Extracorporeal cardiopulmonary resuscitation

Outcomes after extracorporeal cardiopulmonary resuscitation in pediatric in-hospital cardiac arrest: does quality of CPR matter?

BACKGROUND

ECPR patients who receive guideline-compliant CPR will have improved survival to hospital discharge (SHD) compared to patients who do not receive guideline-compliant CPR, regardless of CPR duration.

METHODS

Retrospective, observational study from PediRES-Q of IHCA in children (<18 years) requiring ECMO to achieve ROSC. We assessed compliance of 60-sec chest compression (CC) epochs according to 2020 AHA guideline targets. Guideline-compliant CPR defined as > 60% epochs meeting compliance criteria for each target. Differences assessed utilizing Fisher's exact tests. Logistic regression used to assess guideline compliance and SHD, controlling for age, arterial line, duration of CPR, and clustering by site.

RESULTS

We analyzed 157 index ECPR events (> 5 epochs): 62 infants (<1 year), 52 children (1-<8 years), and 43 adolescents (8-≤18 years) with CPR quality metric data from 20 sites. Median CPR duration 54 mins (IQR 40,66), median weight 12.0 kgs (IQR 6.0,28.5), and 74/157 (47%) with a cardiac diagnosis. Guideline compliance was not significantly associated with SHD after adjusted logistic regression; however, overall compliance was poor across age groups: 0% in < 1 year, 4% in 1-<8 years and 10% in 8-18 years. Age and duration of CPR were significantly associated with SHD, as 8-<18 years had 64% lower odds of SHD than < 8 year (aOR = 0.36 {0.17, 0.76; P = 0.007) and every minute increase in duration of CPR decreased survival odds by 2% (aOR = 0.98 {0.96,1.0; P = 0.02).

CONCLUSION

While adherence to AHA guideline-complaint CPR was not significantly associated with SHD, patient age and CPR duration were significant predictors. These findings emphasize the need to better understand factors associated with survival after pediatric ECPR while also helping to drive improvements in ECPR care models.

Application Results of an Extracorporeal Therapy Protocol in Cardiorespiratory Arrest: A Historical Cohort Study

Background/Objectives: This study sought to evaluate the clinical profile, in-hospital management, prognosis, and survival of patients treated for cardiac arrest using extracorporeal therapy in a third-level Spanish hospital before and after the therapy was protocolised. Methods: This study is a historical single-centre cohort study that was conducted from January 2009 to February 2024. In 2019, an in-hospital extracorporeal reanimation therapy protocol was established in the centre's Coronary Intensive Care Unit. As a result, the cohort was split into two groups: the Pre-Protocol group (between 2009 and December 2018) and the Post-Protocol group (between 2019 and February 2024). Results: A total of 26 patients were recruited, i.e., 10 in the first cohort and 16 in the second, with acute myocardial infarction being the most prevalent cause in both cohorts. A 30% (3) to 43.65% (7) increase in survival was observed between the two cohorts (p = 0.48), with CPC 1-2 neurological functionality exceeding 85% of cases in both cohorts (p = 0.7). The mean time from cardiac arrest to the application of extracorporeal therapy decreased from 104.1 min to 41.87 min (p = 0.09). The longer duration of ECMO (p = 0.03) and the longer hospital stay (p = 0.002) are due to a higher survival. Conclusions: The results show a trend in improvement outcomes. The small cohort size makes it difficult to draw robust conclusions, but we want to highlight the importance of applying a specific protocol based on standardised patient selection criteria and the establishment of extracorporeal reanimation therapy.

Pre-assembled ECMO: Enhancing efficiency and reducing stress in refractory cardiac arrest care

Aim

Extracorporeal cardiopulmonary resuscitation (ECPR) by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest presents significant medical and psychological challenges for healthcare providers. Beyond managing cardiac arrest and preparing for potential coronary angiography, the ECMO circuit must be assembled and primed under strictly sterile conditions, contributing to additional psychological stress and potential delays in ECMO cannulation. This pragmatic study thought to evaluate whether pre-assembled and pre-primed ECMO circuits (pre-primed group) maintain sterility over a 21-day period, expedite ECMO initiation in ECPR patients and alleviate the psychological burden on the ECPR team, compared to newly assembled and primed ECMO circuits (on-demand group).

Methods

In a prospective manner, ECMO circuits were either pre-assembled and pre-primed under sterile conditions, maintained for 21 days with culture samples taken every seventh day, or newly assembled and primed during the acute emergency situation. The transition from on-demand assembly and priming of ECMO circuits to pre-primed ECMO circuits occurred on January 1st, 2021. The interval between patients' arrival in the cardiac catheterization laboratory and the initiation of ECMO was recorded and retrospectively compared between the two treatment groups. The ECPR team, comprising experienced cardiologists and nurses, was prospectively surveyed using the modified Perceived Stress Questionnaire (PSQ-20).

Results

All aseptically pre-assembled and pre-primed ECMO circuits demonstrated sterile cultures for aerobic and anaerobic microorganisms as well as fungal agents over the 21-day period: 0/120 positive cultures (0 %, 95 % CI for binomial probability 0-0.03). The time to ECMO initiation was significantly reduced in the pre-primed group compared to the on-demand group: 13 [IQR 9-17] versus 31 [IQR 27-44] minutes, P < 0.001. Responses from ECPR physicians and nurses on the PSQ-20 were similar across all items. With the use of pre-primed ECMO circuits, all ECPR professionals reported a greater sense of settled inner feeling, considerably less psychological tension, fewer worries and insecurities, as well as more effective ICU shifts with improved personal goal achievement. However, treating ECPR patients with pre-primed ECMO circuits did not lead to increased job satisfaction or higher physical energy levels.

Conclusion

Aseptically pre-assembled and pre-primed ECMO circuits maintain sterility for multiple weeks, significantly reducing ECMO initiation times and alleviating psychological strain on the ECPR team. Consequently, implementing these circuits in ECPR centers could enhance both patient outcomes and healthcare provider well-being.

Enhancing survival in cardiac arrest: the urgent need for optimized extracorporeal cardiopulmonary resuscitation implementation and protocols - editorial

Extracorporeal CPR (ECPR) involves venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with sudden and unexpected pulse loss due to heart-stopping mechanical activity. ECPR in patients with cardiac arrest has been shown to significantly improve the prognosis. In emergency rooms, interdisciplinary coordination exists among emergency medicine, cardiology, critical care, and perfusion technology. However, some problems must be solved, such as excessive costs, resource allocation, and the need for specialized equipment. Resuscitation success and patient outcomes can be enhanced by combining ECPR and emergency care.

