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

Healthcare professional perspective on barriers and facilitators of multidisciplinary team working in acute care setting: a systematic review and meta-synthesis

OBJECTIVE

A multidisciplinary team is essential to providing high-quality, patient-centred care. However, its effectiveness can be either hindered or facilitated by various factors, such as the need for rapid decision-making, which may compromise patient outcomes despite individual efforts. The aim of this study is to synthesise the factors that may act as barriers and facilitators to the work of multidisciplinary teams in managing labour within acute care settings.

DESIGN

A systematic qualitative review and meta-synthesis was conducted following the five-step methodology proposed by Sandelowski et al.

DATA SOURCE

Three databases (Medline, Embase and Scopus) were systematically searched without time restrictions up to 25 May 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Qualitative studies exploring perspectives, experiences and other similar factors were included. These studies were assessed for methodological quality using the Critical Appraisal Skills Programme.

DATA EXTRACTION AND SYNTHESIS

The reviewers independently searched, screened and coded the results of the included studies. Data were synthesised using the method proposed by Thomas and Harden.

RESULTS

Seventeen studies were included in the meta-synthesis. Four key dimensions emerged, reflecting both the barriers and the facilitators of multidisciplinary team performances: (1) organisational variables, (2) individual variables, (3) collaborative variables and (4) role variables. A total of 36 variables were identified, which could function as barriers (n=6; eg, high staff turnover), facilitators (n=6; eg, strong listening skills) or both (n=24; eg, team climate), depending on the context.

CONCLUSIONS

This meta-synthesis identifies specific barriers and facilitators and variables that can act as both. Understanding these factors enables targeted interventions to enhance the performance of multidisciplinary teams in clinical practice, particularly in acute care settings.

PROSPERO REGISTRATION NUMBER

CRD42022297395.

Anticoagulation and associated complications in veno-arterial extracorporeal membrane oxygenation in adult patients: A systematic review and meta-analysis

Objective

To describe the incidence of bleeding and thrombotic complications in VA-ECMO according to anticoagulation strategy.

Design

This systematic review and meta-analysis included randomised controlled trials (RCTs) and observational studies reporting bleeding and thrombotic complications in VA-ECMO. The incidence of primary outcomes according to anticoagulation drug and monitoring test was described.

Data sources

CENTRAL, MEDLINE, Embase and CINAHL (2010-January 2024).

Review methods

Data was extracted using Covidence. A meta-analysis of proportions was performed using STATA MP v18.1 metaprop.

Results

We included 159 studies with 21,942 patients. No studies were at low risk of bias. The incidence of major bleeding or thrombotic events was similar among heparin-, bivalirudin- and anticoagulation-free cohorts. The pooled incidence of major bleeding and thrombotic complications were 40% (95%CI 36-44, I2 = 97.12) and 17% (95%CI 14-19, I 2  = 92.60%), respectively. The most common bleeding site was thoracic. The most common ischaemic complication was limb ischaemia. The incidences of major bleeding or thrombotic events, intracranial haemorrhage and ischaemic stroke were similar among all monitoring tests. Mechanical unloading was associated with a high incidence of major bleeding events (60%, 95%CI 43-77, I2 = 93.32), and ischaemic strokes (13%, 95%CI 7-19, I2 = 81.80).

Conclusions

Available literature assessing the association between anticoagulation strategies in VA-ECMO, and bleeding and thrombosis is of limited quality. We identified a substantially higher incidence of major bleeding events than a previous meta-analysis. Limited numbers of patients anticoagulated with alternatives to heparin were reported. Patients with additional mechanical LV unloading represent a cohort at particular risk of bleeding and thrombotic complications.

Arterial Complications Assessed by Duplex Ultrasound After Decannulation of Peripheral Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Vascular complications are common and can be fatal even after successful decannulation in patients with peripherally cannulated veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, we aimed to accurately determine the incidence of arterial complications assessed by Duplex ultrasound following peripheral VA-ECMO decannulation. In addition, we investigated the predictors of severe complications requiring intervention.

