmolol infusion was significantly shorter for patients in the survival group (SG) than for patients in the dead group (DG) (12 min, IQR: 8.5–19.5 vs. 23.5 min, IQR: 14.4–27 min; p = 0.013). Of those patients, 76% (22 of 29) started esmolol administration after the second dose of amiodarone. No significant difference was observed in the survival rate between this group and groups administered an esmolol bolus simultaneously or before the second dose of amiodarone (43% vs. 64%, p = 0.403). Of those patients, 31% (9 of 29) were administered an esmolol bolus for defibrillation attempts ≤ 5, while the remaining 69% of patients received an esmolol injection after the fifth defibrillation attempt. No significant differences were observed in the rates of ≥ 24-h ROSC (67% vs. 60%, p = 0.73), ≥ 72-h ROSC (67% vs. 55%, p = 0.56), and survival to hospital discharge (67% vs. 55%, p = 0.56) between the groups administered an esmolol bolus for defibrillation attempts ≤ 5 and defibrillation attempts > 5.

Conclusion: IHCA patients with refractory shockable rhythms receiving esmolol bolus exhibited a high chance of sustained ROSC and survival to hospital discharge. Patients with end-stage heart failure tended to have attenuated benefits from beta-blockers. Further large-scale, prospective studies are necessary to determine the effects of esmolol in patients with IHCA with refractory shockable rhythms.

Potential Candidates for Emergency Department Initiated Extracorporeal Cardiopulmonary Resuscitation (ECPR) in a Canadian Institution

Introduction

Out-of-hospital cardiac arrest (OHCA) patients experience poor survival. The use of extracorporeal membrane oxygenation (ECMO), a form of heart-lung bypass, in the setting of cardiac arrest, termed extracorporeal cardiopulmonary resuscitation (ECPR), has promise in improving survival with good neurologic outcomes. The study objective was to determine the number of potential annual ECPR candidates among the OHCA population in a health region within the Atlantic Canadian province of Nova Scotia.

Methods

A retrospective chart review was conducted over a five-year period: January 1st, 2012 to December 31st, 2016. Consecutive non-traumatic OHCA and emergency department (ED) cardiac arrests occurring in a pre-determined catchment area (20-minute transport to ECMO center) defined by a geographic bounding box were identified. Criteria for ECPR were developed to identify candidates for activation of a “Code ECPR”: (1) age 16-70, (2) witnessed arrest, (3) no flow duration (time to CPR, including bystander) <10 minutes, (4) resuscitation >10 minutes without return of spontaneous circulation (ROSC), (5) emergency medical service (EMS) transport to hospital <20 minutes, (6) no patient factors precluding ongoing resuscitation (do not resuscitate status (DNR), palliative care involvement, or metastatic cancer), and (7) initial rhythm not asystole. Candidates were stratified by initial rhythm. Candidates were considered ultimately ED ECPR eligible if they failed conventional treatment, defined by death or resuscitation >30 minutes. Clinical data related to candidacy was extracted by an electronic query from prehospital and ED electronic records and manual chart review by three researchers.

Results

Our search yielded 561 cases of EMS-treated OHCA or in-ED arrests. Of those 204/561 (36%; 95% CI 33-40%) met the criteria for activation of a “Code ECPR”. Ultimately 79/204 (34%; 95% CI 28-41%) of those who met activation criteria were considered ED ECPR eligible; which is 14% (95% CI 11-17%) of the total number of arrests-of the total number of arrests, the initial rhythms were pulseless electrical activity (PEA) 33/79 (42%; 95% CI 32-53%) and shockable 46/79 (58%; 95% CI 47-69%).

Conclusion

Of all cardiac arrests in the area surrounding our ECMO center, approximately 41 per year met the criteria for a Code ECPR activation, with 16 per year ultimately being eligible for ED ECPR. This annual estimate varies based on the inclusion of initial rhythm. This provides insight into both prehospital and hospital implications of an ED ECPR program and will help guide the establishment of a program within our Nova Scotian health region. This study also provides a framework for similar investigation at other institutions contemplating ED ECPR program implementation.