Mortality Predictors and Neurological Outcomes Following Extracorporeal Cardiopulmonary Resuscitation (eCPR): A Single-Center Retrospective Study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (eCPR) offers cardiorespiratory support to patients experiencing cardiac arrest. However, this technology is not yet considered a standard treatment, and the evidence on eCPR criteria and its association with survival and good neurological outcomes remains scarce. Therefore, we aimed to investigate the overall mortality and risk factors for mortality. Moreover, we provide a comparison of demographic, clinical, and laboratory characteristics of patients, including neurological outcomes and adverse events during support.

METHODS

This retrospective analysis included in-hospital and out-of-hospital cardiac arrest patients who received eCPR and were admitted between January 2008 and June 2022 at a tertiary and trauma one-level university hospital in Austria.

RESULTS

In total, 90 patients fulfilled inclusion criteria, 41 (46%) patients survived until intensive care unit discharge, and 39 (43%) survived until hospital discharge. The most common cause of cardiac arrest was myocardial infarction (42, 47%), and non-shockable initial rhythm was reported in 50 patients (56%). Of 33 survivors with documented outcomes, 30 had a good recovery as measured with Cerebral Performance Category score, 2 suffered severe disability, and 1 remained in a persistent vegetative state. Finally, multivariate analysis identified asystole as initial rhythm (HR 2.88, p = 0.049), prolonged CPR (HR 1.02, p = 0.043), and CPR on the weekend (HR 2.57, p = 0.032) as factors with a higher risk of mortality.

CONCLUSIONS

eCPR-related decision-making could be additionally supported by the comprehension of the reported risk factors for mortality and severe disability. Further studies are needed to elucidate the impact of peri-arrest variables on outcomes, aiming to improve patient selection.

Target Temperature Management Effect on the Clinical Outcome of Patients with Out-of-Hospital Cardiac Arrest Treated with Extracorporeal Cardiopulmonary Resuscitation: A Nationwide Observational Study

This study aimed to investigate whether targeted temperature management (TTM) could enhance outcomes in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Using a nationwide OHCA registry, adult patients with witnessed OHCA of presumed cardiac origin who underwent ECPR at the emergency department between 2008 and 2021 were included. We examined the effect of ECPR with TTM on survival and neurological outcomes at hospital discharge using propensity score matching and multivariable logistic regression compared with patients treated with ECPR without TTM. Odds ratios and 95% confidence intervals were determined. A total of 399 ECPR cases were analyzed among 380,239 patients with OHCA. Of these, 330 underwent ECPR without TTM and 69 with TTM. After propensity score matching, 69 matched pairs of patients were included in the analysis. No significant differences in survival and good neurological outcomes between the two groups were observed. In the multivariable logistic regression, no significant differences were observed in survival and neurological outcomes between ECPR with and without TTM. Among the patients who underwent ECPR after OHCA, ECPR with TTM did not improve outcomes compared with ECPR without TTM.

A review of pre-hospital extracorporeal cardiopulmonary resuscitation and its potential application in the North East of England

Patients in the UK who suffer an out-of-hospital cardiac arrest are treated with cardiopulmonary resuscitation in the pre-hospital environment. Current survival outcomes are low in out-of-hospital cardiac arrest. Extracorporeal cardiopulmonary resuscitation is a technique which is offered to patients in specialised centres which provides better blood flow and oxygen delivery than conventional chest compressions. Shortening the interval between cardiac arrest and restoration of circulation is associated with improved outcomes in extracorporeal cardiopulmonary resuscitation. Delivering extracorporeal cardiopulmonary resuscitation in the pre-hospital environment can shorten this interval, improving outcomes in out-of-hospital cardiac arrest. This article will review recently published studies and summarise studies currently being undertaken in pre-hospital extracorporeal cardiopulmonary resuscitation. It will also discuss the potential application of a pre-hospital extracorporeal cardiopulmonary resuscitation programme in the North East of England.

Impact of clinical variables on outcomes in refractory cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation

Background

In the past two decades, extracorporeal resuscitation (ECPR) has been increasingly used in the management of refractory cardiac arrest (CA) patients. Decision algorithms have been used to guide the care such patients, but the effectiveness of such decision-making tools is not well described. The aim of this study was to compare the rate of survival with a good neurologic outcome of patients treated with ECPR meeting all criteria of a clinical decision-making tool for the initiation of ECPR to those for whom ECPR was implemented outside of the algorithm.

Methods

All patients who underwent E-CPR between January 2014 and December 2021 at the Montreal Heart Institute were included in this retrospective analysis. We dichotomized the cohort according to adherence or non-adherence with the ECPR decision-making tool, which included the following criteria: age ≤65 years, initial shockable rhythm, no-flow time <5 min, serum lactate <13 mmol/L. Patients were included in the "IN" group when they met all criteria of the decision-making tool and in the "OUT" group when at least one criterion was not met.

Main outcomes and measures

The primary outcome was survival with intact neurological status at 30 days, defined by a Cerebral Performance Category (CPC) Scale 1 and 2.

Results

A total of 41 patients (IN group, n = 11; OUT group, n = 30) were included. A total of 4 (36%) patients met the primary outcome in the IN group and 7 (23%) in the OUT group [odds ratio (OR): 1.88 (95% CI, 0.42-8.34); P = 0.45]. However, survival with a favorable outcome decreased steadily with 2 or more deviations from the decision-making tool [2 deviations: 1 (11%); 3 deviations: 0 (0%)].

Conclusion and relevance

Most patients supported with ECPR fell outside of the criteria encompassed in a clinical decision-making tool, which highlights the challenge of optimal selection of ECPR candidates. Survival rate with a good neurologic outcome did not differ between the IN and OUT groups. However, survival with favorable outcome decreased steadily after one deviation from the decision-making tool. More studies are needed to help select proper candidates with refractory CA patients for ECPR.

Association between post-cardiac arrest treatments and clinical outcomes according to scene time interval in out-of-hospital cardiac arrest: Retrospective cross-sectional study

BACKGROUND

Previous studies have reported that Post-Cardiac arrest (PCA) treatments including targeted temperature management (TTM), coronary reperfusion therapy (CRT), and extracorporeal membrane oxygenation (ECMO) are time-sensitive; however, there are no reports of the clinical outcomes of PCA treatment according to the scene time interval (STI). Our study aimed to investigated the clinical outcomes of PCA treatment according to the STI.

