Article

Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial)

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Abstract

Introduction: Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia. Methods: The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24h in the intensive care unit. Results: There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients. Conclusions: A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.

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... Survival following out of hospital cardiac arrest (OHCA) has been historically poor, with limited improvements in outcomes over time reported in many settings [1,2]. A limited number of jurisdictions, such as King County in Washington State, have reported step-wise improvements in OHCA outcomes as the result of coordinated interagency and public health initiatives [3,4]. ...
... In order to further the knowledge and understanding of the application of advanced OHCA treatment strategies in an Australasian setting, we set out to prospectively assess the baseline and future management of a contemporary OHCA cohort in a local health district (LHD) with a historically limited use of ECMO for in-patients and no history of use of eCPR in the ED [1]. Using this prospective OHCA database we applied an evidence based selection criteria to determine caseloads that might be experienced by future eCPR teams. ...
... Eligible OHCA were manually evaluated using paper forms with additional data points obtained from eMR and state ambulance records. eCPR eligibility criteria (Table 1) used by the 2-CHEER study were used to retrospectively match the likely use of eCPR in the cohort of OHCA patients ( Fig. 1) [1,14]. ...
Article
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Background Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres. Methods A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly. Results In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n = 58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within “office hours” and no case obtained a return of spontaneous circulation standard advanced life support. Conclusions In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.
... [2] Single center studies have highlighted the utility of E-CPR in patients with out-of-hospital refractory CA. [3] In a prospective study of E-CPR in 26 patients (11 OHCA and 15 IHCA patients), a significant recovery to discharge (with full neurological recovery) was achieved in 60% in IHCA and 45% in OHCA patients. [4] These authors attributed their high success to a combination of E-CPR along with therapeutic hypothermia and mechanical CPR. ...
... Favorable factors associated with successful E-CPR include age <65 years, witnessed arrest, an initial shockable rhythm, good quality immediate CPR (<5 minutes), intermittent CPR and no major comorbidities. [4,5,7] The patient in this case was a young and apparently "normal" active person with no comorbidities. In the CHEER study, the median time between CA and initiation of ECMO was 20 min and between CA and ECMO initiation was 56 min. ...
... In the CHEER study, the median time between CA and initiation of ECMO was 20 min and between CA and ECMO initiation was 56 min. [4] In our patient, ECMO was initiated 32 min after calling the ECMO team and 47 min after the patient's arrival in the ED. In spite of the longer time to ECMO, the excellent neurological outcome in our patient could be attributed to the excellent CPR continued through till initiation of ECMO. ...
Article
Extra corporeal membrane oxygenation (ECMO) for refractory out-of-hospital cardiac arrest (OHCA) has been shown to improve outcome in many Western countries. There are no reports of ECMO being used to support OHCA in India till date. We report a case of a young man who developed cardiac arrest (CA) while driving and was given bystander cardiac massage. He was brought to tertiary care center where an ECMO was utilized for refractory CA. The patient subsequently underwent emergency coronary artery stenting and was weaned off ECMO and ventilation. We discuss the case and highlight the role of bystander cardiopulmonary resuscitation.
... [19][20][21] In view of this, current recommendations by the American Heart Association suggest use of 100% oxygen during CPR and oxygen titration (targeting a peripheral capillary oxygen saturation (SpO 2 ) of 92-96%) after successful return of spontaneous circulation (ROSC). [22] Over the last few years, the use of extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) has been growing, and may provide a signi cant survival bene t over conventional CPR (CCPR) in patients with refractory CA. [23,24] However while ECPR provides both mechanical haemodynamic and oxygenation support, [25][26][27] ECPR may also be associated with signi cantly elevated arterial oxygen levels. [1,12,13] To date, little is known about the incidence of hyperoxia in patients treated with ECPR compared to CCPR, and whether there is an association between hyperoxia and poor outcomes, independent of the method of resuscitation. ...
... [29− 31] CPR was initially performed manually in all cases, but if prolonged > 10 minutes was switched to the Lucas® chest compression system (Physiocontrol, Redmond) to facilitate transportation. [25] Patients with CA were treated via two different pathways: CCPR was initiated in all patients, while ECPR with implementation of VA ECMO was initiated in refractory CA when there were no contraindications. ECPR inclusion and exclusion criteria for CA patients have been previously published. ...
... ECPR inclusion and exclusion criteria for CA patients have been previously published. [25,32] In the ECPR group hemodynamic support was maintained with either the Cardiohelp® (HLS, Maquet) or Rota ow® (PLS, Getinge Group). The initial typical settings of the ECMO were a fresh gas ow oxygen fraction (FsO 2 ) of 1.0, 3l/min blood ow, 3l/min fresh gas (sweep) ow and ventilator settings of FiO 2 0.5, positive end expiratory pressure (PEEP) 10 cmH 2 O and pressure control level above PEEP (PC) 10cmH 2 O. ...
Preprint
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Background Hyperoxia has been associated with adverse outcomes in post cardiac arrest (CA) patients. However, little data are available from mixed cohorts, where extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) and conventional CPR (CCPR) were utilised. The independence of effect of hyperoxia in this setting is not clear. Study-objective was to examine the association between hyperoxia and 30-day mortality in a mixed cohort of ECPR and CCPR patients.Methods and designThis was a retrospective cohort study of CA patients admitted to a tertiary level cardiac arrest centre in Australia from 1st January 2013 to 31st August 2018. Mean arterial oxygen levels (PaO 2 ) and episodes of extreme hyperoxia (PaO 2 ≥ 300mmHg) were analysed over the first 8 days. The primary outcome was 30-day mortality.ResultsA total of 169 post CA patients were assessed over a 6.5-year time period: 79 patients undergoing ECPR vs 90 patients undergoing CCPR. The mean age of the cohort was 54 (± 17) years; 126/169 (74%) were male and 119/169 (70%) were treated for out of hospital cardiac arrest (OHCA). Compared to CCPR, ECPR patients were younger, had a longer low flow time and higher illness severity scores on admission. Mean PaO 2 -levels were higher in patients in the ECPR vs CCPR group (211mmHg ± 58.4 vs 119mmHg ± 18.1; p < 0.0001) as was the proportion with at least one episode of extreme hyperoxia (58/79 (73%) vs 36/90 (40%), p < 0.01). ECPR patients presented with a higher mortality (54.4%) vs CCPR patients (34.4%). After adjusting for age, sex, BMI, highest lactate pre-treatment, use of ECMO, low flow time, pulse pressure on admission day, and severity of illness (APACHE III score), any episode of extreme hyperoxia was independently associated with a 2.57-fold increased risk of 30-day mortality (OR: 2.57, 95% CI: 1.09–6.06; p = 0.031) irrespective of the CPR-mode.Conclusion We found extreme hyperoxia (PaO 2 -level ≥ 300mmHg) was more common in ECPR patients in the first 8 days post CA and was independently associated with higher 30-day mortality, irrespective of whether ECPR was employed. Prospective studies that compare different oxygen targets are needed to see if a strategy of lower oxygen exposure improves outcomes.
... Patients consistently have better outcomes from ECPR in IHCA compared to OHCA [38][39][40][41]. A retrospective study in five European centers (n = 423) demonstrated significantly lower survival with functional recovery using ECPR for OHCA compared with IHCA (9% vs 34%, p < 0.01) [40] despite a lower burden of comorbidities; likely because IHCA subjects had higher rates of witnessed arrest and shorter low-flow times owing to initiation of bystander CPR. ...
... ECPR should be viewed as complementary to highquality conventional CPR given the association between bystander CPR and favorable long-term outcomes [30,34,35]. Indeed, most experienced centers require a minimum time (e.g., 10 min) of failed, high-quality CPR prior to cannulating for ECPR to avoid unnecessary deployment when ROSC might have been achieved by CPR alone [13,15,22,39,63]. To minimize low-flow time beyond this initial attempt at conventional resuscitation, there is a narrow window to perform cannulation. ...
... A detailed description of recommended personnel and supplies and recommendations for the systems design of cardiac ECMO programs in general, including centralization of resources to experienced, high-volume centers, has previously been published in a position paper [66]. Health systems that perform ECPR for OHCA should have formal plans detailing responsibilities of EMS and receiving hospitals to expedite ECPR on arrival to the ED or catheterization laboratory (Fig. 2) [22,39,67]. The relationship may consist of a hub-and-spoke model where local and referral centers initiate ECPR, but transfer patients to the hub for ongoing ECMO management [66]. ...
Article
Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.
... (8) Based on data from the Extracorporeal Life Support Organization (ELSO) Registry, the rising number of ECMO centres (9) and observational studies reporting favourable results (higher survival rates compared with those observed with CCPR) might account for this trend. (10)(11)(12)(13)(14)(15)(16)(17) ...
... The longer transport times to a hospital where they subsequently receive ECPR (if they fit the strict patient selection criteria) can also negatively affect outcomes and survival due to the longer 'low-flow' time before they are started on ECMO. (19) Despite these significant obstacles and challenges to ECPR for patients with OHCA, small single-centre studies (10) and prospective observational cohort studies have reported encouraging results, which suggest that ECPR could yield better survival outcomes than CCPR does for OHCA. ...