Cost-Effectiveness Analysis of Out-Of-Hospital versus In-Hospital Extracorporeal Cardiopulmonary Resuscitation for Out-Hospital Refractory Cardiac Arrest

It has been speculated that out-of-hospital cardiac arrest (OHCA) patients' survival might be improved by implementing extracorporeal cardiopulmonary resuscitation (ECPR) before arrival to hospital. Therefore, we sought to assess the cost-effectiveness of OH-ECPR versus in-hospital (IH)-ECPR in OHCA patients in Qatar. From the hospital perspective, a conventional decision-analytic model was constructed to follow up the clinical and economic consequences of OH-ECPR versus IH-ECPR in a simulated OHCA population over one year. The primary outcome was the survival at discharge after arrest as well as the overall direct healthcare costs of managing OHCA patients. The robustness of this model was evaluated via sensitivity analyses. The OH-ECPR yielded 16% survival at discharge after arrest compared to 7% with IH-ECPR, [risk ratio (RR)=0.91; 95%CI 0.79 to 1.06; P=0.26]. Incorporating the uncertainty associated with this survival rate, and based on the estimated willingness to pay threshold in Qatar, the OH-ECPR was cost-effective with an incremental cost-effectiveness ratio of QAR 464,589 (USD 127,634). Sensitivity and uncertainty analyses confirmed the robustness of the study outcome. This is the first cost-effectiveness evaluation of OH-ECPR versus IH-ECPR in OHCA patients. OH-ECPR is potentially an economically acceptable resuscitative strategy in Qatar.

Quality Evaluation Algorithm for Chest Compressions Based on OpenPose Model

Aiming at the problems of the low evaluation efficiency of the existing traditional cardiopulmonary resuscitation (CPR) training mode and the considerable development of machine vision technology, a quality evaluation algorithm for chest compressions (CCs) based on the OpenPose human pose estimation (HPE) model is proposed. Firstly, five evaluation criteria are proposed based on major international CPR guidelines along with our experimental study on elbow straightness. Then, the OpenPose network is applied to obtain the coordinates of the key points of the human skeleton. The algorithm subsequently calculates the geometric angles and displacement of the selected joint key points using the detected coordinates. Finally, it determines whether the compression posture is standard, and it calculates the depth, frequency, position and chest rebound, which are the critical evaluation metrics of CCs. Experimental results show that the average accuracy of network behavior detection reaches 94.85%, and detection speed reaches 25 fps.

Effects of Different Hypothermia on the Results of Cardiopulmonary Resuscitation in a Cardiac Arrest Rat Model

Objective

To investigate the optimal temperature of hypothermia treatment in rats with cardiac arrest caused by ventricular fibrillation (VF) after the return of spontaneous circulation (ROSC).

Methods

A total of forty-eight male Sprague-Dawley rats were induced by VF through the guidewire with a maximum of 5 mA current and untreated for 8 min. Cardiopulmonary resuscitation (CPR) was performed for 8 min followed by defibrillation (DF). Resuscitated rats were then randomized into the normothermia (37°C) group, milder (35°C) group, mild (33°C) group, or moderate (28°C) group. Hypothermia was immediately induced with surface cooling. The target temperature was maintained for 4 h before rewarming to 37 ± 0.5°C. Moreover, at the end of the 4 h, a rat in each group was randomly selected to be sacrificed for the cerebral cortex electron microscopy observation (n = 1). The other resuscitated animals were observed for up to 72 h after ROSC (n = 7). Left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) were measured. Survival time, survival rate, and neurological deficit score (NDS) were recorded for 72 h.

