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Silvio Taccone F, Minini A, Avalli L, Alm-Kruse K, Annoni F, Bougouin W, Burrell A, Cariou A, Coppalini G, Grunau B, Hifumi T, Heng Yen H, Jouven X, Seung Jung J, Lorusso R, Maekawa K, Rasalingam Mørk S, Rob D, Schober A, Shah AP, Emily Stoll S, Suverein MM, Nakashima T, Cg Vande Poll M, Yannopoulos D, Young Kim W, Belohlavek J. Impact of extracorporeal cardiopulmonary resuscitation on neurological prognosis and survival in adult patients after cardiac arrest: an individual pooled patient data meta-analysis. Resuscitation 2024:110357. [PMID: 39142468 DOI: 10.1016/j.resuscitation.2024.110357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/03/2024] [Accepted: 08/07/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND We aimed to estimate the effect of extracorporeal cardiopulmonary resuscitation (ECPR) on neurological outcome and mortality, when compared to conventional cardiopulmonary resuscitation (CCPR), using an individual patient data meta-analysis (IPDMA). METHODS A systematic literature search was performed up to the 20th of October 2022 in the PubMed, EMBASE and CENTRAL databases. For observational studies with unmatched populations, a propensity score including age, location of arrest and initial rhythm was used to match ECPR and CCPR patients in a 1:1 ratio. The primary and secondary outcomes were unfavorable neurological outcome (Cerebral Performance Category of 3-5) and mortality, respectively, which were both collected at different time-points. RESULTS Data from 17 studies, including 2064 matched cardiac arrest (CA) patients (1031 ECPR and 1033 CCPR cases) were included. In comparison to CCPR, ECPR was associated with a decreased odds of unfavorable neurological outcome (847, 82.2% vs. 897, 86.8% - OR 0.68 [95%CI 0.53-0.87]; p=0.002) and death (803, 77.9% vs. 860, 83.3% - OR 0.68 [95%CI 0.54-0.86]; p=0.001). These results were consistent across most of the prespecified subgroups. Moreover, the odds of both unfavorable neurological outcome and mortality were significantly influenced by initial rhythm, cause of arrest and combinations of lactate levels on admission and duration of resuscitation. CONCLUSIONS This IPDMA showed that ECPR was associated with significantly lower rates of unfavorable neurological outcome and mortality in refractory CA. The overall effect could be influenced by CA characteristics and the severity of the initial injury.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care Hôpital Universitaire de Bruxelles (HUB) Université Libre de Bruxelles (ULB) Brussels, Belgium.
| | - Andrea Minini
- Department of Intensive Care Hôpital Universitaire de Bruxelles (HUB) Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Leonello Avalli
- Cardiac Surgery Anesthesia and Intensive Care Fondazione IRCCS San Gerardo Monza, Italy
| | - Kristin Alm-Kruse
- Department of Research and Development Division of Emergencies and Critical Care Oslo University Hospital Oslo, Norway
| | - Filippo Annoni
- Department of Intensive Care Hôpital Universitaire de Bruxelles (HUB) Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Wulfran Bougouin
- Paris Cardiovascular Research Center (PARCC) INSERM Unit 970 Paris, France; Ramsay Générale de Santé Hôpital Privé Jacques Cartier Massy, France; Paris Sudden Death Expertise Center Paris, France
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC) Department of Epidemiology and Preventive Medicine Monash University, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine The Alfred Hospital, Melbourne, Victoria, Australia
| | - Alain Cariou
- Faculté de Santé - Université Paris Cité, APHP Centre Paris, France; Medical Intensive Care Unit Cochin Hospital AP-HP Centre Université Paris Cité Paris, France
| | - Giacomo Coppalini
- Department of Intensive Care Hôpital Universitaire de Bruxelles (HUB) Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Brian Grunau
- Departments of Emergency Medicine St. Paul's Hospital and the University of British Columbia Vancouver, Canada
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo, Japan
| | - Hsu Heng Yen
- Department of Emergency Medicine Changhua Christian Hospital Changua, Taiwan
| | - Xavier Jouven
- Department of Cardiology and Global Health European Georges Pompidou Hospital Paris Descartes University Paris, France
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery Anam Hospital, Korea University Medical Center Seoul, Republic of Korea
| | - Roberto Lorusso
- Heart & Vascular Centre Maastricht University Medical Centre (MUMC+) Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Maastricht, The Netherlands
| | - Kunihiko Maekawa
- Department of Traumatology and Critical Care Medicine Sapporo Medical University School of Medicine Sapporo, Japan
| | | | - Daniel Rob
- 2(nd) Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital Prague, Czech Republic
| | - Andreas Schober
- Department of Cardiology Karl Landsteiner Institute for Cardiovascular and Critical Care Research Clinic Floridsdorf Vienna, Austria
| | - Atman P Shah
- Department of Medicine The University of Chicago Chicago, United States of America
| | - Sandra Emily Stoll
- Department of Intensive Care and Hyperbaric Medicine The Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Intensive Care Medicine University of Cologne Faculty of Medicine and University Hospital Cologne, Germany
| | - Martje M Suverein
- Department of Intensive Care Maastricht University Medical Centre Maastricht, Netherlands
| | - Takahiro Nakashima
- Department of Emergency Medicine University of Michigan Ann Arbor, United States of America
| | - Marcel Cg Vande Poll
- Department of Intensive Care Maastricht University Medical Centre Maastricht, Netherlands
| | - Demetrios Yannopoulos
- Center for Resuscitation University of Minnesota School of Medicine Minneapolis, United States of America
| | - Won Young Kim
- Department of Emergency Medicine University of Ulsan College of Medicine Asan Medical Center Seoul, South Korea
| | - Jan Belohlavek
- 2(nd) Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital Prague, Czech Republic
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Sami SZ, Hasan M, Murtaza M, Hanif ZM, Nazir A. Letter to the editor: Role of extracorporeal life support for traumatic hemopericardium: A single level I trauma center review. Injury 2024:111796. [PMID: 39147640 DOI: 10.1016/j.injury.2024.111796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/03/2024] [Indexed: 08/17/2024]
Abstract
While this study sheds light on the valuable clinical outcomes regarding the use of extracorporeal life support (ECLS) in managing traumatic hemopericardium, I would like to emphasize a few critical areas that would improve the study's findings.
