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Stratton M, Edmunds K. Extracorporeal Cardiopulmonary Resuscitation: CME Review. Pediatr Emerg Care 2024; 40:618-620. [PMID: 39083660 DOI: 10.1097/pec.0000000000003178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
ABSTRACT Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly being used for refractory cardiac arrest for both in-hospital and out-of-hospital cardiac arrests. The term eCPR refers to cannulating a patient to an extracorporeal membrane oxygenation (ECMO) circuit to provide perfusion after cardiac arrest refractory to standard cardiopulmonary resuscitation. Extracorporeal cardiopulmonary resuscitation has been shown to offer increased survival benefit among a select group of adult and pediatric patients experiencing refractory cardiac arrests, both in hospital and out of hospital. Extracorporeal cardiopulmonary resuscitation should be considered when (1) the cardiac arrest is witnessed, (2) the patient receives high-quality cardiopulmonary resuscitation, (3) the patient is at or in close proximity to an ECMO center, (4) there is a reversible cause for the cardiac arrest where the perfusion from the ECMO circuit serves as a bridge to recovery, and (5) the treating facility has a robust multidisciplinary system in place to facilitate rapidly moving patients from site of arrest to site of cannulation to intensive care unit. To develop an eCPR system of care, a multidisciplinary team consisting of prehospital, emergency medicine, in-hospital, proceduralist, perfusionist, and intensive care medical professionals must be established who support the use of eCPR for refractory cardiac arrest. The future of eCPR is the development of systems of care that use eCPR for a narrow subset of pediatric out-of-hospital cardiac arrests.
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Plodr M, Chalusova E. Current trends in the management of out of hospital cardiac arrest (OHCA). Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:105-116. [PMID: 38441422 DOI: 10.5507/bp.2024.006] [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: 10/04/2023] [Accepted: 02/27/2024] [Indexed: 06/16/2024] Open
Abstract
Sudden cardiac arrest remains a relevant problem with a significant number of deaths worldwide. Although survival rates have more than tripled over the last 20 years (4% in 2001 vs. 14% in 2020), survival rates with good neurological outcomes remain persistently low, representing a major socioeconomic problem. Every minute of delay from patient collapse to start cardiopulmonary resuscitation (CPR) and early defibrillation reduces the chance of survival by approximately 10-12%. Therefore, the time to treatment is a crucial factor in the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Research teams working in the pre-hospital setting are therefore looking for ways to improve the transmission of information from the site of an emergency event and to make it easier for emergency medical dispatch centres (EMDC) to recognise life-threatening conditions with minimal deviation. For emergency unit procedures already at the scene of the event, methods are being sought to efficiently and temporarily replace a non-functioning cardiopulmonary system. In the case of traumatic cardiac arrest (TCA), the focus is mainly on effective affecting non-compressible haemorrhage.
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Affiliation(s)
- Michal Plodr
- Department of Emergency Medicine and Military General Medicine, Military Faculty of Medicine, University of Defence, Hradec Kralove, Czech Republic
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove, Czech Republic
| | - Eva Chalusova
- Department of Emergency Medicine and Military General Medicine, Military Faculty of Medicine, University of Defence, Hradec Kralove, Czech Republic
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Okada Y, Fujita K, Ogura T, Motomura T, Fukuyama Y, Banshotani Y, Tokuda R, Ijuin S, Inoue A, Takahashi H, Yokobori S. Novel and innovative resuscitation systems in Japan. Resusc Plus 2024; 17:100541. [PMID: 38260120 PMCID: PMC10801325 DOI: 10.1016/j.resplu.2023.100541] [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] [Indexed: 01/24/2024] Open
Abstract
Aim Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency that requires rapid and efficient intervention. Recently, several novel approaches have emerged and have been incorporated into resuscitation systems in some local areas of Japan. This review describes innovative resuscitation systems and highlights their strengths. Main text First, we discuss the deployment of a physician-staffed ambulance, in which emergency physicians offer advanced resuscitation to patients with OHCA on site. In addition, we describe the experimental practice of extracorporeal membrane oxygenation (ECPR) in a prehospital setting. Second, we describe a physician-staffed helicopter, wherein a medical team provides advanced resuscitation at the scene. We also explain their initiative to provide early ECPR, even in remote areas. Finally, we provide an overview of the "hybrid ER" system which is a "one-fits-all" resuscitation bay equipped with computed tomography and fluoroscopy equipment. This system is expected to help swiftly identify and rule out irreversible causes of cardiac arrest, such as massive subarachnoid hemorrhage, and implement ECPR without delay. Conclusion Although these revolutionary approaches may improve the outcomes of patients with OHCA, evidence of their effectiveness remains limited. In addition, it is crucial to ensure cost-effectiveness and sustainability. We will continue to work diligently to assess the effectiveness of these systems and focus on the development of cost-effective and sustainable systems.
