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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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2
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Ubben JF, Heuts S, Delnoij TS, Suverein MM, Hermanides RC, Otterspoor LC, Kraemer CVE, Vlaar AP, van der Heijden JJ, Scholten E, den Uil C, Dos Reis Miranda D, Akin S, de Metz J, van der Horst IC, Winkens B, Maessen JG, Lorusso R, van de Poll MC. Favorable resuscitation characteristics in patients undergoing extracorporeal cardiopulmonary resuscitation: A secondary analysis of the INCEPTION-trial. Resusc Plus 2024; 18:100657. [PMID: 38778803 PMCID: PMC11108965 DOI: 10.1016/j.resplu.2024.100657] [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: 02/22/2024] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used as a supportive treatment for refractory out-of-hospital cardiac arrest (OHCA). Still, there is a paucity of data evaluating favorable and unfavorable prognostic characteristics in patients considered for ECPR. Methods We performed a previously unplanned post-hoc analysis of the multicenter randomized controlled INCEPTION-trial. The study group consisted of patients receiving ECPR, irrespective of initial group randomization. The patients were divided into favorable survivors (cerebral performance category [CPC] 1-2) and unfavorable or non-survivors (CPC 3-5). Results In the initial INCEPTION-trial, 134 patients were randomized. ECPR treatment was started in 46 (66%) of 70 patients in the ECPR treatment arm and 3 (4%) of 74 patients in the conventional treatment arm. No statistically significant differences in baseline characteristics, medical history, or causes of arrest were observed between survivors (n = 5) and non-survivors (n = 44). More patients in the surviving group had a shockable rhythm at the time of cannulation (60% vs. 14%, p = 0.037), underwent more defibrillation attempts (13 vs. 6, p = 0.002), and received higher dosages of amiodarone (450 mg vs 375 mg, p = 0.047) despite similar durations of resuscitation maneuvers. Furthermore, non-survivors more frequently had post-ECPR implantation adverse events. Conclusion The persistence of ventricular arrhythmia is a favorable prognostic factor in patients with refractory OHCA undergoing an ECPR-based treatment. Future studies are warranted to confirm this finding and to establish additional prognostic factors.Clinical trial Registration:clinicaltrials.gov registration number NCT03101787.
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Affiliation(s)
- Johannes F.H. Ubben
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Samuel Heuts
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Thijs S.R. Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Martje M. Suverein
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | | | - Luuk C. Otterspoor
- Department of Intensive Care Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | - Carlos V. Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander P.J. Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Joris J. van der Heijden
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Corstiaan den Uil
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Intensive Care Medicine, Maasstad Ziekenhuis, Rotterdam, the Netherlands
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sakir Akin
- Department of Intensive Care Medicine, Haga Ziekehuis, The Hague, the Netherlands
| | - Jesse de Metz
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Iwan C.C. van der Horst
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, the Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Jos G. Maessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Marcel C.G. van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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3
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Lee HS, Lee CH, Jang JS, Cho JW, Jeon YH. Differences in Treatment Outcomes According to the Insertion Method Used in Extracorporeal Cardiopulmonary Resuscitation: A Single-Center Experience. J Chest Surg 2024; 57:281-288. [PMID: 38472119 PMCID: PMC11089061 DOI: 10.5090/jcs.23.118] [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: 08/22/2023] [Revised: 12/19/2023] [Accepted: 01/18/2024] [Indexed: 03/14/2024] Open
Abstract
Background Venoarterial extracorporeal membrane oxygenation (ECMO) is a key treatment method used with patients in cardiac arrest who do not respond to medical treatment. A critical step in initiating therapy is the insertion of ECMO cannulas. Peripheral ECMO cannulation methods have been preferred for extracorporeal cardiopulmonary resuscitation (ECPR). Methods Patients who underwent ECPR at Daegu Catholic University Medical Center between January 2017 and May 2023 were included in this study. We analyzed the impact of 2 different peripheral cannulation strategies (surgical cutdown vs. percutaneous cannulation) on various factors, including survival rate. Results Among the 99 patients included in this study, 66 underwent surgical cutdown, and 33 underwent percutaneous insertion. The survival to discharge rates were 36.4% for the surgical cutdown group and 30.3% for the percutaneous group (p=0.708). The ECMO insertion times were 21.3 minutes for the surgical cutdown group and 10.3 minutes for the percutaneous group (p<0.001). The factors associated with overall mortality included a shorter low-flow time (hazard ratio [HR], 1.045; 95% confidence interval [CI], 1.019-1.071; p=0.001) and whether return of spontaneous circulation was achieved (HR, 0.317; 95% CI, 0.127-0.787; p=0.013). Low-flow time was defined as the time from the start of cardiopulmonary resuscitation to the completion of ECMO cannula insertion. Conclusion No statistically significant difference in in-hospital mortality was observed between the surgical and percutaneous groups. However, regardless of the chosen cannulation strategy, reducing ECMO cannulation time was beneficial, as a shorter low-flow time was associated with significant benefits in terms of survival.
