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Rajsic S, Treml B, Rugg C, Innerhofer N, Eckhardt C, Breitkopf R. Organ Utilization From Donors Following Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review of Graft and Recipient Outcome. Transplantation 2024:00007890-990000000-00816. [PMID: 39020459 DOI: 10.1097/tp.0000000000005133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
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.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2023; 148:e120-e146. [PMID: 37551611 DOI: 10.1161/cir.0000000000001125] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
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.
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2023; 190:109864. [PMID: 37548950 DOI: 10.1016/j.resuscitation.2023.109864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
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.
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Naito H, Sakuraya M, Hongo T, Takada H, Yumoto T, Yorifuji T, Hifumi T, Inoue A, Sakamoto T, Kuroda Y, Nakao A. Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation. Crit Care 2023; 27:252. [PMID: 37370155 DOI: 10.1186/s13054-023-04534-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR. METHODS We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined. RESULTS We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p < 0.001). Primary cerebral disorders as cause of cardiac arrest and higher severity of illness at intensive care unit admission were associated with WLST decisions. CONCLUSION For approximately one-third of ECPR/OHCA patients, WLST was decided during admission, mainly because of perceived unfavorable neurological prognoses. Decisions and neurological assessments for ECPR/OHCA patients need further analysis.
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Affiliation(s)
- Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan.
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-0042, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Hiroaki Takada
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo, 190-0014, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Akashi, Chuo, Tokyo, 104-8560, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakihamakaigandori, Chuo, Kobe, Hyogo, 651-0073, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi, Tokyo, 173-8606, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
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Latsios G, Leopoulou M, Synetos A, Karanasos A, Papanikolaou A, Bounas P, Stamatopoulou E, Toutouzas K, Tsioufis K. Cardiac arrest and cardiopulmonary resuscitation in “hostile” environments: Using automated compression devices to minimize the rescuers’ danger. World J Cardiol 2023; 15:45-55. [PMID: 36911750 PMCID: PMC9993930 DOI: 10.4330/wjc.v15.i2.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/25/2023] [Accepted: 02/15/2023] [Indexed: 02/21/2023] Open
Abstract
Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual, “hands-on”, rescuer-delivered chest compressions. The -theoretical- advantages include high-quality non-stop compressions, thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially “hazardous” victim, or from hazardous and/or difficult resuscitation conditions. Such circumstances involve cardiopulmonary resuscitation (CPR) in the Cardiac Catheterization Laboratory, especially directly under the fluoroscopy panel, where radiation is well known to cause detrimental effects to the rescuer, and CPR during/after land or air transportation of cardiac arrest victims. Lastly, CPR in a coronavirus disease 2019 patient/ward, where the danger of contamination and further serious illness of the health provider is very existent. The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these “hostile” and dangerous settings, while comparing them to manual compressions.
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Affiliation(s)
- George Latsios
- 1st University Department of Cardiology, "Hippokration" University Hospital, Athens Medical School, Athens 11527, Greece
| | - Marianna Leopoulou
- 1st Cardiology Clinic, 'Hippokration' University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
- Department of Cardiology, "Elpis" Athens General Hospital, Athens 11522, Greece
| | - Andreas Synetos
- 1st Department of Cardiology, Athens Medical School, University Athens, Hippokrat Hospital, Athens 11527, Greece
| | - Antonios Karanasos
- 1st University Department of Cardiology, "Hippokration" University Hospital, Athens Medical School, Athens 11527, Greece
| | - Angelos Papanikolaou
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital, Athens 11527, Greece
| | - Pavlos Bounas
- Department of Cardiology, “Thriasio” General Hospital, Thriasio General Hospital, Elefsina 19600, Greece
| | - Evangelia Stamatopoulou
- CathLab, 2nd Department of Cardiology, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Attikon University Hospital, Athens 12462, Greece
| | | | - Kostas Tsioufis
- 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, “Hippokration” General Hospital, "Hippokration" University Hospital, Athens 11527, Greece
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Lim WH, Dominguez-Gil B. Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors. Semin Nephrol 2022; 42:151269. [PMID: 36577644 DOI: 10.1016/j.semnephrol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With the continuing disparity between organ supply to match the increasing demand for kidney transplants in patients with renal failure, donation after the circulatory determination of death (DCDD) has become an important and increasing global source of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor kidney transplants were inferior to those obtained from donors declared dead by neurologic criteria has largely diminished because large-scale registry and single-center reports consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants, outcomes are correspondingly acceptable, although there is a greater risk of primary nonfunction. The potential of DCDD remains unrealized in many countries because of the ethical concerns and resource implications in the utilization of these donor kidneys for transplantation. In this review, we discuss the origin and definitions of DCDD donors, and examine the long-term outcomes of transplants from DCDD donor kidneys. We discuss the controversies, challenges, and ethical and legal barriers in the acceptance of DCDD, including the complexities of implementing and sustaining controlled and uncontrolled DCDD donor programs. The lessons learned from global leaders will assist a wider international recognition, acceptance, and development of DCDD transplant programs that will noticeably facilitate and address the global shortages of kidneys for transplantation, and ensure the opportunity for people who had indicated their desires to become organ donors fulfill their final wishes.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; Internal Medicine, University of Western Australia Medical School, Perth, Australia.
