Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes

Major determinants of primary non function from kidney donation after Maastricht II circulatory death: A single center experience

PURPOSE

Organ shortage greatly limits treatment of patients with end-stage chronic kidney. Maastricht type 2 donation after circulatory death (DCD) has been shown to have similar results in long term outcomes in kidney transplantation, when compared with brain dead donation. Our main goal was to assess Maastricht type 2 DCD and evaluate factors that impact on early graft function.

METHODS

A retrospective study was conducted in an ECMO Referral Centre. All patients who received a kidney transplant from Maastricht type 2 DCD were included in study. Early graft function and short term outcomes were assessed.

RESULTS

From October 2017 to December 2022, 47 renal grafts were collected from 24 uDCD donors. Median warm ischemia time was 106 min (94-115), cannulation time was 10 min (8; 20) and duration of extracorporeal reperfusion (ANOR) was 180 min (126-214). Regarding early graft function, 25% had immediate graft function, 63.6% had delayed graft function and 11.4% had primary non-function (PNF). There was a correlation between cannulation time (p = 0.006) and ANOR with PNF (p = 0.016).

CONCLUSIONS

Cannulation time and ANOR were the main factors that correlated with PNF. Better understanding of underlying mechanisms should be sought in future studies to reduce the incidence of PNF.

Adenosine 2A Receptor Agonism Improves Survival in Extracorporeal Cardiopulmonary Resuscitation

INTRODUCTION

Despite resuscitation advances including extracorporeal cardiopulmonary resuscitation (ECPR), freedom from neurologic and myocardial insult after cardiac arrest remains unlikely. We hypothesized that adenosine 2A receptor (A2AR) agonism, which attenuates reperfusion injury, would improve outcomes in a porcine model of ECPR.

METHODS

Adult swine underwent 20 min of circulatory arrest followed by defibrillation and 6 h of ECPR. Animals were randomized to receive saline vehicle or A2AR agonist (ATL1223 or Regadenoson) infusion during extracorporeal membrane oxygenation. Animals were weaned off extracorporeal membrane oxygenation and monitored for 24 h. Clinical and biochemical end points were compared.

RESULTS

The administration of A2AR agonists increased survival (P = 0.01) after cardiac arrest compared to vehicle. Markers of neurologic damage including S100 calcium binding protein B and glial fibrillary acidic protein were significantly lower with A2AR agonist treatment.

CONCLUSIONS

In a model of cardiac arrest treated with ECPR, A2AR agonism increased survival at 24 h and reduced neurologic damage suggesting A2AR activation may be a promising therapeutic target after cardiac arrest.

Organ Utilization From Donors Following Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review of Graft and Recipient Outcome

BACKGROUND

The global shortage of solid organs for transplantation is exacerbated by high demand, resulting in organ deficits and steadily growing waiting lists. Diverse strategies have been established to address this issue and enhance organ availability, including the use of organs from individuals who have undergone extracorporeal cardiopulmonary resuscitation (eCPR). The main aim of this work was to examine the outcomes for both graft and recipients of solid organ transplantations sourced from donors who underwent eCPR.

METHODS

We performed a systematic literature review using a combination of the terms related to extracorporeal life support and organ donation. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, PubMed and Scopus databases were searched up to February 2024.

RESULTS

From 1764 considered publications, 13 studies comprising 130 donors and 322 organ donations were finally analyzed. On average, included patients were 36 y old, and the extracorporeal life support was used for 4 d. Kidneys were the most often transplanted organs (68%; 220/322), followed by liver (22%; 72/322) and heart (5%; 15/322); with a very good short-term graft survival rate (95% for kidneys, 92% for lungs, 88% for liver, and 73% for heart). Four studies with 230 grafts reported functional outcomes at the 1-y follow-up, with graft losses reported for 4 hearts (36%), 8 livers (17%), and 7 kidneys (4%).

CONCLUSIONS

Following eCPR, organs can be successfully used with very high graft and recipient survival. In terms of meeting demand, the use of organs from patients after eCPR might be a suitable method for expanding the organ donation pool.

The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.

Impact of center volume on in-hospital mortality in adult patients with out‑of‑hospital cardiac arrest resuscitated using extracorporeal cardiopulmonary resuscitation: a secondary analysis of the SAVE-J II study

Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11-20 sessions per year), or low-volume (< 11 sessions per year). The primary outcome was survival rate at the time of discharge. Patient characteristics and outcomes were compared among the three groups. Moreover, a multivariable-adjusted logistic regression model was applied to study the impact of center ECPR volume. A total of 1740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P = 0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P = 0.003) and low-volume centers (adjusted odds ratio 0.983; P = 0.006). The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure.Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Prognostic value of arterial carbon dioxide tension during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients receiving extracorporeal resuscitation

BACKGROUND

Current guidelines on extracorporeal cardiopulmonary resuscitation (ECPR) recommend careful patient selection, but precise criteria are lacking. Arterial carbon dioxide tension (PaCO2) has prognostic value in out-of-hospital cardiac arrest (OHCA) patients but has been less studied in patients receiving ECPR. We studied the relationship between PaCO2 during cardiopulmonary resuscitation (CPR) and neurological outcomes of OHCA patients receiving ECPR and tested whether PaCO2 could help ECPR selection.

METHODS

This single-centre retrospective study enrolled 152 OHCA patients who received ECPR between January 2012 and December 2020. Favorable neurological outcome (FO) at discharge was the primary outcome. We used multivariable logistic regression to determine the independent variables for FO and generalised additive model (GAM) to determine the relationship between PaCO2 and FO. Subgroup analyses were performed to test discriminative ability of PaCO2 in subgroups of OHCA patients.

RESULTS

Multivariable logistic regression showed that PaCO2 was independently associated with FO after adjusting for other favorable resuscitation characteristics (Odds ratio [OR] 0.23, 95% Confidence Interval [CI] 0.08-0.66, p-value = 0.006). GAM showed a near-linear reverse relationship between PaCO2 and FO. PaCO2 < 70 mmHg was the cutoff point for predicting FO. PaCO2 also had prognostic value in patients with less favorable characteristics, including non-shockable rhythm (OR, 3.78) or low flow time > 60 min (OR, 4.66).