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Affiliation(s)
- Syeda Zuha Sami
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara, Karachi, Pakistan.
| | - Myrah Hasan
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara, Karachi, Pakistan
| | - Muzna Murtaza
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara, Karachi, Pakistan
| | - Zainab Muhammad Hanif
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara, Karachi, Pakistan
| | - Ariba Nazir
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara, Karachi, Pakistan
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3
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Koguchi H, Takayama W, Otomo Y, Morishita K, Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Differences in outcomes of patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation between day-time and night-time. Sci Rep 2024; 14:16950. [PMID: 39043770 PMCID: PMC11266344 DOI: 10.1038/s41598-024-67275-4] [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] [Received: 01/17/2024] [Accepted: 07/09/2024] [Indexed: 07/25/2024] Open
Abstract
Although patients who underwent night-time resuscitation for out-of-hospital cardiac arrest (OHCA) had worse clinical outcomes than those who underwent day-time resuscitation, the differences between the outcomes of patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR) in the day-time and night-time remain unclear. We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan. Patients were categorized according to whether they received treatment during the day-time or night-time. The primary outcomes were survival to hospital discharge and favorable neurological outcome at discharge, and the secondary outcomes were estimated low-flow time, implementation time of ECPR, and complications due to ECPR. A multivariate logistic regression model adjusted for confounders was used for comparison. Among the 1644 patients, the night-time patients had a significantly longer ECMO implementation time and estimated low-flow time than the day-time patients, along with a significantly higher number of complications than the day-time patients. However, the survival and neurologically favorable survival rates did not differ significantly between the groups. Thus, although patients who underwent ECPR at night had an increased risk of longer implementation time and complications, their clinical outcomes did not differ from those who underwent day-time ECPR.
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Affiliation(s)
- Hazuki Koguchi
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tokyo, Japan.
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan.
| | - Wataru Takayama
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tokyo, Japan
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Koji Morishita
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
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4
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Tonna JE, Cho SM. Extracorporeal Cardiopulmonary Resuscitation. Crit Care Med 2024; 52:963-973. [PMID: 38224260 PMCID: PMC11098703 DOI: 10.1097/ccm.0000000000006185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Sung-Min Cho
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Division of Neuroscience Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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5
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Gutierrez A, Kalra R, Chang KY, Steiner ME, Marquez AM, Alexy T, Elliott AM, Nowariak M, Yannopoulos D, Bartos JA. Bleeding and Thrombosis in Patients With Out-of-Hospital Ventricular Tachycardia/Ventricular Fibrillation Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation. J Am Heart Assoc 2024; 13:e034516. [PMID: 38700025 PMCID: PMC11179947 DOI: 10.1161/jaha.123.034516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation improves outcomes after out-of-hospital cardiac arrest. However, bleeding and thrombosis are common complications. We aimed to describe the incidence and predictors of bleeding and thrombosis and their association with in-hospital mortality. METHODS AND RESULTS Consecutive patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest between December 2015 and March 2022 who met the criteria for extracorporeal cardiopulmonary resuscitation initiation at our center were included. Major bleeding was defined by the Extracorporeal Life Support Organization's criteria. Adjusted analyses were done to seek out risk factors for bleeding and thrombosis and evaluate their association with mortality. Major bleeding occurred in 135 of 200 patients (67.5%), with traumatic bleeding from cardiopulmonary resuscitation in 73 (36.5%). Baseline demographics and arrest characteristics were similar between groups. In multivariable analysis, decreasing levels of fibrinogen were independently associated with bleeding (adjusted hazard ratio [aHR], 0.98 per every 10 mg/dL rise [95% CI, 0.96-0.99]). Patients who died had a higher rate of bleeds per day (0.21 versus 0.03, P<0.001) though bleeding was not significantly associated with in-hospital death (aHR, 0.81 [95% CI. 0.55-1.19]). A thrombotic event occurred in 23.5% (47/200) of patients. Venous thromboembolism occurred in 11% (22/200) and arterial thrombi in 15.5% (31/200). Clinical characteristics were comparable between groups. In adjusted analyses, no risk factors for thrombosis were identified. Thrombosis was not associated with in-hospital death (aHR, 0.65 [95% CI, 0.42-1.03]). CONCLUSIONS Bleeding is a frequent complication of extracorporeal cardiopulmonary resuscitation that is associated with decreased fibrinogen levels on admission whereas thrombosis is less common. Neither bleeding nor thrombosis was significantly associated with in-hospital mortality.