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Brewer JM, Tran A, Yu J, Ali MI, Poulos CM, Gates J, Gluck J, Underhill D. ECMO after cardiac surgery: a single center study on survival and optimizing outcomes. J Cardiothorac Surg 2021; 16:264. [PMID: 34538270 PMCID: PMC8451085 DOI: 10.1186/s13019-021-01638-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center.
Methods This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent cardiac surgery and required peri-operative ECMO. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n = 53, 88.3%), venous-venous (VV) (n = 5, 8.3%) or venous-arterial-venous (VAV) (n = 2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. Results In-hospital mortality was 60.7% (n = 37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p < 0.001) with longer hospital stays (35 ± 4.0 vs 20 ± 1.5, p < 0.03). Survivors required fewer blood products (13 ± 2.3 vs 25 ± 2.3, p = 0.02) with a net negative fluid balance (− 3.5 ± 1.6 vs 3.4 ± 1.6, p = 0.01). Cardiac re-operations worsened survival. Conclusion ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.
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Affiliation(s)
- Jennifer M Brewer
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA.
| | - Anthony Tran
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Jielin Yu
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - M Irfan Ali
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Constantine M Poulos
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Jonathan Gates
- Division of Trauma and Acute Care Surgery, Hartford Healthcare, Hartford, USA
| | - Jason Gluck
- Department of Cardiology and Mechanical Circulatory Support, Hartford Healthcare, Hartford, USA
| | - David Underhill
- Division of Cardiac Surgery, Hartford Healthcare, Hartford, USA
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Schou A, Mølgaard J, Andersen LW, Holm S, Sørensen M. Ethics in extracorporeal life support: a narrative review. Crit Care 2021; 25:256. [PMID: 34289885 PMCID: PMC8293515 DOI: 10.1186/s13054-021-03689-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
During 50 years of extracorporeal life support (ECLS), this highly invasive technology has left a considerable imprint on modern medicine, and it still confronts researchers, clinicians and policymakers with multifarious ethical challenges. After half a century of academic discussion about the ethics of ECLS, it seems appropriate to review the state of the argument and the trends in it. Through a comprehensive literature search on PubMed, we identified three ethical discourses: (1) trials and evidence accompanying the use of ECLS, (2) ECLS allocation, decision-making and limiting care, and (3) death on ECLS and ECLS in organ donation. All included articles were carefully reviewed, arguments extracted and grouped into the three discourses. This article provides a narrative synthesis of these arguments, evaluates the opportunities for mediation and substantiates the necessity of a shared decision-making approach at the limits of medical care. ![]()
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Affiliation(s)
- Alexandra Schou
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
| | - Jesper Mølgaard
- Centre for Cancer and Organ Diseases, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Lars Willy Andersen
- Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Søren Holm
- Department of Law, School of Social Sciences, Faculty of Humanities, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Marc Sørensen
- Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
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Latsios G, Leopoulou M, Synetos A, Karanasos A, Melidi E, Toutouzas K, Tsioufis K. The role of automated compression devices in out-of- and in- hospital cardiac arrest. Can we spare rescuers’ hands? EMERGENCY CARE JOURNAL 2021. [DOI: 10.4081/ecj.2021.9525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.