Article
The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.
... Survival following out of hospital cardiac arrest (OHCA) has been historically poor, with limited improvements in outcomes over time reported in many settings. (1,2) A limited number of jurisdictions, such as King County in Washington State, have reported step-wise improvements in OHCA outcomes as the result of coordinated interagency and public health initiatives. (3,4) Rates of achieving return of spontaneous circulation (ROSC) following advanced life support (ALS) in a prehospital setting vary depending on local geography, public policy, bystander actions and logistical factors and access to healthcare resources. ...
... eCPR eligibility criteria ( Fig. 1) used by the 2-CHEER study were used to retrospectively match the likely use of eCPR in the cohort of OHCA patients (Fig. 2). (1,14) Analysis Plan ...
Preprint
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Background Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres. Methods A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly. Results In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n=58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within “office hours” and no case obtained a return of spontaneous circulation standard advanced life support. Conclusions In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.
... In our study, an increase in D-dimers and a decrease in fibrinogen paired with an increase in IL6 were associated with significantly higher mortality. The demographic data of our ECPR study population are similar to those of other OHCA studies in terms of age, sex and CA cause [33][34][35]. In our study, however, ECPR patients with cardiac origin had a lower mortality rate (59%) than those from the literature (67-92%) [34,35]. ...
... The demographic data of our ECPR study population are similar to those of other OHCA studies in terms of age, sex and CA cause [33][34][35]. In our study, however, ECPR patients with cardiac origin had a lower mortality rate (59%) than those from the literature (67-92%) [34,35]. ECPR patients with non-cardiac origin (e.g. ...
Article
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Background: Extracorporeal cardiopulmonary resuscitation (ECPR) performed at the emergency scene in out-of-hospital cardiac arrest (OHCA) can minimize low-flow time. Target temperature management (TTM) after cardiac arrest can improve neurological outcome. A combination of ECPR and TTM, both implemented as soon as possible on scene, appears to have promising results in OHCA. To date, it is still unknown whether the implementation of TTM and ECPR on scene affects the time course and value of neurological biomarkers. Methods: 69 ECPR patients were examined in this study. Blood samples were collected between 1 and 72 h after ECPR and analyzed for S100, neuron-specific enolase (NSE), lactate, D-dimers and interleukin 6 (IL6). Cerebral performance category (CPC) scores were used to assess neurological outcome after ECPR upon hospital discharge. Resuscitation data were extracted from the Regensburg extracorporeal membrane oxygenation database and all data were analyzed by a statistician. The data were analyzed using non-parametric methods. Diagnostic accuracy of biomarkers was determined by area under the curve (AUC) analysis. Results were compared to the relevant literature. Results: Non-hypoxic origin of cardiac arrest, manual chest compression until ECPR, a short low-flow time until ECPR initiation, low body mass index (BMI) and only a minimal need of extra-corporeal membrane oxygenation support were associated with a good neurological outcome after ECPR. Survivors with good neurological outcome had significantly lower lactate, IL6, D-dimer, and NSE values and demonstrated a rapid decrease in the initial S100 value compared to non-survivors. Conclusions: A short low-flow time until ECPR initiation is important for a good neurological outcome. Hypoxia-induced cardiac arrest has a high mortality rate even when ECPR and TTM are performed at the emergency scene. ECPR patients with a higher BMI had a worse neurological outcome than patients with a normal BMI. The prognostic biomarkers S100, NSE, lactate, D-dimers and IL6 were reliable indicators of neurological outcome when ECPR and TTM were performed at the emergency scene.
... After 30 min of CPR, VA-ECMO was initiated at standard-blood-flow 65-70 mL·kg −1 ·min −1 based on a theoretical cardiac output and ELSO recommendations. This timing is compatible to ECMO implantation during in-hospital cardiac arrest [17]. Reperfusion of LAD was performed after 30 min of VA-ECMO initiation. ...
... Similar to bedside observations, all animals at T 0 presented high lactate level linked to a prolonged cardiac arrest [16]. The abrupt recovery in systemic flow due to the ECMO device was associated with a severe post-resuscitation syndrome requiring vasopressor and fluid administration [17]. ...
Article
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Background: Refractory cardiac arrest management relies on extracorporeal cardiopulmonary resuscitation (ECPR), requiring the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Circulatory flow recovery can be associated with an ischemia-reperfusion injury, leading to vasoplegia and vasopressor requirement. The aim of this work was to evaluate the impact on hemodynamics of a methylene blue bolus infusion in a porcine model of ischemic refractory cardiac arrest. Methods: Ischemic refractory cardiac arrest was induced in 20 pigs. After a low flow period of 30 min, VA-ECMO was initiated and the pigs were randomly assigned to the standard care group (norepinephrine + crystalloids) or methylene blue group (IV 2 mg·kg-1 bolus of methylene blue over 30 min + norepinephrine and crystalloids). Macrocirculatory parameters and lactate clearance were measured. Sublingual microcirculation was evaluated with sidestream dark field (SDF) imaging. The severity of the ischemic digestive lesions was assessed according to the histologic Chiu/Park scale. Results: Eighteen pigs were included. The total crystalloid load (5000 (6000-8000) mL vs. 17,000 (10,000-19,000) mL, p = 0.007, methylene blue vs. standard care group) and catecholamine requirements (0.31 (0.14-0.44) μg·kg-1·min-1 vs. 2.32 (1.17-5.55) μg·kg-1·min-1, methylene blue vs. standard care group, p = 0.004) were significantly reduced in the methylene blue group. There were no significant between-group differences in lactate clearance, sublingual capillary microvascular parameters assessed by SDF or histologic Chiu/Park scale. Conclusions: In our refractory cardiac arrest porcine model treated with ECPR, methylene blue markedly reduced fluid loading and norepinephrine requirements in comparison to standard care during the first 6 h of VA-ECMO.
... First, from an animal model, scientists found that mild hypothermia (temperature 34 • C) could significantly mitigate brain damage by reducing cerebral oxygen consumption and metabolism. Furthermore, after successful resuscitation, combining with therapeutic hypothermia (TH) could indeed improve neurologic outcome (7,8). In the contemporary society, the standard of successful resuscitation for patients with CA seems to be both survival and good neurologic outcome. ...
... Furthermore, arterial lactate level as a reflection of the body's metabolic level has a strong correlation with the prognosis (40). eCPR combined with TH also significantly decreased the arterial lactate level than eCPR alone [4 mmol/L (3-7) vs. 8 (5)(6)(7)(8)(9)(10)(11)(12), p < 0.01] (25). Despite eCPR being a more effective CPR strategy, complications are frequent, and severe bleeding episodes occur in up to 40% of patients on eCPR (41). ...
Article
Full-text available
Background: Extracorporeal membrane oxygenation with CPR (eCPR) or therapeutic hypothermia (TH) seems to be a very effective CPR strategy to save patients with cardiac arrest (CA). Furthermore, the subsequent post-CA neurologic outcomes have become the focus. Therefore, there is an urgent need to find a way to improve survival and neurologic outcomes for CA. Objective: We conducted this meta-analysis to find a more suitable CPR strategy for patients with CA. Method: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science). From an initial 1,436 articles, 23 studies were eligible into this meta-analysis, including a total of 2,035 patients. Results: eCPR combined with TH significantly improved the short-term (at discharge or 28 days) survival [OR = 2.27, 95% CIs (1.60–3.23), p < 0.00001] and neurologic outcomes [OR = 2.60, 95% CIs (1.92–3.52), p < 0.00001). At 3 months of follow-up, the results of survival [OR = 3.36, 95% CIs (1.65–6.85), p < 0.0008] and favorable neurologic outcomes [OR = 3.02, 95% CIs (1.38–6.63), p < 0.006] were the same as above. Furthermore, there was no difference in any bleeding needed intervention [OR = 1.33, 95% CIs (0.09–1.96), p = 0.16] between two groups. Conclusions: From this meta-analysis, we found that eCPR combined with TH might be a more suitable CPR strategy for patients with CA in improving survival and neurologic outcomes, and eCPR with TH did not increase the risk of bleeding. Furthermore, single-arm meta-analyses showed a plausible way of temperature and occasion of TH.
... In the event of refractory cardiac and/ or pulmonary dysfunction additional mechanical circulatory support may be required. Extracorporeal membrane oxygenation (ECMO) is a bridging mechanical circulatory support with promising results seen in a multitude of post cardiotomy procedures with poor residual cardiac function [1,[6][7][8][9]. Prognostic factors previously identified include: preventing left ventricular overloading, pulmonary edema, lung injury, and myocardial damage. ...
... ECMO is a valuable therapeutic option for postcardiotomy, particularly when the underlying cause is thought to be reversible [4][5][6][7][11][12][13]. This series demonstrates a heterogenous range of cardiac procedures with a similar duration of ECMO support. ...