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Affiliation(s)
- Han Sol Lee
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Chul Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jae Seok Jang
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jun Woo Cho
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Yun-Ho Jeon
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
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Ali S, Moors X, van Schuppen H, Mommers L, Weelink E, Meuwese CL, Kant M, van den Brule J, Kraemer CE, Vlaar APJ, Akin S, Lansink-Hartgring AO, Scholten E, Otterspoor L, de Metz J, Delnoij T, van Lieshout EMM, Houmes RJ, Hartog DD, Gommers D, Dos Reis Miranda D. A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study. Scand J Trauma Resusc Emerg Med 2024; 32:31. [PMID: 38632661 PMCID: PMC11022459 DOI: 10.1186/s13049-024-01198-x] [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: 01/22/2024] [Accepted: 03/16/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients. METHODS The ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18-50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months. DISCUSSION The ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment. TRIAL REGISTRATION Clinicaltyrials.gov under NCT04620070, registration date 3 November 2020.
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Affiliation(s)
- Samir Ali
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands.
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, 3015 GD, the Netherlands.
- Ministry of Defence, Royal Netherlands Air Force, Breda, 4820 ZB, the Netherlands.
| | - Xavier Moors
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, 3015 GD, the Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, 3045 AS, the Netherlands
| | - Hans van Schuppen
- Helicopter Emergency Medical Services, Netwerk Acute Zorg Noordwest, Amsterdam University Medical Centre, Amsterdam, 1081 HV, the Netherlands
| | - Lars Mommers
- Helicopter Emergency Medical Service, Radboud University Medical Centre, Nijmegen, 6525 GA, the Netherlands
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, 6229 HX, the Netherlands
| | - Ellen Weelink
- Helicopter Emergency Medical Service, University Medical Centre Groningen, Groningen, 9713 GZ, the Netherlands
| | - Christiaan L Meuwese
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
| | - Merijn Kant
- Department of Intensive Care, Amphia Hospital, Breda, 4818 CK, the Netherlands
| | - Judith van den Brule
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, 6525 GA, the Netherlands
| | - Carlos Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, 2333 ZA, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Amsterdam, 1105 AZ, the Netherlands
| | - Sakir Akin
- Department of Intensive Care, Haga Teaching Hospital, the Hague, 2545 AA, the Netherlands
| | | | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, 3435 CM, the Netherlands
| | - Luuk Otterspoor
- Department of Intensive Care, Catharina Hospital, Eindhoven, 5623 EJ, the Netherlands
| | - Jesse de Metz
- Department of Intensive Care, OLVG, 1091 AC, Amsterdam, the Netherlands
| | - Thijs Delnoij
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, 6229 HX, the Netherlands
| | - Esther M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, 3015 GD, the Netherlands
| | - Robert-Jan Houmes
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, 3045 AS, the Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, 3015 GD, the Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, 3045 AS, the Netherlands
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Mensink HA, Desai A, Cvetkovic M, Davidson M, Hoskote A, O'Callaghan M, Thiruchelvam T, Roeleveld PP. The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO. Perfusion 2024; 39:81S-94S. [PMID: 38651582 DOI: 10.1177/02676591241236139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.