METHODS

We used a Korean nationwide OHCA cohort database from January 2017 to December 2020. The inclusion criteria were all adult OHCA patients with a presumed cardiac etiology, bystander-witnessed arrest, and prehospital return of spontaneous circulation (ROSC). The outcomes were survival to discharge and good neurological recovery. The main exposure of interest was PCA treatment. We compared the outcomes using multivariable logistic regression, and interaction terms were included in the final model to assess whether the STI modified the effect of PCA treatment on clinical outcomes of OHCA.

RESULTS

TTM and CRT were associated with high survival to discharge and good neurological recovery. In the interaction analysis, ECMO had an interaction effect with the STI on a good CPC among patients with OHCA [short STI (0 to 11 min) (1.16 (0.77-1.75)), middle STI (12 to 15 min) (0.66 (0.41-1.06)), and long STI (16 to 30 min) (0.59 (0.40-0.88)) (p for interaction <0.05)].

CONCLUSION

In adult bystander-witnessed patients with OHCA with prehospital ROSC, an STI of >16 min was a risk factor for poor neurological outcome in those patients who underwent ECMO.

Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR.

METHODS

We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined.

RESULTS

We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p < 0.001). Primary cerebral disorders as cause of cardiac arrest and higher severity of illness at intensive care unit admission were associated with WLST decisions.

CONCLUSION

For approximately one-third of ECPR/OHCA patients, WLST was decided during admission, mainly because of perceived unfavorable neurological prognoses. Decisions and neurological assessments for ECPR/OHCA patients need further analysis.

Resuscitative TEE after open heart surgery: When POCUS fails to FOCUS

Echocardiography is key in evaluating the cause of collapse in the post-cardiac surgery patient. Transesophageal echocardiography provides a greater capability for the diagnosis of pericardial effusion in patients who arrest after cardiac surgery.

Extracorporeal cardiopulmonary resuscitation for adult out-of-hospital cardiac arrest patients: time-dependent propensity score-sequential matching analysis from a nationwide population-based registry

BACKGROUND

There is inconclusive evidence regarding the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients. We aimed to evaluate the association between ECPR and neurologic recovery in OHCA patients using time-dependent propensity score matching analysis.

METHODS

Using a nationwide OHCA registry, adult medical OHCA patients who underwent CPR at the emergency department between 2013 and 2020 were included. The primary outcome was a good neurological recovery at discharge. Time-dependent propensity score matching was used to match patients who received ECPR to those at risk for ECPR within the same time interval. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated, and stratified analysis by the timing of ECPR was also performed.

RESULTS

Among 118,391 eligible patients, 484 received ECPR. After 1:4 time-dependent propensity score matching, 458 patients in the ECPR group and 1832 patients in the no ECPR group were included in the matched cohort. In the matched cohort, ECPR was not associated with good neurological recovery (10.3% in ECPR and 6.9% in no ECPR; RR [95% CI] 1.28 [0.85-1.93]). In the stratified analyses according to the timing of matching, ECPR with a pump-on within 45 min after emergency department arrival was associated with favourable neurological outcomes (RR [95% CI] 2.51 [1.33-4.75] in 1-30 min, 1.81 [1.11-2.93] in 31-45 min, 1.07 (0.56-2.04) in 46-60 min, and 0.45 (0.11-1.91) in over 60 min).

CONCLUSIONS

ECPR itself was not associated with good neurological recovery, but early ECPR was positively associated with good neurological recovery. Research on how to perform ECPR at an early stage and clinical trials to evaluate the effect of ECPR is warranted.

Clinician Perspectives on Cannulation for Extracorporeal Cardiopulmonary Resuscitation: A Mixed Methods Analysis

Out-of-hospital cardiac arrest is a leading cause of mortality with survival rates of less than 10%. In selected patients, survival may be improved via timely application of extracorporeal cardiopulmonary resuscitation (ECPR). However, ECPR is a complex and resource intensive intervention with a high risk of complications that impair widespread clinical adoption. This study employed a mixed approach of qualitative interview analysis embedded with quantitative data collection to uncover the major hurdles faced by clinicians during ECPR initiation. We conducted semi-structured interviews with eight ECPR intensive care specialists with 2-10 years of experience working at a large, tertiary ECPR center in Australia. Clinicians identified dilation as the most time-consuming step, followed by draping, and decision-making during extracorporeal membrane oxygenation patient selection. The most challenging step was the decision-making for patient selection, followed by dilation and imaging. These findings uncovered key barriers to ECPR, and identified priority areas for further research and clinical training. Major logistical hindrances will require well-defined protocols and improved clinical training. Engineering innovations in the identified areas may improve the delivery of ECPR, making it simpler and faster to deliver.

Extracorporeal Cardiopulmonary Resuscitation-A Chance for Survival after Sudden Cardiac Arrest

Extracorporeal membrane oxygenation (ECMO) is an increasingly popular method for the treatment of patients with life-threatening conditions. The case we have described is characterized by the effectiveness of therapy despite resuscitation lasting more than one hour. A 3.5-year-old girl with a negative medical history was admitted to the Department of Cardiology due to ectopic atrial tachycardia. It was decided to perform electrical cardioversion under intravenous anaesthesia. During the induction of anaesthesia, cardiac arrest with pulseless electrical activity (PEA) occurred. Despite resuscitation, a permanent hemodynamically effective heart rhythm was not achieved. Due to prolonged resuscitation (over one hour) and persistent PEA, it was decided to use veno-arterial extracorporeal membrane oxygenation. After three days of intensive ECMO therapy, hemodynamic stabilization was achieved. The time of implementing ECMO therapy and assessment of the initial clinical status of the patient should be emphasized.

Extracorporeal cardiopulmonary resuscitation location, coronary angiography and survival in out-of-hospital cardiac arrest

INTRODUCTION

The best location for safe and timely implementation of extracorporeal cardiopulmonary resuscitation (ECPR) is currently uncertain. We aimed to evaluate the association between the location of ECPR and survival outcomes in out-of-hospital cardiac arrest (OHCA) patients. We also evaluated whether the effects of ECPR location on survival differed between patients who underwent coronary angiography (CAG) and those who did not.

METHODS

We used data collected between 2013 and 2020 from a nationwide OHCA database. Adult OHCA patients with presumed cardiac etiology who underwent ECPR were included in the study. The primary outcome was survival to discharge. The main exposure was the ECPR location (emergency department [ED] or cardiac catheterization laboratory [Cath lab]). We compared primary outcomes of ECPR between the ED and Cath lab using multivariable logistic regression. The interaction between ECPR location and CAG was also evaluated.

