Predictors of survival and neurologic outcome for adults with extracorporeal cardiopulmonary resuscitation: A systemic review and meta-analysis

End-stage renal disease should not Be considered a contraindication for veno-arterial extracorporeal membrane oxygenation

BACKGROUND

This study aims to determine whether end-stage renal disease (ESRD) is a true contraindication for extracorporeal membrane oxygenation in adult patients.

MATERIALS AND METHODS

Adult patients who received VA-ECMO at National Taiwan University Hospital between January 2010 and December 2021 were included. Patients who received regular dialysis before the index admission were included in the ESRD group. The primary outcome was in-hospital mortality.

RESULTS

1341 patients were included in the analysis, 121 of whom had ESRD before index admission. The ESRD group was older (62.3 versus 56.8 years; P < 0.01) and had more comorbidities. Extracorporeal cardiopulmonary resuscitation (ECPR) was used more frequently in the ESRD group (66.1% versus 51.6%; P < 0.001). The ESRD group had higher in-hospital mortality rates (72.7% versus 63.3%; P = 0.03). In the ECPR subgroup, there was no difference of survival between ESRD and others(P = 0.56). In the multivariate Cox regression, ESRD was not an independent predictor for mortality (P = 0.20).

CONCLUSION

ESRD was not an independent predictor of in-hospital mortality after VA-ECMO. The survival of ESRD patients was not inferior to those without ESRD when receiving ECPR. Therefore, ESRD should not be considered a contraindication to VA-ECMO in adults.

Implementing enhanced extracorporeal membrane oxygenation for CPR (ECPR) in the emergency department

Refractory out-of-hospital cardiac arrest (OHCA) has a very poor prognosis, with survival rates at around 10%. Extracorporeal membrane oxygenation (ECMO) for patients in refractory arrest, known as ECPR, aims to provide perfusion to the patient whilst the underlying cause of arrest can be addressed. ECPR use has increased substantially, with varying survival rates to hospital discharge. The best outcomes for ECPR occur when the time from cardiac arrest to implementation of ECPR is minimised. To reduce this time, systems must be in place to identify the correct patient, expedite transfer to hospital, facilitate rapid cannulation and ECMO circuit flows. We describe the process of activation of ECPR, patient selection, and the steps that emergency department clinicians can utilise to facilitate timely cannulation to ensure the best outcomes for patients in refractory cardiac arrest. With these processes in place our survival to hospital discharge for OHCA patients is 35%, with most patients having a good neurological function.

General Surgery Resuscitation Preference Documentation: A Quality Improvement Initiative

BACKGROUND/PURPOSE

Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period.

METHODS

Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures.

RESULTS

The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note.

CONCLUSIONS

We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

Prognostic Significance of Signs of Life in Out-of-Hospital Cardiac Arrest Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation

OBJECTIVES

Signs of life (SOLs) during cardiac arrest (gasping, pupillary light reaction, or any form of body movement) are suggested to be associated with favorable neurologic outcomes in out-of-hospital cardiac arrest (OHCA). While data has demonstrated that extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in cases of refractory cardiac arrest, it is expected that other contributing factors lead to positive outcomes. This study aimed to investigate whether SOL on arrival is associated with neurologic outcomes in patients with OHCA who have undergone ECPR.

DESIGN

Retrospective multicenter registry study.

SETTING

Thirty-six facilities participating in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan II (SAVE-J II).

PATIENTS

Consecutive patients older than 18 years old who were admitted to the Emergency Department with OHCA between January 1, 2013, and December 31, 2018, and received ECPR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were classified into two groups according to the presence or absence of SOL on arrival. The primary outcome was a favorable neurologic outcome (Cerebral Performance Category 1 or 2) at discharge. Of the 2157 patients registered in the SAVE-J II database, 1395 met the inclusion criteria, and 250 (17.9%) had SOL upon arrival. Patients with SOL had more favorable neurologic outcomes than those without SOL (38.0% vs. 8.1%; p < 0.001). Multivariate analysis showed that SOL on arrival was independently associated with favorable neurologic outcomes (odds ratio, 5.65 [95% CI, 3.97-8.03]; p < 0.001).

CONCLUSIONS

SOL on arrival was associated with favorable neurologic outcomes in patients with OHCA undergoing ECPR. In patients considered for ECPR, the presence of SOL on arrival can assist the decision to perform ECPR.

First documented rhythm and clinical outcome in children who undergo extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: A report from the american heart association get with the guidelines® - resuscitation registry (GWTG-R)

INTRODUCTION

Outcomes of conventional cardiopulmonary resuscitation are improved when the initial rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia). In children, the first documented rhythm is typically asystole or pulseless electrical activity. We evaluate the role the initial rhythm plays in outcomes for children undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest.

METHODS

Consecutive patients < 18 years with in-hospital ECPR events ≥ 10 minutes reported to the American Heart Association Get With The Guidelines® - Resuscitation registry from 2014 to 2019 were included. Primary outcome was survival to hospital discharge. Logistic regression modeling was used to compute propensity score matching based on patient, cardiac arrest event and hospital characteristics; patients with initial shockable rhythm were matched to patients with initial non-shockable rhythm.

RESULTS

The final cohort included 466 patients, of which 82 (18%) had a shockable, and 384 (82%) had a non-shockable initial rhythm. After propensity score matching of 287 (62%) patients, there was no difference in survival to hospital discharge (risk ratio [RR] 1.2, 95% CI, 0.95-1.53, p = 0.13) or favorable neurologic outcome, defined as Pediatric Cerebral Performance Category (PCPC) of 1 or 2, or no decline from baseline (RR 1.28, 95% CI, 0.84-1.96, p = 0.25) between patients with and without shockable initial rhythm.

CONCLUSIONS

In children with in-hospital cardiac arrest undergoing ECPR, there was no significant difference in survival or favorable neurologic outcome between those with initial shockable rhythm compared to non-shockable rhythm. Further investigation to evaluate ECPR patient characteristics and outcomes is warranted to help guide eligibility and ECMO deployment practices.

Extracorporeal membrane oxygenation for cardiac arrest: what, when, why, and how

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.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A meta-analysis of randomized controlled trials

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (ECPR) is a resuscitation method for patients with refractory out-of-hospital cardiac arrest (OHCA). However, evidence from randomized controlled trials (RCTs) is lacking.