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Weiss MJ, van Beinum A, Harvey D, Chandler JA. Ethical considerations in the use of pre-mortem interventions to support deceased organ donation: A scoping review. Transplant Rev (Orlando) 2021; 35:100635. [PMID: 34174656 DOI: 10.1016/j.trre.2021.100635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
AIM Pre-mortem interventions (PMIs) are performed on patients before the determination of death in order to preserve or enhance the possibility of organ donation. These interventions can be ethically controversial, and we thus undertook a scoping review of the ethical issues surrounding diverse PMIs. METHODS Using modified scoping review methods, we executed a search strategy created by an information specialist. Screening and iterative coding of each article was done by two researchers using qualitative thematic analysis, and narrative summaries of coded themes were presented. RESULTS We identified and screened 5365 references and coded 196 peer-reviewed publications. The most frequently cited issues were related to possible harms to the patient who is a potential donor, and legitimacy of consent. The most controversial issue was that PMIs may place patients at risk for physical harm, yet benefit is accrued mainly to recipients. Some authors argued that lack of direct medical benefit to the still living patient precluded valid consent from surrogate decision makers (SDMs), while many stated that some medical risk could be approved by SDMs if it aligns with non-medical benefits valued by the patient. CONCLUSION PMIs require consensus that benefit includes concepts beyond medical benefit to the patient who is a potential donor. Informed consent must be confirmed for each PMI and not assumed to be part of general consent for donation. Risk must be proportionate to the potential benefit and newly proposed interventions should be reviewed carefully for medical efficacy and potential risks.
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Affiliation(s)
- Matthew J Weiss
- Transplant Québec, 4100 Rue Molson #200, Montréal, QC H1Y 3N1, Canada; Canadian Donation and Transplantation Research Program (CDTRP), Room 6002, Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB T6G 2E1, Canada; Division of Pediatric Intensive Care, Centre Mère-Enfant Soleil du CHU de Québec, 2705 boul Laurier, Québec, Québec, Canada.
| | - Amanda van Beinum
- Canadian Donation and Transplantation Research Program (CDTRP), Room 6002, Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB T6G 2E1, Canada; Department of Sociology and Anthropology, B750 Loeb Building, Carleton University, 1125 Colonel By Drive, Ottawa, ON K1S 5B6, Canada
| | - Dan Harvey
- Nottingham University Hospital NHS Trust, Derby Road, Nottingham NG72UH, UK; University of Nottingham, University Park, Nottingham NG72RD, UK; National Health Services Blood & Transplant, Fox Den Road, Stoke Gifford, Avon, Bristol BS348RR, UK
| | - Jennifer A Chandler
- Canadian Donation and Transplantation Research Program (CDTRP), Room 6002, Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB T6G 2E1, Canada; Bertram Loeb Research Chair, University of Ottawa, 57 Louis Pasteur St., Ottawa, Ontario K1N 6N5, Canada; Centre for Health Law, Policy and Ethics, Faculty of Law, University of Ottawa, 57 Louis Pasteur St., Ottawa, Ontario K1N 6N5, Canada.
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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Abstract
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.
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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14
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Cacic K, Bonomo J. NeuroEthics and End of Life Care. Emerg Med Clin North Am 2020; 39:217-225. [PMID: 33218659 DOI: 10.1016/j.emc.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.
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Affiliation(s)
- Kelsey Cacic
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Mail Location 0525, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, USA.