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Affiliation(s)
- Alejandra Gutierrez
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Rajat Kalra
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Kevin Y Chang
- Department of Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Marie E Steiner
- Division of Hematology and Oncology, Department of Pediatrics University of Minnesota School of Medicine Minneapolis MN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics University of Minnesota School of Medicine Minneapolis MN
| | - Alexandra M Marquez
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics University of Minnesota School of Medicine Minneapolis MN
| | - Tamas Alexy
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Andrea M Elliott
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | | | - Demetris Yannopoulos
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Jason A Bartos
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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Condella A, Simpson NS, Bilodeau KS, Stewart B, Mandell S, Taylor M, Heather B, Bulger E, Johnson NJ, Prekker ME. Implementation of Extracorporeal CPR Programs for Out-of-Hospital Cardiac Arrest: Another Tale of Two County Hospitals. Ann Emerg Med 2024:S0196-0644(24)00005-2. [PMID: 38323952 DOI: 10.1016/j.annemergmed.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is a form of intensive life support that has seen increasing use globally to improve outcomes for patients who experience out-of-hospital cardiac arrest (OHCA). Hospitals with advanced critical care capabilities may be interested in launching an ECPR program to offer this support to the patients they serve; however, to do so, they must first consider the significant investment of resources necessary to start and sustain the program. The existing literature describes many single-center ECPR programs and often focuses on inpatient care and patient outcomes in hospitals with cardiac surgery capabilities. However, building a successful ECPR program and using this technology to support an individual patient experiencing refractory cardiac arrest secondary to a shockable rhythm depends on efficient out-of-hospital and emergency department (ED) management. This article describes the process of implementing 2 intensivist-led ECPR programs with limited cardiac surgery capability. We focus on emergency medical services and ED clinician roles in identifying patients, mobilizing resources, initiation and management of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the ED, and ongoing efforts to improve ECPR program quality. Each center experienced a significant learning curve to reach goals of arrest-to-flow times of cannulation for ECPR. Building consensus from multidisciplinary stakeholders, including out-of-hospital stakeholders; establishing shared expectations of ECPR outcomes; and ensuring adequate resource support for ECPR activation were all key lessons in improving our ECPR programs.
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Affiliation(s)
- Anna Condella
- Department of Emergency Medicine, University of Washington, Seattle, WA; Trauma & ECLS Programs, Harborview Medical Center, University of Washington, Seattle, WA.
| | | | - Kyle S Bilodeau
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Barclay Stewart
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Samuel Mandell
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Mark Taylor
- Trauma & ECLS Programs, Harborview Medical Center, University of Washington, Seattle, WA
| | - Beth Heather
- Critical Care Nursing, Hennepin County Medical Center, Minneapolis, MN
| | - Eileen Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; Department of Medicine, Hennepin Healthcare, Minneapolis, MN
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8
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Ciullo AL, Tonna JE. The state of emergency department extracorporeal cardiopulmonary resuscitation: Where are we now, and where are we going? J Am Coll Emerg Physicians Open 2024; 5:e13101. [PMID: 38260003 PMCID: PMC10800292 DOI: 10.1002/emp2.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged in the context of the emergency department as a life-saving therapy for patients with refractory cardiac arrest. This review examines the utility of ECPR based on current evidence gleaned from three pivotal trials: the ARREST trial, the Prague study, and the INCEPTION trial. We also discuss several considerations in the care of these complex patients, including prehospital strategy, patient selection, and postcardiac arrest management. Collectively, the evidence from these trials emphasizes the growing significance of ECPR as a viable intervention, highlighting its potential for improved outcomes and survival rates in patients with refractory cardiac arrest when employed judiciously. As such, these findings advocate the need for further research and protocol development to optimize its use in diverse clinical scenarios.
