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Hamaguchi T, Takiguchi T, Seki T, Tominaga N, Nakata J, Yamamoto T, Tagami T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Yokobori S, Study Group TSJI. Association between pupillary examinations and prognosis in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective multicentre cohort study. Ann Intensive Care 2024; 14:35. [PMID: 38448746 PMCID: PMC10917711 DOI: 10.1186/s13613-024-01265-7] [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: 11/26/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND In some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR. RESULTS Out of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17-24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52-2.32) was not significantly associated with favourable neurological outcome. CONCLUSION Among the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.
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Affiliation(s)
- Takuro Hamaguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Toru Takiguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan.
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tomohisa Seki
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [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] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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Isokawa S, Hifumi T, Hirano K, Watanabe Y, Horie K, Shin K, Shirasaki K, Goto M, Inoue A, Sakamoto T, Kuroda Y, Tomita S, Otani N, Group TSJIS. Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study. Ann Intensive Care 2024; 14:16. [PMID: 38280965 PMCID: PMC10821854 DOI: 10.1186/s13613-024-01253-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database. METHODS This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013-2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes. RESULTS A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count (< 10 × 104/μL vs > 10 × 104/μL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252-2.777], p = 0.002). CONCLUSIONS In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety.
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Affiliation(s)
- Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan.
| | - Keita Hirano
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yu Watanabe
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Katsuhiro Horie
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kijong Shin
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kasumi Shirasaki
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Masahiro Goto
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | | | - Norio Otani
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
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Chang SN, Hu NZ, Wu JH, Cheng HM, Caffrey JL, Yu HY, Chen YS, Hsu J, Lin JW. Urine output as one of the most important features in differentiating in-hospital death among patients receiving extracorporeal membrane oxygenation: a random forest approach. Eur J Med Res 2023; 28:347. [PMID: 37715216 PMCID: PMC10503185 DOI: 10.1186/s40001-023-01294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/16/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND It is common to support cardiovascular function in critically ill patients with extracorporeal membrane oxygenation (ECMO). The purpose of this study was to identify patients receiving ECMO with a considerable risk of dying in hospital using machine learning algorithms. METHODS A total of 1342 adult patients on ECMO support were randomly assigned to the training and test groups. The discriminatory power (DP) for predicting in-hospital mortality was tested using both random forest (RF) and logistic regression (LR) algorithms. RESULTS Urine output on the first day of ECMO implantation was found to be one of the most predictive features that were related to in-hospital death in both RF and LR models. For those with oliguria, the hazard ratio for 1 year mortality was 1.445 (p < 0.001, 95% CI 1.265-1.650). CONCLUSIONS Oliguria within the first 24 h was deemed especially significant in differentiating in-hospital death and 1 year mortality.
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Affiliation(s)
- Sheng-Nan Chang
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nian-Ze Hu
- Department of Information Management, National Formosa University, Huwei, Yunlin, Taiwan.
| | - Jo-Hsuan Wu
- Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA
| | - Hsun-Mao Cheng
- Office of Medical Informatics, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan
| | - James L Caffrey
- Physiology and Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jiun Hsu
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan.
- Office of Medical Informatics, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan.
- Department of Surgery, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan.
| | - Jou-Wei Lin
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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5
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Bian W, Bian W, Li Y, Feng X, Song M, Zhou P. Hypothermia may reduce mortality and improve neurologic outcomes in adult patients treated with VA-ECMO: A systematic review and meta-analysis. Am J Emerg Med 2023; 70:163-170. [PMID: 37327682 DOI: 10.1016/j.ajem.2023.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/08/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND VA-ECMO can greatly reduce mortality in critically ill patients, and hypothermia attenuates the deleterious effects of ischemia-reperfusion injury. We aimed to study the effects of hypothermia on mortality and neurological outcomes in VA-ECMO patients. METHODS A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to 31 December 2022. The primary outcome was discharge or 28-day mortality and favorable neurological outcomes in VA-ECMO patients, and the secondary outcome was bleeding risk in VA-ECMO patients. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Based on the heterogeneity assessed by the I2 statistic, meta-analyses were performed using random or fixed-effects models. GRADE methodology was used to rate the certainty in the findings. RESULTS A total of 27 articles (3782 patients) were included. Hypothermia (33-35 °C) lasting at least 24 h can significantly reduce discharge or 28-day mortality (OR, 0.45; 95% CI, 0.33-0.63; I2 = 41%) and significantly improve favorable neurological outcomes (OR, 2.08; 95% CI, 1.66-2.61; I2 = 3%) in VA-ECMO patients. Additionally, there was no risk associated with bleeding (OR, 1.15; 95% CI, 0.86-1.53; I2 = 12%). In our subgroup analysis according to in-hospital or out-of-hospital cardiac arrest, hypothermia reduced short-term mortality in both VA-ECMO-assisted in-hospital (OR, 0.30; 95% CI, 0.11-0.86; I2 = 0.0%) and out-of-hospital cardiac arrest (OR, 0.41; 95% CI, 0.25-0.69; I2 = 52.3%). Out-of-hospital cardiac arrest patients assisted by VA-ECMO for favorable neurological outcomes were consistent with the conclusions of this paper (OR, 2.10; 95% CI, 1.63-2.72; I2 = 0.5%). CONCLUSIONS Our results show that mild hypothermia (33-35 °C) lasting at least 24 h can greatly reduce short-term mortality and significantly improve favorable short-term neurologic outcomes in VA-ECMO-assisted patients without bleeding-related risks. As the grade assessment indicated that the certainty of the evidence was relatively low, hypothermia as a strategy for VA-ECMO-assisted patient care may need to be treated with caution.
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Affiliation(s)
- Wentao Bian
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Wenkai Bian
- Xi'an Radio Research Institute, Xian, Shaanxi Province, China
| | - Yi Li
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xuanlin Feng
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Menglong Song
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Ping Zhou
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China.