RESULTS

Of 564 ECPR patients, 448 (79.4%) and 116 (20.6%) underwent ECPR in the ED and Cath lab, respectively. CAG was observed in 52.5% and 72.4% of the patients in the ED and Cath lab groups, respectively. There were no significant differences in survival to discharge between the ED and Cath lab groups (14.1% vs. 12.9%, p = 0.75, adjusted odds ratio [AOR] [95% confidence interval] 1.87 [0.85-4.11]). AOR of interaction analysis (95% CI) for survival to discharge of the ED group was 2.34 (1.02-5.40) in patients with CAG and 0.28 (0.04-1.84) in patients without CAG (p for interaction was 0.04).

CONCLUSION

In adult OHCA patients who underwent ECPR and CAG, ECPR in the ED shortened time to ECMO pump-on time and increased survival to discharge compared to ECPR in the Cath lab.

Case report: Refractory cardiac arrest supported with veno-arterial-venous extracorporeal membrane oxygenation and left-ventricular Impella CP®-Physiological insights and pitfalls of ECMELLA

INTRODUCTION

To the best of our knowledge, this is the first case report which provides insights into patient-specific hemodynamics during veno-arterio-venous-extracorporeal membrane oxygenation (VAV ECMO) combined with a left-ventricular (LV) Impella® micro-axial pump for therapy-refractory cardiac arrest due to acute myocardial infarction, complicated by acute lung injury (ALI).

PATIENT PRESENTATION

A 54-year-old male patient presented with ST-segment elevation acute coronary syndrome complicated by out-of-hospital cardiac arrest with ventricular fibrillation upon arrival of the emergency medical service. As cardiac arrest was refractory to advanced cardiac life support, the patient was transferred to the Cardiac Arrest Center for immediate initiation of extracorporeal cardiopulmonary resuscitation (ECPR) with peripheral VA ECMO and emergency percutaneous coronary intervention using drug eluting stents in the right coronary artery. Due to LV distension and persistent asystole after coronary revascularization, an Impella® pump was inserted for LV unloading and additional hemodynamic support (i.e., "ECMELLA"). Despite successful unloading by ECMELLA, post-cardiac arrest treatment was further complicated by sudden differential hypoxemia of the upper body. This so called "Harlequin phenomenon" was explained by a new onset of ALI, necessitating escalation of VA ECMO to VAV ECMO, while maintaining Impella® support. Comprehensive monitoring as derived from the Impella® console allowed to illustrate patient-specific hemodynamics of cardiac unloading. Ultimately, the patient recovered and was discharged from the hospital 28 days after admission. 12 months after the index event the patient was enrolled in the ECPR Outpatient Care Program which revealed good recovery of neurologic functions while physical exercise capacities were impaired.

CONCLUSION

A combined mechanical circulatory support strategy may successfully be deployed in complex cases of severe cardio-circulatory and respiratory failure as occasionally encountered in clinical practice. While appreciating potential clinical benefits, it seems of utmost importance to closely monitor the physiological effects and related complications of such a multimodal approach to reach the most favorable outcome as illustrated in this case.

Successful Use of Intravenous B-blocker Therapy in Cardiogenic Shock Supported With Venoarterial Extracorporeal Membrane Oxygenation: A Case Series

Tachycardia in cardiogenic shock (CS) might reduce the cardiac output (CO) by decreasing the ventricular filling time. Nevertheless, heart rate (HR) control with agents that possess negative inotropy might decrease the CO. Therefore, controlling the tachycardia in the setting of CS remains controversial. We herein describe four cases of patients presenting with myocardial infarction complicated with CS that required rescue venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiation. Tachycardia was present with HR ∼130-140 beats per minute after VA-ECMO initiation, and hence esmolol was infused continuously at a starting dose of 10-20 mcg/kg/min and titrated according to HR. With the use of esmolol to control the HR in the setting of CS supported with VA-ECMO, lactate cleared, and echocardiographic parameters improved, allowing the four cases to be successfully decannulated from ECMO. Our report indicates that short-acting beta-blocker could be safely used in the complex scenario of severe tachycardia while supported with VA-ECMO.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Hyperoxia during extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest is associated with severe circulatory failure and increased mortality

Background

High levels of arterial oxygen pressures (PaO₂) have been associated with increased mortality in extracorporeal cardiopulmonary resuscitation (ECPR), but there is limited information regarding possible mechanisms linking hyperoxia and death in this setting, notably with respect to its hemodynamic consequences. We aimed therefore at evaluating a possible association between PaO₂, circulatory failure and death during ECPR.

Methods

We retrospectively analyzed 44 consecutive cardiac arrest (CA) patients treated with ECPR to determine the association between the mean PaO₂ over the first 24 h, arterial blood pressure, vasopressor and intravenous fluid therapies, mortality, and cause of deaths.

Results

Eleven patients (25%) survived to hospital discharge. The main causes of death were refractory circulatory shock (46%) and neurological damage (24%). Compared to survivors, non survivors had significantly higher mean 24 h PaO₂ (306 ± 121 mmHg vs 164 ± 53 mmHg, p < 0.001), lower mean blood pressure and higher requirements in vasopressors and fluids, but displayed similar pulse pressure during the first 24 h (an index of native cardiac recovery). The mean 24 h PaO₂ was significantly and positively correlated with the severity of hypotension and the intensity of vasoactive therapies. Patients dying from circulatory failure died after a median of 17 h, compared to a median of 58 h for patients dying from a neurological cause. Patients dying from neurological cause had better preserved blood pressure and lower vasopressor requirements.

Conclusion

In conclusion, hyperoxia is associated with increased mortality during ECPR, possibly by promoting circulatory collapse or delayed neurological damage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02361-3.

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

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

Association between a Multidisciplinary Team Approach and Clinical Outcomes in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department

BACKGROUND AND OBJECTIVES

Despite recent improvements in advanced life support, the overall survival rate after cardiac arrest remains low. We aimed to examine the association of a multidisciplinary team approach with clinical outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) in the emergency department (ED).

METHODS

This retrospective, single-center, observational study included 125 patients who underwent ECPR in the ED between May 2004-December 2018. In January 2014, our institution implemented a multidisciplinary extracorporeal membrane oxygenation (ECMO) team. Eligible patients were classified into pre-ECMO-team (n=65) and post-ECMO-team (n=60) groups. The primary outcome was in-hospital mortality.