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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15
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Enumah ZO, Carrese J, Choi CW. The Ethics of Extracorporeal Membrane Oxygenation: Revisiting the Principles of Clinical Bioethics. Ann Thorac Surg 2020; 112:61-66. [PMID: 34159900 DOI: 10.1016/j.athoracsur.2020.08.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/27/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Extracorporeal life support has become accepted as a rescue therapy for cardiopulmonary shock, and there have been over 100,000 extracorporeal membrane oxygenation (ECMO) cases since 1987. Rapid growth has presented ethical challenges and concerns. Here, we discuss core principles of bioethics in an attempt to more thoroughly appreciate the ethical concerns and considerations raised by use of this technology. METHODS An extensive literature review was performed on current papers on ECMO and ethics. In this paper, we utilized 3 case studies to highlight 4 major tenets of bioethics as they relate to use of ECMO: autonomy, beneficence, nonmaleficence, and justice. RESULTS Case studies presented involved unique perspectives on utilization of ECMO and a careful balance of benefits and harms as they relate to autonomy, beneficence, nonmaleficence and justice. We present nuanced interpretations of autonomy (eg, physician autonomy) and justice (eg, various providers interpret and offer ECMO differently). An additional challenge includes contending with potentially prolonged clinical courses and/or complications that either result directly from cannulation for ECMO or indirectly from being subject to ensuing extreme conditions and prolongation of life that medical science has yet to fully understand. CONCLUSIONS ECMO programs continue to grow in number and capacity. A deep appreciation of the bioethical dimensions of this technology and its application must be pursued, understood and applied to individual patient scenarios.
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Affiliation(s)
| | - Joseph Carrese
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
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16
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Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, Levy A, Lin Y, Magid DJ, Mahgoub M, Peberdy MA, Rodriguez AJ, Sasson C, Lavonas EJ. Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S580-S604. [PMID: 33081524 DOI: 10.1161/cir.0000000000000899] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.
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17
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Seidlein AH, Hannich A, Nowak A, Gründling M, Salloch S. Ethical aspects of time in intensive care decision making. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2019-105752. [PMID: 32332151 DOI: 10.1136/medethics-2019-105752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting.
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Affiliation(s)
- Anna-Henrikje Seidlein
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Arne Hannich
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Andre Nowak
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle(Saale), Germany
| | - Matthias Gründling
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Sabine Salloch
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
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18
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19
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Molina M, Domínguez-Gil B, Pérez-Villares JM, Andrés A. Uncontrolled donation after circulatory death: ethics of implementation. Curr Opin Organ Transplant 2019; 24:358-363. [PMID: 31090649 DOI: 10.1097/mot.0000000000000648] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite its potential to increase the donor pool, uncontrolled donation after circulatory death (uDCD) is available in a limited number of countries. Ethical concerns may preclude the expansion of this program. This article addresses the ethical concerns that arise in the implementation of uDCD. RECENT FINDINGS The first ethical concern is that associated with the determination of an irreversible cardiac arrest. Professionals must strictly adhere to local protocols and international standards on advanced cardiopulmonary resuscitation, independent of their participation in an uDCD program. Cardiac compression and mechanical ventilation are extended beyond futility during the transportation of potential uDCD donors to the hospital with the sole purpose of preserving organs. Importantly, potential donors remain monitored while being transferred to the hospital, which allows the identification of any return of spontaneous circulation. Moreover, this procedure allows the determination of death to be undertaken in the hospital by an independent health care provider who reassesses that no other therapeutic interventions are indicated and observes a period of the complete absence of circulation and respiration. Extracorporeal-assisted cardiopulmonary resuscitation programs can successfully coexist with uDCD programs. The use of normothermic regional perfusion with ECMO devices for the in-situ preservation of organs is considered appropriate in a setting in which the brain is subject to profound and prolonged ischemic damage. Finally, communication with relatives must be transparent and accurate, and the information should be provided respecting the time imposed by the family's needs and emotions. SUMMARY uDCD can help increase the availability of organs for transplantation while giving more patients the opportunity to donate organs after death. The procedures should be designed to confront the ethical challenges that this practice poses and respect the values of all those involved.
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Affiliation(s)
- María Molina
- Department of Nephrology, Hospital Universitario '12 de Octubre'
- Department of Nephrology, Hospital Universitario Arnau de Vilanova
- Institut de Recerca Biomèdica, Lleida
| | | | - José M Pérez-Villares
- Coordinación Sectorial de Trasplantes de Granada, Servicio de Medicina Intensiva Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario '12 de Octubre'
- Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid
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20
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Gardiner D, Shaw DM, Kilcullen JK, Dalle Ave AL. Intensive care for organ preservation: A four-stage pathway. J Intensive Care Soc 2019; 20:335-340. [PMID: 31695738 DOI: 10.1177/1751143719840254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation. Analysis When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified. Conclusion The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.