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Affiliation(s)
- Anna L. Ciullo
- Division of Cardiothoracic SurgeryDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtahUSA
- Division of Emergency MedicineDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Joseph E. Tonna
- Division of Cardiothoracic SurgeryDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtahUSA
- Division of Emergency MedicineDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtahUSA
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Tanaka S, Tachibana S, Toyohara T, Sonoda H, Yamakage M. Venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation: A retrospective study comparing the outcomes of fluoroscopy. Heliyon 2024; 10:e24565. [PMID: 38304838 PMCID: PMC10831723 DOI: 10.1016/j.heliyon.2024.e24565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/21/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Background Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation is performed for out-of-hospital cardiac arrest; however, it is associated with a risk of several complications. Objective To investigate whether the fluoroscopy equipment was removed from the emergency department (ED) and whether it would be beneficial to transport the patient to the fluoroscopy room to reduce vascular complications without affecting the induction time. Methods This single-center, retrospective, before-and-after analysis was conducted at a tertiary emergency medical center and included 59 patients who underwent ECPR for out-of-hospital cardiac arrest between May 2017 and March 2022. The patients were divided into two groups: those who underwent cannulation in the ED without fluoroscopy (ED-ECPR group) and those who were transferred directly from the ED to the cardiac angiography room (ECPR call group). Results The rate of vascular complications associated with ECPR was significantly lower in the ECPR group than in the ED-ECPR group (40.6 % [14/32] vs. 10 % [2/20], respectively; p = 0.014). The duration from ED arrival to venoarterial extracorporeal membrane oxygenation initiation was similar in the two groups (median: 23.0 min in the ED-ECPR group vs. 25.5 min in the ECPR call group, p = 0.71). Results adjusted for confounding factors showed that performing ECPR under fluoroscopy was a consistent and independent element of vascular complication rates (adjusted odds ratio: 9.92, 95 % confidence interval: 2.04 to 81.2, p = 0.011). Conclusions Fluoroscopy-guided ECPR can significantly reduce the incidence of vascular complications even if the ED and fluoroscopy room are far apart. However, no significant difference was observed in the time required to establish ECPR in the cardiac catheterization laboratories.
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Affiliation(s)
- Soichi Tanaka
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
- Department of Anesthesiology, Kushiro City General Hospital, Japan
| | - Shunsuke Tachibana
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
| | - Takashi Toyohara
- Department of Emergency Medicine, Kushiro City General Hospital, Japan
| | - Hajime Sonoda
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
- Department of Anesthesiology, Kushiro City General Hospital, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
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Isokawa S, Hifumi T, Hirano K, Watanabe Y, Horie K, Shin K, Shirasaki K, Goto M, Inoue A, Sakamoto T, Kuroda Y, Tomita S, Otani N, Group TSJIS. Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study. Ann Intensive Care 2024; 14:16. [PMID: 38280965 PMCID: PMC10821854 DOI: 10.1186/s13613-024-01253-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database. METHODS This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013-2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes. RESULTS A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count (< 10 × 104/μL vs > 10 × 104/μL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252-2.777], p = 0.002). CONCLUSIONS In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety.
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Affiliation(s)
- Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan.
| | - Keita Hirano
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yu Watanabe
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Katsuhiro Horie
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kijong Shin
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kasumi Shirasaki
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Masahiro Goto
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | | | - Norio Otani
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
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11
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Brandorff M, Owyang CG, Tonna JE. Extracorporeal membrane oxygenation for cardiac arrest: what, when, why, and how. Expert Rev Respir Med 2023; 17:1125-1139. [PMID: 38009280 PMCID: PMC10922429 DOI: 10.1080/17476348.2023.2288160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/22/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) facilitated resuscitation was first described in the 1960s, but only recently garnered increased attention with large observational studies and randomized trials evaluating its use. AREAS COVERED In this comprehensive review of extracorporeal cardiopulmonary resuscitation (ECPR), we report the history of resuscitative ECMO, terminology, circuit configuration and cannulation considerations, complications, selection criteria, implementation and management, and important considerations for the provider. We review the relevant guidelines, different approaches to cannulation, postresuscitation management, and expected outcomes, including neurologic, cardiac, and hospital survival. Finally, we advocate for the participation in national/international Registries in order to facilitate continuous quality improvement and support scientific discovery in this evolving area. EXPERT OPINION ECPR is the most disruptive technology in cardiac arrest resuscitation since high-quality CPR itself. ECPR has demonstrated that it can provide up to 30% increased odds of survival for refractory cardiac arrest, in tightly restricted systems and for select patients. It is also clear, though, from recent trials that ECPR will not confer this high survival when implemented in less tightly protocoled settings and within lower volume environments. Over the next 10 years, ECPR research will explore the optimal initiation thresholds, best practices for implementation, and postresuscitation care.
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Affiliation(s)
- Matthew Brandorff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Clark G. Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
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Tran A, Rochwerg B, Fan E, Belohlavek J, Suverein MM, Poll MCGVD, Lorusso R, Price S, Yannopoulos D, MacLaren G, Ramanathan K, Ling RR, Thiara S, Tonna JE, Shekar K, Hodgson CL, Scales DC, Sandroni C, Nolan JP, Slutsky AS, Combes A, Brodie D, Fernando SM. 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. Resuscitation 2023; 193:110004. [PMID: 37863420 DOI: 10.1016/j.resuscitation.2023.110004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/22/2023]
Abstract
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.