CONCLUSION

PaCO2 before ECMO implementation had prognostic value for neurological outcomes in OHCA patients. Patients with PaCO2 < 70 mmHg had higher possibility of FO, even in those with non-shockable rhythm or longer low-flow duration. PaCO2 could serve as an ECPR selection criterion.

Intra-aortic balloon pump in patients with extracorporeal cardiopulmonary resuscitation after cardiac arrest caused by acute coronary syndrome

BACKGROUND

This study evaluated the association between intra-aortic balloon pump (IABP) use in patients with out-of-hospital cardiac arrest (OHCA) caused by acute coronary syndrome (ACS) who received extracorporeal cardiopulmonary resuscitation (ECPR) and 30-day outcomes.

METHODS

This study was a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter registry study involving 36 participating institutions in Japan. Patients with cardiac arrest caused by ACS who received ECPR were divided into two groups depending on whether or not they received IABP. The primary outcome was 30-day survival. Subgroup analysis was performed to detect what type of patients were mostly associated with improved outcomes.

RESULTS

Of 2,157 patients registered in the SAVE-J II study, 877 patients were enrolled in this study, 702 patients in the IABP group and 175 patients in the non-IABP group. Multivariable logistic regression analysis did not reveal a significant difference in 30-day survival (OR 1.37, 95% CI 0.91-2.07, p = 0.13). In the subgroup analysis, 30-day survival among patients without percutaneous coronary intervention (PCI) and stenosis of multiple coronary vessels were associated with IABP use.

CONCLUSIONS

IABP use in patients with OHCA with ACS who received ECPR is not associated with 30-day survival. The use of IABP in patients who did not have PCI and have multiple coronary vessel stenoses warrants further study.

External Validation of the CAST and rCAST Score in Patients With Out-of-Hospital Cardiac Arrest Who Underwent Extracorporeal Cardiopulmonary Resuscitation: A Secondary Analysis of the SAVE-J II Study

BACKGROUND

Risk stratification is important in patients with post-cardiac arrest syndrome. The Post-Cardiac Arrest Syndrome for Therapeutic Hypothermia (CAST) and revised CAST (rCAST) scores have been well validated for predicting neurological outcomes, particularly for conventionally resuscitated patients with post-cardiac arrest syndrome. However, no studies have evaluated patients undergoing extracorporeal cardiopulmonary resuscitation.

METHODS AND RESULTS

Adult patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation were analyzed in this retrospective observational multicenter cohort study. We validated the accuracy of the CAST/rCAST scores for predicting neurological outcomes at 30 days. Moreover, we compared the predictive performance of these scores with the TiPS65 risk score derived from patients with out-of-hospital cardiac arrest who were resuscitated using extracorporeal cardiopulmonary resuscitation. A total of 1135 patients were analyzed. The proportion of patients with favorable neurological outcomes was 16.6%. In the external validation, the area under the receiver operating characteristic curve of the CAST score was significantly higher than that of the rCAST score (area under the receiver operating characteristic curve 0.677 versus 0.603; P<0.001), but there was no significant difference with that of the TiPS65 score (versus 0.633; P=0.154). Both CAST/rCAST risk scores showed good calibration (Hosmer-Lemeshow test: P=0.726 and 0.674), and the CAST score showed significantly better predictability in net reclassification compared with the rCAST (P<0.001) and TiPS65 scores (P=0.001).

CONCLUSIONS

The prognostic accuracy of the CAST score was significantly better than that of other risk scores in net reclassification. The CAST score may help to predict neurological outcomes in patients with out-of-hospital cardiac arrest who undergo extracorporeal cardiopulmonary resuscitation. However, the predictive value of the CAST score was not sufficiently high for clinical application.

REGISTRATION

URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577; Unique identifier: UMIN000036490.

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.

Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation for patients with refractory out-of-hospital cardiac arrest: A retrospective propensity matching analysis

OBJECTIVE

The incidence of out-of-hospital cardiac arrest (OHCA) is high. Though extracorporeal cardiopulmonary resuscitation (ECPR) has been considered a potential treatment for refractory cardiac arrest after failure of conventional cardiopulmonary resuscitation (CCPR), the benefit of ECPR in refractory OHCA remains uncertain.

METHODS

In this retrospective cohort study, we included patients with refractory OHCA who visited the Emergency Department of the Aerospace Center Hospital between January 2018 and April 2023. We divided the patients into the ECPR Group and the CCPR Group. The primary endpoint of the study was the neurological function of the patients in both groups 3 months after the cardiac arrest. We used propensity score matching to reduce selection bias and identified factors associated with good neurological function when OHCA was treated with ECPR by performing univariate and multivariate correlation analyses on surviving patients with good neurological function in the ECPR group.

RESULTS

During the study period, we enrolled 133 patients, consisting of 33 in the ECPR group and 100 in the CCPR group. The survival rate of patients with good neurological function at discharge was 18.2% (6/33 cases) in the ECPR group and 9% (9/100 cases) in the CCPR group, p = .20. Three months after discharge, the survival rate of patients with good neurological function was 15.2% (5/33 cases) in the ECPR group and 8% (8/100 cases) in the CCPR group, p = .31. Using propensity score matching, we identified 22 pairs of patients for further analysis. Among these, 3 months after discharge, the survival rate of patients with good neurological function was 13.6% (3/22 cases) in the ECPR group and 4.5% (1/22 cases) in the CCPR group, p = .61, and the survival rate at discharge was 18.2% (4/22 cases) in the ECPR group and 4.5% (1/22 cases) in the CCPR group, p = .34. The univariate analysis of patients with good neurological function in the ECPR group showed that time without perfusion, hypoperfusion time, and PCI treatment were associated factors affecting the prognosis of neurological function in patients, while multivariate analysis showed that hypoperfusion time was independently associated with good neurological function, with an OR (95% CI) of 1.06 (1.00-1.14) and p = .05.

CONCLUSION

Our findings suggested that ECPR failed to significantly improve neurological outcome in patients with refractory OHCA; however, the small sample size in this study may be insufficient to detect clinically relevant differences. In addition, hypoperfusion time may be a key predictive factor in identifying candidates for ECPR.