RESULTS

In-hospital mortality (72.3% vs. 58.3%, p=0.102) and poor neurological outcomes (78.5% vs. 68.3%, p=0.283) did not differ significantly between the pre- and post-ECMO-team groups. However, among the 60 patients who experienced in-hospital cardiac arrest, in-hospital mortality (75.8% vs. 40.7%, p=0.006) and poor neurological outcomes (78.8% vs. 48.1%, p=0.015) significantly decreased after the multidisciplinary team formation. Multivariable logistic regression analysis showed that the multidisciplinary team approach (adjusted odds ratio, 0.20; 95% confidence interval, 0.07-0.61; p=0.005) was an independent prognostic factor for in-hospital mortality in in-hospital cardiac arrest patients.

CONCLUSIONS

A multidisciplinary team approach was associated with improved clinical outcomes in in-hospital cardiac arrest patients undergoing ECPR in the ED. These findings may help in improving the selection criteria for ECPR in the ED. Further studies to overcome the study limitations may help improving the outcomes of out-of-hospital cardiac arrest patients.

Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience

INTRODUCTION

To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation.

METHODS

A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge.

RESULTS

In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days.

CONCLUSION

Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.

Effect of arterial oxygen partial pressure inflection point on Venoarterial extracorporeal membrane oxygenation for emergency cardiac support

Background

Temporary circulatory support is a bridge between acute circulatory failure and definitive treatment or recovery. Currently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is considered to be one of the effective circulatory support methods, although cardiac function monitoring during the treatment still needs further investigation. Inflection point of arterial oxygen partial pressure (IPPaO2) may occur at an early stage in part of patients with a good prognosis after VA-ECMO treatment, and the relationship between time of IPPaO2 (tIPPaO2) and recovery of cardiac function or prognosis remains unclear.

Methods

To investigate this relationship, we retrospectively analyzed the clinical data of 71 patients with different conditions after treatment with VA-ECMO in the emergency center of Jiangsu Province Hospital between May 2015 and July 2020. Spearman’s correlation analysis was used for the correlation between tIPPaO₂ and quantitative data, and ROC curve for the predictive effect of tIPPaO₂ on the 28-day mortality.

Results

Thirty-five patients were admitted because of refractory cardiogenic shock (26 of 35 survived) and the remaining 36 patients due to cardiac arrest (13 of 36 survived). The overall survival rate was 54.9% (39 of 71 survived). Acute physiology and chronic health evaluation II, ECMO time, tIPPaO2, continuous renal replacement therapy time, mechanical ventilation time, and bleeding complications in the survival group were lower than those in the non-survival group, with length of stay, intensive care unit stay, and platelet levels were being higher. The tIPPaO₂ was negatively correlated with ejection fraction, and the shorter tIPPaO2 resulted in a higher 28-day survival probability, higher predictive value for acute myocardial infarction and fulminant myocarditis.

Conclusions

Therefore, tIPPaO2 could be a reliable qualitative indicator of cardiac function in patients treated with VA-ECMO, which can reveal appropriate timing for adjusting VA-ECMO flow or weaning.

Trial registration

ChiCTR1900026105.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00902-5.

Discharge survival of patients undergoing ECMO therapy after ECPR in a third level hospital

GOAL

The goal of this study was to assess the survival to hospital discharge in patients after the implementation of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) during cardiopulmonary arrest (simultaneously or during the first six hours after the event) in a Spanish tertiary hospital.

METHOD

This is a descriptive and retrospective study conducted with patients subjected to VA-ECMO therapy during or after cardiopulmonary resuscitation (CPR) in the last 10 years. The variables were extracted from the electronic medical record of each patient.

RESULTS

175 ECMO therapies were implemented, 84% (147) were VA-ECMO, and the indication for 17% (25) was CPR. In 40% (10), ECMO therapy was initiated simultaneously during CPR, and the rest (15) during the first six hours after the event. Survival rates reached 44%.

CONCLUSIONS

The use of CPR in well-selected patients can improve their survival.

Urgent coronary artery bypass graft surgery supported by veno-arterial extracorporeal membrane oxygenation: a report of two cases

Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.

Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol

AIM

To compare the outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) fulfilling the criteria for extracorporeal cardiopulmonary resuscitation (ECPR) before and after implementation of an ECPR protocol, whether the patient received ECPR or not.

METHODS

We compared cardiac arrest registry data before (2014-2015) and after (2016-2019) implementation of the ECPR protocol. The ECPR criteria were presumed cardiac origin, witnessed arrest with ventricular fibrillation, bystander CPR, age 18-65, advanced life support (ALS) within 15 min and ALS > 10 min without return of spontaneous circulation (ROSC). The primary outcome was 30-day survival; the secondary outcomes were sustained ROSC, neurological outcome and the proportion of patients transported with ongoing ALS.

RESULTS

There were 1086 and 3135 patients in the pre- and post-implementation sample; 48 (4%) and 100 (3%) met the ECPR criteria, respectively. Of these, 21 (44%) vs. 37 (37%) were alive after 30 days, p = 0.4, and 30 (63%) vs. 50 (50%) achieved sustained ROSC, p = 0.2. All survivors in the pre-implementation sample had cerebral performance category 1-2 vs. 30 (81%) in the post-implementation sample, p = 0.03. Of the patients fulfilling the ECPR criteria, 7 (15%) and 26 (26%), p = 0.1, were transported with ongoing ALS in the pre- and post-implementation sample, respectively.

CONCLUSIONS

There were no differences in 30-day survival or prehospital ROSC in patients with refractory OHCA before and after initiation of an ECPR protocol.

The 'Weekend Effect' in adult patients who receive extracorporeal cardiopulmonary resuscitation after in- and out-of-hospital cardiac arrest

Aim

This study investigates the potentially adverse association between extracorporeal cardiopulmonary resuscitation (ECPR) after cardiac arrest on weekends versus weekdays.

Methods

Single-centre, retrospective, stratified (weekday versus weekend) analysis of 318 patients who underwent in-hospital ECPR after out-of-hospital and in-hospital cardiac arrest (OHCA/IHCA) between 01/2008 and 12/2018. Weekend was defined as the period between Friday 17:00 and Monday 06:59.