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Affiliation(s)
- H A Mensink
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - A Desai
- Paediatric Intensive Care, Royal Brompton Hospital, London, UK
| | - M Cvetkovic
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M Davidson
- Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - A Hoskote
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M O'Callaghan
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - T Thiruchelvam
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - P P Roeleveld
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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Verdonschot RJ, Buissant des Amorie FI, Koopman SS, Rietdijk WJ, Ko SY, Sharma UR, Schluep M, den Uil CA, dos Reis Miranda D, Mandigers L. Eligibility of cardiac arrest patients for extracorporeal cardiopulmonary resuscitation and their clinical characteristics: a retrospective two-centre study. Eur J Emerg Med 2024; 31:118-126. [PMID: 37800634 PMCID: PMC10901221 DOI: 10.1097/mej.0000000000001092] [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: 05/12/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND IMPORTANCE Sudden cardiac arrest has a high incidence and often leads to death. A treatment option that might improve the outcomes in refractory cardiac arrest is Extracorporeal Cardiopulmonary Resuscitation (ECPR). OBJECTIVES This study investigates the number of in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients eligible to ECPR and identifies clinical characteristics that may help to identify which patients benefit the most from ECPR. DESIGN, SETTINGS AND PARTICIPANTS A retrospective two-centre study was conducted in Rotterdam, the Netherlands. All IHCA and OHCA patients between 1 January 2017 and 1 January 2020 were screened for eligibility to ECPR. The primary outcome was the percentage of patients eligible to ECPR and patients treated with ECPR. The secondary outcome was the comparison of the clinical characteristics and outcomes of patients eligible to ECPR treated with conventional Cardiopulmonary Resuscitation (CCPR) vs. those of patients treated with ECPR. MAIN RESULTS Out of 1246 included patients, 412 were IHCA patients and 834 were OHCA patients. Of the IHCA patients, 41 (10.0%) were eligible to ECPR, of whom 20 (48.8%) patients were actually treated with ECPR. Of the OHCA patients, 83 (9.6%) were eligible to ECPR, of whom 23 (27.7%) were actually treated with ECPR. In the group IHCA patients eligible to ECPR, no statistically significant difference in survival was found between patients treated with CCPR and patients treated with ECPR (hospital survival 19.0% vs. 15.0% respectively, 4.0% survival difference 95% confidence interval -21.3 to 28.7%). In the group OHCA patients eligible to ECPR, no statistically significant difference in-hospital survival was found between patients treated with CCPR and patients treated with ECPR (13.3% vs. 21.7% respectively, 8.4% survival difference 95% confidence interval -30.3 to 10.2%). CONCLUSION This retrospective study shows that around 10% of cardiac arrest patients are eligible to ECPR. Less than half of these patients eligible to ECPR were actually treated with ECPR in both IHCA and OHCA.
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Affiliation(s)
| | | | | | - Wim J.R. Rietdijk
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam
- Chief Data Office, Department of Institutional Affairs, Vrije Universiteit, Amsterdam
| | - Sindy Y. Ko
- Emergency Department, Erasmus Medical Center
| | | | - Marc Schluep
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam
- Department of Anesthesiology and Intensive Care, Bravis Hospital, Bergen op Zoom
| | - Corstiaan A. den Uil
- Department of Intensive Care, Erasmus Medical Center
- Department of Cardiology, Erasmus University Medical Center
- Department of Intensive Care, Maasstad Hospital, Rotterdam
| | | | - Loes Mandigers
- Department of Intensive Care, Erasmus Medical Center
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
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Scquizzato T, Calabrò MG, Franco A, Fominskiy E, Pieri M, Nardelli P, Delrio S, Altizio S, Ortalda A, Melisurgo G, Ajello S, Landoni G, Zangrillo A, Scandroglio AM. Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: 10-year experience in a metropolitan cardiac arrest centre in Milan, Italy. Resusc Plus 2024; 17:100521. [PMID: 38130976 PMCID: PMC10733689 DOI: 10.1016/j.resplu.2023.100521] [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] [Indexed: 12/23/2023] Open
Abstract
Introduction Growing evidence supports extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OHCA) patients, especially in experienced centres. We present characteristics, treatments, and outcomes of patients treated with ECPR in a high-volume cardiac arrest centre in the metropolitan area of Milan, Italy and determine prognostic factors. Methods Refractory OHCA patients treated with ECPR between 2013 and 2022 at IRCCS San Raffaele Scientific Institute in Milan had survival and neurological outcome assessed at hospital discharge. Results Out of 307 consecutive OHCA patients treated with ECPR (95% witnessed, 66% shockable, low-flow 70 [IQR 58-81] minutes), 17% survived and 9.4% had favourable neurological outcome. Survival and favourable neurological outcome increased to 51% (OR = 8.7; 95% CI, 4.3-18) and 28% (OR = 6.3; 95% CI, 2.8-14) when initial rhythm was shockable and low-flow (time between CPR initiation and ROSC or ECMO flow) ≤60 minutes and decreased to 9.5% and 6.3% when low-flow exceeded 60 minutes (72% of patients). At multivariable analysis, shockable rhythm (aOR for survival = 2.39; 95% CI, 1.04-5.48), shorter low-flow (aOR = 0.95; 95% CI, 0.94-0.97), intermittent ROSC (aOR = 2.5; 95% CI, 1.2-5.6), and signs of life (aOR = 3.7; 95% CI, 1.5-8.7) were associated with better outcomes. Survival reached 10% after treating 104 patients (p for trend <0.001). Conclusions Patients with initial shockable rhythm, intermittent ROSC, signs of life, and low-flow ≤60 minutes had higher success of ECPR for refractory OHCA. Favourable outcomes were possible beyond 60 minutes of low-flow, especially with concomitant favourable prognostic factors. Outcomes improved as the case-volume increased, supporting treatment in high-volume cardiac arrest centres.