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6
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Hashem A, Mohamed MS, Alabdullah K, Elkhapery A, Khalouf A, Saadi S, Nayfeh T, Rai D, Alali O, Kinzelman-Vesely EA, Parikh V, Feitell SC. Predictors of Mortality in Patients With Refractory Cardiac Arrest Supported With VA-ECMO: A Systematic Review and a Meta-Analysis. Curr Probl Cardiol 2023; 48:101658. [PMID: 36828046 DOI: 10.1016/j.cpcardiol.2023.101658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023]
Abstract
Cardiac arrest (CA) is associated with high mortality rate, ranging between 75% and 93%. Given its significance, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for end-organs perfusion and to maintain adequate oxygenation as a life-saving option in refractory CA. The predictors for the success of VA-ECMO in this setting have not been established yet. In this meta-analysis, we aim to identify the variables associated with increased mortality in patients with CA supported with VA-ECMO. We conducted a systematic review and meta-analysis to evaluate mortality-predicting factors in patients with CA supported with VA-ECMO that were published between January 2000 and July 2022. To identify relevant articles, the MEDLINE (Pubmed, Ovid) and Cochrane Databases were queried with various combinations of our prespecified keywords, including VA-ECMO, CA, and mortality predictors. We performed a meta-analysis using a random-effects model to calculate the odds ratio (OR). We retrieved a total of 4476 records, out of which we included 10 observational studies in our study. A total of 931 patients were included in our study with the age range of 47-68 years, predominantly males (63.9%). The overall mortality was 69.4%. The predictors for mortality were age >65 (OR 4.61, 95% CI 1.63-13.03, P < 0.01), history of chronic kidney disease (OR 2.42, 95% CI 1.37-4.28, P < 0.01), cardiopulmonary resuscitation duration prior to ECMO > 40 minutes (OR 6.62 [95% CI 1.39, 9.02], P < 0.01), having an initial nonshockable rhythm (OR 2.62 [95% CI 1.85, 3.70], P < 0.01) and sequential organ failure assessment score >14 (OR 12.29, 95% CI 2.71-55.74, P <0.01). Regarding blood work, an increase in lactate by 5 mmol/L increased the odds of mortality by 121% (2 studies; OR 2.21 [95% CI 1.26, 3.86], P < 0.01; I2 = 0%) while the increase in lactate by 1 mmol/L increases odd of mortality by 15% (2 studies, OR 1.15 [95% CI 1.02, 1.31], P = 0.03, I = 0%), and an increase in creatinine by 1 mg/dL increased the odds of mortality by 225% (1 study; OR 3.25 [95% CI 1.22, 8.7], P = 0.02). Albumin was protective as for each 1 g/dL increase, the odds of mortality decreased by 68% (1 study; OR 0.32 [95% CI 0.14, 0.74], P < 0.01). Refractory CA requiring VA-ECMO has a high mortality. Predictors of mortality include age >65, history of chronic kidney disease, cardiopulmonary resuscitation duration prior to ECMO > 40 minutes, initial rhythm being non-shockable and Sequential Organ Failure Assessment score >14.
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Affiliation(s)
- Anas Hashem
- Internal Medicine Resident, Rochester General Hospital, Rochester, NY.
| | | | - Khaled Alabdullah
- Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA
| | - Ahmed Elkhapery
- Internal Medicine Resident, Rochester General Hospital, Rochester, NY
| | - Amani Khalouf
- Internal Medicine Resident, Rochester General Hospital, Rochester, NY
| | - Samer Saadi
- Evidence-based Practice Research Program, Mayo Clinic, Rochester, MN
| | - Tarek Nayfeh
- Evidence-based Practice Research Program, Mayo Clinic, Rochester, MN
| | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Omar Alali
- Internal Medicine Resident, Rochester General Hospital, Rochester, NY
| | | | - Vishal Parikh
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Scott C Feitell
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
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7
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Makino Y, Okada Y, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Kobata H, Kiguchi T, Kishimoto M, Kim SH, Ito Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Onoe A, Matsuyama T, Matsui S, Nishioka N, Yoshimura S, Kimata S, Kawai S, Zha L, Kiyohara K, Kitamura T, Iwami T. External validation of the TiPS65 score for predicting good neurological outcomes in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation. Resuscitation 2023; 182:109652. [PMID: 36442597 DOI: 10.1016/j.resuscitation.2022.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
AIM Estimating prognosis of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) is essential for selecting candidates. The TiPS65 score can predict neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated with ECPR. We aimed to perform an external validation of this score. METHODS Data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentred, nationwide, prospectively registered database, were analysed. All adult patients with OHCA and shockable rhythm and treated with ECPR between January 2018 to December 2019 were included. In the TiPS65 score, age, call-to-hospital arrival time, initial cardiac rhythm at hospital arrival, and initial pH value were used as predictors. The primary outcome was 30-day survival with favourable neurological outcomes (Cerebral Performance Category 1 or 2). Discrimination, using the C-statistic, and predictive performances of each score, such as sensitivity and specificity, were investigated. RESULTS Of 590 included patients (517 [81.6%] men; median [interquartile range] age, 60 [50-69] years), 64 (10.8%) reported favourable neurological outcomes. The C-statistic of the TiPS65 score was 0.729 (95% confidence interval (CI): 0.672-0.786). When the cut-off of TiPS65 score was set to >1, the sensitivity and specificity were 0.906 (95%CI: 0.807-0.965) and 0.430 (95%CI: 0.387-0.473), respectively; conversely, when the cut-off was set to >3, they were 0.172 (95%CI: 0.089-0.287) and 0.971 (95%CI: 0.953-0.984), respectively. CONCLUSIONS The TiPS65 score shows reasonable discrimination and predictive performances. This score can be supportive in the decision-making process for the selection of eligible patients for ECPR in clinical settings.