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Affiliation(s)
- Alexandre Tran
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jan Belohlavek
- 2(nd) Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Martje M Suverein
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Susanna Price
- Royal Brompton & Harefield Hospitals, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Demetris Yannopoulos
- Division of Cardiology and Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sonny Thiara
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Joseph E Tonna
- Departments of Emergency Medicine and Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane and Bond University, Gold Coast, Queensland, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care-Research Centre, Monash University, Melbourne, Australia
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Claudio Sandroni
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Institut de Cardiologie, Paris, France
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
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13
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Sugita S, Obata M, Hasunuma F, Sakamoto A. Intraoperative cardiac arrest caused by unexpected vasospastic angina requiring prolonged resuscitation using extracorporeal membrane oxygenation: a case report. JA Clin Rep 2023; 9:77. [PMID: 37940795 PMCID: PMC10632342 DOI: 10.1186/s40981-023-00667-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Vasospastic angina (VSA) occurring during surgery is rare but can lead to sudden intraoperative cardiac arrest. CASE PRESENTATION A 77-year-old man with hypertension, and no history of coronary artery disease, displayed an abrupt ST-segment elevation on the electrocardiogram (ECG) during laparoscopic inguinal hernia surgery under general anesthesia. Subsequently, ventricular fibrillation (VF) occurred, with a finding suggesting ischemic myocardial contracture by transesophageal echocardiography. VF was refractory to cardiopulmonary resuscitation (CPR), and veno-arterial extracorporeal membrane oxygenation (VA ECMO) was introduced. Spontaneous circulation resumed 77 min post-cardiac arrest. VSA was confirmed through the patient's clinical course and coronary angiography. Subsequently, VA ECMO was terminated, and the patient was discharged uneventfully. CONCLUSIONS Extracorporeal CPR may be a valuable alternative to extended resuscitation for refractory ventricular arrhythmias by VSA.
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Affiliation(s)
- Shinji Sugita
- Department of Anesthesiology, Nippon Medical School Musashi-kosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-8533, Japan.
| | - Masanobu Obata
- Department of Anesthesiology, Nippon Medical School Musashi-kosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-8533, Japan
| | - Fumihiko Hasunuma
- Department of Anesthesiology, Nippon Medical School Musashi-kosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-8533, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
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14
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Tonna JE. How confidently can we prognosticate survival when starting ECPR? Resuscitation 2023; 192:109972. [PMID: 37734701 PMCID: PMC10642582 DOI: 10.1016/j.resuscitation.2023.109972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA.
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Kook Kang J, Kalra A, Ameen Ahmad S, Kumar Menta A, Rando HJ, Chinedozi I, Darby Z, Spann M, Keller SP, J. R. Whitman G, Cho SM. A recommended preclinical extracorporeal cardiopulmonary resuscitation model for neurological outcomes: A scoping review. Resusc Plus 2023; 15:100424. [PMID: 37719942 PMCID: PMC10500026 DOI: 10.1016/j.resplu.2023.100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 09/19/2023] Open
Abstract
Background Despite the high prevalence of neurological complications and mortality associated with extracorporeal cardiopulmonary resuscitation (ECPR), neurologically-focused animal models are scarce. Our objective is to review current ECPR models investigating neurological outcomes and identify key elements for a recommended model. Methods We searched PubMed and four other engines for animal ECPR studies examining neurological outcomes. Inclusion criteria were: animals experiencing cardiac arrest, ECPR/ECMO interventions, comparisons of short versus long cardiac arrest times, and neurological outcomes. Results Among 20 identified ECPR animal studies (n = 442), 13 pigs, 4 dogs, and 3 rats were used. Only 10% (2/20) included both sexes. Significant heterogeneity was observed in experimental protocols. 90% (18/20) employed peripheral VA-ECMO cannulation and 55% (11/20) were survival models (median survival = 168 hours; ECMO duration = 60 minutes). Ventricular fibrillation (18/20, 90%) was the most common method for inducing cardiac arrest with a median duration of 15 minutes (IQR = 6-20). In two studies, cardiac arrests exceeding 15 minutes led to considerable mortality and neurological impairment. Among seven studies utilizing neuromonitoring tools, only four employed multimodal devices to evaluate cerebral blood flow using Transcranial Doppler ultrasound and near-infrared spectroscopy, brain tissue oxygenation, and intracranial pressure. None examined cerebral autoregulation or neurovascular coupling. Conclusions The substantial heterogeneity in ECPR preclinical model protocols leads to limited reproducibility and multiple challenges. The recommended model includes large animals with both sexes, standardized pre-operative protocols, a cardiac arrest time between 10-15 minutes, use of multimodal methods to evaluate neurological outcomes, and the ability to survive animals after conducting experiments.