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Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Annalisa Franco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Delrio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Savino Altizio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Melisurgo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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8
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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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9
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Suverein MM, Maessen JG, van de Poll MC. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest - current status. Curr Opin Crit Care 2023; 29:633-639. [PMID: 37865873 PMCID: PMC10624408 DOI: 10.1097/mcc.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging treatment for refractory cardiac arrest. In recent years, several randomized controlled trials have been published that aimed to address the efficacy and effectiveness of ECPR for out-of-hospital cardiac arrest (OHCA). Despite the lack of high-quality evidence concerning clinical effectiveness and cost-effectiveness, ECPR is increasingly implemented throughout the world. In this review, we aim to provide an overview of the current status of ECPR for OHCA. RECENT FINDINGS Randomized controlled trials showed diverging results, largely due to differences in selection criteria and study design. Single-center studies, performed in centers with extraordinary expertise and dedication consistently achieve a low-flow time of around 60 min, but such achievements are rarely reproduced outside these centers. Strict patient selection can improve outcome but simultaneously limits the caseload. Preliminary data suggest that outcome may also be improved by avoiding hyperoxia postresuscitation. SUMMARY The potential of ECPR to increase survival in selected patients in highly dedicated systems seems to be proven, the question remains whether ECPR for OHCA can be widely implemented successfully and can develop into a sustainable, commonplace resource-effective treatment.
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Affiliation(s)
| | - Jos G. Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center Cardiovascular Research Institute Maastricht
| | - Marcel C.G. van de Poll
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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10
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Kucher NM, Marquez AM, Guerguerian AM, Moga MA, Vargas-Gutierrez M, Todd M, Honjo O, Haller C, Goco G, Floh AA. Epinephrine Dosing Use During Extracorporeal Cardiopulmonary Resuscitation: Single-Center Retrospective Cohort. Pediatr Crit Care Med 2023; 24:e531-e539. [PMID: 37439601 DOI: 10.1097/pcc.0000000000003323] [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: 07/14/2023]
Abstract
OBJECTIVES During pediatric cardiac arrest, contemporary guidelines recommend dosing epinephrine at regular intervals, including in patients requiring extracorporeal membrane oxygenation (ECMO). The impact of epinephrine-induced vasoconstriction on systemic afterload and venoarterial ECMO support is not well-defined. DESIGN Nested retrospective observational study within a single center. The primary exposure was time from last dose of epinephrine to initiation of ECMO flow; secondary exposures included cumulative epinephrine dose and arrest time. Systemic afterload was assessed by mean arterial pressure and use of systemic vasodilator therapy; ECMO pump flow and Vasoactive-Inotrope Score (VIS) were used as measures of ECMO support. Clearance of lactate was followed post-cannulation as a marker of systemic perfusion. SETTING PICU and cardiac ICU in a quaternary-care center. PATIENTS Patients 0-18 years old who required ECMO cannulation during resuscitation over the 6 years, 2014-2020. Patients were excluded if ECMO was initiated before cardiac arrest or if the resuscitation record was incomplete. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 92 events in 87 patients, with 69 events having complete data for analysis. The median (interquartile range) of total epinephrine dosing was 65 mcg/kg (37-101 mcg/kg), with the last dose given 6 minutes (2-16 min) before the initiation of ECMO flows. Shorter interval between last epinephrine dose and ECMO initiation was associated with increased use of vasodilators within 6 hours of ECMO ( p = 0.05), but not with mean arterial pressure after 1 hour of support (estimate, -0.34; p = 0.06). No other associations were identified between epinephrine delivery and mean arterial blood pressure, vasodilator use, pump speed, VIS, or lactate clearance. CONCLUSIONS There is limited evidence to support the idea that regular dosing of epinephrine during cardiac arrest is associated with increased in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.