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Affiliation(s)
- Yuto Makino
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan; Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoki Yamada
- Emergency and Critical Care Medical Centre, Osaka Police Hospital, Osaka, Japan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital, Moriguchi, Japan
| | - Changhwi Park
- Department of Emergency Medicine, Tane General Hospital, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine, Kindai University School of Medicine, Osaka-Sayama, Japan
| | - Hitoshi Kobata
- Osaka Mishima Emergency Critical Care Centre, Takatsuki, Japan
| | - Takeyuki Kiguchi
- Critical Care and Trauma Centre, Osaka General Medical Centre, Osaka, Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Centre of Acute Medicine, Higashi-Osaka, Japan
| | - Sung-Ho Kim
- Senshu Trauma and Critical Care Centre, Osaka, Japan
| | - Yusuke Ito
- Senri Critical Care Medical Centre, Saiseikai Senri Hospital, Suita, Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Centre, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Centre, Osaka City General Hospital, Osaka, Japan
| | - Haruko Sakamoto
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | - Keitaro Suzuki
- Emergency and Critical Care Medical Centre, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Atsunori Onoe
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Satoshi Yoshimura
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Shunsuke Kimata
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Shunsuke Kawai
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Ling Zha
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Otsuma Women's University, Tokyo, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan.
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8
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Lim JH, Chakaramakkil MJ, Tan BKK. Extracorporeal life support in adult patients with out-of-hospital cardiac arrest. Singapore Med J 2022; 62:433-437. [PMID: 35001109 DOI: 10.11622/smedj.2021113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.
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Affiliation(s)
- Jia Hao Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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9
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Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci 2022; 1507:37-48. [PMID: 33609316 PMCID: PMC8377067 DOI: 10.1111/nyas.14580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/03/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.
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Affiliation(s)
- Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jason A. Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
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10
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Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis. ASAIO J 2021; 68:987-995. [PMID: 34860714 DOI: 10.1097/mat.0000000000001613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (β = 0.02, 95% CI: 0.007-0.02; p = 0.0004).
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11
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Duan J, Ma Q, Zhu C, Shi Y, Duan B. eCPR Combined With Therapeutic Hypothermia Could Improve Survival and Neurologic Outcomes for Patients With Cardiac Arrest: A Meta-Analysis. Front Cardiovasc Med 2021; 8:703567. [PMID: 34485403 PMCID: PMC8414549 DOI: 10.3389/fcvm.2021.703567] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Extracorporeal membrane oxygenation with CPR (eCPR) or therapeutic hypothermia (TH) seems to be a very effective CPR strategy to save patients with cardiac arrest (CA). Furthermore, the subsequent post-CA neurologic outcomes have become the focus. Therefore, there is an urgent need to find a way to improve survival and neurologic outcomes for CA. Objective: We conducted this meta-analysis to find a more suitable CPR strategy for patients with CA. Method: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science). From an initial 1,436 articles, 23 studies were eligible into this meta-analysis, including a total of 2,035 patients. Results: eCPR combined with TH significantly improved the short-term (at discharge or 28 days) survival [OR = 2.27, 95% CIs (1.60-3.23), p < 0.00001] and neurologic outcomes [OR = 2.60, 95% CIs (1.92-3.52), p < 0.00001). At 3 months of follow-up, the results of survival [OR = 3.36, 95% CIs (1.65-6.85), p < 0.0008] and favorable neurologic outcomes [OR = 3.02, 95% CIs (1.38-6.63), p < 0.006] were the same as above. Furthermore, there was no difference in any bleeding needed intervention [OR = 1.33, 95% CIs (0.09-1.96), p = 0.16] between two groups. Conclusions: From this meta-analysis, we found that eCPR combined with TH might be a more suitable CPR strategy for patients with CA in improving survival and neurologic outcomes, and eCPR with TH did not increase the risk of bleeding. Furthermore, single-arm meta-analyses showed a plausible way of temperature and occasion of TH.
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Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Changju Zhu
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanchao Shi
- The First Clinical Medicine School, Lanzhou University, Lanzhou, China
| | - Baomin Duan
- Emergency Department, Kaifeng Centre Hospital, Kaifeng, China
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A. Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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13
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Kumar KM. ECPR-extracorporeal cardiopulmonary resuscitation. Indian J Thorac Cardiovasc Surg 2021; 37:294-302. [PMID: 33432257 PMCID: PMC7787697 DOI: 10.1007/s12055-020-01072-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is a salvage procedure in which extracorporeal membrane oxygenation (ECMO) is initiated emergently on patients who have had cardiac arrest (CA) and on whom the conventional cardiopulmonary resuscitation (CCPR) has failed. Awareness and usage of ECPR are increasing all over the world. Significant advancements have taken place in the ECPR initiation techniques, in its device and in its post-procedure care. ECPR is a team work requiring multidisciplinary experts, highly skilled health care workers and adequate infrastructure with appropriate devices. Perfect coordination and communication among team members play a vital role in the outcome of the ECPR patients. Ethical, legal and financial issues need to be considered before initiation of ECPR and while withdrawing the support when the ECPR is futile. Numerous studies about ECPR are being published more frequently in the last few years. Hence, keeping updated about the ECPR is very important for proper selection of cases and its management. This article reviews various aspects of ECPR and relevant literature to date.
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Affiliation(s)
- Kuppuswamy Madhan Kumar
- Heart and Lung Transplant Centre, Heart Institute, Apollo Hospitals, Ground floor, Main Block 21, Greams Lane off, Greams Road, Chennai, 600006 India
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Miraglia D, Ayala JE. Extracorporeal cardiopulmonary resuscitation for adults with shock-refractory cardiac arrest. J Am Coll Emerg Physicians Open 2021; 2:e12361. [PMID: 33506232 PMCID: PMC7813516 DOI: 10.1002/emp2.12361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/28/2020] [Accepted: 12/23/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation has increasingly emerged as a feasible treatment to mitigate the progressive multiorgan dysfunction that occurs during cardiac arrest, in support of further resuscitation efforts. OBJECTIVES Because the recent systematic review commissioned in 2018 by the International Liaison Committee on Resuscitation Advanced Life Support task did not include studies without a control group, our objective was to conduct a review incorporating these studies to increase available evidence supporting the use of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest patients, while waiting for high-quality evidence from randomized controlled trials (RCTs). METHODS MEDLINE, Embase, and Science Citation Index (Web of Science) were searched for eligible studies from database inception to July 20, 2020. The population of interest was adult patients who had suffered cardiac arrest in any setting. We included all cohort studies with 1 exposure/1 group and descriptive studies (ie, case series studies). We excluded RCTs, non-RCTs, and observational analytic studies with a control group. Outcomes included short-term survival and favorable neurological outcome. Short-term outcomes (ie, hospital discharge, 30 days, and 1 month) were combined into a single category. RESULTS Our searches of databases and other sources yielded a total of 4302 citations. Sixty-two eligible studies were included (including a combined total of 3638 participants). Six studies were of in-hospital cardiac arrest, 34 studies were of out-of-hospital cardiac arrest, and 22 studies included both in-hospital and out-of-hospital cardiac arrest. Seven hundred and sixty-eight patients of 3352 (23%) had short-term survival; whereas, 602 of 3366 (18%) survived with favorable neurological outcome, defined as a cerebral performance category score of 1 or 2. CONCLUSIONS Current clinical evidence is mostly drawn from observational studies, with their potential for confounding selection bias. Although studies without controls cannot supplant case-control or cohort studies, several ECPR studies without a control group show successful resuscitation with impressive results that may provide valuable information to inform a comparison.