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Affiliation(s)
- Dale Gardiner
- Adult Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Jack K Kilcullen
- Medical Critical Care Services, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
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21
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Anticoagulation Levels and Bleeding After Emergency Department Extracorporeal Cardiopulmonary Resuscitation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Rojas SV, Haverich A. [Heart failure: ventricular assist devices and cardiac transplantation : A review of current surgical innovations]. Chirurg 2019; 90:110-116. [PMID: 30607463 DOI: 10.1007/s00104-018-0774-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND End-stage heart failure is one of the leading causes of death in Germany. Cardiac transplantation is still considered the gold standard for the treatment of terminal heart failure; however, there is a discrepancy between patients on the waiting list and yearly performed transplantations. As an alternative, ventricular assist devices have achieved a high level of importance but treatment is still associated with challenges. Novel systems as well as innovative surgical techniques contribute to improving the safety and effectiveness of the treatment. OBJECTIVE To generate an overview of current surgical innovations in cardiac transplantation and mechanical circulatory support. MATERIAL AND METHODS A Medline search was conducted regarding innovations in cardiac transplantation and mechanical circulatory support. RESULTS AND CONCLUSION Not only the number of yearly performed cardiac transplantations has changed but also recipient profiles. While in the pioneering era of transplantation the typical candidate was young, not previously operated on and with lower levels of comorbidities, today's patients are significantly older, have been fitted with ventricular assist devices and have increased operative risk profiles. Modern methods of organ preservation enable longer transportation and operation times as well as an improved assessment of graft function and perspectives for graft optimization in the future. In the area of ventricular assist devices, advances in the reduction of the stroke rate seem to have been achieved by the latest generation devices. From a surgical perspective, less invasive surgical techniques with promising initial results have been established at numerous centers.
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Affiliation(s)
- S V Rojas
- Klinik für Herz‑, Thorax‑, Transplantations- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - A Haverich
- Klinik für Herz‑, Thorax‑, Transplantations- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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23
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Del Río F, Andrés A, Padilla M, Sánchez-Fructuoso AI, Molina M, Ruiz Á, Pérez-Villares JM, Peiró LZ, Aldabó T, Sebastián R, Miñambres E, Pita L, Casares M, Galán J, Vidal C, Terrón C, Castro P, Sanroma M, Coll E, Domínguez-Gil B. Kidney transplantation from donors after uncontrolled circulatory death: the Spanish experience. Kidney Int 2018; 95:420-428. [PMID: 30579725 DOI: 10.1016/j.kint.2018.09.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 10/27/2022]
Abstract
Donation after uncontrolled circulatory death (uDCD) refers to donation from persons who have died following cardiac arrest and unsuccessful attempt at resuscitation. We report the Spanish experience of uDCD kidney transplantation, and identify factors related to short-term post-transplant outcomes. The Spanish CORE system compiles data on all donation and transplant procedures in the country. Between 2012-2015, 517 kidney transplants from 288 uDCD donors were performed. The incidence of primary non-function was 10%, and the incidence of delayed graft function was 76%. One-year death-censored graft survival was 87%. In a Cox-Model, donor age ≥ 60 years (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.2-6.1), in situ cooling of kidneys versus normothermic regional perfusion (OR 5.6; 95% CI 2.7-11.5) or hypothermic regional perfusion based on the use of extracorporeal membrane oxygenation devices (OR 4.3; 95% CI 2.1-8.6), and a recipient history of prior kidney transplant (OR 3.5; 95% CI 1.5-8.3) all significantly increased the risk of graft loss during the first year after transplantation. Kidney transplantation from uDCD donors provides acceptable 1-year outcomes, although there is room for improvement. Hypothermic and normothermic regional perfusion strategies are preferable to in situ cooling of kidneys from uDCD donors.
