Extracorporeal cardiopulmonary resuscitation

Extracorporeal cardiopulmonary resuscitation in bedside echocardiography-diagnosed massive pulmonary embolism

Acute pulmonary embolism (PE) is one of the major causes of inhospital cardiac arrest as well as out-of-hospital cardiac arrest. Bedside diagnosis of acute PE in the emergency department (ED) can be challenging, especially in a cardiac arrest setting. Even if the early diagnosis of an acute massive PE had been made, hemodynamic instability may be worsened unless obstructive shock gets resolved. We present a case of a 46-year-old woman who developed pulseless electrical activity (PEA) after complaining of weakness and dyspnea in an ambulance, presumptively diagnosed as acute PE by bedside focused echocardiography. She received thrombolytic therapy and was rescued by extracorporeal cardiopulmonary resuscitation for recurrent PEA arrest in the ED. Focused bedside echocardiography provides a rapid diagnostic adjunct, and extracorporeal cardiopulmonary resuscitation can be a valuable rescue therapy for PEA arrest from massive PE.

Conditions and procedures for in-hospital extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR) of adult patients

The use of extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR; ECPR) has been repeatedly published as non-randomized studies, mainly case series and case reports. The aim of this article is to support physicians, perfusionists, nurses and extracorporeal membrane oxygenation (ECMO) specialists who regularly perform ECPR or are willing to start an ECPR program by establishing standards for safe and efficient ECPR procedures. This article represents the experience and recommendations of physicians who provide ECPR routinely. Based on its survival and outcome rates, ECPR can be considered when determining the optimal treatment of patients who require CPR. The successful performance of ECLS cannulation during CPR is a life-saving measure and has been associated with improved outcome (including neurological outcome) after CPR. We summarize the general structure of an ECLS team and describe the cannulation procedure and the approaches for post-resuscitation care. The differences in hospital organizations and their regulations may result in variations of this model.

Duration of conventional cardiopulmonary resuscitation prior to extracorporeal cardiopulmonary resuscitation and survival among adult cardiac arrest patients

PURPOSE

The purpose of this study was to evaluate the association between survival and the duration of conventional cardiopulmonary resuscitation (CCPR) prior to extracorporeal cardiopulmonary resuscitation (ECPR) and possible confounding factors.

METHODS

This was a retrospective analysis of 31 adults who received ECPR at an academic medical center between 2004 and 2013. Odds of 30-day survival and Kaplan Meier survival curves were compared among patients who received CCPR ⩾ 45 min (n=8, 26%) vs. <45 min (n=23, 74%).

RESULTS

There was a trend for greater survival up to 14 days in patients who received CCPR <45 vs. ⩾ 45 minutes (57% vs. 50%) with no significant difference at 30 days (OR 1.09, 95% CI 0.22-5.45) and survival did not differ by demographic factors.

CONCLUSION

More than half of all patients who received ECPR survived to 30 days. Longer duration CCPR was associated with reduced survival within 2 weeks, but not at 30 days.

Veno-arterial extracorporeal membrane oxygenation for adult cardiovascular failure

PURPOSE OF REVIEW

To examine the utility and technical challenges of applying veno-arterial extracorporeal membrane oxygenation for acute cardiovascular failure in adults with acute and chronic causes of heart failure.

RECENT FINDINGS

The role of mechanical circulatory support in acute cardiovascular continues to evolve as technology and clinical experience develop. There is increasing interest in the role of veno-arterial extracorporeal membrane oxygenation as a bridging therapy and as an adjunct to conventional cardiopulmonary resuscitation.

SUMMARY

Veno-arterial extracorporeal membrane oxygenation is an expensive, complex, resource intensive support. It is essential that its future use be guided by evidence obtained from centres that have demonstrated timely, safe support.

Relationship between duration of prehospital resuscitation and favorable prognosis in ventricular fibrillation

OBJECTIVE

There appears to be an optimal point in balancing the relative benefits of extending the resuscitation time to obtain return of spontaneous circulation in the prehospital setting and the initiation of therapies such as extracorporeal cardiopulmonary resuscitation (CPR). This study investigated how prehospital CPR duration is related to survival and neurologic outcome in ventricular fibrillation (VF) and tried to find the tolerable time for prehospital resuscitation.

MATERIALS AND METHODS

Out-of-hospital cardiac arrest patients with VF in Funabashi City, Japan, from January 2009 to December 2013 were reviewed. Resuscitation teams that included physicians were dispatched to incident sites. Survival rate at 24 hours and neurologic outcome at 30 days were analyzed with respect to prehospital CPR duration.

RESULTS

A total of 172 patients were evaluated. Seventy-three patients were alive at 24 hours. Thirty-four patients had favorable neurologic outcomes after 30 days. Of the 69 patients who required prolonged prehospital CPR (>30 minutes), 6 were alive at 24 hours, and only 1 had a favorable neurologic outcome at 30 days. Logistic regression model showed that both survival rate at 24 hours and neurologic outcome at 30 days deteriorated with the increase in prehospital CPR duration (both P < .001).

CONCLUSION

The prognosis of out-of-hospital cardiac arrest patients with VF deteriorated with the increase in prehospital CPR duration. Favorable results are less likely especially in cases of prolonged prehospital CPR (>30 minutes). Therefore, it may be necessary to consider transportation to a more definitive treatment facility rather than extending conventional CPR in the prehospital setting.

Extracorporeal membrane oxygenation for critically ill adults

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain.

OBJECTIVES

The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias.

MAIN RESULTS

We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest).

AUTHORS' CONCLUSIONS

Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.

The Role of Percutaneous Haemodynamic Support in High-risk Percutaneous Coronary Intervention and Cardiogenic Shock

The experience and usage of percutaneous cardiac assist devices in cardiogenic shock as well as high-risk percutaneous coronary intervention have increased over the years. Nonetheless, there is still little evidence of clinical benefit of these devices other than immediate haemodynamic improvement. Despite the fact that these devices are used to treat a rather complex patient population, clinical testing remains important in order to evaluate their true impact on clinical outcome before being adopted into clinical practice. Therefore, this review shows an overview of the current experience and evidence of the available percutaneous cardiac assist devices.

An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study

INTRODUCTION

Prolonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR.

METHODS

This study is a retrospective analysis based on a prospective cohort. We included patients ≥ 18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group.

RESULTS

Of 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥ 21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥ 60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome.

CONCLUSIONS

ECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥ 21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.