Extracorporeal cardiopulmonary resuscitation-based approach to refractory out-of-hospital cardiac arrest: A focus on organ donation, a secondary analysis of a Prague OHCA randomized study

BACKGROUND

Refractory out-of-hospital cardiac arrest (OHCA) has a poor outcome. In patients, who cannot be rescued despite using advanced techniques like extracorporeal cardiopulmonary resuscitation (ECPR), organ donation may be considered. This study aims to evaluate, in refractory OHCA, how ECPR versus a standard-based approach allows organ donorship.

METHODS

The Prague OHCA trial randomized adults with a witnessed refractory OHCA of presumed cardiac origin to either an ECPR-based or standard approach. Patients who died of brain death or those who died of primary circulatory reasons and were not candidates for cardiac transplantation or durable ventricle assist device were evaluated as potential organ donors by a transplant center. In this post-hoc analysis, the effect on organ donation rates and one-year organ survival in recipients was examined.

RESULTS

Out of 256 enrolled patients, 75 (29%) died prehospitally or within 1 hour after admission and 107 (42%) during the hospital stay. From a total of 24 considered donors, 21 and 3 (p = 0.01) were recruited from the ECPR vs standard approach arm, respectively. Fifteen brain-dead and none cardiac-dead subjects were ultimately accepted, 13 from the ECPR and two from the standard strategy group. A total of 36 organs were harvested. The organs were successfully transplanted into 34 recipients. All transplanted organs were fully functional, and none of the recipients died due to graft failure within the one-year period post-transplant.

CONCLUSION

The ECPR-based approach in the refractory OHCA trial is associated with increased organ donorship and an excellent outcome of transplanted organs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01511666. Registered January 19, 2012.

Prognostic factors associated with favourable functional outcome among adult patients requiring extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A systematic review and meta-analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR), has demonstrated promise in the management of refractory out-of-hospital cardiac arrest (OHCA). However, evidence from observational studies and clinical trials are conflicting and the factors influencing outcome have not been well established.

METHODS

We conducted a systematic review and meta-analysis summarizing the association between pre-ECPR prognostic factors and likelihood of good functional outcome among adult patients requiring ECPR for OHCA. We searched Medline and Embase databases from inception to February 28, 2023 and screened studies with two independent reviewers. We performed meta-analyses of unadjusted and adjusted odds ratios, adjusted hazard ratios and mean differences separately. We assessed risk of bias using the QUIPS tool and certainty of evidence using the GRADE approach.

FINDINGS

We included 29 observational and randomized studies involving 7,397 patients. Factors with moderate or high certainty of association with increased survival with favourable functional outcome include pre-arrest patient factors, such as younger age (odds ratio (OR) 2.13, 95% CI 1.52 to 2.99) and female sex (OR 1.37, 95% CI 1.11 to 1.70), as well as intra-arrest factors, such as shockable rhythm (OR 2.79, 95% CI 2.04 to 3.80), witnessed arrest (OR 1.68 (95% CI 1.16 to 2.42), bystander CPR (OR 1.55, 95% CI 1.19 to 2.01), return of spontaneous circulation (OR 2.81, 95% CI 2.19 to 3.61) and shorter time to cannulation (OR 1.14, 95% CI 1.17 to 1.69 per 10 minutes).

INTERPRETATION

The findings of this review confirm several clinical concepts wellestablished in the cardiac arrest literature and their applicability to the patient for whom ECPR is considered - that is, the impact of pre-existing patient factors, the benefit of timely and effective CPR, as well as the prognostic importance of minimizing low-flow time. We advocate for the thoughtful consideration of these prognostic factors as part of a risk stratification framework when evaluating a patient's potential candidacy for ECPR.

Extracorporeal Life Support for Recurrent Hypothermic Cardiac Arrest: A Case Report

Hypothermia-associated cardiac arrest (HACA) is a challenge for emergency physicians. Standard cardiopulmonary resuscitation (CPR) remains the primary intervention for the treatment of HACA, but extracorporeal life support (ECLS) may be needed as an adjunct to CPR. In this report, we present the case of an adult Asian patient who experienced two episodes of HACA at a two-year interval. In both episodes, the patient was treated with ECLS in addition to standard CPR. We discuss the fundamentals of HACA and how to safely and effectively incorporate ECLS into its management. No-flow time, age, comorbidities, and the cause of the cardiac arrest are criteria to consider when deciding on the duration of CPR and the intensity of the resources deployed. Hypothermia is a reversible cause of cardiac arrest, justifying prolonged CPR. According to the Hypothermia Outcome Prediction after ECLS (HOPE) score, active rewarming through ECLS is recommended. However, a history of cardiac arrest is rare and might be considered a severe comorbidity contraindicating ECLS use. Nevertheless, the indication is determined on a case-by-case basis.

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

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

Feasibility of HEMS performed prehospital extracorporeal-cardiopulmonary resuscitation in paediatric cardiac arrests; two case reports

INTRODUCTION

A broad range of pathophysiologic conditions can lead to cardiopulmonary arrest in children. Some of these children suffer from refractory cardiac arrest, not responding to basic and advanced life support. Extracorporeal-Cardiopulmonary Resuscitation (E-CPR) might be a life-saving option for this group. Currently this therapy is only performed in-hospital, often necessitating long transport times, thereby negatively impacting eligibility and chances of survival. We present the first two cases of prehospital E-CPR in children performed by regular Helicopter Emergency Medical Services (HEMS).

CASE PRESENTATIONS

The first patient was a previously healthy 7 year old boy who was feeling unwell for a couple of days due to influenza. His course deteriorated into a witnessed collapse. Direct bystander CPR and subsequent ambulance advanced life support was unsuccessful in establishing a perfusing rhythm. While doing chest compressions, the patient was seen moving both his arms and making spontaneous breathing efforts. Echocardiography however revealed a severe left ventricular impairment (near standstill). The second patient was a 15 year old girl, known with bronchial asthma and poor medication compliance. She suffered yet another asthmatic attack, so severe that she progressed into cardiac arrest in front of the attending ambulance and HEMS crews. Despite maximum bronchodilator therapy, intubation and the exclusion of tension pneumothoraxes and dynamic hyperinflation, no cardiac output was achieved.