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Affiliation(s)
| | - Amado Andrés
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - María Molina
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Teresa Aldabó
- Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Lidia Pita
- Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | | | - Juan Galán
- Hospital Universitario y Politécnico de la Fe, Valencia, Spain
| | | | | | - Pablo Castro
- Regional Coordination of the Autonomous Community of Andalucía, Sevilla, Spain
| | - Marga Sanroma
- Regional Coordination of the Autonomous Community of Cataluña, Barcelona, Spain
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24
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Roncon-Albuquerque R, Gaião S, Figueiredo P, Príncipe N, Basílio C, Mergulhão P, Silva S, Honrado T, Cruz F, Pestana M, Oliveira G, Meira L, França A, Almeida-Sousa JP, Araújo F, Paiva JA. An integrated program of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation and uncontrolled donation after circulatory determination of death in refractory cardiac arrest. Resuscitation 2018; 133:88-94. [PMID: 30321624 DOI: 10.1016/j.resuscitation.2018.10.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
AIM To assess the feasibility of an integrated program of extracorporeal cardiopulmonary resuscitation (ECPR) and uncontrolled donation after circulatory determination of death (uDCDD) in refractory cardiac arrest (rCA). METHODS Single center, prospective, observational study of selected patients with in-hospital (IHCA) and out-of-hospital (OHCA) rCA occurring in an urban area of ∼1.5 million inhabitants, between October-2016 and May-2018. 65 year old or younger patients without significant bleeding or comorbidities with witnessed nonasystolic cardiac arrests were triaged to ECPR if they had a reversible cause and high quality CPR lasting < 60 min. Otherwise they were considered for uDCDD after a ten minute no touch period using normothermic regional perfusion. RESULTS 58 patients were included, of which 41 (71%) were OHCA and 18 (31%) had ECPR initiated. Median age was 52 (IQR 45-56) years. Cannulation was successful in 49/58 (84%) cases. Compared to ECPR, patients referred for uDCDD were more frequently OHCA (90 vs. 28%), had bystander CPR (28 vs. 83%) and prolonged low-flow period (40 (35-50) vs. 60 (49-78) min). Survival to hospital discharge with full neurological recovery (cerebral performance category 1) occurred in 6/18 (33%) ECPR patients. uDCDD resulted in transplantation of 44 kidneys. CONCLUSIONS An integrated program for rCA consisting of a formal pathway to uDCDD referral in ECPR ineligible patients is feasible. ECPR-referred patients had a reasonable survival with full neurologic recovery. Successful kidney transplantation was achieved with uDCDD.
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Affiliation(s)
- Roberto Roncon-Albuquerque
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal.
| | - Sérgio Gaião
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Portugal
| | - Paulo Figueiredo
- Department of Infectious Diseases, São João Hospital Centre, Porto, Portugal
| | - Nuno Príncipe
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Carla Basílio
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Paulo Mergulhão
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Portugal
| | - Sofia Silva
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Teresa Honrado
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Francisco Cruz
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal; Department of Urology, São João Hospital Centre, Porto, Portugal; i3S: Instituto de Investigação e Inovação em Saúde, Portugal
| | - Manuel Pestana
- Department of Medicine, Faculty of Medicine, University of Porto, Portugal; Department of Nephrology, São João Hospital Centre, Porto, Portugal; Nephrology and Infectious Diseases R&D Group, Instituto de Investigação e Inovação em Saúde (INEB-i3S), Universidade do Porto, Portugal
| | - Gerardo Oliveira
- Department of Medicine, Faculty of Medicine, University of Porto, Portugal; Organ Donation and Transplant Coordination Office, São João Hospital Centre, Porto, Portugal
| | - Luis Meira
- National Institute of Medical Emergency, Portugal
| | - Ana França
- Portuguese Institute for Blood and Transplantation, Portugal
| | | | | | - José-Artur Paiva
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Portugal
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25
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Abstract
PURPOSE OF REVIEW Difficult discussions regarding end-of-life care are common in neurocritical care. Because of a patient's neurological impairment, decisions regarding continuing or limiting aggressive care must often be made by patients' families in conjunction with medical providers. This review provides perspective on three major aspects of this circumstance: prognostication, family-physician discussions, and determination of death (specifically as it impacts on organ donation). RECENT FINDINGS Numerous studies have now demonstrated that prediction models developed from populations of brain-injured patients may be misleading when applied to individual patients. Early care limitations may lead to the self-fulfilling prophecy of poor outcomes because of care decisions rather than disease course. A shared decision-making approach that emphasizes transmission of information and trust between families and medical providers is ethically appropriate in severely brain-injured patients and as part of the transition to end-of-life palliative care. Standard definitions of death by neurological criteria exist, although worldwide variation and the relationship to organ donation make this complex. SUMMARY End-of-life care in patients with severe brain injuries is common and represents a complex intersection of prognostication, family communication, and decision-making. Skills to optimize this should be emphasized in neurocritical care providers.