Results

Seventy-three patients (23%) received ECPR during the weekend and 245 arrests (77%) occurred during the weekday. Whereas survival to discharge did not differ between both groups, long-term survival was significantly lower in the weekend group (p = 0.002). In the multivariate analysis, independent risk factors associated with hospital mortality were no flow time (OR 1.014; 95% CI 1.004–1.023) and serum lactate prior ECPR (OR 1.011; 95% CI 1.006–1.012), whereas each unit serum haemoglobin above average had a protective effect on in-hospital mortality (OR 0.87; 95% CI 0.79–0.96). New onset kidney failure requiring renal replacement therapy occurred more often in the weekend group (30.1% versus 18.4%; p = 0.04). One third of patients experienced complications regardless ECPR was initiated at weekdays or weekends.

Conclusion

Extracorporeal cardiopulmonary resuscitation at weekends adversely seems to impact long-term survival regardless timing (dayshift/nightshift). Duration of CPR and serum lactate prior ECPR were demonstrated as independent risk factors for in-hospital mortality. As ECPR at weekends could not be shown to be an independent outcome predictor a thorough analysis of clinical events subsequent to this intervention is warranted to understand long-term consequences of ECPR initiation after cardiac arrest.

Clinical Significance of Low-Flow Time in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: Results from the RESCUE Registry

Limited data are available on the association between low-flow time and survival in patients with in-hospital cardiac arrest (IHCA) who undergo extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated data from 183 IHCA patients who underwent ECPR as a rescue procedure. Patients were divided into two groups: patients undergoing extracorporeal membrane oxygenation as an adjunct to standard cardiopulmonary resuscitation for less than 38 min (n = 110) or for longer than 38 min (n = 73). The ECPR ≤ 38 min group had a significantly greater incidence of survival to discharge compared to the ECPR > 38 min group (40.0% versus 24.7%, p = 0.032). The incidence of good neurologic outcomes at discharge tended to be greater in the ECPR ≤ 38 min group than in the ECPR > 38 min group (35.5% versus 24.7%, p = 0.102). The incidences of limb ischemia (p = 0.354) and stroke (p = 0.805) were similar between the two groups, but major bleeding occurred less frequently in the ECPR ≤ 38 min group compared to the ECPR > 38 min group (p = 0.002). Low-flow time ≤ 38 min may reduce the risk of mortality and fatal neurologic damage and could be a measure of optimal management in patients with IHCA.

Discharge survival of patients undergoing ECMO therapy after ECPR in a third level hospital

GOAL

The goal of this study was to assess the survival to hospital discharge in patients after the implementation of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) during cardiopulmonary arrest (simultaneously or during the first six hours after the event) in a Spanish tertiary hospital.

METHOD

This is a descriptive and retrospective study conducted with patients subjected to VA-ECMO therapy during or after cardiopulmonary resuscitation (ECPR) in the last 10 years. The variables were extracted from the electronic medical record of each patient.

RESULTS

175 ECMO therapies were implemented, 84% (147) were VA-ECMO, and the indication for 17% (25) was ECPR. In 40% (10), ECMO therapy was initiated simultaneously during CPR, and the rest (15) during the first six hours after the event. Survival rates reached 44%.

CONCLUSIONS

The use of CPR in well-selected patients can improve their survival.

Sub30: Protocol for the Sub30 feasibility study of a pre-hospital Extracorporeal membrane oxygenation (ECMO) capable advanced resuscitation team at achieving blood flow within 30 ​min in patients with refractory out-of-hospital cardiac arrest

Background

Out-of-hospital cardiac arrest carries a poor prognosis with survival less than 10% in many patient cohorts. Survival is inversely associated with duration of resuscitation as external chest compressions do not provide sufficient blood flow to prevent irreversible organ damage during a prolonged resuscitation. Extracorporeal membrane oxygenation (ECMO) instituted during cardiac arrest can provide normal physiological blood flows and is termed Extracorporeal Cardio-Pulmonary Resuscitation (ECPR). ECPR may improve survival when used with in-hospital cardiac arrests. This possible survival benefit has not been replicated in trials of out-of-hospital cardiac arrests, possibly because of the additional time it takes to transport the patient to hospital and initiate ECPR. Pre-hospital ECPR may shorten the time between cardiac arrest and physiological blood flows, potentially improving survival. It may also mitigate some of the neurological injury that many survivors suffer.

Methods

Sub30 is a prospective six patient feasibility study. The primary aim is to test whether it is possible to institute ECPR within 30 ​min of collapse in adult patients with refractory out of hospital cardiac arrest (OHCA). The secondary aims are to gather preliminary data on clinical outcomes, resource utilisation, and health economics associated with rapid ECPR delivery in order to plan any subsequent clinical investigation or clinical service. On study days a dedicated fast-response vehicle with ECPR capability will be tasked to out-of-hospital cardiac arrests in an area of London served by Barts Heart Centre. If patients suffer a cardiac arrest refractory to standard advanced resuscitation and meet eligibility criteria, ECPR will be started in the pre-hospital environment.

Discussion

Delivering pre-hospital ECPR within 30 ​min of an out-of-hospital cardiac arrest presents significant ethical, clinical, governance and logistical challenges. Prior to conducting an efficacy study of ECPR the feasibility of timely and safe application must be demonstrated first. Extensive planning, multiple high-fidelity multiagency simulations and a unique collaboration between pre-hospital and in-hospital institutions will allow us to test the feasibility of this intervention in London. The study has been reviewed, refined and endorsed by the International ECMO Network (ECMONet).

Trial registration

Clinicaltrials. gov NCT03700125, prospectively registered October 9, 2018.

Establishment of an extracorporeal cardio-pulmonary resuscitation program in Berlin - outcomes of 254 patients with refractory circulatory arrest

Objective

Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined.

Design

Prospective cohort study.

Setting

Tertiary referral university hospital center.

Patients

Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017.

Intervention

eCPR program for OHCA.

Mesurements and main results

A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR.

State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol.

Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p <  0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p <  0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality.

Conclusion

An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival.

Merging Two Hospitals: The Effects on Pediatric Extracorporeal Cardiopulmonary Resuscitation Outcomes

In this article, a retrospective study was performed to describe the impact of merging two pediatric intensive care units on the overall and neurocognitive outcomes of children who required extracorporeal cardiopulmonary resuscitation (ECPR). Results from three cohorts were compared: 2008 to 2014: premerge, 2014 to 2017: initial time period postmerge, and 2018 to 2019: established merge. Survival to hospital discharge (and with good neurological outcome) was of 68% (61%), 46% (36%), and 79% (71%), respectively, for the three time periods. Merging two hospitals resulted in a nonsignificant trend toward temporary worse outcomes in pediatric patients requiring ECPR.