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Affiliation(s)
- Dennis Miraglia
- Department of Emergency MedicineSan Francisco HospitalSan JuanPuerto RicoUSA
| | - Jonathan E. Ayala
- Department of Emergency MedicineGood Samaritan HospitalAguadillaPuerto RicoUSA
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Yannopoulos D, Kalra R, Kosmopoulos M, Walser E, Bartos JA, Murray TA, Connett JE, Aufderheide TP. Rationale and methods of the Advanced R 2Eperfusion STrategies for Refractory Cardiac Arrest (ARREST) trial. Am Heart J 2020; 229:29-39. [PMID: 32911433 DOI: 10.1016/j.ahj.2020.07.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 07/08/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation has emerged as a prominent therapy for patients with refractory cardiac arrest. However, the optimal time of initiation remains unknown. AIM The aim was to assess the rate of survival to hospital discharge in adult patients with refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest treated with 1 of 2 local standards of care: (1) early venoarterial extracorporeal membrane oxygenation-facilitated resuscitation for circulatory support and percutaneous coronary intervention, when needed, or (2) standard advanced cardiac life support resuscitation. DESIGN Phase II, single-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial. POPULATION Adults (aged 18-75), initial out-of-hospital cardiac arrest rhythm of ventricular fibrillation/pulseless ventricular tachycardia, no ROSC following 3 shocks, body morphology to accommodate a Lund University Cardiac Arrest System automated cardiopulmonary resuscitation device, and transfer time of <30 minutes. SETTING Hospital-based. OUTCOMES Primary: survival to hospital discharge. Secondary: safety, survival, and functional assessment at hospital discharge and 3 and 6 months, and cost. SAMPLE SIZE Assuming success rates of 12% versus 37% in the 2 arms and 90% power, a type 1 error rate of .05, and a 15% rate of withdrawal prior to hospital discharge, the required sample size is N = 174 evaluated patients. CONCLUSIONS The ARREST trial will generate safety/effectiveness data and comparative costs associated with extracorporeal cardiopulmonary resuscitation, informing broader implementation and a definitive Phase III clinical trial.
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Affiliation(s)
- Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN.
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Emily Walser
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Jason A Bartos
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - John E Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
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16
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Miraglia D, Miguel LA, Alonso W. Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: systematic review and meta-analysis of propensity score-matched cohort studies. J Am Coll Emerg Physicians Open 2020; 1:342-361. [PMID: 33000057 PMCID: PMC7493557 DOI: 10.1002/emp2.12091] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In this systematic review and meta-analysis of propensity score-matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30-day and long-term favorable neurological outcomes and survival in patients resuscitated from in- and out-of-hospital cardiac arrest. METHODS We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Six cohort studies using propensity score-matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30-day and long-term favorable neurological outcome in adults compared to CCPR for in- and out-of-hospital cardiac arrest (RR = 2.02, 95% CI = 1.29-3.16; I2 = 20%, P = 0.002; very low-quality evidence) and (RR = 2.86, 95% CI = 1.64-5.01; I2 = 0%, P = 0.0002; moderate-quality evidence), respectively. When we analyzed in- and out-of-hospital cardiac arrest separately, ECPR was likely associated with improved 30-day favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.18, 95% CI = 1.24-3.81; I2 = 9%, P = 0.006; very low-quality evidence), but not for out-of-hospital cardiac arrest (RR = 2.61, 95% CI = 0.56-12.20; I2 = 59%, P = 0.22; very low-quality evidence). ECPR was also likely associated with improved long-term favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.50, 95% CI = 1.33-4.71; I2 = 0%, P = 0.005; moderate-quality evidence) and out-of-hospital cardiac arrest (RR = 4.64, 95% CI = 1.41-15.25; I2 = 0%, P = 0.01; moderate-quality evidence). CONCLUSIONS Our analysis suggests that VA-ECMO used as ECPR may improve long-term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well-designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Lourdes A Miguel
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Wilfredo Alonso
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
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Chien CY, Tsai SL, Tsai LH, Chen CB, Seak CJ, Weng YM, Lin CC, Ng CJ, Chien WC, Huang CH, Lin CY, Chaou CH, Liu PH, Tseng HJ, Fang CT. Impact of Transport Time and Cardiac Arrest Centers on the Neurological Outcome After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study. J Am Heart Assoc 2020; 9:e015544. [PMID: 32458720 PMCID: PMC7429006 DOI: 10.1161/jaha.119.015544] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Should all out‐of‐hospital cardiac arrest (OHCA) patients be directly transported to cardiac arrest centers (CACs) remains under debate. Our study evaluated the impacts of different transport time and destination hospital on the outcomes of OHCA patients. Methods and Results Data were collected from 6655 OHCA patients recorded in the regional prospective OHCA registry database of Taoyuan City, Taiwan, between January 2012 and December 2016. Patients were matched on propensity score, which left 5156 patients, 2578 each in the CAC and non‐CAC groups. Transport time was dichotomized into <8 and ≥8 minutes. The relations between the transport time to CACs and good neurological outcome at discharge and survival to discharge were investigated. Of the 5156 patients, 4215 (81.7%) presented with nonshockable rhythms and 941 (18.3%) presented with shockable rhythms. Regardless of transport time, transportation to a CAC increased the likelihoods of survival to discharge (<8 minutes: adjusted odds ratio [aOR], 1.95; 95% CI, 1.11–3.41; ≥8 minutes: aOR, 1.92; 95% CI, 1.25–2.94) and good neurological outcome at discharge (<8 minutes: aOR, 2.70; 95% CI, 1.40–5.22; ≥8 minutes: aOR, 2.20; 95% CI, 1.29–3.75) in OHCA patients with shockable rhythms but not in patients with nonshockable rhythms. Conclusions OHCA patients with shockable rhythms transported to CACs demonstrated higher probabilities of survival to discharge and a good neurological outcome at discharge. Direct ambulance delivery to CACs should thus be considered, particularly when OHCA patients present with shockable rhythms.