Results

During hypothermia, higher LVEF was observed in the hypothermia groups when compared with normothermia group (35°C vs. 37°C, p < 0.05, 33°C and 28°C vs. 37°C, p < 0.01). Among the hypothermia groups, LVEF was higher in the 28°C group than that of 35°C (p < 0.05). However, both the heart rate (HR) (p < 0.01) and LVEDV (28°C vs. 35°C, p < 0.01, 28°C vs. 37°C and 33°C, p < 0.05) were lowest in the 28°C group when compared with the other groups. There were no significant differences of LVEF and LVEDV between the group 35°C and 33°C (p > 0.05). After rewarming, the LVEF of 35°C group was higher than that of group 37°C, 33°C, and 28°C (35°C vs. 37°C and 28°C, p < 0.01, 35°C vs. 33°C, p < 0.05). Group 35°C and 33°C resulted in longer survival (p < 0.01), higher survival rate (p < 0.01), and lower NDS (35°C vs. 37°C and 28°C, p < 0.01, 33°C vs. 37°C and 28°C, p < 0.05) compared with the group 37°C and 28°C. The extent of damage to cerebral cortex cells in group of 35°C and 33°C was lighter than that in group of 37°C and 28°C. The 35°C group spent less time in the process of cooling and rewarming than the group 33°C and 28°C (p < 0.01).

Conclusions

An almost equal protective effect of milder hypothermia (35°C) and mild hypothermia (33°C) in cardiac arrest (CA) rats was achieved with more predominant effect than moderate hypothermia (28°C) and normothermia (37°C). More importantly, shorter time spent in cooling and rewarming was required in the 35°C group, indicating its potential clinical application. These findings support the possible use of milder hypothermia (35°C) as a therapeutic agent for postresuscitation.

Characteristics, prognostic factors, and chronological trends of out-of-hospital cardiac arrests with shockable rhythms in Taiwan - A 7-year observational study

BACKGROUND

The study aimed to explore the characteristics, predictors, and chronological trends of outcomes for adult out-of-hospital cardiac arrests (OHCAs) with shockable rhythms.

METHODS

A 7-year, community-wide observational study using an Utstein-style registry was conducted. Patients who were not transported, those who experienced trauma and those who lacked electronic electrocardiography data were excluded; those with initial shockable rhythms of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) were included. Outcomes were survival of discharge (SOD) and favorable neurological status (CPC 1-2). The outcome predictors, chronological trends, and their relationship with system interventions were analyzed.

RESULTS

Of the 1544 shockable OHCAs (incidence 12.6%) included, 97.6% had VF and 2.4% had pVT. VF showed better outcomes than pVT. Predictors for both outcomes (SOD; CPC 1-2) were chronological change (adjusted odds ratio [aOR]: 1.133; 1.176), younger age (aOR: 0.973; 0.967), shorter response time (aOR: 0.998; 0.999), shorter scene time (aOR: 0.999; 0.999), witnessed collapse (aOR: 1.668; 1.670), and bystander cardiopulmonary resuscitation (BCPR) (aOR: 1.448; 1.576). Predictors for only SOD were public location (aOR: 1.450) and successful prehospital defibrillation (aOR: 3.374). The use of the supraglottic airway was associated with adverse outcomes. Chronologically with system interventions, BCPR rate, the proportion of shockable OHCA, and improved neurological outcomes increased over time.

CONCLUSIONS

The incidence of shockable OHCA remained low in Asian community. VF showed better outcomes than pVT. Over time, the incidence of shockable rhythm, BCPR rate and patient outcomes did improve with health system interventions. The number of prehospital defibrillations did not predict outcomes.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized and propensity score-matched studies

BACKGROUND

In selected patients with refractory out-of-hospital cardiac arrest, extracorporeal cardiopulmonary resuscitation represents a promising approach when conventional cardiopulmonary resuscitation fails to achieve return of spontaneous circulation. This systematic review and meta-analysis aimed to compare extracorporeal cardiopulmonary resuscitation to conventional cardiopulmonary resuscitation.

METHODS

We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials up to November 28, 2021, for randomized trials and observational studies reporting propensity score-matched data and comparing adults with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation with those treated with conventional cardiopulmonary resuscitation. The primary outcome was survival with favorable neurological outcome at the longest follow-up available. Secondary outcomes were survival at the longest follow-up available and survival at hospital discharge/30 days.