INTERVENTION

After consultation with the nearest paediatric E-CPR facilities, both patients were on-scene cannulated by regular HEMS. The femoral artery and vein were cannulated (15-17Fr and 21Fr respectively) under direct ultrasound guidance using an out-of-plane Seldinger approach. Extracorporeal Life Support flow of 2.1 and 3.8 l/min was established in 20 and 16 min respectively (including preparation and cannulation). Both patients were transported uneventfully to the nearest paediatric intensive care with spontaneous breathing efforts and reactive pupils during transport.

CONCLUSION

This case-series shows that a properly trained regular HEMS crew of only two health care professionals (doctor and flight nurse) can establish E-CPR on-scene in (older) children. Ambulance transport with ongoing CPR is challenging, even more so in children since transportation times tend to be longer compared to adults and automatic chest compression devices are often unsuitable and/or unapproved for children. Prehospital cannulation of susceptible E-CPR candidates has the potential to reduce low-flow time and offer E-CPR therapy to a wider group of children suffering refractory cardiac arrest.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Kidneys recovered from brain dead cardiac arrest patients resuscitated with ECPR show similar one-year graft survival compared to other donors

INTRODUCTION

Among patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) as a second line of treatment for refractory out-of-hospital cardiac arrest (OHCA), some may develop brain death and become eligible for organ donation. The objective of this study was to evaluate long-term outcomes of kidney grafts recovered from these patients.

MATERIAL AND METHODS

We conducted a retrospective monocentric observational study between January 1, 2011, and December 31, 2017. We exclusively included patients eligible for planned donation after brainstem death and from whom at least one organ graft was retrieved and transplanted. We compared two groups of brain dead patients: those treated with ECPR for refractory OHCA (ECPR group) and a diverse group of patients who did not receive ECPR, from which only 5/23 (22%) had OHCA (control group). The primary outcome was one-year kidney graft survival.

RESULTS

We included 45 patients, 23 in the control group and 22 in the ECPR group. Although patients in the ECPR group were younger and had a lower prevalence of chronic renal disease (p = 0.01), their kidney function was more severely impaired upon admission in the ICU. A total of 68 kidney grafts were retrieved, transplanted, and studied, 34 in each study group. There was no significant difference between the two groups in terms of one-year kidney graft survival (p = 0.52).

CONCLUSION

Organ transplantation from patients treated with ECPR after refractory OHCA showed one-year kidney graft survival rates comparable to those of patients not treated with ECPR.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest

Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.

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.

Update on Mechanical Circulatory Support

Mechanical circulatory support (MCS) devices provide temporary or intermediate- to long-term support for acute cardiopulmonary support. In the last 20 to 30 years, tremendous growth in MCS device usage has been seen. These devices offer support for isolated respiratory failure, isolated cardiac failure, or both. Initiation of MCS devices requires the input from multidisciplinary teams using patient factors and institutional resources to guide decision making, along with a planned "exit strategy" for bridge to decision, bridge to transplant, bridge to recovery, or as destination therapy. Important considerations for MCS use include patient selection, cannulation/insertion strategies, and complications of each device.

Neurological monitoring in ECMO patients: current state of practice, challenges and lessons

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) in critically ill patients serves as a management option for end-stage cardiorespiratory failure in medical and surgical conditions. Patients on ECMO are at a high risk of neurologic adverse events including intracranial hemorrhage (ICH), acute ischemic stroke (AIS), seizures, diffuse cerebral edema, and hypoxic brain injury. Standard approaches to neurological monitoring for patients receiving ECMO support can be challenging for multiple reasons, including the severity of critical illness, deep sedation, and/or paralysis. This narrative literature review provides an overview of the current landscape for neurological monitoring in this population.

METHODS

A literature search using PubMed was used to aid the understanding of the landscape of published literature in the area of neurological monitoring in ECMO patients.

RESULTS

Review articles, cohort studies, case series, and individual reports were identified. A total of 73 varied manuscripts were summarized and included in this review which presents the challenges and strategies for performing neurological monitoring in this population.

CONCLUSION

Neurological monitoring in ECMO is an area of interest to many clinicians, however, the literature is limited, heterogenous, and lacks consensus on the best monitoring practices. The evidence for optimal neurological monitoring that could impact clinical decisions and functional outcomes is lacking. Additional studies are needed to identify effective measures of neurological monitoring while on ECMO.

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.

Outcomes of Patients With in- and out-of-hospital Cardiac Arrest on Extracorporeal Cardiopulmonary Resuscitation: A Single-center Retrospective Cohort Study

Extracorporeal membrane oxygenation (ECMO) support has been suggested to improve the survival rate in patients with refractory in- and out-of-hospital cardiac arrest (IHCA and OHCA). Several factors predict outcome in these patients, including initial heart rhythm and low-flow time. Literature shows variable survival rates among patients who received extracorporeal cardiopulmonary resuscitation (EPCR). The objective of this study is to analyze the outcomes (survival rate as well as neurological and disability outcomes) of patients treated with ECPR following refractory OHCA and IHCA. This single-center, retrospective cohort study was conducted on patients with refractory cardiac arrest treated with ECPR between February 2016 and March 2020. The primary outcomes were 24-hour, hospital discharge and 1-year survival after CA and the secondary endpoints were neurological and disability outcomes. Forty-eight patients were included in the analysis. 11/48 patients are In Hospital Cardiac Arrest (IHCA) and 37/48 patients are Out of Hospital Cardiac Arrest (OHCA). Time from collapse to CPR for 79.2% of the patients was less than 5 minutes. The median CPR duration and collapse to ECMO were 40 and 45 minutes, respectively. The rate of survival was significantly higher in patient who presented with initial shockable rhythm (P = 0.006) and to whom targeted temperature management (TTM) post cardiac arrest was applied (P = 0.048). This first descriptive study about ECPR in the middle east region shows that 20.8% of ECPR patients survived until hospital discharge. Our analysis revealed that initial shockable rhythm and TTM are most important prognostic factors that predicts favorable neurological survival.

Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study

Aim

Several studies have reported that corticosteroid administration for cardiac arrest patients may improve outcomes. However, these previous studies have not examined the effect of corticosteroid use in out-of-hospital cardiac arrest (OHCA) patients administered extracorporeal cardiopulmonary resuscitation (ECPR). Therefore, we aimed to examine the effectiveness of corticosteroids in OHCA patients administered ECPR.