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Affiliation(s)
- Cheng-Yu Chien
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Ton-Yen General Hospital Zhubei Taiwan.,Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan
| | - Shang-Li Tsai
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Chang Gung Memorial Hospital Taipei Branch Taipei Taiwan
| | - Li-Heng Tsai
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan
| | - Chen-Bin Chen
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan
| | - Yi-Ming Weng
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Taoyuan General Hospital Ministry of Health and Welfare Taoyuan Taiwan
| | - Chi-Chun Lin
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Ton-Yen General Hospital Zhubei Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan
| | - Wei-Che Chien
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Chang Gung Memorial Hospital Taipei Branch Taipei Taiwan
| | - Chien-Hsiung Huang
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Taoyuan General Hospital Ministry of Health and Welfare Taoyuan Taiwan
| | - Cheng-Yu Lin
- Department of Emergency Medicine Ton-Yen General Hospital Zhubei Taiwan
| | - Chung-Hsien Chaou
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan
| | - Peng-Huei Liu
- Department of Emergency Medicine Chang Gung Memorial Hospital Linkou and College of Medicine Chang Gung University Tao-Yuan Taiwan.,Department of Emergency Medicine Chang Gung Memorial Hospital Taipei Branch Taipei Taiwan
| | - Hsiao-Jung Tseng
- Biostatistics Unit Clinical Trial Center Chang Gung Memorial Hospital Linkou Taiwan
| | - Chi-Tai Fang
- Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan.,Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan
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18
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Lotz C, Muellenbach RM, Meybohm P, Rolfes C, Wulf H, Reyher C. [Preclinical management of cardiac arrest-extracorporeal cardiopulmonary resuscitation]. Anaesthesist 2020; 69:404-413. [PMID: 32435820 DOI: 10.1007/s00101-020-00787-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The chances of surviving out-of-hospital cardiac arrest (OHCA) are still very low. Despite intensive efforts the outcome has remained relatively poor over many years. In specific situations, new technologies, such as extracorporeal cardiopulmonary resuscitation (eCPR) could significantly improve survival with a good neurological outcome. OBJECTIVE Does the immediate restoration of circulation and reoxygenation via eCPR influence the survival rate after OHCA? Is eCPR the new link in the chain of survival? MATERIAL AND METHODS Discussion of current study results and guideline recommendations. RESULTS The overall survival rates after OHCA have remained at 10-30% over many years. Despite low case numbers more recent retrospective studies showed that an improved outcome can be achieved with eCPR. In selected patient collectives survival with a favorable neurological outcome is possible in 38% of the cases. CONCLUSION Survival after cardiac arrest and the subsequent quality of life dependent on many different factors. The time factor, i.e. the avoidance of a no-flow phase and reduction of the low-flow phase is of fundamental importance. The immediate restoration of the circulation and oxygen supply by eCPR can significantly improve survival; however, large randomized, controlled trials are currently not available.
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Affiliation(s)
- C Lotz
- Klinik und Poliklinik für Anästhesiologie, Direktor: Univ.-Prof. Dr. P. Meybohm, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - R M Muellenbach
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Kassel, Kassel, Deutschland
| | - P Meybohm
- Klinik und Poliklinik für Anästhesiologie, Direktor: Univ.-Prof. Dr. P. Meybohm, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - C Rolfes
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Kassel, Kassel, Deutschland.,Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Marburg, Marburg, Deutschland
| | - H Wulf
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Marburg, Marburg, Deutschland
| | - C Reyher
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Kassel, Kassel, Deutschland
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19
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Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Adult Patients. J Am Heart Assoc 2020; 9:e015291. [PMID: 32204668 PMCID: PMC7428656 DOI: 10.1161/jaha.119.015291] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out-of-hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra-aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.
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Affiliation(s)
- Akihiko Inoue
- Department of Emergency, Disaster and Critical Care MedicineFaculty of MedicineKagawa UniversityKagawaJapan
- Department of Emergency and Critical Care MedicineHyogo Emergency Medical CenterKagawaJapan
| | - Toru Hifumi
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalTokyoJapan
| | | | - Yasuhiro Kuroda
- Department of Emergency, Disaster and Critical Care MedicineFaculty of MedicineKagawa UniversityKagawaJapan
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Chen X, Zhen Z, Na J, Wang Q, Gao L, Yuan Y. Associations of therapeutic hypothermia with clinical outcomes in patients receiving ECPR after cardiac arrest: systematic review with meta-analysis. Scand J Trauma Resusc Emerg Med 2020; 28:3. [PMID: 31937354 PMCID: PMC6961259 DOI: 10.1186/s13049-019-0698-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia has been recommended for eligible patients after cardiac arrest (CA) in order to improve outcomes. Up to now, several comparative observational studies have evaluated the combined use of extracorporeal cardiopulmonary resuscitation (ECPR) and therapeutic hypothermia in adult patients with CA. However, the effects of therapeutic hypothermia in adult CA patients receiving ECPR are inconsistent. METHODS Relevant studies in English databases (PubMed, ISI web of science, OVID, and Embase) were systematically searched up to September 2019. Odds ratios (ORs) from eligible studies were extracted and pooled to summarize the associations of therapeutic hypothermia with favorable neurological outcomes and survival in adult CA patients receiving ECPR. RESULTS 13 articles were included in the present meta-analysis study. There were nine studies with a total of 806 cases reporting the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Pooling analysis suggested that therapeutic hypothermia was significantly associated with favorable neurological outcomes in overall (N = 9, OR = 3.507, 95%CI = 2.194-5.607, P < 0.001, fixed-effects model) and in all subgroups according to control type, regions, sample size, CA location, ORs obtained methods, follow-up period, and modified Newcastle Ottawa Scale (mNOS) scores. There were nine studies with a total of 806 cases assessing the association of therapeutic hypothermia with survival in CA patients receiving ECPR. After pooling the ORs, therapeutic hypothermia was found to be significantly associated with survival in overall (N = 9, OR = 2.540, 95%CI = 1.245-5.180, P = 0.010, random-effects model) and in some subgroups. Publication bias was found when evaluating the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Additional trim-and-fill analysis estimated four "missing" studies, which adjusted the effect size to 2.800 (95%CI = 1.842-4.526, P < 0.001, fixed-effects model) for neurological outcomes. CONCLUSIONS Therapeutic hypothermia may be associated with favorable neurological outcomes and survival in adult CA patients undergoing ECPR. However, the result should be treated carefully because it is a synthesis of low-level evidence and other limitations exist in present study. It is necessary to perform randomized controlled trials to validate our result before considering the result in clinical practices.