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26
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Poole K, Couper K, Smyth MA, Yeung J, Perkins GD. Mechanical CPR: Who? When? How? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:140. [PMID: 29843753 PMCID: PMC5975402 DOI: 10.1186/s13054-018-2059-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/10/2018] [Indexed: 12/12/2022]
Abstract
In cardiac arrest, high quality cardiopulmonary resuscitation (CPR) is a key determinant of patient survival. However, delivery of effective chest compressions is often inconsistent, subject to fatigue and practically challenging. Mechanical CPR devices provide an automated way to deliver high-quality CPR. However, large randomised controlled trials of the routine use of mechanical devices in the out-of-hospital setting have found no evidence of improved patient outcome in patients treated with mechanical CPR, compared with manual CPR. The limited data on use during in-hospital cardiac arrest provides preliminary data supporting use of mechanical devices, but this needs to be robustly tested in randomised controlled trials. In situations where high-quality manual chest compressions cannot be safely delivered, the use of a mechanical device may be a reasonable clinical approach. Examples of such situations include ambulance transportation, primary percutaneous coronary intervention, as a bridge to extracorporeal CPR and to facilitate uncontrolled organ donation after circulatory death. The precise time point during a cardiac arrest at which to deploy a mechanical device is uncertain, particularly in patients presenting in a shockable rhythm. The deployment process requires interruptions in chest compression, which may be harmful if the pause is prolonged. It is recommended that use of mechanical devices should occur only in systems where quality assurance mechanisms are in place to monitor and manage pauses associated with deployment. In summary, mechanical CPR devices may provide a useful adjunct to standard treatment in specific situations, but current evidence does not support their routine use.
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Affiliation(s)
- Kurtis Poole
- Warwick Medical School, University of Warwick, Coventry, UK.,South Central Ambulance Service NHS Foundation Trust, Bicester, UK
| | - Keith Couper
- Warwick Medical School, University of Warwick, Coventry, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael A Smyth
- Warwick Medical School, University of Warwick, Coventry, UK.,West Midlands Ambulance Service NHS Foundation Trust, Brierly Hill, UK
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK. .,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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27
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Dalle Ave AL, Shaw DM, Elger B. Practical Considerations in Donation After Circulatory Determination of Death in Switzerland. Prog Transplant 2017; 27:291-294. [PMID: 29187117 DOI: 10.1177/1526924817715458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Faced with similar issues of organ scarcity to its neighbors, Switzerland has developed donation after circulatory determination of death (DCDD) as a way to expand the organ pool since 1985. Here, we analyze the history, practical considerations, and ethical issues relating to the Swiss donation after circulatory death programs. In Switzerland, determination of death for DCDD requires a stand-off period of 10 minutes. This time between cardiac arrest and the declaration of death is mandated in the guidelines of the Swiss Academy of Medical Sciences. As in other DCDD programs, safeguards are put to avoid physicians denying lifesaving treatment to savable patients because of being influenced by receivers' interest. An additional recommendation could be made: Recipients should be transparently informed of the worse graft outcomes with DCDD programs and given the possibility to refuse such organs.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,2 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,3 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - David M Shaw
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice Elger
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,4 Centre for Legal Medicine, University of Geneva, Geneva, Switzerland
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28
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Lazaridis C. Resuscitation Versus Donation: Conflict, Priority, and Rational Consent. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:27-29. [PMID: 28430062 DOI: 10.1080/15265161.2017.1299242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Christos Lazaridis