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Affiliation(s)
- Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Syed Ameen Ahmad
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
| | - Arjun Kumar Menta
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Hannah J. Rando
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Ifeanyi Chinedozi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Marcus Spann
- Informationist Services, Johns Hopkins School of Medicine, Baltimore, USA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
| | - Glenn J. R. Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
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16
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Zieger B, Schneider D, Brixius SJ, Scherer C, Buchwald A, Trummer G, Czerny M, Beyersdorf F, Busch HJ, Benk C, Pooth JS. Development of an in-vitro model for extracorporeal blood pumps to study the effects of artificial pulsatility on human blood. Front Med (Lausanne) 2023; 10:1237002. [PMID: 37711739 PMCID: PMC10497958 DOI: 10.3389/fmed.2023.1237002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction The application of extracorporeal circulation (ECC) systems is known to be associated with several implications regarding hemolysis, inflammation, and coagulation. In the last years, systems with pulsatile blood flow are increasingly used with the intention to improve hemodynamics in reperfusion. However, their implications on the aforementioned aspects remain largely unknown. To investigate the effects of pulsatility, this ex-vivo study was initiated. Methods Test circuits (primed with human whole blood) were set up in accordance with the recommendations of international standards for in-vitro evaluation of new components and systems of ECC. Diagonal pumps were either set up with non-pulsatile (n = 5, NPG) or pulsatile (n = 5, PG) pump settings and evaluated for 6 h. All analyses were conducted with human whole blood. Blood samples were repeatedly drawn from the test circuits and analyzed regarding free hemoglobin, interleukin 8 (IL-8), platelet aggregation and acquired von Willebrand syndrome (AVWS). Results After 1 h of circulation, a significant coagulation impairment (impaired platelet function and AVWS) was observed in both groups. After 6 h of circulation, increased IL-8 concentrations were measured in both groups (NPG: 0.05 ± 0.03 pg./mL, PG: 0.03 ± 0.01 pg./mL, p = 0.48). Pulsatile pump flow resulted in significantly increased hemolysis after 6 h of circulation (NPG: 37.3 ± 12.4 mg/100 L; PG: 59.6 ± 14.5 mg/100 L; p < 0.05). Conclusion Our results indicate that the coagulative impairment takes place in the early phase of ECC. Pulsatility did not affect the occurrence of AVWS ex-vivo. Prolonged durations of pulsatile pump flow led to increased hemolysis and therefore, its prolonged use should be employed cautiously in clinical practice with appropriate monitoring.
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Affiliation(s)
- Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Denise Schneider
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sam Joé Brixius
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Armin Buchwald
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hans-Jörg Busch
- Department of Emergency Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Emergency Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Macherey-Meyer S, Heyne S, Meertens MM, Braumann S, Niessen SF, Baldus S, Lee S, Adler C. Outcome of Out-of-Hospital Cardiac Arrest Patients Stratified by Pre-Clinical Loading with Aspirin and Heparin: A Retrospective Cohort Analysis. J Clin Med 2023; 12:3817. [PMID: 37298012 PMCID: PMC10253358 DOI: 10.3390/jcm12113817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Background: Out-of-hospital cardiac arrest (OHCA) has a high prevalence of obstructive coronary artery disease and total coronary occlusion. Consequently, these patients are frequently loaded with antiplatelets and anticoagulants before hospital arrival. However, OHCA patients have multiple non-cardiac causes and high susceptibility for bleeding. In brief, there is a gap in the evidence for loading in OHCA patients. Objective: The current analysis stratified the outcome of patients with OHCA according to pre-clinical loading. Material and Methods: In a retrospective analysis of an all-comer OHCA registry, patients were stratified by loading with aspirin (ASA) and unfractionated heparin (UFH). Bleeding rate, survival to hospital discharge and favorable neurological outcomes were measured. Results: Overall, 272 patients were included, of whom 142 were loaded. Acute coronary syndrome was diagnosed in 103 patients. One-third of STEMIs were not loaded. Conversely, 54% with OHCA from non-ischemic causes were pretreated. Loading was associated with increased survival to hospital discharge (56.3 vs. 40.3%, p = 0.008) and a more favorable neurological outcome (80.7 vs. 62.6% p = 0.003). Prevalence of bleeding was comparable (26.8 vs. 31.5%, p = 0.740). Conclusions: Pre-clinical loading did not increase bleeding rates and was associated with favorable survival. Overtreatment of OHCA with non-ischemic origin, but also undertreatment of STEMI-OHCA were documented. Loading without definite diagnosis of sustained ischemia is debatable in the absence of reliable randomized controlled data.
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Affiliation(s)
- Sascha Macherey-Meyer
- Clinic III for Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50931 Cologne, Germany; (S.H.); (M.M.M.); (S.B.); (S.F.N.); (S.B.); (S.L.); (C.A.)
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Sinning C, Zengin-Sahm E, Pöss J. „Extracorporeal cardiopulmonary resuscitation“ – derzeitiger Stand und Indikationen. Notf Rett Med 2023. [DOI: 10.1007/s10049-023-01129-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Ciullo AL, Tonna JE. ECPR may be the most effective intervention for refractory cardiac arrest-ever. Resuscitation 2022; 179:18-20. [PMID: 35931270 PMCID: PMC9644978 DOI: 10.1016/j.resuscitation.2022.07.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Anna L Ciullo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA.