METHODS

We searched several electronic databases until March 2023 for RCTs comparing ECPR with conventional CPR in OHCA patients. RevMan 5.4 was used to pool risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

A total of four RCTs were included. The results of our meta-analysis showed no statistically significant benefit of ECPR regarding mid-term survival (RR 1.21; 95% CI 0.64 to 2.28; I2 = 48%; p = .55). We found a significant improvement with ECPR in mid-term favorable neurological outcome (RR 1.59; 95% CI 1.09 to 2.33; I2 = 0%; p = .02). There was no significant difference between ECPR and conventional CPR in long-term survival (RR 1.32; 95% CI 0.18 to 9.50; I2 = 64%; p = .79), and long-term favorable neurological outcome (RR 1.47; 95% CI 0.89 to 2.43; I2 = 25%; p = .13). There was an increased incidence of adverse events in the ECPR group (RR 3.22; 95% CI 1.18 to 8.80; I2 = 63%; p = .02).

CONCLUSION

ECPR in OHCA patients was not associated with improved survival or long-term favorable neurological outcome but did improve favorable neurological outcome in the mid-term. However, these results are likely underpowered due to the small number of available RCTs. Large-scale confirmatory RCTs are needed to provide definitive conclusions.

Impact of bystander cardiopulmonary resuscitation on neurological outcomes in patients undergoing veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) requires a large amount of economic and human resources. The presence of bystander cardiopulmonary resuscitation (CPR) was focused on selecting appropriate V-A ECMO candidates.

RESULT

This study retrospectively enrolled 39 patients with V-A ECMO due to out-of-hospital cardiac arrest (CA) between January 2010 and March 2019. The introduction criteria of V-A ECMO included the following: (1) < 75 years old, (2) CA on arrival, (3) < 40 min from CA to hospital arrival, (4) shockable rhythm, and (5) good activity of daily living (ADL). The prescribed introduction criteria were not met by 14 patients, but they were introduced to V-A ECMO at the discretion of their attending physicians and were also included in the analysis. Neurological prognosis at discharge was defined using The Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories of Brain Function (CPC). Patients were divided into good or poor neurological prognosis (CPC ≤ 2 or ≥ 3) groups (8 vs. 31 patients). The good prognosis group had a significantly larger number of patients who received bystander CPR (p = 0.04). The mean CPC at discharge was compared based on the combination with the presence of bystander CPR and all five original criteria. Patients who received bystander CPR and met all original five criteria showed significantly better CPC than patients who did not receive bystander CPR and did not meet some of the original five criteria (p = 0.046).

CONCLUSION

Considering the presence of bystander CPR help in selecting the appropriate candidate of V-A ECMO among out-of-hospital CA cases.

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience

Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.

Extracorporeal versus conventional cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a secondary analysis of the Prague OHCA trial

BACKGROUND

Survival rates in refractory out-of-hospital cardiac arrest (OHCA) remain low with conventional advanced cardiac life support (ACLS). Extracorporeal life support (ECLS) implantation during ongoing resuscitation, a method called extracorporeal cardiopulmonary resuscitation (ECPR), may increase survival. This study examined whether ECPR is associated with improved outcomes.

METHODS

Prague OHCA trial enrolled adults with a witnessed refractory OHCA of presumed cardiac origin. In this secondary analysis, the effect of ECPR on 180-day survival using Kaplan-Meier estimates and Cox proportional hazard model was examined.

RESULTS

Among 256 patients (median age 58 years, 83% male) with median duration of resuscitation 52.5 min (36.5-68), 83 (32%) patients achieved prehospital ROSC during ongoing conventional ACLS prehospitally, 81 (32%) patients did not achieve prehospital ROSC with prolonged conventional ACLS, and 92 (36%) patients did not achieve prehospital ROSC and received ECPR. The overall 180-day survival was 51/83 (61.5%) in patients with prehospital ROSC, 1/81 (1.2%) in patients without prehospital ROSC treated with conventional ACLS and 22/92 (23.9%) in patients without prehospital ROSC treated with ECPR (log-rank p < 0.001). After adjustment for covariates (age, sex, initial rhythm, prehospital ROSC status, time of emergency medical service arrival, resuscitation time, place of cardiac arrest, percutaneous coronary intervention status), ECPR was associated with a lower risk of 180-day death (HR 0.21, 95% CI 0.14-0.31; P < 0.001).

CONCLUSIONS

In this secondary analysis of the randomized refractory OHCA trial, ECPR was associated with improved 180-day survival in patients without prehospital ROSC.

TRIAL REGISTRATION

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

Predictors of survival for pediatric extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis

BACKGROUND

The use of extracorporeal cardiopulmonary resuscitation (ECPR) has improved survival in patients with cardiac arrest; however, factors predicting survival remain poorly characterized. A systematic review and meta-analysis was conducted to examine the predictors of survival of ECPR in pediatric patients.

METHODS

We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from 2010 to 2021 for pediatric ECPR studies comparing survivors and non-survivors. Thirty outcomes were analyzed and classified into 5 categories: demographics, pre-ECPR laboratory measurements, pre-ECPR co-morbidities, intra-ECPR characteristics, and post-ECPR complications.

RESULTS

Thirty studies (n = 3794) were included. Pooled survival to hospital discharge (SHD) was 44% (95% CI: 40%-47%, I2 = 67%). Significant predictors of survival for pediatric ECPR include the pre-ECPR lab measurements of PaO2, pH, lactate, PaCO2, and creatinine, pre-ECPR comorbidities of single ventricle (SV) physiology, renal failure, sepsis, ECPR characteristics of extracorporeal membrane oxygenation (ECMO) duration, ECMO flow rate at 24 hours, cardiopulmonary resuscitation (CPR) duration, shockable rhythm, intra-ECPR neurological complications, and post-ECPR complications of pulmonary hemorrhage, renal failure, and sepsis.

CONCLUSION

Prior to ECPR initiation, increased CPR duration and lactate levels had among the highest associations with mortality, followed by pH. After ECPR initiation, pulmonary hemorrhage and neurological complications were most predictive for survival. Clinicians should focus on these factors to better inform potential prognosis of patients, advise appropriate patient selection, and improve ECPR program effectiveness.

Association between stress hyperglycemia on admission and unfavorable neurological outcome in OHCA patients receiving ECPR

BACKGROUND

Stress hyperglycemia is a normal response to stress and has been associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, this association remained unknown in OHCA patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to examine the association between degree of stress hyperglycemia on admission and neurological outcomes at discharge in OHCA patients receiving ECPR.

PATIENTS AND METHODS

This was a retrospective cohort study of adult OHCA patients receiving ECPR between 2011 and 2021. Patients were classified into three groups: absence of stress hyperglycemia (blood glucose level on admission < 200 mg/dL), moderate stress hyperglycemia (200-299 mg/dL), and severe stress hyperglycemia (≥ 300 mg/dL). The primary outcome was unfavorable neurological outcome (Cerebral Performance Category: 3-5) at discharge.