RESULTS

We included six studies, two randomized and four propensity score-matched studies. Patients treated with extracorporeal cardiopulmonary resuscitation had higher rates of survival with favorable neurological outcome (81/584 [14%] vs. 46/593 [7.8%]; OR = 2.11; 95% CI, 1.41-3.15; p < 0.001, number needed to treat 16) and of survival (131/584 [22%] vs. 102/593 [17%]; OR = 1.40; 95% CI, 1.05-1.87; p = 0.02) at the longest follow-up available compared with conventional cardiopulmonary resuscitation. Survival at hospital discharge/30 days was similar between the two groups (142/584 [24%] vs. 122/593 [21%]; OR = 1.26; 95% CI, 0.95-1.66; p = 0.10).

CONCLUSIONS

Evidence from randomized trials and propensity score-matched studies suggests increased survival and favorable neurological outcome in patients with refractory out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation. Large, multicentre randomized studies are still ongoing to confirm these findings.

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

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

Association Between Converting Asystole From Initial Shockable ECG Rhythm Before Extracorporeal Cardiopulmonary Resuscitation and Outcome

BACKGROUND

Initial electrocardiogram (ECG) rhythm is a predictor of outcomes in out-of-hospital cardiac arrest (OHCA) in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). However, ECG rhythm often changes before ECPR, and the consequence of this change remains unclear. This study aimed to assess the relationship between the conversion of ECG rhythm from initial shockable rhythm before ECPR and mortality.

PATIENTS AND METHODS

This was a retrospective cohort study of OHCA patients with initial shockable rhythm who underwent ECPR between January 2010 and September 2020. Patients were classified into two groups: asystole (patients whose ECG rhythm converted to asystole at any time before initiating ECPR) and non-asystole (patients whose ECG rhythm did not convert to asystole at any time before initiating ECPR) groups. The primary outcome was in-hospital mortality.

RESULTS

A total of 102 patients were included in the study; in-hospital mortality rate was 46.1% (n = 47) and 76 (74.5%) patients had unfavorable neurological outcomes (Cerebral Performance Category: 3-5). There were 33 and 69 patients in the asystole and non-asystole groups, respectively. The mortality rates in the asystole and non-asystole groups were 69.7% and 34.8%, respectively (P = 0.001). On multivariable analysis, the asystole group showed a significant association with mortality (odds ratio, 5.42; 95% confidence interval, 2.11-15.36; P < 0.001).

CONCLUSION

Conversion to asystole before ECPR at any time in patients with OHCA is associated with mortality in patients with an initial shockable ECG rhythm.

Arrhythmic storm from ischemic ventricular fibrillation treated with intravenous quinidine

We present a case who developed an acute right ventricular infarction. The leads demonstrating ST-segment elevation were different than those expected based on previous publications. We explain why this happened with the aid of 3-dimentional imaging. Our case then developed an arrhythmic storm caused by ischemic ventricular fibrillation (VF). Emergency revascularization failed and the VF-storm failed to respond to sedation, lidocaine and amiodarone but responded to intravenous quinidine.

Neurological Complications of Veno-Arterial Extracorporeal Membrane Oxygenation: A Retrospective Case-Control Study

Background: To explore the epidemiology, clinical features, risk indicators, and long-term outcomes of neurological complications caused by veno-arterial extracorporeal membrane oxygenation (V-A ECMO).

Methods: We retrospectively analyzed 60 adult patients who underwent V-A ECMO support in our unit from February 2012 to August 2020. These patients were separated into the neurological complications group (NC group) and the non-neurological complications group (nNC group). The differences in basic data and ECMO data between the two groups were compared. The data of long-term neurological prognosis were collected by telephone follow-up.

Results: Thirty-nine patients (65.0%) had neurological complications. There were significant differences between the two groups in terms of median age, hypertension, median blood urea nitrogen, median troponin I (TNI), median lactic acid, pre-ECMO percutaneous coronary intervention, continuous renal replacement therapy (CRRT), median Sequential Organ Failure Assessment score, median Acute Physiology and Chronic Health Evaluation II score, median peak inspiratory pressure, median positive end expiratory pressure, and median fresh frozen plasma (P < 0.05). The median Intensive Care Unit length of stay (ICU LOS), 28-day mortality, median post-ECMO vasoactive inotropic score, non-pulsate perfusion (NP), and median ECMO duration of the NC group were significantly higher than those of the nNC group (P < 0.05). Furthermore, multiple logistic regression analysis revealed that TNI (P = 0.043), CRRT (P = 0.047), and continuous NP > 12 h (P = 0.043) were independent risk indicators for neurological complications in patients undergoing ECMO. Forty-four patients (73.3%) survived after discharge, and 38 patients (63.3%) had Cerebral Performance Category score of 1–2. And there were significant differences between the two groups in long-term neurological outcomes after discharge for 6 months (P < 0.05).