Methods

Using the Japanese Diagnosis Procedure Combination inpatient database, we included OHCA patients who were administered ECPR on the day of admission between July 2010 and March 2019. The patients were categorized into the corticosteroid and control groups according to whether they received corticosteroids on the day of admission or not. The primary outcome was in-hospital mortality and the secondary outcomes included percentages of neurologically favorable survival, major bleeding complications, and infection-related complications. We compared the outcomes using a propensity score matching analysis.

Results

We identified 6,142 eligible patients (459 vs 5,683, the corticosteroid and control group, respectively). One-to-four propensity score matching analysis (457 vs 1,827) showed in-hospital mortality was significantly higher in the corticosteroid group compared with the control group (82.1% vs 76.6%; risk difference, 5.5%; 95% CI, 1.5 to 9.5%). Neurologically favorable outcomes did not differ between the two groups (13.6% vs 16.9%; risk difference, −3.3%; 95% CI, −6.9 to 0.3%). The percentage of major bleeding complications and infection-related complications did not significantly differ between the two groups.

Conclusions

The results of this study demonstrated that administration of corticosteroids on the day of admission to OHCA patients administered ECPR was associated with increased in-hospital mortality.

Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial

BACKGROUND

The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible and effective treatment strategy in refractory OHCA. Here we present a post-hoc analysis of the role of initial rhythm on patient outcomes.

METHODS

The study enrolled patients who had a witnessed OHCA of presumed cardiac cause without early recovery of spontaneous circulation. The initial rhythm was classified as either a shockable or a non-shockable rhythm. The primary outcome was a composite of 180 day-survival with Cerebral Performance in Category 1 or 2.

RESULTS

256 (median age 58y, 17% females) patients were enrolled. The median (IQR) duration of resuscitation was 52 (33-68) minutes. 156 (61%) and 100 (39%) of patients manifested a shockable and non-shockable rhythm, respectively. The primary outcome was achieved in 63 (40%) patients with a shockable rhythm and in 5 (5%) patients with a non-shockable rhythm (p < 0.001). When patients were analyzed separately based on whether the treatment was invasive (n = 124) or standard (n = 132), the difference in the primary endpoint between shockable and non-shockable initial rhythms remained significant (35/72 (49%) vs 4/52 (8%) in the invasive arm and 28/84 (33%) vs 1/48 (2%) in the standard arm; p < 0.001).

CONCLUSION

An initial shockable rhythm and treatment with an invasive approach is associated with a reasonable neurologically favorable survival for 180 days despite refractory OHCA. Non-shockable initial rhythms bear a poor prognosis in refractory OHCA even when ECPR is readily available.

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.

Extracorporeal cardiopulmonary resuscitation: a national study on the association between favourable neurological status and biomarkers of hypoperfusion, inflammation, and organ injury

Aims

In refractory out-of-hospital cardiac arrest (OHCA) with prolonged whole-body ischaemia, global tissue injury proceeds even after establishment of circulation with extracorporeal cardiopulmonary resuscitation (ECPR). We aimed to investigate the role of biomarkers reflecting hypoperfusion, inflammation, and organ injury in prognostication of patients with refractory OHCA managed with ECPR.

Methods and results

This nationwide retrospective study included 226 adults with refractory OHCA managed with ECPR in Denmark (2011–2020). Biomarkers the first days after ECPR-initiation were assessed. Odds ratio of favourable neurological status (Cerebral Performance Category 1–2) at hospital discharge was estimated by logistic regression analyses. Cut-off values were calculated using the Youden’s index. Fifty-six patients (25%) survived to hospital discharge, 51 (91%) with a favourable neurological status. Factors independently associated with favourable neurological status were low flow time &lt;81 min, admission leukocytes ≥12.8 × 109/L, admission lactate &lt;13.2 mmol/L, alkaline phosphatase (ALP) &lt; 56 (day1) or &lt;55 U/L (day2), and day 1 creatine kinase MB (CK-MB) &lt; 500 ng/mL. Selected biomarkers (leukocytes, C-reactive protein, and lactate) were significantly better predictors of favourable neurological status than classic OHCA-variables (sex, age, low-flow time, witnessed arrest, shockable rhythm) alone (P = 0.001) after hospital admission.

Conclusion

Biomarkers of hypoperfusion (lactate), inflammation (leucocytes), and organ injury (ALP and CK-MB) were independently associated with neurological status at hospital discharge. Biomarkers of hypoperfusion and inflammation (at hospital admission) and organ injury (days 1 and 2 after ECPR) may aid in the clinical decision of when to prolong or terminate ECPR in cases of refractory OHCA.

Program of Uncontrolled Donation After Circulatory Death as Potential Solution to the Shortage of Organs: A Canadian Single-Center Retrospective Cohort Study

Purpose

Worldwide, the number of patients waiting for organ transplantation exceeds the number of organs available. Program for uncontrolled donation after circulatory death (uDCD) implemented in Europe has resulted in a 10–15% expansion of the donor pool. We aimed to describe the number of patients eligible for an uDCD program in a regional tertiary care center.

Methods

We conducted a retrospective cohort study in a Canadian tertiary academic center located in a rural area including all adults who received cardiopulmonary resuscitation in 2016 and died in the emergency department (ED) or during their hospitalization. The primary outcome was the number of patients eligible for uDCD defined as aged between 18 and 60 years old whose collapse was witnessed and where the time between cardiac arrest to cardiopulmonary resuscitation and ED arrival was, respectively, less than 30 and 120 minutes. As a secondary outcome, we determined the number of patients eligible for controlled donation after circulatory death.

Results

Of the 130 patients included, 84 did not return to spontaneous circulation. We identified 15 potential uDCD candidates, with a mean age of 46.6 (95% Confidence Interval [CI] 41.3 to 52) years. Twelve had an out-of-hospital cardiac arrest with a mean time between collapse and arrival to the ED of 43.2 (29.8 to 56.6) minutes. Among the 46 patients who died after a return of spontaneous circulation, 10 (21.7%) were eligible for organ donation after circulatory death.

Conclusion

Implementing an uDCD program in a tertiary hospital covering a rural area could increase the number of donors.