RESULTS

This study included 160 patients; unfavorable neurological outcomes totaled 79.4% (n = 127). There were 23, 52, and 85 patients in the absence, moderate, and severe stress hyperglycemia groups, respectively. Of each group, unfavorable neurological outcomes constituted 91.3%, 71.2%, and 81.2%, respectively. Multivariable analysis showed that, compared with moderate stress hyperglycemia, absence of stress hyperglycemia on admission was significantly associated with unfavorable neurological outcome at discharge (odds ratio [OR], 4.70; 95% confidence interval [CI], 1.07-33.35; p = 0.039).

CONCLUSION

Compared with moderate stress hyperglycemia on admission, absence of stress hyperglycemia showed significant association with unfavorable neurological outcome at discharge in OHCA patients receiving ECPR.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of Initial Pulseless Electrical Activity Heart Rate and Clinical Outcomes Following Adult Non-Traumatic Out-of-Hospital Cardiac Arrest

OBJECTIVE

Studies evaluating the prognostic value of the pulseless electrical activity (PEA) heart rate in out-of-hospital cardiac arrest (OHCA) patients have reported conflicting results. The objective of this study was to evaluate the association between the initial PEA heart rate and favorable clinical outcomes for OHCA patients.

METHODS

The present post-hoc cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry Version 3, which included OHCA patients in seven US and three Canadian sites from April 2011 to June 2015. The primary outcome was survival to hospital discharge and the secondary outcome was survival with a good functional outcome. For the primary analysis, the patients were separated into eight groups according to their first rhythms and PEA heart rates: (1) initial PEA heart rate of 1-20 beats per minute (bpm); (2) 21-40 bpm; (3) 41-60 bpm; (4) 61-80 bpm; (5) 81-100 bpm; (6) 101-120 bpm; (7) over 120 bpm; (8) initial shockable rhythm (reference category). Multivariable logistic regression models were used to assess the associations of interest.

RESULTS

We identified 17,675 patients (PEA: 7,089 [40.1%]; initial shockable rhythm: 10,797 [59.9%]). Patients with initial PEA electrical frequencies ≤100 bpm were less likely to survive to hospital discharge than patients with initial shockable rhythms (1-20 bpm: adjusted odds ratio [AOR] = 0.15 [95%CI 0.11-0.21]; 21-40 bpm: AOR =0.21 [0.18-0.25]; 41-60 bpm: AOR =0.30 [0.25-0.36]; 61-80 bpm: AOR =0.37 [0.28-0.49]; 81-100 bpm: AOR =0.55 [0.41-0.65]). However, there were no statistical outcome differences between PEA patients with initial electrical frequencies of >100 bpm and patients with initial shockable rhythms (101-120 bpm: AOR =0.65 [95%CI 0.42-1.01]; >120 bpm: AOR =0.72 [95%CI 0.37-1.39]). Similar results were observed for survival with good functional outcomes (101-120 bpm: AOR =0.60 [95%CI 0.31-1.15]; >120 bpm: AOR =1.08 [95%CI 0.50-2.28]).

CONCLUSIONS

We observed a good association between higher initial PEA electrical frequency and favorable clinical outcomes for OHCA patients. As there is no significant difference in outcomes between patients with initial PEA heart rates of more than 100 bpm and those with initial shockable rhythms, we can hypothesize that these patients could be considered in the same prognostic category.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest - who, when, and where?

PURPOSE OF REVIEW

Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive and resource-intensive therapy used to care for patients with refractory cardiac arrest. In this review, we highlight considerations for the establishment of an ECPR system of care for patients suffering refractory out-of-hospital cardiac arrest (OHCA).

RECENT FINDINGS

ECPR has been shown to improve neurologically favorable outcomes in patients with refractory cardiac arrest in numerous studies, including a single randomized control trial. Successful ECPR programs are typically part of a comprehensive system of care that optimizes all phases of OHCA management. Given the resource-intensive and time-sensitive nature of ECPR, patient selection criteria, timing of ECPR, and location must be well defined. Many knowledge gaps remain within ECPR systems of care, postcardiac arrest management, and neuroprognostication strategies for ECPR patients.

SUMMARY

To be consistently successful, ECPR must be a part of a comprehensive OHCA system of care that optimizes all phases of cardiac arrest management. Future investigation is needed for the knowledge gaps that remain.

Extracorporeal Cardiopulmonary Resuscitation Guided by End-Tidal Carbon Dioxide-a Porcine Model

Extracorporeal membrane cardiopulmonary resuscitation (ECPR) during cardiopulmonary resuscitation (CPR) for selected cases and end-tidal carbon dioxide (ETCO₂) could be used to guide initiation of ECPR. Ventricular fibrillation was induced in 12 pigs and CPR was performed until ETCO₂ fell below 10 mmHg; then, ECPR was performed. Animals were divided into group short (G_Short) and group long (G_Long), according to time of CPR. Carotid blood flow was higher (p = 0.02) and mean arterial blood pressure lower in G_Long during CPR (p < 0.05). B-Lactate was lower and pH higher in G_Short (p < 0.01). In microdialysis lactate-pyruvate ratio, glycerol and glutamate increased in both groups during CPR, but considerably in G_Long (p < 0.01). No difference could be seen in histopathology of the brain or kidney post-ECPR. No apparent histological differences of tissue damage in brains or levels of S100B in plasma were detected between groups. This might suggest that ETCO₂ could be used as a marker for brain injury following ECPR.

Predictors of Survival and Favorable Neurologic Outcome in Patients Treated with eCPR: a Systematic Review and Meta-analysis

Extracorporeal cardiopulmonary resuscitation (eCPR) can improve survival in selected patients with cardiac arrest (CA). In this meta-analysis, we evaluated factors associated with short-term survival and favorable neurologic outcome (FNO) post-eCPR. In June 2019, we systematically searched electronic databases for studies reporting on survival and predictors associated with short-term survival or FNO post-eCPR using multivariable analysis. We meta-analyzed outcomes and predictors using the inverse variance method with a random-effects model. We identified 92 studies with 13 factors amenable to meta-analysis. Pooled short-term survival and FNO were 25% and 16% respectively. Lower lactate, return of spontaneous circulation, shockable rhythm, shorter CPR duration, baseline pH, shorter low-flow time, and history of hypertension were significantly associated with short-term survival. In addition, shockable rhythm, lower lactate, and use of targeted temperature management were associated with FNO. The identified factors associated with short-term survival and FNO post-eCPR could guide prognosis prediction at the time of CA.