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Tonna JE, Keenan HT, Weir C. A qualitative analysis of physician decision making in the use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest. Resusc Plus 2022; 11:100278. [PMID: 35898590 PMCID: PMC9309663 DOI: 10.1016/j.resplu.2022.100278] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
- Corresponding author at: 30 N 1900 E, 3C127, Salt Lake City, UT 84132, USA.
| | - Heather T. Keenan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
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Bernhard P, Bretthauer BA, Brixius SJ, Bügener H, Groh JE, Scherer C, Damjanovic D, Haberstroh J, Trummer G, Benk C, Beyersdorf F, Schilling O, Pooth JS. Serum proteome alterations during conventional and extracorporeal resuscitation in pigs. J Transl Med 2022; 20:238. [PMID: 35606879 PMCID: PMC9125930 DOI: 10.1186/s12967-022-03441-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/13/2022] [Indexed: 11/26/2022] Open
Abstract
Background Only a small number of patients survive an out-of-hospital cardiac arrest (CA) and can be discharged from hospital alive with a large percentage of these patients retaining neurological impairments. In recent years, extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a beneficial strategy to optimize cardiac arrest treatment. However, ECPR is still associated with various complications. To reduce these problems, a profound understanding of the underlying mechanisms is required. This study aims to investigate the effects of CA, conventional cardiopulmonary resuscitation (CPR) and ECPR using a whole-body reperfusion protocol (controlled and automated reperfusion of the whole body—CARL) on the serum proteome profiles in a pig model of refractory CA. Methods N = 7 pigs underwent 5 min of untreated CA followed by 30 min CPR and 120 min perfusion with CARL. Blood samples for proteomic analysis were drawn at baseline, after CPR and at the end of the CARL period. Following albumin-depletion, proteomic analysis was performed using liquid chromatography–tandem mass spectrometry. Results N = 21 serum samples were measured resulting in the identification and quantification of 308–360 proteins per sample and 388 unique proteins in total. The three serum proteome profiles at the investigated time points clustered individually and segregated almost completely when considering a 90% confidence interval. Differential expression analysis showed significant abundance changes in 27 proteins between baseline and after CPR and in 9 proteins after CARL compared to CPR. Significant findings were further validated through a co-abundance cluster analysis corroborating the observed abundance changes. Conclusions The presented data highlight the impact of systemic ischemia and reperfusion on the entire serum proteome during resuscitation with a special focus on changes regarding haemolysis, coagulation, inflammation, and cell-death processes. Generally, the observed changes contribute to post-ischemic complications. Better understanding of the underlying mechanisms during CA and resuscitation may help to limit these complications and improve therapeutic options. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03441-4.
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Affiliation(s)
- Patrick Bernhard
- Institute for Surgical Pathology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Spemann Graduate School of Biology and Medicine (SGBM), University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Berit Amelie Bretthauer
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Sam Joé Brixius
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Hannah Bügener
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Johannes Elias Groh
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jörg Haberstroh
- Department of Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Oliver Schilling
- Institute for Surgical Pathology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
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Tonna JE, Selzman CH, Bartos JA, Presson AP, Ou Z, Jo Y, Becker LB, Youngquist ST, Thiagarajan RR, Austin Johnson M, Cho SM, Rycus P, Keenan HT. The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest. Resuscitation 2022; 174:53-61. [PMID: 35331803 PMCID: PMC9050917 DOI: 10.1016/j.resuscitation.2022.03.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 01/19/2023]
Abstract
RESEARCH QUESTION Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival? METHODS Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival. RESULTS Hospital survival was decreased with higher PaO2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. CONCLUSION Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA. https://twitter.com/JoeTonnaMD
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Yeonjung Jo
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Lance B Becker
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
| | - Scott T Youngquist
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Austin Johnson
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Heather T Keenan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
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Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, Zhang C, Rycus P, Keenan HT. Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation. JACC Cardiovasc Interv 2022; 15:237-247. [PMID: 35033471 PMCID: PMC8837656 DOI: 10.1016/j.jcin.2021.09.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The aim of this study was to develop and validate a score to accurately predict the probability of death for adult extracorporeal cardiopulmonary resuscitation (ECPR). BACKGROUND ECPR is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20% to 40%. METHODS Adult patients with extracorporeal membrane oxygenation for IHCA (ECPR) were identified from the American Heart Association GWTG-R (Get With the Guidelines-Resuscitation) registry. A multivariate survival prediction model and score were developed to predict hospital death. Findings were externally validated in a separate cohort of patients from the Extracorporeal Life Support Organization registry who underwent ECPR for IHCA. RESULTS A total of 1,075 patients treated with ECPR were included. Twenty-eight percent survived to discharge in both the derivation and validation cohorts. A total of 6 variables were associated with in-hospital death: age, time of day, initial rhythm, history of renal insufficiency, patient type (cardiac vs noncardiac and medical vs surgical), and duration of the cardiac arrest event, which were combined into the RESCUE-IHCA (Resuscitation Using ECPR During IHCA) score. The model had good discrimination (area under the curve: 0.719; 95% CI: 0.680-0.757) and acceptable calibration (Hosmer and Lemeshow goodness of fit P = 0.079). Discrimination was fair in the external validation cohort (area under the curve: 0.676; 95% CI: 0.606-0.746) with good calibration (P = 0.66), demonstrating the model's ability to predict in-hospital death across a wide range of probabilities. CONCLUSIONS The RESCUE-IHCA score can be used by clinicians in real time to predict in-hospital death among patients with IHCA who are treated with ECPR.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA; Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lance B Becker
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, New York, USA
| | - Chong Zhang
- Division of Epidemiology, Department of Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan, USA
| | - Heather T Keenan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
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How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis. Am J Emerg Med 2021; 51:127-138. [PMID: 34735971 DOI: 10.1016/j.ajem.2021.08.072] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. METHODS We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. RESULTS We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. CONCLUSIONS Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.