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Affiliation(s)
- Yohei Okada
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Department of Preventive Services, Kyoto University, Kyoto, Japan
| | - Kensuke Fujita
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai Utsunomiya Hospital, Japan
| | - Takayuki Ogura
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai Utsunomiya Hospital, Japan
| | - Tomokazu Motomura
- Shock and Trauma Center/Hokusoh HEMS Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Yuita Fukuyama
- Shock and Trauma Center/Hokusoh HEMS Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Yuki Banshotani
- Tajima Emergency and Critical Care Medical Center, Hyogo, Japan
| | - Rina Tokuda
- Tajima Emergency and Critical Care Medical Center, Hyogo, Japan
| | - Shinichi Ijuin
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Hyogo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Hyogo, Japan
| | | | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Graduate School of Nippon Medical School, Tokyo, Japan
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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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Dennis M, Shekar K, Burrell AJ. Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in Australia: a narrative review. Med J Aust 2024; 220:46-53. [PMID: 37872830 DOI: 10.5694/mja2.52130] [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: 06/27/2023] [Accepted: 08/14/2023] [Indexed: 10/25/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) in patients with prolonged or refractory out-of-hospital cardiac arrest (OHCA) is likely to be beneficial when used as part of a well developed emergency service system. ECPR is technically challenging to initiate and resource-intensive, but it has been found to be cost-effective in hospital-based ECPR programs. ECPR expansion within Australia has thus far been reactive and does not provide broad coverage or equity of access for patients. Newer delivery strategies that improve access to ECPR for patients with OHCA are being trialled, including networked hospital-based ECPR and pre-hospital ECPR programs. The efficacy, scalability, sustainability and cost-effectiveness of these programs need to be assessed. There is a need for national collaboration to determine the most cost-effective delivery strategies for ECPR provision along with its place in the OHCA survival chain.
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Affiliation(s)
- Mark Dennis
- Royal Prince Alfred Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Kiran Shekar
- Prince Charles Hospital, Brisbane, QLD
- Critical Care Research Group and Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving Organ Support, University of Queensland, Brisbane, QLD
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Wengenmayer T, Tigges E, Staudacher DL. Extracorporeal cardiopulmonary resuscitation in 2023. Intensive Care Med Exp 2023; 11:74. [PMID: 37902904 PMCID: PMC10616028 DOI: 10.1186/s40635-023-00558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/20/2023] [Indexed: 11/01/2023] Open
Affiliation(s)
- Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Eike Tigges
- Department of Cardiology and Critical Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
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Carr CT, Becker TK. Out of hospital extracorporeal cardiopulmonary resuscitation: Maybe. Eur J Emerg Med 2023; 30:311-312. [PMID: 37598349 DOI: 10.1097/mej.0000000000001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Affiliation(s)
- Casey T Carr
- Division of Critical Care Medicine, Department of Emergency Medicine, College of Medicine, University of Florida, Florida, USA
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Jeung KW, Jung YH, Gumucio JA, Salcido DD, Menegazzi JJ. Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature. Clin Exp Emerg Med 2023; 10:265-279. [PMID: 37439142 PMCID: PMC10579726 DOI: 10.15441/ceem.23.063] [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: 05/24/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023] Open
Abstract
The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.
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Affiliation(s)
- Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jorge Antonio Gumucio
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David D. Salcido
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James J. Menegazzi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kruit N, Song C, Tian D, Moylan E, Dennis M. ECPR Survivor Estimates: A Simulation-Based Approach to Comparing ECPR Delivery Strategies. PREHOSP EMERG CARE 2023; 28:147-153. [PMID: 37364040 DOI: 10.1080/10903127.2023.2229912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
Objective: The number of out-of-hospital cardiac arrest (OHCA) patients who may benefit from prehospital extracorporeal cardiopulmonary resuscitation (ECPR) is yet to be elucidated. Patient eligibility is determined both by case characteristics and physical proximity to an ECPR service. We applied accessibility principles to historical cardiac arrest data, to identify the number of patients who would have been eligible for prehospital ECPR in Sydney, Australia, and the potential survival benefit had prehospital ECPR been available.Methods: The New South Wales cardiac arrest registry between January 2017 to June 2021 included 39,387 cardiac arrests. We retrospectively defined two groups: 1) possible ECPR eligible arrests that would have triggered activation of a team, and 2) ECPR eligible arrests, those arrests that met ECPR inclusion criteria and remained refractory. Transport accessibility modeling was used to ascertain the number of arrests that would have been served by a hypothetical prehospital service and the potential survival benefit.Results: There were 699 arrests screened as possibly ECPR eligible in the Sydney metropolitan area, 488 of whom were subsequently confirmed as ECPR eligible refractory OHCA. Of these, 38% (n = 185) received intra-arrest transfer to hospital, with 37% (n = 180) arriving within 60 min. Using spatial and transport modeling, a prehospital team located at an optimal location could establish 437 (90%) patients onto ECMO within 60 min, with an estimated survival of 48% (IQR 38-57). Based on existing survival curves, compared to conventional CPR, an optimally located prehospital ECPR service has the potential to save one additional life for every 3.0 patients.Conclusions: A significant number of historical OHCA patients could have benefited from prehospital ECPR, with a potential survival benefit above conventional CPR.
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Affiliation(s)
- Natalie Kruit
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Anaethesia, Westmead Hospital, Sydney, Australia
- Greater Sydney Area Helicopter Emergency Medical Service, New South Wales, Ambulance Service, Australia
| | - Changle Song
- School of Civil Engineering, The University of Sydney, Australia
| | - David Tian
- Department of Anaethesia, Westmead Hospital, Sydney, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Emily Moylan
- School of Civil Engineering, The University of Sydney, Australia
| | - Mark Dennis
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Hutin A, Lamhaut L. What if prehospital ECPR was part of the solution? Resuscitation 2023:109868. [PMID: 37302684 DOI: 10.1016/j.resuscitation.2023.109868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Alice Hutin
- SAMU de Paris-ICU, Necker University Hospital, Paris, France; INSERM U955, Team 3, Créteil, France.
| | - Lionel Lamhaut
- SAMU de Paris-ICU, Necker University Hospital, Paris, France; INSERM U970, Team 4 "Sudden Death Expertise Center", Paris, France; Paris Cité University, Paris, France.
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Scquizzato T, Hutin A, Landoni G. Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation? J Cardiothorac Vasc Anesth 2023; 37:755-757. [PMID: 36764896 DOI: 10.1053/j.jvca.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/14/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alice Hutin
- SAMU de Paris, Necker University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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