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Affiliation(s)
- Nicholas M Kucher
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alexandra M Marquez
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael-Alice Moga
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Mariella Vargas-Gutierrez
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mark Todd
- Department of Respiratory Therapy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Osami Honjo
- Labatt Family Heart Centre, Division of Cardiac Surgery, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Christoph Haller
- Labatt Family Heart Centre, Division of Cardiac Surgery, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Geraldine Goco
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alejandro A Floh
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
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11
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Mommers L, Slagt C, RN FC, van der Crabben R, Moors X, Dos Reis Miranda D. Feasibility of HEMS performed prehospital extracorporeal-cardiopulmonary resuscitation in paediatric cardiac arrests; two case reports. Scand J Trauma Resusc Emerg Med 2023; 31:49. [PMID: 37726847 PMCID: PMC10510161 DOI: 10.1186/s13049-023-01119-4] [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: 06/27/2023] [Accepted: 09/10/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION A broad range of pathophysiologic conditions can lead to cardiopulmonary arrest in children. Some of these children suffer from refractory cardiac arrest, not responding to basic and advanced life support. Extracorporeal-Cardiopulmonary Resuscitation (E-CPR) might be a life-saving option for this group. Currently this therapy is only performed in-hospital, often necessitating long transport times, thereby negatively impacting eligibility and chances of survival. We present the first two cases of prehospital E-CPR in children performed by regular Helicopter Emergency Medical Services (HEMS). CASE PRESENTATIONS The first patient was a previously healthy 7 year old boy who was feeling unwell for a couple of days due to influenza. His course deteriorated into a witnessed collapse. Direct bystander CPR and subsequent ambulance advanced life support was unsuccessful in establishing a perfusing rhythm. While doing chest compressions, the patient was seen moving both his arms and making spontaneous breathing efforts. Echocardiography however revealed a severe left ventricular impairment (near standstill). The second patient was a 15 year old girl, known with bronchial asthma and poor medication compliance. She suffered yet another asthmatic attack, so severe that she progressed into cardiac arrest in front of the attending ambulance and HEMS crews. Despite maximum bronchodilator therapy, intubation and the exclusion of tension pneumothoraxes and dynamic hyperinflation, no cardiac output was achieved. INTERVENTION After consultation with the nearest paediatric E-CPR facilities, both patients were on-scene cannulated by regular HEMS. The femoral artery and vein were cannulated (15-17Fr and 21Fr respectively) under direct ultrasound guidance using an out-of-plane Seldinger approach. Extracorporeal Life Support flow of 2.1 and 3.8 l/min was established in 20 and 16 min respectively (including preparation and cannulation). Both patients were transported uneventfully to the nearest paediatric intensive care with spontaneous breathing efforts and reactive pupils during transport. CONCLUSION This case-series shows that a properly trained regular HEMS crew of only two health care professionals (doctor and flight nurse) can establish E-CPR on-scene in (older) children. Ambulance transport with ongoing CPR is challenging, even more so in children since transportation times tend to be longer compared to adults and automatic chest compression devices are often unsuitable and/or unapproved for children. Prehospital cannulation of susceptible E-CPR candidates has the potential to reduce low-flow time and offer E-CPR therapy to a wider group of children suffering refractory cardiac arrest.