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Affiliation(s)
- Xi Chen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Zhen Zhen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Jia Na
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Qin Wang
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Lu Gao
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Yue Yuan
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
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Agarwal S, Morris N, Der-Nigoghossian C, May T, Brodie D. The Influence of Therapeutics on Prognostication After Cardiac Arrest. Curr Treat Options Neurol 2019; 21:60. [PMID: 31768661 DOI: 10.1007/s11940-019-0602-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to highlight the influence of therapeutic maneuvers on neuro-prognostication measures administered to comatose survivors of cardiac arrest. We focus on the effect of sedation regimens in the setting of targeted temperature management (TTM), one of the principle interventions known to improve neurological recovery after cardiac arrest. Further, we discuss the critical need for novel markers, as well as refinement of existing markers, among patients receiving extracorporeal membrane oxygenation (ECMO) in the setting of failed conventional resuscitation, known as extracorporeal cardiopulmonary resuscitation (ECPR). RECENT FINDINGS Automated pupillometry may have some advantage over standard pupillary examination for prognostication following TTM, sedation, or the use of ECMO after cardiac arrest. New serum biomarkers such as Neurofilament light chain have shown good predictive abilities and need further validation in these populations. There is a high-level uncertainty in brain death declaration protocols particularly related to apnea testing and appropriate ancillary tests in patients receiving ECMO. Both sedation and TTM alone and in combination have been shown to affect prognostic markers to varying degrees. The optimal approach to analog-sedation is unknown, and requires further study. Moreover, validation of known prognostic markers, as well as brain death declaration processes in patients receiving ECMO is warranted. Data on the effects of TTM, sedation, and ECMO on biomarkers (e.g., neuron-specific enolase) and electrophysiology measures (e.g., somatosensory-evoked potentials) is sparse. The best approach may be one customized to the individual patient, a precision-medicine approach.
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Affiliation(s)
- Sachin Agarwal
- Division of Neurocritical Care and Hospitalist Neurology, Department of Neurology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.
| | - Nicholas Morris
- Department of Neurology, Program in Trauma, University of Maryland Medical Center, Baltimore, MD, USA
| | - Caroline Der-Nigoghossian
- Clinical Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Teresa May
- Division of Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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Miraglia D, Miguel LA, Alonso W. The evolving role of novel treatment techniques in the management of patients with refractory VF/pVT out-of-hospital cardiac arrest. Am J Emerg Med 2019; 38:648-654. [PMID: 31836341 DOI: 10.1016/j.ajem.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 01/07/2023] Open
Abstract
STUDY OBJECTIVES The purpose of this review is to provide a brief overview of new life-saving interventions and novel techniques that have been proposed as viable treatment options for patients presenting with refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest (OHCA). METHODS We conducted a comprehensive literature search of PubMed recent, Medline and Embase databases via the Ovid interface and Google Scholar from inception to July 2019. Eligible studies were observational in nature reporting outcomes of extracorporeal membrane oxygenation (ECMO), esmolol, double sequential defibrillation (DSD), and stellate ganglion block (SGB). Two investigators conducted the literature search, study selection, and data extraction. Any disagreements were resolved by consensus. RESULTS Our database search identified 5331 records. We included in our review 23 articles that met our inclusion criteria. The selected studies included 16 observational studies on ECMO, 2 observational studies on esmolol, and 5 observational studies on DSD. CONCLUSION We would like to suggest that there is not enough evidence in the existing literature to support at large-scale the effects of these techniques in the treatment of refractory VF/pVT OHCA. Randomized studies are warranted to evaluate the significant effects of these approaches against the best current standard of care.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States.
| | - Lourdes A Miguel
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Wilfredo Alonso
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
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Acute Neurologic Complications During Extracorporeal Membrane Oxygenation: A Systematic Review. Crit Care Med 2019; 46:1506-1513. [PMID: 29782356 DOI: 10.1097/ccm.0000000000003223] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We determine the frequency, risk factors, and mortality of neurologic complications in adults on extracorporeal membrane oxygenation and propose an algorithm for preventive strategies. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY SELECTION Screening was performed using predefined search terms to identify cohort studies reporting neurologic complications in adults during extracorporeal membrane oxygenation from 1990 to 2017. DATA EXTRACTION The final reference list was generated on the basis of relevance to the discussed topics. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation classification of evidence scheme. DATA SYNTHESIS In 44 studies, the median frequency of acute neurologic complications is 13% (1-78%; 5% intracranial hemorrhages, 5% ischemic strokes, 2% seizures). Neurologic complications are reported more frequently with venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation (14 vs eight studies) with a median proportion of complications of 15% (6-33%; 95% CI, 8-19) for venoarterial extracorporeal membrane oxygenation. Median in-hospital mortality is higher with neurologic complications (83%; interquartile range, 54-100% vs 42%; interquartile range, 24-55% without neurologic complications; p < 0.001). Median mortality is 96% for hemorrhages, 84% for ischemic strokes 84%, and 40% for seizures. Risk factors are age, preextracorporeal membrane oxygenation cardiac arrest, hypoglycemia, and administration of inotropes. Hemorrhages are associated with female gender, duration of ventilation and extracorporeal membrane oxygenation, decreased serum fibrinogen, heparin, serum creatinine greater than 2.6 mg/dL, hemodialysis, and thrombocytopenia. Increased odds for ischemic stroke is seen with a preextracorporeal membrane oxygenation serum lactate greater than 10 mmol/L. No studies report daily coagulation monitoring and neurologic assessments, and quality of evidence was low to very low. CONCLUSIONS Neurologic complications are reported frequently and with high occurrence rate, especially with venoarterial extracorporeal membrane oxygenation, and associated with high mortality calling for daily weaning from sedation and neuromuscular blockers for neurologic assessment and coagulation monitoring. The low quality of evidence indicates the need for higher quality studies in this context.