Article
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Background The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center. Methods This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent cardiac surgery and required peri-operative ECMO. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n = 53, 88.3%), venous-venous (VV) (n = 5, 8.3%) or venous-arterial-venous (VAV) (n = 2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. Results In-hospital mortality was 60.7% (n = 37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p < 0.001) with longer hospital stays (35 ± 4.0 vs 20 ± 1.5, p < 0.03). Survivors required fewer blood products (13 ± 2.3 vs 25 ± 2.3, p = 0.02) with a net negative fluid balance (− 3.5 ± 1.6 vs 3.4 ± 1.6, p = 0.01). Cardiac re-operations worsened survival. Conclusion ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.
... Mild therapeutic hypothermia is achieved for 24-48 hours by cooling the patient to 33-34°C through integrated heat exchanger in the ECMO circuit. Permissive hypothermia reduces the tissue metabolism including cerebral metabolism, giving a better chance of survival of the patient, and reducing the progressive cerebral injury [54][55][56]. The patient is connected to the ventilator to reduce the work of breathing. ...
... ROSC was seen in all the patients, and more than half could be taken off ECMO, eventually making the survival rate above fifty percent. Neurological recovery was seen in over half of the patients who were discharged from the hospital in similar numbers [54]. Another retrospective review from Canada by Sun et al. in patients who received ECMO for cardiac arrest (8 IHCA, 1 OHCA) or cardiogenic shock (13 patients) from April 2009 to July 2015 at Vancouver General Hospital in Canada reported that ECMO was successfully weaned off in 18 patients and 16 could be discharged. ...
Chapter
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In the United States, ~100,000 patients are hospitalized annually for cardiogenic shock with 27-51% mortality. Similarly, ~356,000 patients develop out-of-hospital cardiac arrests (OHCA) annually with 90% mortality. In the last few decades, several acute mechanical circulatory support (AMCS) devices have been developed to provide hemodynamic support and to improve outcomes in patients with cardiogenic shock and cardiac arrest. Among all the devices, venoarterial extracorporeal membrane oxy-genation (VA-ECMO) is the only AMCS device that provides immediate and complete cardiopulmonary support. With an increase in clinical experience with VA-ECMO, use of VA-ECMO has expanded beyond post-cardiotomy cardiogenic shock. In the last two decades, there has also been a rapid growth in the observational and randomized data describing the clinical and logistical considerations with successful clinical outcomes in patients with cardiogenic shock and cardiac arrest. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO, its indications, contra-indications, and the complications that are encountered in the setting of VA-ECMO in patients with cardiac arrest and cardiogenic shock of various etiologies.
... Early data on the utilization of ECPR for OHCA is based largely on a handful of landmark trials and studies published over the last decade. In 2014, Stub et al. 8 conducted the prospective, observational CHEER trial (mechanical CPR, Hypothermia, ECMO, and Early Reperfusion); they found a survival-to-discharge rate of 54% in their patient population undergoing ECPR. In their single-institution study, Sun and colleagues found an even higher survival rate of ECPR for OHCA and IHCA, reaching 73%. 9 The limitation of such single-center studies in the assessment of ECPR, however, is that such results may not be reproducible at other institutions in nonstudy settings. ...
Article
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Objective The utilization of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has demonstrated promising evidence for the management of out‐of‐hospital cardiac arrest (OHCA). We aim to describe contemporary utilization and predictors of survival of patients receiving ECPR for OHCA. Methods The National Inpatient Sample (NIS) was queried to identify hospital discharge records of patients aged ≥18 years who underwent ECPR from 2012 to 2017. Patients with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of cardiac arrest, admitted urgently and placed on ECMO on Day 0 of hospitalization, were selected. Patients with a primary diagnosis indicative of veno‐venous ECMO were excluded. Predictors of mortality were assessed using multivariable analyses. Results There were 1675 cases of ECPR, increasing from 185 cases in 2012 to 400 in 2017 (p < .001). Overall mortality was 63.3%, which remained stable over time (p = .441). Common diagnoses included ST‐elevation myocardial infarction (39.1%), non‐ST‐elevation myocardial infarction (9.3%), and pulmonary embolism (13.7%). Percutaneous coronary intervention was performed in 495 patients (29.6%); coronary artery bypass grafting was performed in 125 patients (7.5%). In multivariable analysis, decreased age, female gender, and left ventricular (LV) decompression were associated with reduced mortality. Conclusion Utilization of ECPR is increasing nationally with stable mortality rates. Younger age, female gender, and utilization of LV decompression were associated with increased survival.
... Exclusion of ECMO is another concern. The characteristics of patients treated with ECMO are different from those of other OHCA patients because of the limited indications [31], and the reported outcomes of these patients vary widely [32,33]. However, most studies included in a meta-analysis report neither mentioned about the inclusion of ECMO patients nor provided data on the actual number of patients treated with ECMO [30]. ...
Article
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Background Little is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm. Methods We retrospectively analysed data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW). Results In the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76–3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19–4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83–2.36; OR 1.87, 95% CI 1.01–3.47 among the initial shockable and non-shockable patients, respectively). Conclusion We suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important.
... In our observation, as many as 32 patients who experienced SCA and another 53 who were admitted to the hospital with acute cardiac injury (Figure 3) required prompt cardiocirculatory revival and bridging with ECMO. Moreover, SCA treated with ECMO in our series was not associated with increased in-hospital mortality (OR 1.02, P=0.95), showing a satisfactory survival-to-discharge rate of 34%, comparable to previous studies of in-hospital SCA in which the reported values ranged from 19 to 60% [15,16,17]. ...
Article
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Introduction: The data regarding venoarterial extracorporeal membrane oxygenation (VA ECMO) as a temporary circulatory support in cardiogenic shock (CS) for Central Europe are scarce. Objectives: To disclose the indications, in-hospital and long-term (1 year) mortality along with risk factors. Patients and methods: The study is a retrospective investigation of patients who underwent VA ECMO for CS at a cardiosurgical tertiary center, from January 2013 to June 2018. A broad spectrum of pre- and postimplantation factors was tested using univariable analysis. Results: 198 patients met the inclusion criteria. The median duration of support was 207 (IQR;91-339) hours, with no significant disparity among hospital survivors and nonsurvivors (P=0.09). 40.4% deceased during ECMO support, while the joined in-hospital and six-month mortality progressed to 65.2%, and one-year mortality to 67.2%. 9% underwent a subsequent heart transplantation. Main adverse events were bleeding (76%), infection (56%), neurologic injury (15%) and limb ischemia (15%). Multiorgan failure was the most decisive risk factor of in-hospital mortality (OR 4.45, P<0.001). Patients with postcardiotomy CS had a significantly lower out-of-hospital survival rate than the nonsurgical group (32.3% vs 45%, log-rank P=0.037). Conclusion: The study showed survival benefit, despite frequent complications. The protocol focusing on proper candidate selection and timing can positively impact patient survival. Additional risk reduction can be achieved with a further increase of the team experience with ECMO.
... Although randomized controlled trials demonstrating the effectiveness of ECPR in in-hospital cardiac arrest (IHCA) are lacking, observational studies have reported 20% to 40% survival (3,4). However, there is large variation in this survival benefit, highlighting the importance of patient selection (5). ...
Article
Objectives The aim of this study was to develop and validate a score to accurately predict the probability of death for adult extracorporeal cardiopulmonary resuscitation (ECPR). Background ECPR is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20% to 40%. Methods Adult patients with extracorporeal membrane oxygenation for IHCA (ECPR) were identified from the American Heart Association GWTG-R (Get With the Guidelines–Resuscitation) registry. A multivariate survival prediction model and score were developed to predict hospital death. Findings were externally validated in a separate cohort of patients from the Extracorporeal Life Support Organization registry who underwent ECPR for IHCA. Results A total of 1,075 patients treated with ECPR were included. Twenty-eight percent survived to discharge in both the derivation and validation cohorts. A total of 6 variables were associated with in-hospital death: age, time of day, initial rhythm, history of renal insufficiency, patient type (cardiac vs noncardiac and medical vs surgical), and duration of the cardiac arrest event, which were combined into the RESCUE-IHCA (Resuscitation Using ECPR During IHCA) score. The model had good discrimination (area under the curve: 0.719; 95% confidence interval: 0.680-0.757) and acceptable calibration (Hosmer and Lemeshow goodness of fit P = 0.079). Discrimination was fair in the external validation cohort (area under the curve: 0.676; 95% confidence interval: 0.606-0.746) with good calibration (P = 0.66), demonstrating the model’s ability to predict in-hospital death across a wide range of probabilities. Conclusions The RESCUE-IHCA score can be used by clinicians in real time to predict in-hospital death among patients with IHCA who are treated with ECPR.
... 29 ECPR has been performed in an out-of-hospital setting and is gaining popularity after recent successes in resuscitating refractory cardiac arrest patients. [30][31][32] In an out-of-hospital setting, smaller cannulae may be easier and, therefore, faster to insert. Partial support (as simulated in this research) may be adequate to support the patient until they reach the hospital, at which time full ECMO support and additional interventions can be considered. ...