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Affiliation(s)
- Lars Mommers
- Department of Anaesthesiology and Pain Medicine, Maastricht University Medical Centre, P.Debyelaan 25, Maastricht, 6229 HX The Netherlands
- Helicopter Emergency Medical Service Lifeliner 3 Radboudumc, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
| | - Cornelis Slagt
- Helicopter Emergency Medical Service Lifeliner 3 Radboudumc, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
| | - Freek Coumou RN
- Helicopter Emergency Medical Service Lifeliner 3 Radboudumc, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
| | - Ruben van der Crabben
- Department of Anaesthesiology, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
- Helicopter Emergency Medical Service Lifeliner 2, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
| | - Xavier Moors
- Department of Anaesthesiology, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
- Helicopter Emergency Medical Service Lifeliner 2, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
| | - Dinis Dos Reis Miranda
- Helicopter Emergency Medical Service Lifeliner 2, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
- Department of Adult Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
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12
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Ubben JFH, Heuts S, Delnoij TSR, Suverein MM, van de Koolwijk AF, van der Horst ICC, Maessen JG, Bartos J, Kavalkova P, Rob D, Yannopoulos D, Bělohlávek J, Lorusso R, van de Poll MCG. Extracorporeal cardiopulmonary resuscitation for refractory OHCA: lessons from three randomized controlled trials-the trialists' view. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:540-547. [PMID: 37480551 PMCID: PMC10449372 DOI: 10.1093/ehjacc/zuad071] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/24/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation is a promising treatment for refractory out-of-hospital cardiac arrest. Three recent randomized trials (ARREST trial, Prague OHCA study, and INCEPTION trial) that addressed the clinical benefit of extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest yielded seemingly diverging results. The evidence for extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest, derived from three recent randomized controlled trials, is not contradictory but rather complementary. Excellent results can be achieved with a very high level of dedication, provided that strict selection criteria are applied. However, pragmatic implementation of extracorporeal cardiopulmonary resuscitation does not necessarily lead to improved outcome of refractory out-of-hospital cardiac arrest. Centres that are performing extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest or aspire to do so should critically evaluate whether they are able to meet the pre-requisites that are needed to conduct an effective extracorporeal cardiopulmonary resuscitation programme.
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Affiliation(s)
- Johannes F H Ubben
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- Department of Anesthesia and Pain Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Martje M Suverein
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Anina F van de Koolwijk
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jason Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Petra Kavalkova
- 2nd Department of Medicine—Department of Cardiovascular Medicine, First Medical School, General University Hospital and Charles University in Prague, U Nemocnice 2, Prague, Czech Republic
| | - Daniel Rob
- 2nd Department of Medicine—Department of Cardiovascular Medicine, First Medical School, General University Hospital and Charles University in Prague, U Nemocnice 2, Prague, Czech Republic
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jan Bělohlávek
- 2nd Department of Medicine—Department of Cardiovascular Medicine, First Medical School, General University Hospital and Charles University in Prague, U Nemocnice 2, Prague, Czech Republic
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
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13
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Scquizzato T, Yannopoulos D, Bělohlávek J, Taccone FS, Lorusso R, Scandroglio AM, Landoni G, Swol J. Extracorporeal CPR after the INCEPTION trial: No one steps twice into the same river. Artif Organs 2023; 47:802-805. [PMID: 37171146 DOI: 10.1111/aor.14520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The use of veno-arterial extracorporeal membrane oxygenation as extracorporeal cardiopulmonary resuscitation in patients suffering out-of-hospital cardiac arrest, largely increased in the last decade despite evidence supporting this practice being limited to non-randomized studies. However, between 2020 and 2023, four randomized studies were published comparing extracorporeal cardiopulmonary resuscitation to conventional cardiopulmonary resuscitation with controversial findings that triggered great debates. In this controversy, we discuss merits and pitfalls, and provide a critical interpretation of the available evidence from randomized trials on the use of extracorporeal cardiopulmonary resuscitation, with a particular focus on the recent multi-center INCEPTION trial.