METHODS AND RESULTS

We retrospectively reviewed 1,350 adult patients who underwent ECMO between January 2012 and April 2023. Of 839 patients treated with peripherally cannulated VA-ECMO, 596 were successfully weaned off and 212 underwent Duplex ultrasound for final analysis. The primary outcome was arterial complications requiring vascular intervention. Thirty-three (15.6%) patients experienced such complications after decannulation. Acute limb ischemia due to thrombotic occlusion was the most common complication, occurring in 23 (10.8%) patients, followed by stenosis (3.8%), pseudoaneurysm (3.8%), arteriovenous fistula (0.9%), and dissection (0.9%). No significant differences in complication rates were found between the percutaneous and surgical decannulation groups in the propensity score-matched population (12.7% vs. 15.9%, respectively; P=0.799). Multivariable analysis revealed disseminated intravascular coagulation (DIC; odds ratio 2.6; 95% confidence interval 1.17-5.69; P=0.019) as the only predictor of arterial complications after decannulation.

CONCLUSIONS

Arterial complications requiring vascular intervention frequently occur following successful weaning from VA-ECMO regardless of the decannulation strategy. In this setting, DIC appears to be associated with an increased rate of arterial complications.

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

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.

A novel strategy sequentially linking mechanical cardiopulmonary resuscitation with extracorporeal cardiopulmonary resuscitation optimizes prognosis of refractory cardiac arrest: an illustrative case series

Background

Extracorporeal membrane oxygenation (ECMO) to support cardiopulmonary resuscitation (CPR), also known as extracorporeal cardiopulmonary resuscitation (ECPR), has shown encouraging results in refractory cardiac arrest (RCA) resuscitation. However, its therapeutic benefits are linked to instant and uninterrupted chest compression (CC), besides early implementation. Mechanical CC can overcome the shortcomings of conventional manual CC, including fatigue and labor consumption, and ensure adequate blood perfusion. A strategy sequentially linking mechanical CPR with ECPR may earn extra favorable outcomes.

Case series

We present a four-case series with ages ranging from 8 to 94 years who presented with prolonged absences of return of spontaneous circulation (ROSC) after CA associated with acute fulminant myocarditis (AFM) and myocardial infarction (MI). All the cases received VA-ECMO (ROTAFLOW, Maquet) assisted ECPR, with intra-aortic balloon pump (IABP) or continuous renal replacement treatment (CRRT) appended if persistently low mean blood pressure (MAP) or ischemic kidney injury occurred. All patients have successfully weaned off ECMO and the assistant life support devices with complete neurological recovery. Three patients were discharged, except the 94-year-old patient who died of irreversible sepsis 20 days after ECMO weaning-off. These encouraging results will hopefully lead to more consideration of this lifesaving therapy model that sequentially integrates mechanical CPR with ECPR to rescue RCA related to reversible cardiac causes.

Conclusions

This successful case series should lead to more consideration of an integrated lifesaving strategy sequentially linking mechanical cardiopulmonary resuscitation with ECPR, as an extra favorable prognosis of refractory cardiac arrest related to this approach can be achieved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00711-1.

Current Unmet Needs and Clues to the Solution in the Management of Tricuspid Regurgitation

The clinical importance of tricuspid regurgitation (TR) has been recently highlighted. However, there remain several unmet needs with the diagnosis and treatment of TR. The major dilemma is a delayed treatment decision and an intervention at an advanced stage. Other important unmet needs are limitations in diagnostic imaging modalities, ambiguity in the guidelines regarding the interventional criteria, high surgical mortality, uncertainty in the reversibility of the right ventricle, and lack of long-term clinical data after the intervention. We have discussed such overall aspects of TR, the problems frequently experienced by clinical physicians and future strategies to improve the treatment of TR.

Although tricuspid regurgitation (TR) is a general medical issue with growing prevalence and socioeconomic burden, most clinicians have not paid much attention to TR in the past. Several problems of TR have been pointed out in clinical practice, which include: ambiguous clinical manifestations and the difficulty in initial detection, limitations in generally used diagnostic tools, the absence of objective criterion for therapeutic intervention, high operative morbidity and mortality, and lack of long-term clinical data after the intervention for TR. Therefore, patients with TR usually visit clinicians at a much-advanced state, and this delay gives a major dilemma in clinical decision-making in a routine clinical practice. To improve the clinical outcome of TR, we need more knowledge about TR for solving the current problems and making strategies for better clinical practice. With this background, we have discussed in the present article about the pathophysiology of TR and the problems frequently experienced by clinical physicians in the diagnosis and treatment of TR. Furthermore, we have discussed the future strategy to improve the treatment of TR.