Article
Background: Venoarterial extracorporeal membrane oxygenation (ECMO) provides mechanical support for critically ill patients with cardiogenic shock. Typically, the size of the arterial return cannula is chosen to maximize flow. However, smaller arterial cannulae may reduce cannula-related complications and be easier to insert. This in vitro study quantified the hemodynamic effect of different arterial return cannula sizes in a simulated acute heart failure patient. Methods: Baseline support levels were simulated with a 17 Fr arterial cannula in an ECMO circuit attached to a cardiovascular simulator with targeted partial (2.0 L/min ECMO flow, 60-65 mmHg mean aortic pressure - MAP) and targeted full ECMO support (3.5 L/min ECMO flow and 70-75 mmHg MAP). Return cannula size was varied (13-21 Fr), and hemodynamics were recorded while keeping ECMO pump speed constant and adjusting pump speed to restore desired support levels. Results: Minimal differences in hemodynamics were found between cannula sizes in partial support mode. A maximum pump speed change of +600 rpm was required to reach the support target and arterial cannula inlet pressure varied from 79 (21 Fr) to 224 mmHg (13 Fr). The 15 Fr arterial cannula could provide the target full ECMO support at the targeted hemodynamics; however, the 13 Fr cannula could not due to the high resistance associated with the small diameter. Conclusions: A 15 Fr arterial return cannula provided targeted partial and full ECMO support to a simulated acute heart failure patient. Balancing reduced cannula size and ECMO support level may improve patient outcomes by reducing cannula-related adverse events.
... Data regarding this approach has been available in the literature for over a decade. Survival rates for out-of-hospital cardiac arrest with ECPR use have varied widely from 7 to 45% (135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)(147)(148)(149). The disparity in outcomes seen in observational data is likely attributable to the broad heterogeneity of the study protocols. ...
Article
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Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
... In our center, we administer at least 5000 IU of unfractionated heparin after initiation of extracorporeal circulation. In a retrospective analysis, Stub et al. found that 75% of patients undergoing eCPR experienced hemorrhagic complications [18]. In comparison, major bleeding was much less experienced in our series, even in the mCPR group. ...
Article
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Background Extracorporeal cardiopulmonary resuscitation (eCPR) is an established treatment option for cardiac arrest. Mechanical reanimation devices are increasingly used but have been associated with complications. This study evaluates typical injury patterns and differences after mechanical versus manual chest compressions among patients undergoing eCPR. Methods From 2016 to 2020, 108 eCPR patients were retrospectively analyzed. Primary endpoints were traumatic, hemorrhagic, or inner organ-related complications, defined as pneumothorax, pulmonary bleeding, major bleeding, gastrointestinal bleeding, gastrointestinal ischemia, cardiac tamponade, aortic dissection, sternal or rib fracture. Results 70 patients were treated with mechanical CPR (mCPR) and 38 with conventional CPR (cCPR). There were more CPR-related injuries in the mCPR group (55 % vs. 83 %, p = 0.01), CPR duration was longer (cCPR 40 ± 28 min vs. mCPR 69 ± 25 min, p = 0.01). There was no significant difference in mortality between the groups. Conclusion Mechanical CPR devices are associated with a higher incidence of traumatic and hemorrhagic injuries in patients undergoing eCPR.
... In a prehospital setting, it is generally difficult to precisely determine the specific moment at which an OHCA occurred. For patients with an unwitnessed OHCA, the NFT is all the more uncertain, and this factor currently often excludes these patients from being candidates to ECPR (12)(13)(14). However, it has been proposed that the initial rhythm may help identify patients with unwitnessed OHCA who are more likely to have a short NFT, based on the observation that shockable and organized rhythms tend to deteriorate over time (15)(16)(17)(18). ...
Article
Objectives: The no-flow time (NFT) can help establish prognosis in out-of-hospital cardiac arrest (OHCA) patients. It is often used as a selection criterion for extracorporeal resuscitation. In patients with an unwitnessed OHCA for whom the NFT is unknown, the initial rhythm has been proposed to identify those more likely to have had a short NFT. Our objective was to determine the predictive accuracy of an initial shockable rhythm for an NFT of 5 minutes or less (NFT ≤ 5). Design: Retrospective analysis of prospectively collected data. Setting: Prehospital OHCA in eight U.S. and three Canadian sites. Patients: A total of 28,139 adult patients with a witnessed nontraumatic OHCA were included, of whom 11,228 (39.9%) experienced an emergency medical service-witnessed OHCA (NFT = 0), 695 (2.7%) had a bystander-witnessed OHCA, and an NFT less than or equal to 5, and 16,216 (57.6%) with a bystander-witnessed OHCA and an NFT greater than 5. Interventions: Sensitivity, specificity, and likelihood ratios of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 minutes. Measurements and main results: The sensitivity of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 was poor (25% [95% CI, 25-26]), but specificity was moderate (70% [95% CI, 69-71]). The positive and likelihood ratios were inverted (negative accuracy) (positive likelihood ratio, 0.76 [95% CI, 0.74-0.79]; negative likelihood ratio, 1.12 [95% CI, 1.10-1.12]). Including only patients with a bystander-witnessed OHCA improved the sensitivity to 48% (95% CI, 45-52), the positive likelihood ratio to 1.45 (95% CI, 1.33-1.58), and the negative likelihood ratio to 0.77 (95% CI, 0.72-0.83), while slightly lowering the specificity to 67% (95% CI, 66-67). Conclusions: Our analysis demonstrated that the presence of a shockable rhythm at the time of initial assessment was poorly sensitive and only moderately specific for OHCA patients with a short NFT. The initial rhythm, therefore, should not be used as a surrogate for NFT in clinical decision-making.
... Cardiac arrest is frequent in severe hypothermia. Observational studies suggest that extracorporeal cardiopulmonary resuscitation can be associated with improved survival in very selected patients experiencing cardiac arrest even though randomized controlled trials are lacking [3,4]. Out-of-hospital cardiac arrests are always associated with less favorable outcomes [5]. ...
Article
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We report the cases of two patients experiencing persistent severe hypothermia. They were 45 and 30 years old and had a witnessed cardiac arrest managed with mechanized cardiopulmonary resuscitation (CPR) for 4 and 2.5 hours, respectively. Extracorporeal membrane oxygenation was used in both patients who fully recovered without any neurological sequelae. These two cases illustrate the important role of extracorporeal CPR (eCPR) in persistent severe hypothermia leading to cardiac arrest. 1. Introduction Hypothermia is defined as a core temperature below 35°C. Management of severe hypothermia associates rehydration and rewarming after having retrieved the patient from his cold environment [1]. Rehydration usually consists in perfusion of warmed (42°C) isotonic fluids. Combinations of rewarming also include forced warm air, warm infusions, forced peritoneal lavage, or hemofiltration [2]. More recently, venoarterial extracorporeal membrane oxygenation (ECMO) has been the method of choice for in-hospital rewarming in severe hypothermia. Cardiac arrest is frequent in severe hypothermia. Observational studies suggest that extracorporeal cardiopulmonary resuscitation can be associated with improved survival in very selected patients experiencing cardiac arrest even though randomized controlled trials are lacking [3, 4]. Out-of-hospital cardiac arrests are always associated with less favorable outcomes [5]. We would like to report two young patients with severe hypothermia and refractory long-lasting cardiac arrest treated by extracorporeal membrane oxygenation technique. 2. Cases Reports The first patient, a 45-year-old Caucasian male, was found unconscious in a park this winter. Emergency medical services started cardiopulmonary resuscitation (CPR) on arrival. First rhythm was ventricular fibrillation. The patient received 4 inefficient defibrillation attempts and received a total of 4 mg of epinephrine after asystole appeared. Core temperature was 22.7°C on a low-reading thermometer. Main medical history was chronic alcohol abuse. The patient was homeless. On hospital arrival, the patient was put under a Lund University Cardiac Arrest System (LUCAS®) while awaiting the ECMO team. Admission arterial gas analysis showed a severe mixed acidosis associated with hypoxia: pH 6.98, PaCO2 57, and PaO2 49. Laboratory testing showed anemia with Hb 9.8 g/dL (13-18), a thrombocytopenia at 65000/mm³ (150-440 000), and leucopenia with a total white cell count of 2470/mm³ (3.5-11). Coagulation disorders were also present. Admission ethanol was 2.4 g/L. No liver cytolysis or cholestasis was seen. The patient was transferred to the Intensive Care Unit. A venoarterial extracorporeal membrane oxygenation system was installed 110 minutes after hospital arrival (flow 1.8 L/min/m², FiO2 100% with femorofemoral approach including a 25 F venous catheter and a 19 F arterial catheter. The total time of CPR was 4.0 hours. Unfractionated heparin was given to keep anti-Xa between 0.5 and 0.7 IU/mL). At 33°C, a new defibrillation resulted in the appearance of a regular sinus rhythm. The patient was under mechanical ventilation