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Yannopoulos D, Bartos JA, Aufderheide TP, Callaway CW, Deo R, Garcia S, Halperin HR, Kern KB, Kudenchuk PJ, Neumar RW, Raveendran G. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e530-e552. [DOI: 10.1161/cir.0000000000000630] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.
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Anticoagulation Levels and Bleeding After Emergency Department Extracorporeal Cardiopulmonary Resuscitation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gregers E, Kjærgaard J, Lippert F, Thomsen JH, Køber L, Wanscher M, Hassager C, Søholm H. Refractory out-of-hospital cardiac arrest with ongoing cardiopulmonary resuscitation at hospital arrival - survival and neurological outcome without extracorporeal cardiopulmonary resuscitation. Crit Care 2018; 22:242. [PMID: 30268147 PMCID: PMC6162879 DOI: 10.1186/s13054-018-2176-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 09/04/2018] [Indexed: 11/20/2022] Open
Abstract
Background The prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR. Methods We included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002–2011. Results A total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n = 1285, 92%) or with refractory OHCA (n = 108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5–9] vs. 7 [5–10] min, p = 0.8; ROSC, 15 [9–22] vs. 27 [20–41] min, p < 0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2–5.8]; p < 0.001), witnessed OHCA (OR, 3.7 [2.0–7.1]; p < 0.001), shockable rhythm (OR, 3.0 [1.9–4.7]; p < 0.001), younger age (OR, 1.2 [1.1–1.2]; p < 0.001), and later calendar year (OR, 1.4 [1.2–1.6]; p < 0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p < 0.001). Four of 28 refractory OHCA patients with duration of resuscitation > 60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p = 0.7). Conclusions Survival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.
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Affiliation(s)
- Emilie Gregers
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark.
| | - Jesper Kjærgaard
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | | | - Jakob H Thomsen
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Lars Køber
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia 4142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Helle Søholm
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark.,Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
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Beyea MM, Tillmann BW, Iansavichene AE, Randhawa VK, Van Aarsen K, Nagpal AD. Neurologic outcomes after extracorporeal membrane oxygenation assisted CPR for resuscitation of out-of-hospital cardiac arrest patients: A systematic review. Resuscitation 2018; 130:146-158. [PMID: 30017957 DOI: 10.1016/j.resuscitation.2018.07.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation-assisted CPR (ECPR) is an evolving adjunct for resuscitation of OHCA patients. The primary objective of this systematic review was to assess survival-to-hospital discharge with good neurologic recovery after OHCA among patients treated with ECPR compared to conventional CPR (CCPR). METHODS A systematic search of MEDLINE® and EMBASE® electronic databases was performed from inception until July 2016 to identify studies reporting ECPR use in adults with OHCA and survival outcomes. RESULTS Of the 1512 citations identified, 75 studies met our inclusion criteria (63 case series and 12 cohort studies). Among case series, 0 to 71.4% of patients treated with ECPR survived to discharge with a good neurologic outcome. Subgroup analysis of the cohort studies demonstrated survival-to-hospital discharge with good neurologic recovery in the ECPR group ranging from 8.3 to 41.6% compared to 1.5 to 9.1% in the CCPR group. Five cohort studies adjusted for confounders, 3 of which demonstrated significantly increased adjusted odds ratios of survival among the ECPR-treated patients. Due to significant heterogeneity (I2 = 63%, p = 0.03), pooling of outcomes and a meta-analysis were not conducted. CONCLUSION Although a trend towards improved survival with good neurologic outcome was reported in controlled, low-risk of bias cohort studies, a preponderance of low quality evidence may ascribe an optimistic effect size of ECPR on survival among OHCA patients. Our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. In this state of equipoise, high quality RCT data is urgently needed.