- a Baylor College of Medicine and Baylor College of Medicine Medical Center
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Bernat JL. Declare Death or Attempt Experimental Resuscitation? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:17-19. [PMID: 28430067 DOI: 10.1080/15265161.2017.1299249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Rodríguez-Arias D, Wilkinson D, Youngner S. How Can You Be Transparent About Labeling the Living as Dead? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:24-25. [PMID: 28430057 DOI: 10.1080/15265161.2017.1299243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Dalle Ave AL, Bernat JL. Uncontrolled Donation After Circulatory Determination of Death: A Systematic Ethical Analysis. J Intensive Care Med 2016; 33:624-634. [PMID: 28296536 DOI: 10.1177/0885066616682200] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient's condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,2 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - James L Bernat
- 3 Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Marton-Popovici M, Glogar D. New Developments in the Treatment of Acute Myocardial Infarction Associated with Out-of-Hospital Cardiac Arrest. A Review. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2016. [DOI: 10.1515/jce-2016-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Out-of-hospital cardiac arrest (OHCA) occurring as the first manifestation of an acute myocardial infarction is associated with very high mortality rates. As in comatose patients the etiology of cardiac arrest may be unclear, especially in cases without ST-segment elevation on the surface electrocardiogram, the decision to perform or not to perform urgent coronary angiography can have a significant impact on the prognosis of these patients. This review summarises the current knowledge and recommendations for treating patients with acute myocardial infarction presenting with OHCA. New therapeutic measures for the post-resuscitation phase are presented, such as hypothermia or extracardiac life support, together with strategies aiming to restore the coronary flow in the resuscitation phase using intra-arrest percutaneous revascularization performed during resuscitation. The role of regional networks in providing rapid access to the hospital facilities and to a catheterization laboratory for these critical cardiovascular emergencies is described.
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Affiliation(s)
- Monica Marton-Popovici
- Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, United States of America
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Benedek T, Popovici MM, Glogar D. Extracorporeal Life Support and New Therapeutic Strategies for Cardiac Arrest Caused by Acute Myocardial Infarction - a Critical Approach for a Critical Condition. ACTA ACUST UNITED AC 2016; 2:164-174. [PMID: 29967856 DOI: 10.1515/jccm-2016-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/20/2016] [Indexed: 12/14/2022]
Abstract
This review summarizes the most recent developments in providing advanced supportive measures for cardiopulmonary resuscitation, and the results obtained using these new therapies in patients with cardiac arrest caused by acute myocardial infarction (AMI). Also detailed are new approaches such as extracorporeal cardiopulmonary resuscitation (ECPR), intra-arrest percutaneous coronary intervention, or the regional models for systems of care aiming to reduce the critical times from cardiac arrest to initiation of ECPR and coronary revascularization.
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Affiliation(s)
- Theodora Benedek
- University of Medicine and Pharmacy Tirgu Mures, Clinic of Cardiology, Tirgu Mures, Romania
| | - Monica Marton Popovici
- Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, USA
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Manara AR, Dominguez-Gil B, Pérez-Villares JM, Soar J. What follows refractory cardiac arrest: Death, extra-corporeal cardiopulmonary resuscitation (E-CPR), or uncontrolled donation after circulatory death? Resuscitation 2016; 108:A3-A5. [PMID: 27614286 DOI: 10.1016/j.resuscitation.2016.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Alexander R Manara
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, Bristol BS10 5NB, United Kingdom.
| | - Beatriz Dominguez-Gil
- Organización Nacional de Trasplantes, C/Sinesio Delgado 6, pabellón 3, 28029 Madrid, Spain
| | - Jose Miguel Pérez-Villares
- Division of Critical Care Medicine, Neurocritical Care Unit, Complejo Hospitalario, Universitario de Granada, Avenida del Conocimiento 33, 18016 Granada, Spain
| | - Jasmeet Soar
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, Bristol BS10 5NB, United Kingdom
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