Cases of prolonged cardiac arrest with preserved gasping successfully resuscitated with ECPR

Longer cardiopulmonary resuscitation (CPR) time is associated with worsened neurological outcomes in out-of-hospital cardiac arrest (OHCA). Gasping during CPR is a favorable neurological predictor for OHCA. Recently, the efficacy of extracorporeal cardiopulmonary resuscitation (ECPR) in refractory cardiac arrest has been reported. However, the significance of gasping in refractory cardiac arrest patients with long CPR durations treated with ECPR is still unclear. We report two cases of cardiac arrest with gasping that were successfully resuscitated by ECPR, despite extremely long low-flow times. In case 1, a 58-year-old man presented with cardiac arrest and ventricular fibrillation (VF). Gasping was observed when the patient arrived at the hospital. ECPR was initiated 82 min after cardiac arrest. The patient was diagnosed with hypertrophic cardiomyopathy. ECMO was withdrawn on day 4, and the patient was discharged without neurological impairment. In case 2, a 49-year-old man experienced cardiac arrest with VF, and his gasping was preserved during transportation. On arrival, VF persisted, and gasping was observed; therefore, ECMO was initiated 93 min after cardiac arrest. He was diagnosed with acute myocardial infarction. ECMO was withdrawn on day 4 and he was discharged from the hospital without any neurological impairment. Resuscitation and ECPR should not be abandoned in case of preserved gasping, even when the low-flow time is extremely long.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation

AIM

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA.

METHODS

We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale.

RESULTS

Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26).

CONCLUSION

We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Eligibility of extracorporeal cardiopulmonary resuscitation on in-hospital cardiac arrests in Sweden: a national registry study

AIMS

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (CA) is used in selected cases. The incidence of ECPR-eligible patients is not known. The aim of this study was to identify the ECPR-eligible patients among in-hospital CAs (IHCA) in Sweden and to estimate the potential gain in survival and neurological outcome, if ECPR was to be used.

METHODS AND RESULTS

Data between 1 January 2015 and 30 August 2019 were extracted from the Swedish Cardiac Arrest Register (SCAR). Two arbitrary groups were defined, based on restrictive or liberal inclusion criteria. In both groups, logistic regression was used to determine survival and cerebral performance category (CPC) for conventional cardiopulmonary resuscitation (cCPR). When ECPR was assumed to be possible, it was considered equivalent to return of spontaneous circulation, and the previous logistic regression model was applied to define outcome for comparison of conventional CPR and ECPR. The assumption in the model was a minimum of 15 min of refractory CA and 5 min of cannulation. A total of 9209 witnessed IHCA was extracted from SCAR. Depending on strictness of inclusion, an average of 32-64 patients/year remains in refractory after 20 min of cCPR, theoretically eligible for ECPR. If optimal conditions for ECPR are assumed and potential negative side effects disregarded of, the estimated potential benefit of survival of ECPR in Sweden would be 10-19 (0.09-0.19/100 000) patients/year, when a 30% success rate is expected. The benefit of ECPR on survival and CPC scoring was found to be detrimental over time and minimal at 60 min of cCPR.

CONCLUSION

The number of ECPR-eligible patients among IHCA in Sweden is dependent on selection criteria and predicted to be low. There is an estimated potential benefit of ECPR, on survival and neurological outcome if initiated within 60 min of the IHCA.

Accuracy of the Initial Rhythm to Predict a Short No-Flow Time in Out-of-Hospital Cardiac Arrest

OBJECTIVES

The no-flow time (NFT) can help establish prognosis in out-of-hospital cardiac arrest (OHCA) patients. It is often used as a selection criterion for extracorporeal resuscitation. In patients with an unwitnessed OHCA for whom the NFT is unknown, the initial rhythm has been proposed to identify those more likely to have had a short NFT. Our objective was to determine the predictive accuracy of an initial shockable rhythm for an NFT of 5 minutes or less (NFT ≤ 5).

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Prehospital OHCA in eight U.S. and three Canadian sites.

PATIENTS

A total of 28,139 adult patients with a witnessed nontraumatic OHCA were included, of whom 11,228 (39.9%) experienced an emergency medical service-witnessed OHCA (NFT = 0), 695 (2.7%) had a bystander-witnessed OHCA, and an NFT less than or equal to 5, and 16,216 (57.6%) with a bystander-witnessed OHCA and an NFT greater than 5.

INTERVENTIONS

Sensitivity, specificity, and likelihood ratios of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 minutes.

MEASUREMENTS AND MAIN RESULTS

The sensitivity of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 was poor (25% [95% CI, 25-26]), but specificity was moderate (70% [95% CI, 69-71]). The positive and likelihood ratios were inverted (negative accuracy) (positive likelihood ratio, 0.76 [95% CI, 0.74-0.79]; negative likelihood ratio, 1.12 [95% CI, 1.10-1.12]). Including only patients with a bystander-witnessed OHCA improved the sensitivity to 48% (95% CI, 45-52), the positive likelihood ratio to 1.45 (95% CI, 1.33-1.58), and the negative likelihood ratio to 0.77 (95% CI, 0.72-0.83), while slightly lowering the specificity to 67% (95% CI, 66-67).

CONCLUSIONS

Our analysis demonstrated that the presence of a shockable rhythm at the time of initial assessment was poorly sensitive and only moderately specific for OHCA patients with a short NFT. The initial rhythm, therefore, should not be used as a surrogate for NFT in clinical decision-making.

The effect of a structured ECPR protocol aided by specific simulation training in a quaternary ECMO centre: A retrospective pre-post study

Background

There is limited literature exploring the relationship between simulation training and extracorporeal cardiopulmonary resuscitation (ECPR) outcomes. We examined whether there was an association between the implementation of an in situ simulation training program and ECPR utilisation, time to extracorporeal membrane oxygenation (ECMO), and neurologically intact survival.

Methods

In this retrospective pre-post study of in-hospital cardiac arrests (IHCA) and out-of-hospital cardiac arrests (OHCA), we analysed data for all patients recorded as receiving ECPR from September 2009 to December 2020 at our institution, relative to the implementation of an in situ ECPR simulation training program and a standardised procedure for high-quality ECPR. The primary outcome was Cerebral Performance Category (CPC) 1 or 2 at hospital discharge.