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Gaisendrees C, Gerfer S, Ivanov B, Sabashnikov A, Merkle J, Luehr M, Schlachtenberger G, Walter SG, Eghbalzadeh K, Kuhn E, Djordjevic I, Wahlers T. Outcomes after mechanical versus manual chest compressions in eCPR patients. Expert Rev Med Devices 2021; 18:1023-1028. [PMID: 34424111 DOI: 10.1080/17434440.2021.1970528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (eCPR) is an established treatment option for cardiac arrest. Mechanical reanimation devices are increasingly used but have been associated with complications. This study evaluates typical injury patterns and differences after mechanical versus manual chest compressions among patients undergoing eCPR. METHODS From 2016 to 2020, 108 eCPR patients were retrospectively analyzed. Primary endpoints were traumatic, hemorrhagic, or inner organ-related complications, defined as pneumothorax, pulmonary bleeding, major bleeding, gastrointestinal bleeding, gastrointestinal ischemia, cardiac tamponade, aortic dissection, sternal or rib fracture. RESULTS 70 patients were treated with mechanical CPR (mCPR) and 38 with conventional CPR (cCPR). There were more CPR-related injuries in the mCPR group (55% vs. 83%, p = 0.01), CPR duration was longer (cCPR 40 ± 28 min vs. mCPR 69 ± 25 min, p = 0.01). There was no significant difference in mortality between the groups. CONCLUSION Mechanical CPR devices are associated with a higher incidence of traumatic and hemorrhagic injuries in patients undergoing eCPR.
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Affiliation(s)
- Christopher Gaisendrees
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Maximilian Luehr
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Georg Schlachtenberger
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Sebastian G Walter
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
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Gaisendrees C, Vollmer M, Walter SG, Djordjevic I, Eghbalzadeh K, Kaya S, Elderia A, Ivanov B, Gerfer S, Kuhn E, Sabashnikov A, Kahlert HA, Deppe AC, Kröner A, Mader N, Wahlers T. Management of out-of hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation in 2021. Expert Rev Med Devices 2021; 18:179-188. [PMID: 33538204 DOI: 10.1080/17434440.2021.1886076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Over the last decade, eCPR programs have become more and more popular, at least amongst high-volume centers. Despite its rise in popularity and promising outcome, strategies concerning pre- and post-implantation of VA-ECMO remain at least debatable. Besides, integrating the appropriate set-up, managing anticoagulation, implementing LV-venting, and predicting neurological outcome play important roles in caring for thise highly selective patient-collective. We sought to present our institutional´s techniques for establishing an eCPR program and managing patients peri- and post implantation in eCPR-runs. AREAS COVERED This manuscript covers the majority of clinical concerns and parameters for establishing an eCPR program and its recent advantages. We will describe a safe way of cannulation, setting anticoagulation goals, strategies for LV-venting and ICU-treatment. Also included, an elaboration on neurological and cardiac prognostication. EXPERT OPINION We advocate ultrasound-guided cannula placement in eCPR patients. Also, we emphasize the importance of using stiffer wires and smaller arterial cannula sizes due to the different physiological parameters of OHCA patients. After cannulation, we aim for lower flow goals, the concept of 'partial VA-ECMO,' and lower anticoagulatory targets. LV-venting with Impella should remain an individual case to case decision.
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Affiliation(s)
- Christopher Gaisendrees
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Matias Vollmer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Sebastian G Walter
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Süreyya Kaya
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ahmed Elderia
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Heike A Kahlert
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
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Chiumello D, Coppola S. Extracorporeal cardiopulmonary resuscitation: Don't miss the patient. Resuscitation 2020; 157:272-273. [PMID: 33171170 DOI: 10.1016/j.resuscitation.2020.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022]
Affiliation(s)
- D Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy; Centro Ricerca Coordinata di Insufficienza Respiratoria, Italy.
| | - S Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
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