Conclusion: The incidence of neurological complications was higher in patients undergoing V-A ECMO and was closely related to adverse outcomes (including ICU LOS and 28-day mortality). TNI, CRRT, and continuous NP > 12 h were independent risk indicators for predicting neurological complications in ECMO supporting patients. And the neurological complications of patients during ECMO support had significant adverse effect on long-term surviving and neurological outcomes of patients after discharge for 6 months.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Evidence-Based Approach to Out-of-Hospital Cardiac Arrest

Purpose of review

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death. Despite improvements in the cardiac disease management, OHCA outcomes remain poor. The purpose of this review is to provide information on the management of OHCA survivors, evidence-based treatments, and current gaps in the knowledge.

Recent findings

Most common cause of death from OHCA is neurological injury followed by shock and multiorgan failure. Prognostication tools are available to help with the clinical decision-making. Taking measures to improve EMS response time, encouraging bystander CPR, early defibrillation, and targeted temperature management are shown to improve survival. Early activation of cardiac catheterization lab for coronary angiography, hemodynamic assessment, and mechanical circulatory support should be considered in patients with shockable rhythm and presumed cardiac cause, those with ST elevation, ongoing ischemia, or evidence of hemodynamic and electrical instability. Randomized controlled trials are lacking in this field and benefits of interventions should be weighed against risk of pursuing a futile treatment. COVID-19 pandemic has added new challenges to the care of OHCA patients.

Summary

Clinical decision-making to care for OHCA patients is challenging. There is a need for trials to provide evidence-based knowledge on the care of OHCA patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11936-021-00924-3.

Association between age and neurological outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: a nationwide multicentre observational study

AIMS

Little is known about the difference in outcomes between young and old patients who received extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). Therefore, we aimed to investigate the differences in outcomes between those aged ≥75 years and <75 years who experienced OHCA and were resuscitated with ECPR.

METHODS AND RESULTS

We performed a secondary analysis of a nationwide prospective cohort study using the Japanese Association for Acute Medicine OHCA registry. We identified patients aged ≥18 years with OHCA who received ECPR. The patients were classified into three age groups (18-59 years, 60-74 years, and ≥75 years). The primary outcome was a 1-month neurological outcome. To examine the association between age and 1-month neurological outcome, we performed logistic regression analyses fitted with generalized estimating equations. From 2014 to 2017, we identified 875 OHCA patients aged ≥18 years who received ECPR. The proportion of patients who survived with favourable neurological outcome in the patients aged 18-59 years, 60-74 years, and ≥75 years were 15% (64/434), 8.9% (29/326), and 1.7% (2/115), respectively. In the multivariable analysis, compared with the age of 18-59 years, the proportions of favourable neurological outcomes were significantly lower in patients aged 60-74 years [adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.32-0.61] and those aged ≥75 years (adjusted OR, 0.26; 95% CI, 0.11-0.59).

CONCLUSION

Advanced age (age ≥75 years in particular) was significantly associated with poor neurological outcomes in patients with OHCA who received ECPR.

ECPR-extracorporeal cardiopulmonary resuscitation

Extracorporeal cardiopulmonary resuscitation (ECPR) is a salvage procedure in which extracorporeal membrane oxygenation (ECMO) is initiated emergently on patients who have had cardiac arrest (CA) and on whom the conventional cardiopulmonary resuscitation (CCPR) has failed. Awareness and usage of ECPR are increasing all over the world. Significant advancements have taken place in the ECPR initiation techniques, in its device and in its post-procedure care. ECPR is a team work requiring multidisciplinary experts, highly skilled health care workers and adequate infrastructure with appropriate devices. Perfect coordination and communication among team members play a vital role in the outcome of the ECPR patients. Ethical, legal and financial issues need to be considered before initiation of ECPR and while withdrawing the support when the ECPR is futile. Numerous studies about ECPR are being published more frequently in the last few years. Hence, keeping updated about the ECPR is very important for proper selection of cases and its management. This article reviews various aspects of ECPR and relevant literature to date.