Clinical predictors of in-hospital mortality in venoarterial extracorporeal membrane oxygenation

INTRODUCTION

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized as a life-saving procedure and bridge to myocardial recovery for patients in refractory cardiogenic shock. Despite technical advancements, VA-ECMO retains high mortality. This study aims to identify the clinical predictors of in-hospital mortality after VA-ECMO to improve risk stratification for this tenuous patient population.

METHODS

The REgistry for Cardiogenic Shock: Utility and Efficacy of Device Therapy database is a multicenter, observational registry of ECMO patients. From 2013 to 2018, 789 patients underwent VA-ECMO. Bivariate analysis was performed on more than 300 variables regarding their association with in-hospital mortality. Logistic regression analyses were performed with variables chosen based upon clinical and statistical significance in the bivariate analysis. Tests were considered significant at a two-sided P < .05.

RESULTS

Although 63.5% patients were successfully weaned from VA-ECMO, in-hospital mortality was 57.9%. Nonsurvivors were older (P < .0001), had higher body mass index (P = .01), higher rates of hypertension (P = .02), coronary artery disease (P = .02), chronic obstructive pulmonary disease (P = .02), chronic liver disease (P = .008), percutaneous coronary intervention (P = .02), and surgical revascularization (P = .02). Multivariate predictors for in-hospital mortality include older age (odds ratio [OR], 1.019; P = .007), cardiac arrest (OR, 2.76; P = .006), chronic liver disease (OR, 8.87; P = .04), elevated total bilirubin (OR, 1.093; P < .0001), and the presence of a left ventricular vent (OR, 2.018; P = .03). Pre-ECMO sinus rhythm was protective (OR, 0.374; P = .006).

CONCLUSIONS

In a large study of recent VA-ECMO patients, in-hospital mortality remains significant, but acceptable given the severe pathology manifested in this population. Identification of pre-ECMO predictors of mortality helps stratify high-risk patients when deciding on ECMO placement, prolonged support, and prognosis.

A retrospective analysis of inpatient cardiac arrests over one year at a tertiary heart attack and cardiothoracic centre identifying potential candidates for an inpatient extracorporeal cardiopulmonary resuscitation service

Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) is an internationally recognised treatment for refractory cardiac arrest, with evidence of improved outcomes in selected patient groups from cohort studies and case series. In order to establish the clinical need for an in-hospital extracorporeal cardiopulmonary resuscitation service at a tertiary cardiac centre, we analysed the inpatient cardiac arrest database for the previous 12 months.

Methods

Evidence-based inclusion criteria were used to retrospectively identify the number of patients potentially eligible for extracorporeal cardiopulmonary resuscitation over a 12-month period.

Results

A total of 261 inpatient cardiac arrests were analysed with 21 potential extracorporeal cardiopulmonary resuscitation candidates meeting the inclusion criteria (1.75 patients per month, or 8% of inpatient cardiac arrests (21/261)). The majority (71%) of these cardiac arrests occurred outside of normal working hours. Survival-to-discharge within this sub-group with conventional cardiopulmonary resuscitation was 19% (4/21).

Conclusion

Sufficient numbers of refractory inpatient cardiac arrests occur to justify an extracorporeal cardiopulmonary resuscitation service, but a 24-h on-site extracorporeal membrane oxygenation team presents a significant financial and logistical challenge.

Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries

OBJECTIVES

The aim of this study was to determine cardiac arrest- and extracorporeal membrane oxygenation-related risk factors associated with unfavorable outcomes after extracorporeal cardiopulmonary resuscitation.

DESIGN

We performed an analysis of merged data from the Extracorporeal Life Support Organization and the American Heart Association Get With the Guidelines-Resuscitation registries.

SETTING

A total of 32 hospitals reporting to both registries between 2000 and 2014.

PATIENTS

Children younger than 18 years old who suffered in-hospital cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 593 children included in the final cohort, 240 (40.5%) died prior to decannulation from extracorporeal membrane oxygenation and 352 (59.4%) died prior to hospital discharge. A noncardiac diagnosis and preexisting renal insufficiency were associated with increased odds of death (adjusted odds ratio, 1.85 [95% CI, 1.19-2.89] and 4.74 [95% CI, 2.06-10.9], respectively). The median time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was 48 minutes (interquartile range, 28-70 min). Longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was associated with higher odds of death prior to hospital discharge (adjusted odds ratio for each 5 additional minutes of cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation initiation, 1.04 [95% CI, 1.01-1.07]). Each individual adverse event documented during the extracorporeal membrane oxygenation course, including neurologic, pulmonary, renal, metabolic, cardiovascular and hemorrhagic, was associated with higher odds of death, with higher odds as the cumulative number of documented adverse events during the extracorporeal membrane oxygenation course increased.

CONCLUSIONS

Outcomes after extracorporeal cardiopulmonary resuscitation reported by linking two national registries are encouraging. Noncardiac diagnoses, preexisting renal insufficiency, longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation, and adverse events during the extracorporeal membrane oxygenation course are associated with worse outcomes.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Introduction of an Extracorporeal Cardiopulmonary Resuscitation Eligibility Protocol for Paramedics in Atlantic Canada: A Pilot Knowledge Translation Project

Introduction

There is currently no protocol for the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest (OHCA) in Atlantic Canada. Advanced care paramedics (ACPs) perform advanced cardiac life support in the prehospital setting often completing the entire resuscitation on-scene. Implementation of ECPR will present a novel intervention that is only available at the receiving hospital. Our objective is to determine if an educational program can improve identification of ECPR candidates by paramedics. Establishing paramedic competence will ensure rapid transfer of eligible patients for a potentially life-saving intervention.

Methods

An educational program was delivered to paramedics including a short seminar and pocket card coupled with simulated OHCA cases. A before-and-after study design using a case-based survey was employed. Paramedics were scored on their ability to correctly identify patients suffering OHCA who met the inclusion criteria for our ECPR protocol. A Wilcoxon matched-pairs signed rank test was employed to compare paramedics’ scores before and after the education delivery. A six-month follow-up is planned to assess retention. Qualitative data was also collected from paramedics during simulation to help identify practical issues, potential barriers, and to refine inclusion and exclusion criteria prior to the implementation of our protocol in the prehospital setting.