Results

There were 27 patients in the pre-intervention period and 39 patients in the post-intervention period. The median ECPR rate per year was 2 pre-intervention and 7 post-intervention (p = 0.073). There was an association between the implementation of the program and decreased median time from OHCA to ECMO flow, from 87 (IQR 78–95) minutes pre-intervention to 70 (IQR 69–72) minutes post-intervention (p = 0.002). Median time from IHCA to ECMO flow was 40 (IQR 20–75) minutes pre-intervention and 28 (IQR 16–41) minutes post-intervention (p = 0.134). Survival with CPC 1 or 2 was 7/27 (25.9%) pre-intervention and 15/39 (38.5%) post-intervention (p = 0.288).

Conclusion

We observed an association between the implementation of an ECPR-specific simulation program and decreased time from OHCA to ECMO flow. There was no association between the implementation of the program and neurologically intact survival at hospital discharge.

Changes of Key Rate-Limiting Enzyme Activity in Glucose Metabolism After Cardiopulmonary Resuscitation

OBJECTIVES

To investigate the activity of key rate-limiting enzymes of glucose metabolism after restoration of spontaneous circulation (ROSC), to explore the potential pathophysiological mechanism of impaired myocardial energy metabolism after cardiopulmonary resuscitation (CPR).

METHODS

Twenty-one male Sprague-Dawley rats were randomized into three experimental groups assigned in accordance with different observation times after ROSC: Sham, instrumented rats without induced cardiac arrest or resuscitation; post-resuscitation (PR2 h); PR24 h. In these groups, CPR, including precordial compressions and synchronized mechanical ventilation, was initiated 6 min after asphyxia-induced cardiac arrest. Hearts were harvested after ROSC and samples were used to detect high-energy phosphate and glucose metabolic enzyme activity.

RESULTS

Compared with sham, the contents of phosphocreatine and adenosine triphosphate reduced in the PR2 h group, while remained unchanged in the PR24 h group. Activities of hexokinase and pyruvate kinase did not change after ROSC. Phosphofructokinase activity decreased only in the PR24 h group. Activities of pyruvate dehydrogenase and citrate synthase fell in PR2 h group and recovered in the PR24 h group. However, isocitrate dehydrogenase and α-ketoglutarate dehydrogenase activities fell in the PR2 h group, but did not recover in the PR24 h group.

CONCLUSIONS

Lowered key rate-limiting enzymes activity in glucose metabolism resulted in impairment of energy production in the early stage of ROSC, but partially recovered in 24 h. This process has a role in the mechanism of impaired myocardial energy metabolism after CPR. This investigation might shed light on new strategies to treat post resuscitation myocardial dysfunction.

Out of hospital cardiac arrest in Western Sydney-an analysis of outcomes and estimation of future eCPR eligibility

Background

Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres.

Methods

A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly.

Results

In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n = 58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within “office hours” and no case obtained a return of spontaneous circulation standard advanced life support.

Conclusions

In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.

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.

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

IMPORTANCE

Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and treatment (invasive strategy) is beneficial in this setting remains uncertain.

OBJECTIVE

To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival.

DESIGN, SETTING, AND PARTICIPANTS

Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021).

INTERVENTIONS

In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132).

MAIN OUTCOMES AND MEASURES

The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category [CPC] 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours).

RESULTS

The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 [17%] women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio [OR], 1.63 [95% CI, 0.93 to 2.85]; difference, 9.5% [95% CI, -1.3% to 20.1%]; P = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 [95% CI, 1.11 to 3.57]; difference, 12.4% [95% CI, 1.9% to 22.7%]; P = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 [95% CI, 0.91 to 2.47]; difference, 9.4% [95% CI, -2.5% to 21%]; P = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively).

CONCLUSIONS AND RELEVANCE

Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01511666.

Successful Coil Embolization Using Percutaneous Cardiopulmonary Support in a Patient with Refractory Out-of-hospital Cardiac Arrest Caused by Aneurysmal Subarachnoid Hemorrhage

In recent years, extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to be an effective alternative to conventional CPR for treating patients with reversible causes of cardiac arrest. Nevertheless, the definite indication for ECPR and also surgical interventions during ECPR treatment have not been established, especially in patients with out-of-hospital cardiac arrest (OHCA) caused by subarachnoid hemorrhage (SAH). We treated a comatose 50-year-old woman with refractory cardiac arrest due to aneurysmal SAH-induced takotsubo cardiomyopathy (TCM). The initial cardiac rhythm was ventricular fibrillation. This is the first case report on coil embolization being successfully performed on a patient undergoing ECPR and therapeutic hypothermia (TH) while the patient was still in cardiac arrest, which resulted in complete social rehabilitation. Moreover, the success of this treatment suggests that ECPR and endovascular therapy should be considered for highly selected patients when cardiopulmonary and neurological functions are potentially reversible even in the setting of SAH.

Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support

The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.

Extracorporeal life support in adult patients with out-of-hospital cardiac arrest

The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.

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).

Hydrogen gas with extracorporeal cardiopulmonary resuscitation improves survival after prolonged cardiac arrest in rats

BACKGROUND

Despite the benefits of extracorporeal cardiopulmonary resuscitation (ECPR) in cohorts of selected patients with cardiac arrest (CA), extracorporeal membrane oxygenation (ECMO) includes an artificial oxygenation membrane and circuits that contact the circulating blood and induce excessive oxidative stress and inflammatory responses, resulting in coagulopathy and endothelial cell damage. There is currently no pharmacological treatment that has been proven to improve outcomes after CA/ECPR. We aimed to test the hypothesis that administration of hydrogen gas (H₂) combined with ECPR could improve outcomes after CA/ECPR in rats.

METHODS

Rats were subjected to 20 min of asphyxial CA and were resuscitated by ECPR. Mechanical ventilation (MV) was initiated at the beginning of ECPR. Animals were randomly assigned to the placebo or H₂ gas treatment groups. The supplement gas was administered with O₂ through the ECMO membrane and MV. Survival time, electroencephalography (EEG), brain functional status, and brain tissue oxygenation were measured. Changes in the plasma levels of syndecan-1 (a marker of endothelial damage), multiple cytokines, chemokines, and metabolites were also evaluated.