Neurologic Outcomes After Extracorporeal Cardiopulmonary Resuscitation: Recent Experience at a Single High-Volume Center

Extracorporeal cardiopulmonary resuscitation (ECPR)-veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest-has grown rapidly, but its widespread adoption has been limited by frequent neurologic complications. With individual centers developing best practices, utilization may be increasing with an uncertain effect on outcomes. This study describes the recent ECPR experience at the University of Maryland Medical Center from 2016 through 2018, with attention to neurologic outcomes and predictors thereof. The primary outcome was dichotomized Cerebral Performance Category (≤2) at hospital discharge; secondary outcomes included rates of specific neurologic complications. From 429 ECMO runs over 3 years, 57 ECPR patients were identified, representing an increase in ECPR utilization compared with 41 cases over the previous 6 years. Fifty-two (91%) suffered in-hospital cardiac arrest, and 36 (63%) had an initial nonshockable rhythm. Median low-flow time was 31 minutes. Overall, 26 (46%) survived hospitalization and 23 (88% of survivors, 40% overall) had a favorable discharge outcome. Factors independently associated with good neurologic outcome included lower peak lactate, initial shockable rhythm, and higher initial ECMO mean arterial pressure. Neurologic complications occurred in 18 patients (32%), including brain death in 6 (11%), hypoxic-ischemic brain injury in 11 (19%), ischemic stroke in 6 (11%), intracerebral hemorrhage in 1 (2%), and seizure in 4 (7%). We conclude that good neurologic outcomes are possible for well-selected ECPR patients in a high-volume program with increasing utilization and evolving practices. Markers of adequate peri-resuscitation tissue perfusion were associated with better outcomes, suggesting their importance in neuroprognostication.

Predictors of Favorable Neurologic Outcomes in a Territory-First Extracorporeal Cardiopulmonary Resuscitation Program

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced resuscitation method that has been associated with better outcomes after cardiac arrest compared with conventional cardiopulmonary resuscitation. This is a retrospective analysis of all patients who received ECPR for cardiac arrest in Hong Kong's first ECPR program from 2012 to 2020. The primary outcome was favorable neurologic outcome at 3 months. A new risk prediction model was developed and its performance was compared with published risk scores. One-hundred two patients received ECPR and 19 (18.6%) patients survived with favorable neurologic outcome. Having a shockable rhythm was the strongest predictor of favorable neurologic outcome in multivariate analysis (odds ratio, 9.64; 95% confidence interval [CI], 1.49 to 62.30; P = 0.017). We developed a simple model with three parameters for the prediction of favorable neurologic outcomes - presence of shockable rhythm, mean arterial pressure after extracorporeal membrane oxygenation, and the Acute Physiology And Chronic Health Evaluation IV score, with an area under receiver operating characteristic curve of 0.85 (95% CI, 0.77 to 0.94). In Hong Kong's first ECPR program, 18.6% patients survived with favorable neurologic outcomes, and having a shockable rhythm at presentation was the strongest predictor. Risk scores are useful in predicting important patient outcomes and should be included in clinical decision-making for patients who received ECPR.

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

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

Extracorporeal cardiopulmonary resuscitation in-hospital cardiac arrest due to acute coronary syndrome

Background

The aim of this study was to analyze the effect of extracorporeal cardiopulmonary resuscitation on survival and neurological outcomes in in-hospital cardiac arrest patients.

Methods

Between January 2018 and December 2020, a total of 22 patients (17 males, 5 females; mean age: 52.8±9.0 years; range, 32 to 70 years) treated with extracorporeal cardiopulmonary resuscitation using veno-arterial extracorporeal membrane oxygenation support for in-hospital cardiac arrest after acute coronary syndrome were retrospectively analyzed. The patients were divided into two groups as those weaned (n=13) and non-weaned (n=9) from the veno-arterial extracorporeal membrane oxygenation. Demographic data of the patients, heart rhythms at the beginning of conventional cardiopulmonary resuscitation, the angiographic and interventional results, survival and neurological outcomes of the patients before and after extracorporeal cardiopulmonary resuscitation were recorded.

Results

There was no significant difference between the groups in terms of comorbidity and baseline laboratory test values. The underlying rhythm was ventricular fibrillation in 92% of the patients in the weaned group and there was no cardiac rhythm in 67% of the patients in the non-weaned group (p=0.125). The recovery in the mean left ventricular ejection fraction was significantly evident in the weaned group (36.5±12.7% vs. 21.1±7.4%, respectively; p=0.004). The overall wean rate from veno-arterial extracorporeal membrane oxygenation was 59.1%; however, the discharge rate from hospital of survivors without any neurological sequelae was 36.4%.

Conclusion

In-hospital cardiac arrest is a critical emergency situation requiring instantly life-saving interventions through conventional cardiopulmonary resuscitation. If it fails, extracorporeal cardiopulmonary resuscitation should be initiated, regardless the underlying etiology or rhythm disturbances. An effective conventional cardiopulmonary resuscitation is mandatory to prevent brain and body hypoperfusion.

Does cerebral near-infrared spectroscopy (NIRS) help to predict futile cannulation in extracorporeal cardiopulmonary resuscitation (ECPR)?

AIM OF THE STUDY

Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving technique to improve cardiopulmonary resuscitation (CPR) outcomes. Identifying a readily available tool helpful for predicting patient's outcome is warranted. The aim of the study was to evaluate the capability of cranial near-infrared spectroscopy (cNIRS) to identify non-survivors or patients with unfavorable neurologic outcome prior to cannulation for ECPR to avoid futile cannulations.

METHODS

Retrospective analysis (2015-2021) of 97 patients requiring ECPR due to cardiac arrest with prior cNIRS measurement, which was performed immediately after ECPR team arrived on scene. Lowest possible regional cerebral oxygen saturation (rSO₂) is 15%.

RESULTS

Mortality was 72.1% (70/97). Survivors showed in 88.9% (24/27) good neurological outcome (Cerebral Performance Category (CPC) 1 + 2). rSO2 = 15% (11/97) prior to cannulation was only found in non-survivors. Among survivors, initial rSO₂ was not associated with neurological outcome. Non-shockable initial rhythm was associated with higher mortality (44/50). In survivors, time to ECPR was shorter (p = 0.006), and initial lactate was significantly lower, whereas initial pH and hemoglobin levels were higher (p = 0.001). Survivors and those with favorable neurological outcome showed lower maximal NSE levels in the first 72 hours (p < 0.001; p = 0.041).

CONCLUSION

In our patient cohort, rSO₂ = 15% immediately prior to cannulation for ECPR did not result in any survivors, thus might be a marker for futile cannulation in ECPR. Higher rSO₂ values were not associated with favorable neurologic outcome. Lower initial lactate and lower maximal NSE within the first 72 h after arrest were associated with favorable outcome.