Results

The median score pre-education was 10 (IQR: 9-10.5) compared to 14 (IQR: 13-15) after education delivery. The median difference between groups was 5. The Wilcoxon matched-pairs test demonstrated a significant improvement in the paramedics’ ability to correctly identify ECPR candidates after completing our educational program z = -2.67, p = 0.0039.

Conclusion

Paramedic training through a didactic session coupled with a pocket card and simulation appeared to be a feasible method of knowledge translation. Six-month follow-up data will help ensure knowledge retention is achieved.

Update on anesthesia management for explantation of veno-arterial extracorporeal membrane oxygenation in adult patients

The utilization of temporary circulatory support in the form of extracorporeal membrane oxygenation (ECMO) has increased and its indications are expanding. Anesthesiologists may be involved in the care of these patients during the initiation of and weaning off from ECMO, surgical procedures with an ECMO in situ, and transfer of patients on ECMO between the operating theater and intensive care unit. This article addresses the anesthetic considerations and management for explant of veno-arterial ECMO in adults.

Prehospital extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A retrospective eligibility study

OBJECTIVE

We sought to identify out-of-hospital cardiac arrest (OOHCA) patients who might benefit from a future prehospital extracorporeal cardiopulmonary resuscitation (ECPR) programme in a moderately sized city. We described the 2014 OOHCA data and identified those who fulfilled hypothetical prehospital ECPR eligibility criteria.

METHODS

We identified patients aged 18-65 years in cardiac arrest, where CPR was commenced by paramedics on arrival. Traumatic cardiac arrest and end-of-life needs were patient exclusions. Patients were then included in one of three hypothetical 'ECPR eligible' groups. Patients were included in an 'ECPR eligible' group if they met author agreed criteria. Select patients in refractory VT/VF; pulseless electrical activity (PEA); and non-refractory VT/VF, or asystole with subsequent VT/VF or transient return of spontaneous circulation (ROSC), were assigned to three separate groups. Descriptive statistics were applied to each group. Outcomes of ECPR eligible patients who developed sustained ROSC after 20 min of conventional CPR were characterised.

RESULTS

A total of 206 patients were included. A significant positive association between initial shockable rhythm (odds ratio [OR] 15.32, confidence interval [CI] 5.4-43.2) and sustained ROSC, and PEA (OR 6.93, CI 2.4-19.8) and sustained ROSC, versus asystole was identified (P < 0.001). Sixty-eight (33%) patients were eligible for one of the hypothetical ECPR groups. Twelve (17.6%) of the 68 ECPR eligible patients developed sustained ROSC after 20 min of conventional CPR, with only two surviving neurologically intact to hospital discharge.

CONCLUSION

Sixty-three (30.6%) patients could have derived benefit from a prehospital ECPR programme. Further analyses of prehospital ECPR logistics and economics are necessary to ensure that any future prehospital ECPR programme is effective and efficient.

Recent advances in personalizing cardiac arrest resuscitation

Cardiac arrest remains a significant cause of death and disability throughout the world. However, as our understanding of cardiac arrest and resuscitation physiology has developed, new technologies are fundamentally altering our potential to improve survival and neurologic sequela. Some advances are relatively simple, requiring only alterations in current basic life support measures or integration with pre-hospital organization, whereas others, such as extra-corporeal membrane oxygenation, require significant time and resource investments. When combined with consistent rescuer and patient-physiologic monitoring, these innovations allow an unprecedented capacity to personalize cardiac arrest resuscitation to patient-specific pathophysiology. However, as more extensive options are established, it can be difficult for providers to incorporate novel resuscitation techniques into a cardiac arrest protocol which can fit a wide variety of cases with varying complexity. This article will explore recent advances in our understanding of cardiac arrest physiology and resuscitation sciences, with particular focus on the metabolic phase after significant ischemia has been induced. To this end, we establish a practical consideration for providers seeking to integrate novel advances in cardiac arrest resuscitation into daily practice.

Time from arrest to extracorporeal cardiopulmonary resuscitation and survival after out-of-hospital cardiac arrest

OBJECTIVES

The association between the time from arrest to extracorporeal cardiopulmonary resuscitation (ECPR) and survival from out-of-hospital cardiac arrest (OHCA) is unclear. The aim of this study was to determine whether time to ECPR is associated with survival in OHCA.

METHODS

We analysed the Korean national OHCA registry from 2013 to 2016. We included adult witnessed OHCA patients with presumed cardiac aetiology who underwent ECPR. Patients were excluded if their arrest times or outcomes were unknown. The primary outcome was survival to discharge. Multivariable logistic regression analysis controlling for potential confounders was conducted and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated to determine the association between time to ECPR and survival.

RESULTS

There were 40 352 witnessed OHCAs with presumed cardiac aetiology. One hundred and forty patients had ECPR applied on arriving at their ED, 13 of these patients survived to discharge and seven were neurologically intact. Median time from arrest to ECPR was 74 min (IQR 61-90). Time from arrest to ECPR was significantly and inversely associated with survival to discharge for every 10 min increase in time (AOR 0.73, 95% CI 0.53-1.00) in 10 min intervals. AOR for time from arrest to ECPR ≤60 min was independently associated with improved survival (AOR 6.48, 95% CI 1.54-27.20).

CONCLUSION

Early initiation of ECPR is associated with improved survival after OHCA. Because we analysed a nationwide OHCA registry, which lacks uniform selection criteria for ECPR, further prospective study is warranted.

Cardiogenic Shock Following Acute Myocardial Infarction: What's New?

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion primarily due to cardiac dysfunction. This condition is the most common cause of death in patients affected by acute myocardial infarction (AMI). Despite early revascularization, prompt optimal medical therapy, and up-to-date mechanical circulatory supports, mortality of patients with CS remains high.The objective of this review is to summarize epidemiology, pathophysiology, and treatment options of CS in light of the new European Society of Cardiology (ESC) recommendations. The latest European guidelines on myocardial revascularization have reviewed the previous guidelines with respect to early multivessel revascularization and routine use of intra-aortic balloon pump (IABP) in patients with AMI-related CS.Most of the current evidences come partly from randomized trials, but mostly from observational registries because of the difficulty to test different treatments in this life-threatening clinical setting.Some of the latest studies highlight the potential crucial benefit of newly introduced mechanical circulatory support devices, although evidences are not sufficient to definitely assess the benefit/risk ratio of the different systems.Many questions remain unanswered in this field, and further trials are advocated to better elucidate the best medical, reperfusion, and circulatory support approaches aimed to improve the poor prognosis of patients with CS after AMI.