RESULTS

The survival rate at 4 h was 77.8% (7 out of 9) in the H₂ group and 22.2% (2 out of 9) in the placebo group. The Kaplan-Meier analysis showed that H₂ significantly improved the 4 h-survival endpoint (log-rank P = 0.025 vs. placebo). All animals treated with H₂ regained EEG activity, whereas no recovery was observed in animals treated with placebo. H₂ therapy markedly improved intra-resuscitation brain tissue oxygenation and prevented an increase in central venous pressure after ECPR. H₂ attenuated an increase in syndecan-1 levels and enhanced an increase in interleukin-10, vascular endothelial growth factor, and leptin levels after ECPR. Metabolomics analysis identified significant changes at 2 h after CA/ECPR between the two groups, particularly in D-glutamine and D-glutamate metabolism.

CONCLUSIONS

H₂ therapy improved mortality in highly lethal CA rats rescued by ECPR and helped recover brain electrical activity. The underlying mechanism might be linked to protective effects against endothelial damage. Further studies are warranted to elucidate the mechanisms responsible for the beneficial effects of H₂ on ischemia-reperfusion injury in critically ill patients who require ECMO support.

Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock

The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.

Extracorporeal Cardiopulmonary Resuscitation and Survival After Refractory Cardiac Arrest: Is ECPR Beneficial?

The level of evidence of expert recommendations for starting extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) is low. Therefore, we reported our experience in the field to identify factors associated with hospital mortality. We conducted a retrospective cohort study of all consecutive patients treated with ECPR for refractory cardiac arrest without return to spontaneous circulation, regardless of cause, at the Caen University Hospital. Factors associated with hospital mortality were analyzed. Eighty-six patients (i.e., 35 OHCA and 51 IHCA) were included. The overall hospital mortality rate was 81% (i.e., 91% and 75% in the OHCA and IHCA groups, respectively). Factors independently associated with mortality were: sex, age > 44 years, and time from collapse until extracorporeal life support (ECLS) initiation. Interestingly, no-shockable rhythm was not associated with mortality. The receiver operating characteristic-area under the curve values of pH value (0.75 [0.60-0.90]) and time from collapse until ECLS initiation over 61 minutes (0.87 [0.76-0.98]) or 74 minutes (0.90 [0.80-1.00]) for predicting hospital mortality showed good discrimination performance. No-shockable rhythm should not be considered a formal exclusion criterion for ECPR. Time from collapse until ECPR initiation is the cornerstone of success of an ECPR strategy in refractory cardiac arrest.

Protective effect of extracorporeal membrane pulmonary oxygenation combined with cardiopulmonary resuscitation on post-resuscitation lung injury

BACKGROUND

Cardiac arrest (CA) is a critical condition that is a concern to healthcare workers. Comparative studies on extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) technologies have shown that ECPR is superior to CCPR. However, there is a lack of studies that compare the protective effects of these two resuscitative methods on organs. Therefore, we aim to perform experiments in swine models of ventricular fibrillation-induced CA to study whether the early application of ECPR has advantages over CCPR in the lung injury and to explore the protective mechanism of ECPR on the post-resuscitation pulmonary injury.

METHODS

Sixteen male swine were randomized to CCPR (CCPR; n=8; CCPR alone) and ECPR (ECPR; n=8; extracorporeal membrane oxygenation with CCPR) groups, with the restoration of spontaneous circulation at 6 hours as an endpoint.

RESULTS

For the two groups, the survival rates between the two groups were not statistically significant (P>0.05), the blood and lung biomarkers were statistically significant (P<0.05), and the extravascular lung water and pulmonary vascular permeability index were statistically significant (P<0.01). Compared with the ECPR group, electron microscopy revealed mostly vacuolated intracellular alveolar type II lamellar bodies and a fuzzy lamellar structure with widening and blurring of the blood-gas barrier in the CCPR group.

CONCLUSIONS

ECPR may have pulmonary protective effects, possibly related to the regulation of alveolar surface-active proteins and mitigated oxidative stress response post-resuscitation.

Membrane Lung and Blood Pump Use During Prolonged Extracorporeal Membrane Oxygenation: Trends From 2002 to 2017

Extracorporeal life support (ECLS) has grown in its application since its first clinical description in the 1970s. The technology has been used to support a wide variety of mechanical support modalities and diseases, including respiratory failure, cardiorespiratory failure, and cardiac failure. Over many decades and safety and efficacy studies, followed by randomized clinical trials and thousands of clinical uses, ECLS is considered as an accepted treatment option for severe pulmonary and selected cardiovascular failure. Extracorporeal life support involves the use of support artificial organs, including a membrane lung and blood pump. Over time, changes in the technology and the management of ECLS support devices have evolved. This manuscript describes the use of membrane lungs and blood pumps used during ECLS support from 2002 to 2017 in over 65,000 patients reported to the Extracorporeal Life Support Organization Registry. Device longevity and complications associated with membrane lungs and blood pump are described and stratified by age group: neonates, pediatrics, and adults.

A Pragmatic Parallel Group Implementation Study of a Prehospital-Activated ECPR Protocol for Refractory Out-of-Hospital Cardiac Arrest

OBJECTIVES

Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival among patients with refractory out-of-hospital cardiac arrest (OHCA). We evaluated outcomes after incorporating ECPR into a conventional resuscitation system.

METHODS

We introduced a prehospital-activated ECPR protocol for select refractory OHCAs into one of four metropolitan regions in British Columbia. We prospectively identified ECPR-eligible patients in both the ECPR region and the three other regions to serve as the control group. We compared the proportion with favorable neurological outcomes at hospital discharge (cerebral performance category ≤2) and used logistic regression to estimate the association with treatment region.

RESULTS

The study was terminated prematurely due to changes in hospital protocols and COVID-19. In the ECPR region, 15/58 (25.9%) patients had favourable neurological outcomes owing to conventional resuscitation and 2/58 (3.4%) owing to ECPR, for a total of 17/58 (29.3%). In the control regions, 67/250 (26.8%) patients had a favourable outcome owing to conventional resuscitation, for a between-group difference of 2.5% (95% CI -10 to 15%). We did not detect a statistically significant association between treatment region and outcomes.

CONCLUSION

In this prematurely-terminated study of ECPR for refractory OHCA, we did not detect an association between a regional ECPR protocol and neurologically favorable outcomes. However, our data suggests that outcomes owing to conventional resuscitation were similar, with the potential for additional survivors due to ECPR therapies.