Importance of pulse pressure after extracorporeal cardiopulmonary resuscitation

BACKGROUND

Recent reports have revealed better clinical outcomes for extracorporeal cardiopulmonary resuscitation (ECPR) than conventional cardiopulmonary resuscitation (CPR). In this retrospective study, we attempted to identify predictors associated with successful weaning off extracorporeal membrane oxygenation (ECMO) support after ECPR.

METHODS

The demographic and clinical data of 30 ECPR patients aged over 18 years treated between August 2016 and January 2019 were analyzed. All clinical data were retrospectively collected. The primary endpoint was successful weaning off ECMO support after ECPR. Patients were divided into two groups based on successful or unsuccessful weaning off ECMO support (Weaned (n = 14) vs. Failed (n = 16)).

RESULTS

Univariate logistic regression analysis showed that age, CPR duration, ECMO complications, and loss of pulse pressure significantly predicted the results of weaning off ECMO support. However, multivariate logistic regression analysis showed that only CPR duration and loss of pulse pressure independently predicted unsuccessful weaning from ECMO support.

CONCLUSION

We conclude that long CPR duration and loss of pulse pressure after ECPR predict unsuccessful weaning from ECMO. However, unlike CPR duration, loss of pulse pressure during post-ECPR was related to subsequent management. In patients with reduced pulse pressure after ECPR, careful management is warranted because this reduction is closely associated with unsuccessful weaning off ECMO support after ECPR.

Peripheral cannulation for extracorporeal membrane oxygenation yields superior neurologic outcomes in adult patients who experienced cardiac arrest following cardiac surgery

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest has improved mortality in post-cardiac surgery patients; however, loss of neurologic function remains one of the main and devastating complications. We reviewed our experience with ECPR and investigated the effect of cannulation strategy on neurologic outcome in adult patients who experienced cardiac arrest following cardiac surgery that was managed with ECPR.

METHODS

Patients were categorized by central versus percutaneous peripheral VA-extracorporeal membrane oxygenation (ECMO) cannulation strategy. We reviewed patient records and evaluated in-hospital mortality, cause of death, and neurologic status 72 hours after cannulation.

RESULTS

From January 2010 to September 2019, 44 patients underwent post-cardiac surgery ECPR for cardiac arrest. Twenty-six patients received central cannulation; 18 patients received peripheral cannulation. Mean post-operative day of the cardiac arrest was 3 and 9 days (p = 0.006), and mean time between initiation of CPR and ECMO was 40 ± 24 and 28 ± 22 minutes for central and peripheral cannulation, respectively. After 72 hours of VA-ECMO support, 30% of centrally cannulated patients versus 72% of peripherally cannulated patients attained cerebral performance status 1-2 (p = 0.01). Anoxic brain injury was the cause of death in 26.9% of centrally cannulated and 11.1% of peripherally cannulated patients. Survival to discharge was 31% and 39% for central and peripheral cannulation, respectively.

CONCLUSIONS

Peripheral VA-ECMO allows for continuous CPR and systemic perfusion while obtaining vascular access. Compared to central cannulation, a peripheral cannulation strategy is associated with improved neurologic outcomes and decreased likelihood of anoxic brain death.

Identifying prognostic factors and developing accurate outcome predictions for in-hospital cardiac arrest by using artificial neural networks

BACKGROUND

Accurate estimation of neurological outcomes after in-hospital cardiac arrest (IHCA) provides crucial information for clinical management. This study used artificial neural networks (ANNs) to determine the prognostic factors and develop prediction models for IHCA based on immediate preresuscitation parameters.

METHODS

The derived cohort comprised 796 patients with IHCA between 2006 and 2014. We applied ANNs to develop prediction models and evaluated the significance of each parameter associated with favorable neurological outcomes. An independent dataset of 108 IHCA patients receiving targeted temperature management was used to validate the identified parameters. The generalizability of the models was assessed through fivefold cross-validation. The performance of the models was assessed using the area under the curve (AUC).

RESULTS

ANN model 1, based on 19 baseline parameters, and model 2, based on 11 prearrest parameters, achieved validation AUCs of 0.978 and 0.947, respectively. ANN model 3 based on 30 baseline and prearrest parameters achieved an AUC of 0.997. The key factors associated with favorable outcomes were the duration of cardiopulmonary resuscitation; initial cardiac arrest rhythm; arrest location; and whether the patient had a malignant disease, pneumonia, and respiratory insufficiency. On the basis of these parameters, the validation performance of the ANN models achieved an AUC of 0.906 for IHCA patients who received targeted temperature management.

CONCLUSION

The ANN models achieved highly accurate and reliable performance for predicting the neurological outcomes of successfully resuscitated patients with IHCA. These models can be of significant clinical value in assisting with decision-making, especially regarding optimal postresuscitation strategies.

The prognostic value of early lactate clearance for survival after out-of-hospital cardiac arrest

BACKGROUND

Prognostication of survival after out-of-hospital cardiac arrest (OHCA) remains challenging with current guidelines recommending the prognostication no earlier than 72 h after return of spontaneous circulation (ROSC). Prognostic factors that could be used earlier after ROSC, like lactate clearance, are still being studied.

OBJECTIVES

This paper aims to investigate the prognostic strength of early lactate clearance for survival after OHCA.

METHODS

This retrospective observational single-center study focuses on patients for whom ROSC was achieved after OHCA. Patients ≥18 years admitted between September 2012 and January 2019, for which arterial serum lactate measurements were available immediately at and 3 h after hospital admission (T0 and T3), were included.

RESULTS

192 patients were included. Lactate clearance at T3 (p < 0.001) was identified as an independent predictor for 24 h, 48 h and 72 h survival. Witnessed arrest, bystander CPR and initial shockable rhythm were independent significant predictors for long term survival after ROSC (1 month, 3 months and 1 year; p < 0.05), but not for 24 h survival. Age (above or below 65 years) was not significant for predicting survival. Upon combination of witnessed arrest, bystander CPR and initial shockable rhythm in a multivariate logistic regression model for long term survival, the initial rhythm was the dominant factor in the combined model, making witnessed arrest and bystander CPR redundant.

CONCLUSION

Lactate clearance at T3 after ROSC is associated with 24 h, 48 h and 72 h survival. Further research is needed to determine how to incorporate lactate clearance as part of a clinically useful tool to predict long term survival.

Application of extracorporeal cardiopulmonary resuscitation in adult patients with refractory cardiac arrest

Background

The aim of this study was to summarize the clinical experience of extracorporeal cardiopulmonary resuscitation (ECPR) in the treatment of adult patients with refractory cardiac arrest.

Methods

The clinical data of 12 cases of adult patients with cardiac arrest hospitalized between June 2015 and September 2019 who were unable to achieve return of spontaneous circulation effectively with conventional cardiopulmonary resuscitation (CCPR) and were treated with ECPR technology were retrospectively analyzed. The group included six males and six females aged between 18 and 69 years. All the patients underwent veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support with the adoption of femoral artery and vein catheterization.