A review of ECMO for cardiac arrest

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

Application of extracorporeal cardiopulmonary resuscitation in adult patients with refractory cardiac arrest

Background

The aim of this study was to summarize the clinical experience of extracorporeal cardiopulmonary resuscitation (ECPR) in the treatment of adult patients with refractory cardiac arrest.

Methods

The clinical data of 12 cases of adult patients with cardiac arrest hospitalized between June 2015 and September 2019 who were unable to achieve return of spontaneous circulation effectively with conventional cardiopulmonary resuscitation (CCPR) and were treated with ECPR technology were retrospectively analyzed. The group included six males and six females aged between 18 and 69 years. All the patients underwent veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support with the adoption of femoral artery and vein catheterization.

Results

The duration of cardiopulmonary resuscitation (CPR) for the 12 patients was 32-125 min, and the ECMO duration was 2-190 h. Four patients were successfully weaned from ECMO and survived until hospital discharge. The other eight patients died in hospital; hemodynamic collapse (four patients) in the early stage of ECMO and severe neurological complications (three patients) were the main causes of death.

Conclusions

Single-center data showed that ECPR provided a new rescue alternative for some patients with reversible refractory cardiac arrest. We have demonstrated that the success rate of treatment could be improved by selecting suitable patients and reducing the CPR duration as much as possible.

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: a scoping review

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging concept in cardiac arrest and cardiopulmonary resuscitation. Recent research has documented a significant improvement in favorable outcomes, notable survival to discharge, and neurologically intact survival.

OBJECTIVES

The present study undertakes a scoping review to summarize the available evidence by assessing the use of ECPR, compared with no ECPR or the standard of care, for adult patients who sustain cardiac arrest in any setting, in studies which record survival and neurologic outcomes.

METHODS

This review followed the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Four online databases were used to identify papers published from database inception to July 12, 2020. We selected 23 observational studies from Asia, Europe, and North America that used survival to discharge or neurologically intact survival as a primary or secondary endpoint variable in patients with cardiac arrest refractory to standard treatment.

RESULTS

Twenty-three observational studies were included in the review. Eleven studies were of out-of-hospital cardiac arrest, 7 studies were of in-hospital cardiac arrest, and 5 studies included mixed populations. Ten studies reported long-term favorable neurological outcomes (ie, Cerebral Performance Category score of 1 - 2 at 3 months [n = 3], 6 months [n = 3], and 1 year [n = 4]), of which only 4 had statistical significance at 5% significance levels. Current knowledge is mostly drawn from single-center observations, with most of the evidence coming from case series and cohort studies, hence is prone to publication bias. No randomized control trials were included.

CONCLUSIONS

This scoping review highlights the need for high-quality studies to increase the level of evidence and reduce knowledge gaps to change the paradigm of care for patients with shock-refractory cardiac arrest.

The utility of extracorporeal membrane oxygenation in patients with circulatory collapse by electrical storm

In patients experiencing electrical storm, intensive care using extracorporeal membrane oxygenation (ECMO) is an efficient treatment to overcome a hemodynamically unstable condition. The aim of this study was to examine the utility of ECMO in patients with circulatory collapse by electrical storm. We retrospectively examined 17 consecutive patients receiving veno-arterial ECMO for electrical storm between January 2016 and December 2018 in our institution. We compared survivors (n = 11) and non-survivors (n = 6). Thirteen were weaned from ECMO, of whom 11 patients (64.7%) survived and were discharged from hospital, while 6 patients died (35.3%). In comparisons between survivors and non-survivors, blood pH before starting ECMO was significantly higher in survivors (pH 7.32) than in non-survivors (pH 6.89, p = 0.027). Blood lactate level was significantly lower in survivors (6.2 mmol/L) than in non-survivors (12.2 mmol/L, p = 0.044). Complications of hypoxic ischemic encephalopathy were found in 4 non-survivors (66.7%), compared to survivors (0%, p = 0.006). Durations of intensive care unit stay and hospital stay were significantly longer in survivors (271 h, 62 days) than in non-survivors (50 h, 3 days, respectively). Outcomes of treatment using ECMO in patients with circulatory collapse due to electrical storm proved satisfactory. Increases in blood lactate level and decreases in blood pH before starting ECMO were thought to be related to mortality due to suspected irreversible organ damage by hypoxia before ECMO.