as from admission on a volume control basis with a tidal volume of 420 mL, 20 times per minute with at first an FIO2 of 100% then after VA ECMO and return to sinus rhythm after correction of hypothermia; the FiO2 was decreased to 40% in order to maintain SpO2 at 95%. Pulmonary infection with H. influenzae led to antimicrobial therapy by amoxiclav for 5 days. Seeing the total cardiovascular recuperation, ECMO was weaned on day 4 by the surgical team. Thorough neurological examination was done on days 3, 5, and 6 with good results. The patient was extubated on day 6. He left the ICU on day 7 and the hospital on day 14 without any neurological sequelae. The second patient, a 30-year-old Caucasian male, was admitted this winter to our Emergency Department with severe hypothermia. Main medical history was also chronic alcohol abuse. The patient was again homeless. Clinical examination revealed profound hypotension (77/42 mmHg), bradycardia (50 bpm), and coma (Glasgow coma scale E2, V2, and M2). Core temperature was 25.3°C. The arterial blood gas analysis showed a severe acidosis with a pH of 6.95, a PaCO2 of 26 mmHg, and hyperoxia at 155. Lactic acidosis was present with a first value of 20 mmol/L (<2) as well as a severe anemia with Hb 3 g/dL (13-18). Concentrated red blood cells were administered to maintain Hb above 8.5 g/L. Passive and active warming were started with forced hot air and warmed normal saline perfusions. Cerebral CT excluded any important ischemic stroke or intracerebral hemorrhage. Injected multiple phase abdominal CT excluded internal bleeding. Persistent coma led to intubation and mechanical ventilation with volume control with a tidal volume of 400 mL, 20 times per minute with again at first an FiO2 of 100% then after VA ECMO and after correction of hypothermia and anemia; the FiO2 was decreased to 45% in order to maintain SpO2 at 95%. The total CPR was finally 2.5 hours. Upon Intensive Care Unit arrival, the patient developed a cardiac arrest with ventricular fibrillation. Three defibrillation attempts failed to restore ROSC. No epinephrine was administered. Mechanized CPR was started with a LUCAS® device, and the ECMO team was called. A venoarterial extracorporeal membrane oxygenation system was installed (flow 2 L/min/m², FiO2 100% with femorofemoral approach with a 25 F venous catheter and a 17 F arterial catheter). This permitted to achieve a full flow after 150 minutes. Unfractionated heparin was given with anti-Xa kept between 0.5 and 0.7 IU/mL. At 30°C, the defibrillation attempt was successful as in the first patient. The ECMO was weaned on day 3, and the patient was extubated the next morning. Pulmonary infection with oxacillin-sensitive Staphylococcus aureus was treated for 7 days with flucloxacillin. He was transferred to a normal ward on day 6 to assess the exact nature of the anemia. A full digestive endoscopy including the upper part by esophagogastroduodenoscopy and the lower part with a full colonoscopy did not show any active or sequelae of bleeding. He left our hospital on day 11 with full neurological recovery. Figure 1 shows the first 24 h trend of temperature in these two patients.
... Nevertheless, the abovementioned medical techniques are very rare due to medical complications and their limited availability. [16][17][18][19] Utstein guidelines have been implemented for easily comparing CPR data of different countries and medical centers. They enable a uniform method of SCA data presentation. ...
Article
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Background Sudden cardiac arrest (SCA) is one of the main reasons for admission to the intensive care unit (ICU), which influences discharge in a good neurological state. Hypothesis To analyze patients who had recovery of spontaneous circulation (ROSC) during hospitalization in the ICU using the Glasgow Outcome Scale (GOS). Methods The study group comprised 78 patients after SCA (35 after out-of-hospital cardiac arrest [OHCA] and 43 after in-hospital cardiac arrest [IHCA]) with ROSC who were admitted to the ICU of Regional Hospital No. 5 in Sosnowiec from January 1, 2016 to December 31, 2016. GOS was used to assess neurological status. Basic anthropological data, with, arterial blood pH, lactate concentration (LAC), and catecholamine treatment were also collected. Results In the study group, 32.1% (n = 25/78) of patients survived until ICU discharge and 30.8% (n = 24/78) until discharge from the hospital. SCA in cardiac mechanism was more common in OHCA than in the IHCA group (OHCA vs. IHCA: 85.7% vs. 62.8%, p = .02). There was no statistically significant difference between the two groups for neurological status assessed using GOS. There was no statistically significant difference between LAC or arterial blood pH and survival to ICU discharge, survival to hospital discharge, or mortality. The need for using catecholamines increased the mortality rate (GOS 1) (p < .001). Conclusions Most patients after RSOC were assigned to a group other than GOS 1, and 25% of all subjects belonged to GOS 4–5. Treatment with catecholamines was more common in patients who do not survive hospital or ICU discharge.
... 20 For example, patients with an unwitnessed OHCA are usually not considered for ECPR, as an uncertain NFT is association with worse prognosis. [21][22][23] The initial rhythm has been proposed as a tool to identify patients with unwitnessed OHCA that are more likely to have short NFT, but with contradictory results. 13,19 A better understanding of the dynamics of the inevitable degeneration of shockable rhythms with increasing NFT and BLFT would allow for better prognostication among patients with an unwitnessed OHCA. ...
Article
Aims For out-of-hospital cardiac arrest (OHCA) patients, the influence of the delay before the initiation of resuscitation, termed the no-flow time (NFT), and duration of bystander-only resuscitation low-flow time (BLFT) on the type of electrical rhythm observed has not been well described. The objective of this study is to determine the relationship between NFT, BLFT and the likelihood of a shockable rhythm over time. Methods Using a North American prospective registry (2005-2015; mostly urban settings), we selected adult (18 years and over) patients who experienced a witnessed OHCA from a suspected cardiac etiology. Patients with an emergency medical services witnessed OHCA were only included in sensitivity analyses. The association between the NFT, BLFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression adjusting for the registry version, age, sex, and public location. Results A total of 229,632 patients were logged in the registry, 50,957 of whom were included. Of these, 17,704 (34.7%) had an initial shockable rhythm. After the first minute, a significant decrease over time in the occurrence of shockable rhythm is observed but is slower when bystander cardiopulmonary resuscitation (CPR) is provided (each supplemental minute of BLFT: adjusted odds ratio=0.95, 95%CI=0.94-0.95; each supplemental minute of NFT: adjusted odds ratio=0.91, 95%CI=0.90-0.91]). Conclusions In this large observational study, we were able to demonstrate that longer NFT were associated with lower odds of shockable presenting rhythms. Bystander CPR significantly mitigates the degradation of shockable rhythms over time, strengthening the need to improve bystander CPR rates around the world.
... In particular, there have been no reports on the effects of early oxygenated blood perfusion in relieving post-resuscitation lung injury in experimental animals such as swine. [8][9][10] In this study, using a swine model of ventricular fibrillation-induced CA, we aim to evaluate whether early application of ECPR has advantages over CCPR in the lung injury and to explore the protective mechanism of ECPR on the post-resuscitation pulmonary injury. ...
Article
Background: Cardiac arrest (CA) is a critical condition that is a concern to healthcare workers. Comparative studies on extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) technologies have shown that ECPR is superior to CCPR. However, there is a lack of studies that compare the protective effects of these two resuscitative methods on organs. Therefore, we aim to perform experiments in swine models of ventricular fibrillation-induced CA to study whether the early application of ECPR has advantages over CCPR in the lung injury and to explore the protective mechanism of ECPR on the post-resuscitation pulmonary injury. Methods: Sixteen male swine were randomized to CCPR (CCPR; n=8; CCPR alone) and ECPR (ECPR; n=8; extracorporeal membrane oxygenation with CCPR) groups, with the restoration of spontaneous circulation at 6 hours as an endpoint. Results: For the two groups, the survival rates between the two groups were not statistically significant (P>0.05), the blood and lung biomarkers were statistically significant (P<0.05), and the extravascular lung water and pulmonary vascular permeability index were statistically significant (P<0.01). Compared with the ECPR group, electron microscopy revealed mostly vacuolated intracellular alveolar type II lamellar bodies and a fuzzy lamellar structure with widening and blurring of the blood-gas barrier in the CCPR group. Conclusions: ECPR may have pulmonary protective effects, possibly related to the regulation of alveolar surface-active proteins and mitigated oxidative stress response post-resuscitation.
... Previous studies on hypothermia during heart ischemia have demonstrated multiple benefits, [17][18][19][20][21]72] including reduced infarction size and improved outcomes. [73,74] Hypothermia in patients with pre-hospital cardiac arrest also improves outcomes. [75,76] A recent study has shown that pre-reperfusion ischemic hypothermia and intra-ischemia hypothermia translates to functional benefit in ischemic stroke using a pharmacological approach. ...