Results

The duration of cardiopulmonary resuscitation (CPR) for the 12 patients was 32-125 min, and the ECMO duration was 2-190 h. Four patients were successfully weaned from ECMO and survived until hospital discharge. The other eight patients died in hospital; hemodynamic collapse (four patients) in the early stage of ECMO and severe neurological complications (three patients) were the main causes of death.

Conclusions

Single-center data showed that ECPR provided a new rescue alternative for some patients with reversible refractory cardiac arrest. We have demonstrated that the success rate of treatment could be improved by selecting suitable patients and reducing the CPR duration as much as possible.

Gender-related differences in treatment and outcome of extracorporeal cardiopulmonary resuscitation-patients

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to significant improvement in selected patients' survival rates. Gender-related differences might impact the outcome of therapeutic measures. Therefore, we sought to investigate patients with eCPR at our interdisciplinary extracorporeal membrane oxygenation center regarding sex-related differences with the view to potentially adjusting current selection criteria. From January 2016 to December 2019, 71 patients underwent eCPR at our institution. Data before eCPR and early outcome parameters were analyzed comparing male and female patients. The cohort analyzed consisted of 60 male (84%) and 11 female (15%) patients. Comparing both groups, male patients significantly more frequently suffered out-of-hospital cardiac arrest (68% male vs. 36% female, P = .04), whereas female patients were associated with more in-hospital cardiac arrest (32% male vs. 64% female, P = .04). Creatinine levels differed significantly (1.5 (1.1;2.1) mg/dL in male vs. 1.0 (0.7;1.5) mg/dL in female patients, P = .03). Also, several hepatic parameters showed a significant difference between the groups: aspartate aminotransferase 423 (249;804) U/L in male vs. 115 (61;408) U/L in female patients, P = .01; alanine aminotransferase 174 (102;446) U/L in male vs. 86 (36;118) U/L in female patients, P = .01). Renal failure requiring hemodialysis occurred more frequently in men than in women (P < .01). There is a significant effect of male sex regarding renal failure with subsequent continuous venovenous hemodialysis (CVVH) (R²  = 0.11, ANOVA P = .01, 95% CI = -0.79--0.079). However, in-hospital mortality was comparable between the groups (78% in male vs. 72% in female patients, P = .68). Our retrospective study showed several gender-related differences associated with different cardiac arrest scenarios. Male sex was associated with a significantly higher risk for renal failure requiring CVVH. Survival rates were comparable between the groups. Further investigations should include gender in the evaluation of risk stratification for eCPR-related complications to further improve selection criteria for this demanding therapy.

Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used as extracorporeal cardiopulmonary resuscitation (ECPR) to support further resuscitation efforts in patients with cardiac arrest, yet its clinical effectiveness remains uncertain.

OBJECTIVES

This study reviews the role of ECPR in contemporary resuscitation care compared to no ECPR and/or standard care, e.g. conventional CPR, and quantitatively summarize the rates of long-term neurologically intact survival after adult in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA).

METHODS

We searched the following databases on January 31 st, 2020: CENTRAL, MEDLINE, Embase, and Web of Science. We followed PRISMA guidelines and used PICO format to summarize the research questions. Risk of bias was assessed using the ROBINS-I tool. Pooled risk ratios (RRs) for each outcome of interest were calculated. Quality of evidence was evaluated according to GRADE guidelines.

RESULTS

Six cohort studies were included, totaling 1750 patients. Of these, 530 (30.3%) received the intervention, and 91 (17.2%) survived with long-term neurologically intact survival. ECPR compared to no ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest in any setting (risk ratio [RR] 3.11, 95% confidence interval [CI] 2.06-4.69; p < 0.00001) (GRADE: Very low quality). Similar results were found for long-term neurologically intact survival after IHCA (RR 3.21, 95% CI 1.74-5.94; p < 0.0002) (GRADE: Very low quality) and OHCA (RR 3.11, 95% CI 1.50-6.47; p < 0.002) (GRADE: Very low quality). Long-term time frames for neurologically intact survival (three months to two years) were combined into a single category, defined a priori as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1 or 2.

CONCLUSIONS

VA-ECMO used as ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest. Future evidence from randomized trials is very likely to have an important impact on the estimated effect of this intervention and will further define optimal clinical practice. Review registration: PROSPERO CRD42020171945.

Early use of hemoadsorption in patients after out-of hospital cardiac arrest - a matched pair analysis

Background

Pro- and anti-inflammatory mediators are released during and after cardiac arrest, which may be unfavourable. Small case-series and observational studies suggested that unselective hemoadsorption may reduce inadequately high cytokine levels during sepsis or cardiac surgery. We aimed to assess the effect of cytokine adsorbtion on mortality in patients following out-of-hospital cardiac arrest by comparing a patient cohort with hemoadsorption after resuscitation for out-of-hospital cardiac arrest to a control cohort without adsorption within the HAnnover COling REgistry (HACORE).

Methods

We adopted an early routine use of hemoadsorption in patients after out-of-hospital cardiac arrest with increased vasopressor need and performed a 1:2 match according to age, gender, time to return of spontaneous circulation, initial left-ventricular ejection fraction, extracorporeal membrane-oxygenation or left-ventricular unloading by Impella, need for renal replacement therapy, admission lactate, pH, glomerular filtration rate to patients without an adsorber from HACORE. The primary endpoint was 30-day mortality.

Results

Twenty-four patients receiving hemoadsorption were matched to 48 patients without hemoadsorption (mean age 62±13 years, 83% male). While there was no significant difference in baseline parameters, 30-day mortality was higher in patients treated with hemoadsorption than in the matched control group (83% vs 65%, Log rank p = 0.011).

Conclusions

Routine use of hemoadsorption did not reduce, but seems to be associated with higher 30-day mortality in patients after OHCA. Prior to routine adoption in daily practice, hemoadsorption should be evaluated in properly sized randomized controlled trials.

Development and Validation of a Clinical Score to Predict Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation

IMPORTANCE

Extracorporeal cardiopulmonary resuscitation (ECPR) is expected to improve the neurological outcomes of patients with refractory cardiac arrest; however, it is invasive, expensive, and requires substantial human resources. The ability to predict neurological outcomes would assist in patient selection for ECPR.

OBJECTIVE

To develop and validate a prediction model for neurological outcomes of patients with out-of-hospital cardiac arrest with shockable rhythm treated with ECPR.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study analyzed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multi-institutional nationwide cohort study that included 87 emergency departments in Japan. All adult patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR between June 2014 and December 2017 were included. Patients were randomly assigned to the development and validation cohorts based on the institutions. The analysis was conducted between November 2019 and August 2020.