Promising candidates for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Precise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

Resuscitating Resuscitation: Advanced Therapies for Resistant Ventricular Dysrhythmias

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.

Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis

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.

Current trends and outcomes of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Japan: A nationwide observational study

AIM

The present study aimed to describe the prevalence, prognosis and annual trends of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients, using a nationwide inpatient database in Japan.

METHODS

This was a nationwide retrospective cohort study, using the Japanese Diagnosis Procedure Combination inpatient database. We included OHCA patients registered in the database from July 2010 to March 2017 and analyzed the annual prevalence of OHCA patients who received ECPR. The outcomes included survival to hospital discharge and survival with favorable neurologic outcome at hospital discharge. The annual trends on the outcomes were also analyzed.

RESULTS

We identified 217,907 eligible patients. OHCA patients were divided into patients with ECPR (n = 5,612) and conventional CPR (n = 212,295). The prevalence of ECPR performed in OHCA patients was 2.6%. ECPR prevalence significantly increased from 2.1% in 2010 to 3.0% in 2016 (P < 0.001). Overall survival to hospital discharge was 16.4% and 2.7% in patients with ECPR and conventional CPR, respectively. Prevalence of patients who were discharged from hospital with favorable neurologic outcome was 12.4% and 1.6% in those with ECPR and conventional CPR, respectively.Increasing age was associated with progressively deteriorating outcomes. The trend of survival to hospital discharge significantly increased on an annual basis.

CONCLUSIONS

The annual prevalence of ECPR significantly increased from 2010 to 2016. Improvements in overall survival to hospital discharge were noted for ECPR in OHCA patients and there was a trend in the tendency for ECPR patients discharged from the hospital to have favorable neurologic outcomes.

Can a Shockable Initial Rhythm Identify Out-of-Hospital Cardiac Arrest Patients with a Short No-flow Time?

AIMS

Initial shockable rhythms may be a marker of shorter duration between collapse and initiation of cardiopulmonary resuscitation, known as no-flow time (NFT), for patients suffering an out-of-hospital cardiac arrest (OHCA). Eligibility for extracorporeal resuscitation is conditional on a short NFT. Patients with an unwitnessed OHCA could be candidate for extracorporeal resuscitation despite uncertain NFT if an initial shockable rhythm is a reliable stand-in. Herein, we sought to describe the sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minutes or less.

METHODS

Using a registry of OHCA in Montreal, Canada, adult patients who experienced a witnessed non-traumatic OHCA, but who did not receive bystander cardiopulmonary resuscitation, were included. The sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minute or less were calculated. The association between the NFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression.

RESULTS

A total of 2450 patients were included, of whom 863 (35%) had an initial shockable rhythm and 1085 (44%) a NFT of five minutes or less. The sensitivity of an initial shockable rhythm to predict a NFT of five minutes or less was 36% (95% confidence interval [95%CI] 33-39), specificity was 66% (95%CI 63-68), the positive likelihood ratio was 1.05 (95%CI 0.94-1.17) and the negative likelihood ratio of 0.97 (95%CI 0.92-1.03). The probabilities of observing a shockable rhythm stayed stable up to 15 minutes, while the probabilities of observing a PEA lowered rapidly initially. Longer NFT were associated with lower odds of observing an initial shockable rhythm (adjusted odds ratio = 0.97 [95%CI 0.94-0.99], p = 0.012).

CONCLUSIONS

An initial shockable rhythm is a poor predictor of a short NFT, despite there being an association between the NFT and the presence of a shockable rhythm.