Article
Stroke kills or disables approximately 15 million people worldwide each year. It is the leading cause of brain injury, resulting in persistent neurological deficits and profound physical handicaps. In spite of over 100 clinical trials, stroke treatment modalities are limited in applicability and efficacy, and therefore, identification of new therapeutic modalities is required to combat this growing problem. Poststroke oxidative damage and lactic acidosis are widely-recognized forms of brain ischemia/reperfusion injury. However, treatments directed at these injury mechanisms have not been effective. In this review, we offer a novel approach combining these well-established damage mechanisms with new insights into brain glucose handling. Specifically, emerging evidence of brain gluconeogenesis provides a missing link for understanding oxidative injury and lactate toxicity after ischemia. Therefore, dysfunctional gluconeogenesis may substantially contribute to oxidative and lactate damage. We further review that hypothermia initiated early in ischemia and before reperfusion may ameliorate gluconeogenic dysfunction and subsequently provide an important mechanism of hypothermic protection. We will focus on the efficacy of pharmacologically assisted hypothermia and suggest a combination that minimizes side effects. Together, this study will advance our knowledge of basic mechanisms of ischemic damage and apply this knowledge to develop new therapeutic strategies that are desperately needed in the clinical treatment of stroke.
... Stable pulmonary status and euvolemia are particularly important (14). ECMO flow is decreased by approximately 1 L/h over a period of 3-4 h, although the slower rates of weaning at 0.5 L every 6-24 h have been reported (70,73). The patient should be able to maintain mixed venous saturation >65%, and arterial saturation of >90% with an ECMO flow <1.5 L/min (70). ...
Article
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Previous studies have shown that poisoning is a major threat to human health. Inhalation of acute toxic gas has been linked to serious health consequences. Among the antidotes for poisoning currently used, supportive care is the most common intervention in clinical practice. Severe acute respiratory distress syndrome (ARDS) and/or refractory cardiogenic shock or cardiac arrest caused by toxins are associated with high mortality and are difficult to treat. Extracorporeal membrane oxygenation (ECMO) is an aggressive supportive measure used to manage severely poisoned patients. This study presents two cases of acute toxic gases inhalation, severe ARDS and circulatory instability induced by bromine inhalation, and ARDS induced by nitric acid inhalation which were successfully treated with ECMO. The ECMO techniques used in the animal models and in human cases to treat severe poisoning are described as well as the indications, contraindications, complications, and weaning of ECMO.
... Second, the resuscitation guidelines in 2015 highlighted postcardiac arrest care with therapeutic temperature management, extracorporeal membrane oxygenation and percutaneous coronary intervention, which have been shown to improve neurological outcomes [16,37]. Our study did not analyze those confounders due to data unavailability. ...
Article
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Background Resuscitation guidance has advanced; however, the predictive performance of the termination of resuscitation (TOR) rule has not been validated for different resuscitation protocols published by the American Heart Association (AHA). Methods A retrospective study validating the basic life support (BLS) and advanced life support (ALS) TOR rules was conducted using an Utstein-style database in Tainan city, Taiwan. Adult patients with nontraumatic out-of-hospital cardiac arrests from January 1, 2015, to December 31, 2015, (using the AHA 2010 resuscitation protocol) and from January 1, 2020, to December 31, 2020, (using the AHA 2015 resuscitation protocol) were included. The characteristics of rule performance were calculated, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value. Results Among 1260 eligible OHCA patients in 2015, 757 met the BLS TOR rule and 124 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 61.1% and 99.0%, respectively, for the BLS TOR rule and 93.8% and 99.2%, respectively, for the ALS TOR rule. A total of 970 OHCA patients were enrolled in 2020, of whom 438 met the BLS TOR rule and 104 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 85.7% and 100%, respectively, for the BLS TOR rule and 99.5% and 100%, respectively, for the ALS TOR rule. Conclusions Both the BLS and ALS TOR rules performed better when using the 2015 AHA resuscitation protocols compared to the 2010 protocols, with increased PPVs and decreased false-positive rates in predicting survival to discharge and good neurological outcomes at discharge. The BLS and ALS TOR rules can perform differently while the resuscitation protocols are updated. As the concepts and practices of resuscitation progress, the BLS and ALS TOR rules should be evaluated and validated accordingly.
Article
IMPORTANCE:. It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes. OBJECTIVES:. To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival. DESIGN:. Observational cohort study using case-mix adjusted survival analysis. SETTING AND PARTICIPANTS:. Adult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019. MAIN OUTCOMES AND MEASURES:. Generalized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR. RESULTS:. Case-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44–64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08–1.55; p = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11– 1.61; p = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05–1.84; p = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04–1.45; p = 0.015) versus medium- and low-volume centers. CONCLUSIONS AND RELEVANCE:. Modifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesis-generating associations are causal in nature.
Article
Objectives Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival among patients with refractory out-of-hospital cardiac arrest (OHCA). We evaluated outcomes after incorporating ECPR into a conventional resuscitation system. Methods We introduced a prehospital-activated ECPR protocol for select refractory OHCAs into one of four metropolitan regions in British Columbia. We prospectively identified ECPR-eligible patients in both the ECPR region and the three other regions to serve as the control group. We compared the proportion with favorable neurological outcomes at hospital discharge (cerebral performance category ≤2) and used logistic regression to estimate the association with treatment region. Results The study was terminated prematurely due to changes in hospital protocols and COVID-19. In the ECPR region, 15/58 (25.9%) patients had favourable neurological outcomes owing to conventional resuscitation and 2/58 (3.4%) owing to ECPR, for a total of 17/58 (29.3%). In the control regions, 67/250 (26.8%) patients had a favourable outcome owing to conventional resuscitation, for a between-group difference of 2.5% (95% CI -10 to 15%). We did not detect a statistically significant association between treatment region and outcomes. Conclusion In this prematurely-terminated study of ECPR for refractory OHCA, we did not detect an association between a regional ECPR protocol and neurologically favorable outcomes. However, our data suggests that outcomes owing to conventional resuscitation were similar, with the potential for additional survivors due to ECPR therapies.
Article
The susceptibility of the brain to ischaemic injury dramatically limits its viability following interruptions in blood flow. However, data from studies of dissociated cells, tissue specimens, isolated organs and whole bodies have brought into question the temporal limits within which the brain is capable of tolerating prolonged circulatory arrest. This Review assesses cell type-specific mechanisms of global cerebral ischaemia, and examines the circumstances in which the brain exhibits heightened resilience to injury. We suggest strategies for expanding such discoveries to fuel translational research into novel cytoprotective therapies, and describe emerging technologies and experimental concepts. By doing so, we propose a new multimodal framework to investigate brain resuscitation following extended periods of circulatory arrest.
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Background The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center. Methods This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent ECMO after cardiac surgery. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n=53, 88.3%), venous-venous (VV) (n=5, 8.3%) or venous-arterial-venous (VAV) (n=2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. Results In-hospital mortality was 60.7% (n=37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p < 0.001) with longer hospital stays (35 ± 4.0 vs 20 ± 1.5, p < 0.03). Survivors required fewer blood products (13 ± 2.3 vs 25 ± 2.3, p = 0.02) with a net negative fluid balance (-3.5 ± 1.6 vs 3.4 ± 1.6, p = 0.01). Cardiac re-operations worsened survival. Conclusion ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.
Article
Background: The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to 1) describe OHCA ED outcomes and reasons for ED deaths, and 2) whether these differed between hospitals. Methods: Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC). Results: Of 1,547 eligible OHCA cases, 81% (N=1,254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n=65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n=952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR=3.43, 95% CI 1.89-6.21). Conclusion: Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality.
Article
Evaluate the utility of whole-body computed tomography (WBCT) imaging in detecting clinically significant findings in patients who have undergone extracorporeal membrane oxygenation (ECMO) cannulation for cardiac arrest (extracorporeal cardiopulmonary resuscitation or "eCPR"). Single-center retrospective review of 52 consecutive patients from 2017 to 2019 who underwent eCPR and received concomitant WBCT imaging. WBCT images were reviewed for clinically significant findings (compression-related injuries, cannulation-related complications, etiology of cardiac arrest, incidental findings, and evidence of hypoxic brain injury) as well as the frequency of interventions performed as a direct result of such findings. Thirty-eight patients met inclusion criteria for analysis. Clinically significant WBCT findings were present in 37/38 (97%) of patients with 3.3 ± 1.7 findings per patient. An intervention as a direct result of WBCT findings was performed in 54% (20/37) of patients with such findings. Evidence of hypoxic brain injury on WBCT was associated with clinical brain death as compared with those without such findings (10/15 [67%] vs 1/22 [4%], P < 0.001), respectively. WBCT scan after eCPR frequently detects clinically significant findings which commonly prompt an intervention directly affecting the patient's clinical course. We advocate for protocolized use of WBCT imaging in all eCPR patients.
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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.
Chapter
Out‐of‐hospital cardiac arrest is a leading cause of death globally. In the United States, nearly nine of ten patients suffering out‐of‐hospital cardiac arrest will die. Only one third will receive bystander CPR. Improving survival requires a comprehensive community systems approach. No one component, including emergency medical services, can improve survival by itself. EMS agencies and medical directors must work to strengthen the chain of survival in their communities by promoting and implementing a coordinated plan.