EXPOSURES

Age (<65 years), time from call to hospital arrival (≤25 minutes), initial cardiac rhythm on hospital arrival (shockable), and initial pH value (≥7.0).

MAIN OUTCOMES AND MEASURES

The primary outcome was 1-month survival with favorable neurological outcome, defined by Cerebral Performance Category 1 or 2. In the development cohort, a simple scoring system was developed to predict this outcome using a logistic regression model. The diagnostic ability and calibration of the scoring system were assessed in the validation cohort.

RESULTS

A total of 916 patients were included, 458 in the development cohort (median [interquartile range {IQR}] age, 61 [47-69] years, 377 [82.3%] men) and 458 in the validation cohort (median [IQR] age, 60 [49-68] years; 393 [85.8%] men). The cohorts had the same proportion of favorable neurological outcome (57 patients [12.4%]). The prediction scoring system was developed, attributing a score of 1 for each clinical predictor. Patients were divided into 4 groups, corresponding to their scores on the prediction model, as follows: very low probability (score 0), low probability (score 1), middle probability (score 2), and high probability (score 3-4) of good neurological outcome. The mean predicted probabilities in the groups stratified by score were as follows: very low, 1.6% (95% CI, 1.6%-1.6%); low, 4.4% (95% CI, 4.2%-4.6%); middle, 12.5% (95% CI, 12.1%-12.8%); and high, 30.8% (95% CI, 29.1%-32.5%). In the validation cohort, the C statistic of the scoring system was 0.724 (95% CI, 0.652-0.786). The predicted probability was evaluated as well calibrated to the observed favorable outcome in both cohorts by visual assessment of the calibration plot.

CONCLUSIONS AND RELEVANCE

In this study, the scoring system had good discrimination and calibration performance to predict favorable neurological outcomes of patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR.

Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: A systematic review

Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.

Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

In-hospital cardiac arrest (IHCA) is a major adverse event with a high mortality rate if not treated appropriately. Extracorporeal cardiopulmonary resuscitation (ECPR), as adjunct to conventional cardiopulmonary resuscitation (CCPR), is a promising technique for IHCA treatment. Evidence pertaining to neurological outcomes after ECPR is still scarce.

METHODS

We performed a comprehensive systematic search of all studies up to December 20, 2019. Our primary outcome was neurological outcome after ECPR at any moment after hospital discharge, defined by the Cerebral Performance Category (CPC) score. A score of 1 or 2 was defined as favourable outcome. Our secondary outcome was post-discharge mortality. A fixed-effects meta-analysis was performed.

RESULTS

Our search yielded 1215 results, of which 19 studies were included in this systematic review. The average survival rate was 30% (95% CI 28-33%, I2 = 0%, p = 0.24). In the surviving patients, the pooled percentage of favourable neurological outcome was 84% (95% CI 80-88%, I2 = 24%, p = 0.90).

CONCLUSION

ECPR as treatment for in-hospital cardiac arrest is associated with a large proportion of patients with good neurological outcome. The large proportion of favourable outcome could potentially be explained by the selection of patients for treatment using ECPR. Moreover, survival is higher than described in the conventional CPR literature. As indications for ECPR might extend to older or more fragile patient populations in the future, research should focus on increasing survival, while maintaining optimal neurological outcome.

Gasping during refractory out-of-hospital cardiac arrest is a prognostic marker for favourable neurological outcome following extracorporeal cardiopulmonary resuscitation: a retrospective study

Background

Gasping during cardiac arrest is associated with favourable neurological outcomes for out-of-hospital cardiac arrest. Moreover, while extracorporeal cardiopulmonary resuscitation (ECPR) performed for refractory cardiac arrest can improve outcomes, factors for favourable neurological outcomes remain unknown. This study aimed to examine whether gasping during cardiac arrest resuscitation during transport by emergency medical services (EMS) was independently associated with a favourable neurological outcome for patients who underwent ECPR. This retrospective study was based on medical records of all adult patients who underwent ECPR due to refractory cardiac arrest. The primary endpoint was neurologically intact survival at discharge. The study was undertaken at Sapporo Medical University Hospital, a tertiary care centre approved by the Ministry of Health, Labour and Welfare, located in the city of Sapporo, Japan, between January 2012 and December 2018.

Results

Overall, 166 patients who underwent ECPR were included. During transportation by EMS, 38 patients exhibited gasping, and 128 patients did not. Twenty patients who exhibited gasping during EMS transportation achieved a favourable neurological outcome (20/38; 52.6%); 14 patients who did not exhibit gasping achieved a favourable neurological outcome (14/128; 10.9%). Gasping during transportation by EMS was independently associated with favourable neurological outcome irrespective of the type of analysis performed (multiple logistic regression analysis, odds ratio [OR] 9.52; inverse probability of treatment weighting using propensity score, OR 9.14).

Conclusions

The presence of gasping during transportation by EMS was independently associated with a favourable neurological outcome in patients who underwent ECPR. The association of gasping with a favourable neurological outcome in patients with refractory cardiac arrest suggests that ECPR may be considered in such patients.

A systematic review of current ECPR protocols. A step towards standardisation

Aim

Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Our goal was to identify the best protocol for survival with good neurological outcome through the evaluation of current inclusion criteria, exclusion criteria, cannulation strategies and additional therapeutic measures.

Methods

A systematic literature search was used to identify eligible publications from PubMed, Embase, Web of Science and Cochrane for articles published from 29 June 2009 until 29 June 2019.

Results

The selection process led to a total of 24 eligible articles, considering 1723 patients in total. A good neurological outcome at hospital discharge was found in 21.3% of all patients. The most consistent criterion for inclusion was refractory cardiac arrest (RCA), used in 21/25 (84%) of the protocols. The preferred cannulation method was the percutaneous Seldinger technique (44%).

Conclusion

ECPR is a feasible option for cardiac arrest and should already be considered in an early stage of CPR. One of the key findings is that time-to-ECPR seems to be correlated with good neurological survival. An important contributing factor is the definition of RCA. Protocols defining RCA as >10 ​min had a mean good neurological survival of 26.7%. Protocols with a higher cut-off, between 15 and 30 ​min, had a mean good neurological survival of 14.5%. Another factor contributing to the time-to-ECPR is the preferred access technique. A percutaneous Seldinger technique combined with ultrasonography and fluoroscopic guidance leads to a reduced cannulation time and complication rate. Conclusive research around prehospital cannulation still needs to be conducted.