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Affiliation(s)
- Michael M Beyea
- Division of Emergency Medicine, London Health Sciences Centre, Western University, London, ON, Canada; Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
| | - Bourke W Tillmann
- Department of Critical Care Medicine, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Alla E Iansavichene
- Health Science Library, London Health Sciences Centre, Victoria Campus, London, ON, Canada
| | - Varinder K Randhawa
- Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kristine Van Aarsen
- Division of Emergency Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - A Dave Nagpal
- Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada
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Strangl F, Schwarzl M, Schrage B, Söffker G. Severe ischaemic cardiogenic shock with cardiac arrest and prolonged asystole: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2018; 2:yty088. [PMID: 31020165 PMCID: PMC6177078 DOI: 10.1093/ehjcr/yty088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/06/2018] [Indexed: 11/23/2022]
Abstract
Background Extracorporeal life support (ECLS) by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a valuable treatment option during severe cardiogenic shock and during cardiac arrest unresponsive to conventional management. It is applied to bridge the first critical days until the patient recovers or a destination therapy is established.1 Prolonged episodes without cardiac electrical activity during VA-ECMO are a major problem, as they may cause pulmonary oedema and severe left ventricular (LV) thrombosis.2 Here, we report a case of a 50-year-old man who presented with a 30-h episode of complete absence of electromechanical activity during ECLS and finally recovered with favourable neurological outcome. Case summary A 50-year-old man with out-of-hospital cardiac arrest was transferred to a peripheral hospital after initial successful cardiopulmonary resuscitation (CPR). In the emergency room, he presented with ST-segment elevation myocardial infarction and cardiogenic shock with third-degree atrioventricular block. After immediate insertion of a temporary pacemaker, he received percutaneous coronary intervention of the left anterior descending artery and the circumflex artery. Due to worsening cardiogenic shock, ECLS with VA-ECMO and an Impella® pump was established. Cumulative time of CPR (out of hospital and in hospital) was 41 min. After transfer to our institution’s intensive care unit, both the heart’s mechanical and electrical activity ceased for more than 24 h and recovered slowly thereafter. After showing promising neurological outcome, epicardial pacemaker leads, an implantable cardioverter-defibrillator, and finally, a LV assist device were implanted. He was dismissed into rehabilitation with only minor neurological residua 6 weeks later. Discussion Impella® implantation on top of VA-ECMO may be considered beneficial in the therapy of prolonged cardiac arrest.3 While VA-ECMO ensures oxygenation and organ perfusion, Impella® vents the left ventricle and enhances coronary perfusion. In the presented case, a favourable outcome was reached despite an ‘untreated’ prolonged absence of cardiac electromechanical activity. Under specific circumstances during ECLS with extracorporeal membrane oxygenation and Impella®, waiving of temporary pacing may be considered in absent cardiac electromechanical activity to avoid further complications.
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Affiliation(s)
- Felix Strangl
- Department of Cardiology, University Heart Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Michael Schwarzl
- Department of Cardiology, University Heart Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
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Predictors of Survival for Nonhighly Selected Patients Undergoing Resuscitation With Extracorporeal Membrane Oxygenation After Cardiac Arrest. ASAIO J 2018; 64:368-374. [DOI: 10.1097/mat.0000000000000644] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Retrospective Analysis of Transcranial Doppler Patterns in Veno-Arterial Extracorporeal Membrane Oxygenation Patients: Feasibility of Cerebral Circulatory Arrest Diagnosis. ASAIO J 2018; 64:175-182. [DOI: 10.1097/mat.0000000000000636] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Leoni D, Rello J. Cardiac arrest among patients with infections: causes, clinical practice and research implications. Clin Microbiol Infect 2017; 23:730-735. [DOI: 10.1016/j.cmi.2016.11.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/17/2016] [Accepted: 11/22/2016] [Indexed: 12/17/2022]
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Jabbour RJ, Sen S, Mikhail GW, Malik IS. Out-of-hospital cardiac arrest: Concise review of strategies to improve outcome. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:450-455. [DOI: 10.1016/j.carrev.2017.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/09/2017] [Indexed: 01/01/2023]
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Yonezu K, Sakakura K, Watanabe Y, Taniguchi Y, Yamamoto K, Wada H, Momomura SI, Fujita H. Determinants of survival and favorable neurologic outcomes in ischemic heart disease treated by veno-arterial extracorporeal membrane oxygenation. Heart Vessels 2017; 33:25-32. [DOI: 10.1007/s00380-017-1031-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/28/2017] [Indexed: 10/19/2022]
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Cho YS, Song KH, Lee BK, Jeung KW, Jung YH, Lee DH, Lee SM. Five-year Experience of Extracorporeal Life Support in Emergency Physicians. Korean J Crit Care Med 2017; 32:52-59. [PMID: 31723616 PMCID: PMC6786739 DOI: 10.4266/kjccm.2016.00885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/19/2016] [Accepted: 02/09/2017] [Indexed: 01/01/2023] Open
Abstract
Background This study aimed to present our 5-year experience of extracorporeal cardiopulmonary resuscitation (ECPR) performed by emergency physicians. Methods We retrospectively analyzed 58 patients who underwent ECPR between January 2010 and December 2014. The primary parameter analyzed was survival to hospital discharge. The secondary parameters analyzed were neurologic outcome at hospital discharge, cannulation time, and ECPR-related complications. Results Thirty-one patients (53.4%) were successfully weaned from extracorporeal membrane oxygenation, and 18 (31.0%) survived to hospital discharge. Twelve patients (20.7%) were discharged with good neurologic outcomes. The median cannulation time was 25.0 min (interquartile range 20.0-31.0 min). Nineteen patients (32.8%) had ECPR-related complications, the most frequent being distal limb ischemia. Regarding the initial presentation, 52 patients (83.9%) collapsed due to a cardiac etiology, and acute myocardial infarction (33/62, 53.2%) was the most common cause of cardiac arrest. Conclusions The survival to hospital discharge rate for cardiac arrest patients who underwent ECPR conducted by an emergency physician was within the acceptable limits. The cannulation time and complications following ECPR were comparable to those found in previous studies.
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Affiliation(s)
- Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | | | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Min Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
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Benedek T, Popovici MM, Glogar D. Extracorporeal Life Support and New Therapeutic Strategies for Cardiac Arrest Caused by Acute Myocardial Infarction - a Critical Approach for a Critical Condition. ACTA ACUST UNITED AC 2016; 2:164-174. [PMID: 29967856 DOI: 10.1515/jccm-2016-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/20/2016] [Indexed: 12/14/2022]
Abstract
This review summarizes the most recent developments in providing advanced supportive measures for cardiopulmonary resuscitation, and the results obtained using these new therapies in patients with cardiac arrest caused by acute myocardial infarction (AMI). Also detailed are new approaches such as extracorporeal cardiopulmonary resuscitation (ECPR), intra-arrest percutaneous coronary intervention, or the regional models for systems of care aiming to reduce the critical times from cardiac arrest to initiation of ECPR and coronary revascularization.
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Affiliation(s)
- Theodora Benedek
- University of Medicine and Pharmacy Tirgu Mures, Clinic of Cardiology, Tirgu Mures, Romania
| | - Monica Marton Popovici
- Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, USA
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Le Guennec L, Schmidt M, Bréchot N, Lebreton G, Leprince P, Combes A, Luyt CE. Complications neurologiques de l’assistance circulatoire de courte durée. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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