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Background Extracorporeal cardiopulmonary resuscitation (E-CPR) is used for the treatment of refractory cardiac arrest. However, the optimal target to reach for mean arterial pressure (MAP) remains to be determined. We hypothesized that MAP levels critically modify cerebral hemodynamics during E-CPR and tested two distinct targets (65–75 vs 80–90 mmHg) in a porcine model. Methods Pigs were submitted to 15 min of untreated ventricular fibrillation followed by 30 min of E-CPR. Defibrillations were then delivered until return of spontaneous circulation (ROSC). Extracorporeal circulation was initially set to an average flow of 40 ml/kg/min. The dose of epinephrine was set to reach a standard or a high MAP target level (65–75 vs 80–90 mmHg, respectively). Animals were followed during 120-min after ROSC. Results Six animals were included in both groups. During E-CPR, high MAP improved carotid blood flow as compared to standard MAP. After ROSC, this was conversely decreased in high versus standard MAP, while intra-cranial pressure was superior. The pressure reactivity index (PRx), which is the correlation coefficient between arterial blood pressure and intracranial pressure, also demonstrated inverted patterns of alteration according to MAP levels during E-CPR and after ROSC. In standard-MAP, PRx was transiently positive during E-CPR before returning to negative values after ROSC, demonstrating a reversible alteration of cerebral autoregulation during E-CPR. In high-MAP, PRx was negative during E-CPR but became sustainably positive after ROSC, demonstrating a prolonged alteration in cerebral autoregulation after ROSC. It was associated with a significant decrease in cerebral oxygen consumption in high- versus standard-MAP after ROSC. Conclusions During early E-CPR, MAP target above 80 mmHg is associated with higher carotid blood flow and improved cerebral autoregulation. This pattern is inverted after ROSC with a better hemodynamic status with standard versus high-MAP.
Chapter
Selective aortic arch perfusion (SAAP) is an endovascular extracorporeal perfusion technique specifically designed for cardiac arrest resuscitation. SAAP is applicable to both medical and traumatic cardiac arrest. SAAP involves the insertion of a large-lumen balloon occlusion catheter into the thoracic aorta via a femoral artery. With the balloon inflated, the aortic arch vessels, including the coronary, carotid, and vertebral arteries, have been relatively isolated for perfusion with an oxygen-carrying perfusate infused through the central large-lumen of the catheter. The primary objective of SAAP resuscitation is to provide temporary heart and brain perfusion support until return of spontaneous circulation (ROSC), defined as recovery of intrinsic cardiac contractility with a viable arterial blood pressure, while protecting the ischemic brain. A series of SAAP modalities, including the use of an exogenous oxygen carrier followed by autologous blood, allows for extracorporeal perfusion support until ROSC and, if needed, bridging perfusion support until cannulation for sustained venoarterial extracorporeal life support (VA-ECLS) to the entire body. SAAP has been studied in laboratory models of both hemorrhage-induced traumatic cardiac arrest (HiTCA) and ventricular fibrillation (VF) medical cardiac arrest with highly favorable results. In HiTCA, SAAP provides for rapid replacement of lost intravascular volume and arterial hemorrhage control caudal to the inflated thoracic aortic balloon, in addition to promoting ROSC. SAAP is an aortic balloon–catheter extracorporeal perfusion therapy that fits in the endovascular resuscitation spectrum between basic CPR/advanced cardiac life support and REBOA on one side and sustained VA-ECLS and resuscitative thoracotomy on the other.
Article
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
Article
Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA. Methods: We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale. Results: Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26). Conclusion: We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.
Article
Despite potential clinical roles of extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) compared to that of conventional cardiopulmonary resuscitation (CCPR), use of ECLS for OHCA is not strongly endorsed by current clinical guidelines. The purpose of this study is to investigate the clinical roles of extracorporeal life support (ECLS) compared with that of conventional cardiopulmonary resuscitation (CCPR) for out-of-hospital cardiac arrest (OHCA) patients. The outcomes of OHCA between 2015 and 2020, enrolled in the Korean Cardiac Arrest Research Consortium (KoCARC), a multicenter OHCA patient registry including 65 participating hospitals throughout the Republic of Korea (ClinicalTrials.gov, number NCT03222999). Differences in clinical features were adjusted by matching the propensity for ECLS. The primary outcome was 30-day neurologically favorable survival with cerebral performance category of 1 or 2. Restricted mean survival time (RMST) was used to compare outcomes between groups. Of 12,006 patients included, ECLS was applied to 272 patients (2.2%). The frequency of neurologically favorable survival was higher in the ECLS group than the CCPR group (RMST difference, 5.5 days [95% CI, 4.1–7.0 days], P < 0.001). In propensity score-matched 271 pairs, the clinical outcome of ECLS and CCPR did not differ to a statistically significant extent (RMST difference, 0.4 days [95% CI –1.6 to 2.5 days], P = 0.67). Subgroup analyses revealed that the clinical roles of ECLS was evident in patients with nonshockable rhythm or CPR time ≥20 min (RMST difference, 2.7 days [95% CI 0.5–4.8 days], P = 0.015), but not in patients without these features (RMST difference, –3.7 days [95% CI –7.6 to 0.2 days], P = 0.07). In this real-world data analysis, ECLS compared to CCPR did not result in better overall clinical outcomes of OHCA. The clinical efficacy of ECLS may be limited to a subgroup of high-risk patients.
Article
Objective The primary purpose of this study was to compare the percentage of return of spontaneous circulation of in-flight cardiac arrest (IFCA) patients on admission to the emergency department (ED) who received in-flight standard cardiopulmonary resuscitation (s-CPR) versus automated cardiopulmonary resuscitation (a-CPR). Setting EMS helicopter (HEMS) service in Midwest USA. Methods This was a prospective, consecutive case series of adult patients who had IFCA of any cause managed with a-CPR between October 1, 2012, and February 8, 2016 (40 months), at a helicopter emergency medical service (HEMS) in the Midwestern United States. The series was compared with a historical control of patients who had IFCA managed by s-CPR between June 1, 2009, and September 30, 2012 (40 months). Results Ninety-five runs (39 s-CPR and 54 a-CPR) were included. There was no significant difference in survival between the 2 groups upon HEMS leaving the ED. Cardiopulmonary resuscitation was performed for a significantly longer period of time in the a-CPR cohort than in the s-CPR cohort, and a significantly higher percentage of patients were undergoing active compressions upon loading into the aircraft in the a-CPR cohort. Conclusion There was no difference in return of spontaneous circulation on ED admission between the 2 compression methodologies. In-flight use of a-CPR allows HEMS providers to be safe and compliant with Federal Aviation Administration regulations. It also meets the public and medical profession's expectations of the treatment of IFCA with high-quality cardiopulmonary resuscitation by HEMS.
Article
Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used in patients with out-of-hospital or in-hospital cardiac arrest in whom conventional cardiopulmonary resuscitation remains unsuccessful. The aim of this study was to analyze the impact of initial cardiac rhythm - detected on-site of the cardiac arrest - on mortality. Methods: We performed a retrospective cohort study of patients who received ECPR in our tertiary care cardiac arrest center. Patients were divided into three groups depending on their cardiac rhythm: shockable rhythm, pulseless electrical activity, and asystole. The primary endpoint was mortality within the first 7 days after ECPR deployment. Secondary endpoints were mortality within 28 days and impact of pre-ECPR potassium, serum lactate, pH and pCO2 on mortality. The association of the initial cardiac rhythm and the location of arrhythmia detection (patient monitored in hospital [category: monitored], not monitored but hospitalized [in-hospital], not monitored, not hospitalized [out-of hospital]) with the primary and secondary outcome was examined by means of univariable and multivariable logistic regression. Results: Sixty-five patients could be included in the final analysis. Thirty-two patients (49.2%, 95%CI 36.6% - 61.9%) died within the first 7 days. In terms of 7-day-mortality patients differed in the initial cardiac rhythm (p=0.040) and with respect of the location of arrhythmia detection (p=0.002). Shockable cardiac rhythm (crude OR 0.21; 95%CI 0.03 - 0.98) and pulseless electrical activity (0.13; 0.02 - 0.61) as the initial rhythm on-site showed better odds for survival compared to asystole. However, this association did neither persist in adjusted analysis nor in pairwise comparison. Discussion: The study could not demonstrate a better outcome with shockable rhythm after ECPR. More homogeneous and adequately powered cohorts are needed to better understand the impact of cardiac rhythm on patient outcome after ECPR.
Article
Objectives This study aimed to examine coronary angiography (CAG) findings, percutaneous coronary intervention (PCI) results and outcomes in out-of-hospital cardiac arrest patients (OHCA) without return of spontaneous circulation (ROSC) on admission to hospital. Methods We analyzed the OHCA register and compared CAG, PCI, and outcome data in patients with and without ROSC on admission to hospital. Results Between January 2012 and December 2020, 697 OHCA patients were analyzed. Of these, 163 (23%) did not have ROSC at admission. Patients without ROSC were younger (59 vs. 61 years, p=0.001) and had a longer resuscitation time (62 vs. 18 minutes, p<0.001) than patients with ROSC. Significant coronary artery disease was highly prevalent in both groups (65% vs. 68%, p=0.48). Patients without ROSC had higher rates of acute coronary occlusions (42% vs. 33%, p=0.046), specifically affecting the left main stem (16% vs. 1%, p<0.001). PCI was performed in 81 patients (50%) without ROSC and in 295 (55%) with ROSC (p=0.21). The success rate was 86% in patients without ROSC and 90% in patients with ROSC (p=0.33). Thirty-day survival was 24% in patients without ROSC and 70% in patients with ROSC. Conclusions OHCA patients without ROSC on admission to hospital had higher acute coronary occlusion rates than patients with prehospital ROSC. PCI is feasible with a high success rate in patients without ROSC. Despite prolonged resuscitation times, meaningful survival in patients admitted without ROSC is achievable.