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Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - 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
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University, Nuremberg, Germany
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14
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Scquizzato T, Bonaccorso A, Swol J, Gamberini L, Scandroglio AM, Landoni G, Zangrillo A. Refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta-analysis of randomized trials. Artif Organs 2023; 47:806-816. [PMID: 36929354 DOI: 10.1111/aor.14516] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND In adults with refractory out-of-hospital cardiac arrest, when conventional cardiopulmonary resuscitation (CPR) alone does not achieve return of spontaneous circulation, extracorporeal CPR is attempted to restore perfusion and improve outcomes. Considering the contrasting findings of recent studies, we conducted a meta-analysis of randomized controlled trials to ascertain the effect of extracorporeal CPR on survival and neurological outcome. METHODS Pubmed via MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched up to February 3, 2023, for randomized controlled trials comparing extracorporeal CPR versus conventional CPR in adults with refractory out-of-hospital cardiac arrest. Survival with a favorable neurological outcome at the longest follow-up available was the primary outcome. RESULTS Among four randomized controlled trials included, extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome at the longest follow-up available for all rhythms (59/220 [27%] vs. 39/213 [18%]; OR = 1.72; 95% CI, 1.09-2.70; p = 0.02; I2 = 26%; number needed to treat of 9), for initial shockable rhythms only (55/164 [34%] vs. 38/165 [23%]; OR = 1.90; 95% CI, 1.16-3.13; p = 0.01; I2 = 23%; number needed to treat of 7), and at hospital discharge or 30 days (55/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13-2.92; p = 0.01; I2 = 0.0%). Overall survival at the longest follow-up available was similar (61/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13-2.92; p = 0.59; I2 = 58%). CONCLUSIONS Extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome in adults with refractory out-of-hospital cardiac arrest, especially when the initial rhythm was shockable. REVIEW REGISTRATION PROSPERO CRD42023396482.
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Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Bonaccorso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore, Bologna, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - 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
| | - Alberto Zangrillo
- 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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15
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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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16
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Kruit N, Rattan N, Tian D, Dieleman S, Burrell A, Dennis M. Prehospital Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2022; 37:748-754. [PMID: 36641307 DOI: 10.1053/j.jvca.2022.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 11/25/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To evaluate the available published evidence of the effects of extracorporeal cardiopulmonary resuscitation (ECPR) in the prehospital setting on clinical outcomes in patients with out-of-hospital cardiac arrest. DESIGN A systematic review and meta-analysis designed according to the Preferred Reporting Items for Systematic Reviews an Meta-Analyses guidelines. SETTING In the prehospital setting. PARTICIPANTS All randomized control trials (RCTs) and observational trials using pre-hospital ECPR in adult patients (>17 years). INTERVENTIONS Prehospital ECPR. MEASUREMENTS AND MAIN RESULTS The study authors searched Medline, Embase, and PUBMED for all RCTs and observational trials. The studies were assessed for clinical, methodologic, and statistical heterogeneity. The primary outcome was survival at hospital discharge. The study outcomes were aggregated using random-effects meta-analysis of means or proportions as appropriate. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence. Four studies were included, with a total of 222 patients receiving prehospital ECPR (mean age = 51 years [95% CI 44-57], 81% of patients were male (CI 74-87), and 60% patients had a cardiac cause for their arrest (95% CI 43-76). Overall survival at discharge was 23.4% (95% CI 15.5-33.7; I2 = 62%). The pooled low-flow time was 61.1 minutes (95% CI 45.2-77.0; I2 = 97%). The quality of evidence was assessed to be low, and the overall risk of bias was assessed to be serious, with confounding being the primary source of bias. CONCLUSION No definitive conclusions can be made as to the efficacy of prehospital ECPR in refractory cardiac arrest. Higher quality evidence is required.
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Affiliation(s)
- Natalie Kruit
- Department of Anaesthesia, Westmead Hospital, Westmead, New South Wales, Australia; Royal Prince Alfred Hospitals, Sydney, New South Wales, Australia; Greater Sydney Helicopter Emergency Service, Sydney, New South Wales, Australia; Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Westmead, New South Wales, Australia.
| | - Nevidita Rattan
- Royal Prince Alfred Hospitals, Sydney, New South Wales, Australia
| | - David Tian
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Westmead, New South Wales, Australia; The George Institute for Global Health, University of New South Wales, Westmead, New South Wales, Australia
| | - Stefan Dieleman
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Westmead, New South Wales, Australia; Western Sydney University, Sydney, New South Wales, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive care Research Centre, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Dennis
- Department of Cardiology, Royal Prince Alfred Hospital, Faculty of Medicine, Sydney, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
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