Shortening of low-flow duration over time was associated with improved outcomes of extracorporeal cardiopulmonary resuscitation in in-hospital cardiac arrest

Introduction

Quality improvement in the administration of extracorporeal cardiopulmonary resuscitation (ECPR) over time and its association with low-flow duration (LFD) and outcomes of cardiac arrest (CA) have been insufficiently investigated. In this study, we hypothesized that quality improvement in efforts to shorten the duration of initiating ECPR had decreased LFD over the last 15 years of experience at an academic tertiary care hospital, which in turn improved the outcomes of in-hospital CA (IHCA).

Methods

This was a single-center retrospective observational study of ECPR patients between January 2003 and December 2017. A rapid response system (RRS) and an extracorporeal membrane oxygenation (ECMO) program were initiated in 2011 and 2013. First, the association of LFD per minute with the 90-day mortality and neurological outcome was analyzed using multiple logistic regression analysis. Then, the temporal changes in LFD were investigated.

Results

Of 175 study subjects who received ECPR, 117 had IHCA. In the multivariate logistic regression, IHCA patients with shorter LFD experienced significantly increased 90-day survival and favorable neurological outcomes (LFD per minute, 90-day survival: odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.94–1.00, P = 0.032; 90-day favorable neurological outcome: OR = 0.97, 95% CI = 0.94–1.00, P = 0.049). In the study period, LFD significantly decreased over time (slope − 5.39 [min/3 years], P < 0.0001).

Conclusion

A shorter LFD was associated with increased 90-day survival and favorable neurological outcomes of IHCA patients who received ECPR. The quality improvement in administering ECPR over time, including the RRS program and the ECMO program, appeared to ameliorate clinical outcomes.

Rapid outdoor non-compression intubation (RONCI) of cardiac arrests to mitigate COVID-19 exposure to emergency department staff

The COVID-19 pandemic has introduced numerous challenges for Health Care Professionals, including exposing Emergency Department (ED) staff to the SARS-CoV-2 virus during Cardiopulmonary Resuscitation (CPR). Recent guidelines from the American Heart Association (AHA) prioritize early intubation with viral filter placement to minimize hospital staff exposure. We propose a novel technique for rapid outdoor non-compression intubation (RONCI) of cardiac arrest patients while en route from the ambulance bay to the resuscitation bay to further decrease the risk of viral aerosolization.

Myocardial infarction type 1 is frequent in refractory out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR)

Extracorporeal cardiopulmonary resuscitation (ECPR) is a last resort treatment option for refractory cardiac arrest performed in specialized centers. Following consensus recommendations, ECPR is mostly offered to younger patients with witnessed collapse but without return of spontaneous circulation (ROSC). We report findings from a large single-center registry with 252 all-comers who received ECPR from 2011-2019. It took a median of 52 min to establish stable circulation by ECPR. Eighty-five percent of 112 patients with out-of-hospital cardiac arrest (OHCA) underwent coronary angiography, revealing myocardial infarction (MI) type 1 with atherothrombotic vessel obstruction in 70 patients (63% of all OHCA patients, 74% of OHCA patients undergoing coronary angiography). Sixty-six percent of 140 patients with intra-hospital cardiac arrest (IHCA) underwent coronary angiography, which showed MI type 1 in 77 patients (55% of all IHCA patients, 83% of IHCA patients undergoing coronary angiography). These results suggest that MI type 1 is a frequent finding and - most likely - cause of cardiac arrest (CA) in patients without ROSC, especially in OHCA. Hospital survival rates were 30% and 29% in patients with OHCA and IHCA, respectively. According to these findings, rapid coronary angiography may be advisable in patients with OHCA receiving ECPR without obvious non-cardiac cause of arrest, irrespective of electrocardiogram analysis. Almost every third patient treated with ECPR survived to hospital discharge, supporting previous data suggesting that ECPR may be beneficial in CA without ROSC. In conclusion, interventional cardiology is of paramount importance for ECPR programs.

Association between low pH and unfavorable neurological outcome among out-of-hospital cardiac arrest patients treated by extracorporeal CPR: a prospective observational cohort study in Japan

Background

We aimed to identify the association of pH value in blood gas assessment with neurological outcome among out-of-hospital cardiac arrest (OHCA) patients treated by extracorporeal cardiopulmonary resuscitation (ECPR).

Methods

We retrospectively analyzed the database of a multicenter prospective observational study on OHCA patients in Osaka prefecture, Japan (CRITICAL study), from July 1, 2012 to December 31, 2016. We included adult OHCA patients treated by ECPR. Patients with OHCA from external causes such as trauma were excluded. We conducted logistic regression analysis to identify the odds ratio (OR) and 95% confidence interval (CI) of the pH value for 1 month favorable neurological outcome adjusted for potential confounders including sex, age, witnessed by bystander, CPR by bystander, pre-hospital initial cardiac rhythm, and cardiac rhythm on hospital arrival.

Results

Among the 9822 patients in the database, 260 patients were finally included in the analysis. The three groups were Tertile 1: pH ≥ 7.030, Tertile 2: pH 6.875–7.029, and Tertile 3: pH < 6.875. The adjusted OR of Tertiles 2 and 3 compared with Tertile 1 for 1 month favorable neurological outcome were 0.26 (95% CI 0.10–0.63) and 0.24 (95% CI 0.09–0.61), respectively.

Conclusions

This multi-institutional observational study showed that low pH value (< 7.03) before the implementation of ECPR was associated with 1 month unfavorable neurological outcome among OHCA patients treated with ECPR. It may be helpful to consider the candidate for ECPR.

Prediction of the neurological outcome using regional cerebral oxygen saturation in patients with extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest: a multicenter retrospective cohort study

Aim

To investigate the association between regional cerebral oxygen saturation (rSO2) and neurological outcomes in extracorporeal cardiopulmonary resuscitation (ECPR) patients after out‐of‐hospital cardiac arrest (OHCA).

Methods

We used data from the Japan‐Prediction of Neurological Outcomes in Patients Post‐Cardiac Arrest Registry. This registry included consecutive comatose patients after OHCA who were transferred to 15 hospitals in Japan from 2011 to 2013. Our primary end‐point was a good neurological outcome (cerebral performance categories 1 or 2) at 90 days after OHCA.

Results

Among the enrolled patients, 121 (6.3%) received ECPR. Eleven (9.1%) had a good neurological outcome. Receiver operating characteristic curve analysis revealed the optimal cut‐off value as >16%. Good neurological outcomes were observed in 19.6% (9/46) and 2.7% (2/74) of patients with rSO2 >16% and rSO2 ≤16%, respectively.

Conclusion

The neurological outcome of ECPR patients differed according to their rSO2 values. When considering ECPR, the rSO2 value could be important in addition to other criteria. Further studies that focus on ECPR patients and serial rSO2 values are needed.