Article
Background: Surgical neck cannulation for pediatric extracorporeal cardiopulmonary resuscitation (ECPR) requires multiple interruptions of manual chest compressions to facilitate the procedure. Effective uninterrupted CPR is essential to prevent neurological injury. We hypothesized that an automated chest compression device can be used to provide effective and uninterrupted chest compressions during pediatric neck ECPR cannulation. The feasibility of surgically cannulating the right carotid artery and right internal jugular vein in an infant during ongoing automated chest compressions was tested in a simulation study. Methods: A working prototype of a pediatric chest compression device was designed to provide automated chest compressions on an infant CPR manikin at the rate of 120 compressions/minute. A feedback device attached to the manikin was used to monitor the effectiveness of CPR. A synthetic artery, vein along with carotid sheath and skin was utilized to simulate surgical neck exploration. ECPR simulation was conducted using the compression device to provide chest compressions. Results: Four ECPR simulations were conducted during which vessel sparing (n = 2) and non-vessel sparing (n = 2) cannulation of the right internal carotid artery and right internal jugular vein were performed during ongoing mechanical chest compressions. All four cannulations were successfully performed without the need to interrupt chest compressions. Conclusions: In a simulated environment, pediatric ECPR neck cannulation with uninterrupted chest compressions may be accomplished using an automated chest compression device. The strategy of compression device-assisted ECPR cannulation requires further study and could potentially reduce the neurological complications of ECPR.
Article
Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.
Article
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.
Article
The duration of low flow prior to initiation of extracorporeal cardiopulmonary resuscitation (eCPR) appears to influence survival. Strategies to reduce the low-flow interval for out-of-hospital cardiac arrest have been focused on expediting patient transport to the hospital or initiating extracorporeal support in the prehospital setting. To date, a direct comparison of low-flow interval between these strategies has not been made. To attempt this comparison, a model was created to predict low-flow intervals for each strategy at different locations across the city of Albuquerque, New Mexico. The data, specific to Albuquerque, suggest that a prehospital cannulation strategy consistently outperforms an expedited transport strategy, with an estimated difference in low-flow interval of 34.3 to 37.2 minutes, depending on location. There is no location within the city in which an expedited transport strategy results in a shorter low-flow interval than prehospital cannulation. It would be rare to successfully initiate eCPR by either strategy in fewer than 30 minutes from the time of patient collapse. Using a prehospital cannulation strategy, the entire coverage area could be eligible for eCPR within 60 minutes of patient collapse. The use of predictive modeling can be a low-cost solution to assist with strategic deployment of prehospital resources and may have potential for real-time decision support for prehospital clinicians.
Article
Objective: Studies evaluating the prognostic value of the pulseless electrical activity (PEA) heart rate in out-of-hospital cardiac arrest (OHCA) patients have reported conflicting results. The objective of this study was to evaluate the association between the initial PEA heart rate and favorable clinical outcomes for OHCA patients. Methods: The present post-hoc cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry Version 3, which included OHCA patients in seven US and three Canadian sites from April 2011 to June 2015. The primary outcome was survival to hospital discharge and the secondary outcome was survival with a good functional outcome. For the primary analysis, the patients were separated into eight groups according to their first rhythms and PEA heart rates: (1) initial PEA heart rate of 1-20 beats per minute (bpm); (2) 21-40 bpm; (3) 41-60 bpm; (4) 61-80 bpm; (5) 81-100 bpm; (6) 101-120 bpm; (7) over 120 bpm; (8) initial shockable rhythm (reference category). Multivariable logistic regression models were used to assess the associations of interest. Results: We identified 17,675 patients (PEA: 7,089 [40.1%]; initial shockable rhythm: 10,797 [59.9%]). Patients with initial PEA electrical frequencies ≤100 bpm were less likely to survive to hospital discharge than patients with initial shockable rhythms (1-20 bpm: adjusted odds ratio [AOR] = 0.15 [95%CI 0.11-0.21]; 21-40 bpm: AOR =0.21 [0.18-0.25]; 41-60 bpm: AOR =0.30 [0.25-0.36]; 61-80 bpm: AOR =0.37 [0.28-0.49]; 81-100 bpm: AOR =0.55 [0.41-0.65]). However, there were no statistical outcome differences between PEA patients with initial electrical frequencies of >100 bpm and patients with initial shockable rhythms (101-120 bpm: AOR =0.65 [95%CI 0.42-1.01]; >120 bpm: AOR =0.72 [95%CI 0.37-1.39]). Similar results were observed for survival with good functional outcomes (101-120 bpm: AOR =0.60 [95%CI 0.31-1.15]; >120 bpm: AOR =1.08 [95%CI 0.50-2.28]). Conclusions: We observed a good association between higher initial PEA electrical frequency and favorable clinical outcomes for OHCA patients. As there is no significant difference in outcomes between patients with initial PEA heart rates of more than 100 bpm and those with initial shockable rhythms, we can hypothesize that these patients could be considered in the same prognostic category.
Article
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Objective To assess the feasibility of delivering extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out-of-hospital cardiac arrests (OHCA) by low volume extracorporeal membrane oxygenation (ECMO) centers and to explore pre-ECPR predictors of survival. Methods Between 2016 and 2020, we studied 21 ECPR patients admitted in 2 tertiary ECMO centers in Liège, Belgium. Our ECPR protocol was based on 6 prehospital criteria (no flow < 3 minutes, low flow < 60 minutes, initial shockable rhythm, end-tidal CO2 > 15 mmHg, age < 65 years, and absence of comorbidities). A dedicated training, prehospital checklist and call number for 24/7 ECMO team assistance were implemented. Hemodynamics and blood gases on admission also were assessed. Results Twenty-one (28%) out of 75 refractory OHCA patients referred were treated by ECPR, with a hospital survival rate of 43% (n = 9/21), comparable to ECPR results from the international extracorporeal life support organization registry. Transient return of spontaneous circulation before ECPR (89% in survivors vs 17% in non-survivors, P = 0.002) and higher initial serum bicarbonate (med [P25-P75] 14.0 [10.6–15.2] vs 7.5 [3.7–10.5] mmol/L, P = 0.019) or lower initial base deficit (14.9 [11.9–18.2] vs 21.6 [17.9–28.9] mmol/L, P = 0.039) were associated with a more favorable outcome. Conclusion In low volume ECMO centers, the implementation of a specific ECPR protocol for refractory OHCA patients is feasible and provides potential clinical benefit. Highly selective inclusion criteria seem essential to select candidates for ECPR. Initial serum bicarbonate and base deficit integrating cumulative cell failure may be relevant pre-ECMO prognostic factors and require larger-scale evaluation.
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Background: Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. Our objective was to compare two target temperatures, both intended to prevent fever. Methods: In an international trial, we randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale. Results: In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar. Conclusions: In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C. (Funded by the Swedish Heart-Lung Foundation and others; TTM ClinicalTrials.gov number, NCT01020916.).
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Introduction Mortality of patients on extracorporeal membrane oxygenation (ECMO) remains high. The objectives of this study were to assess the factors associated with outcome of patients undergoing ECMO in a large ECMO referral centre and to compare veno-arterial ECMO (VA ECMO) with veno-venous ECMO (VV ECMO). Methods We reviewed a prospectively obtained ECMO database and patients' medical records between January 2005 and June 2011. Demographic characteristics, illness severity at admission, ECMO indication, organ failure scores before ECMO and the ECMO mode and configuration were recorded. Bleeding, neurological, vascular and infectious complications that occurred on ECMO were also collected. Demographic, illness, ECMO support descriptors and complications associated with hospital mortality were analysed. Results ECMO was initiated 158 times in 151 patients. VA ECMO (66.5%) was twice as common as VV ECMO (33.5%) with a median duration significantly shorter than for VV ECMO (7 days (first and third quartiles: 5; 10 days) versus 10 days (first and third quartiles: 6; 16 days)). The most frequent complications during ECMO support were bleeding and bloodstream infections regardless of ECMO type. More than 70% of the ECMO episodes were successfully weaned in each ECMO group. The overall mortality was 37.3% (37.1% for the patients who underwent VA ECMO, and 37.7% for the patients who underwent VV ECMO). Haemorrhagic events, assessed by the total of red blood cell units received during ECMO, were associated with hospital mortality for both ECMO types. Conclusions Among neurologic, vascular, infectious and bleeding events that occurred on ECMO, bleeding was the most frequent and had a significant impact on mortality. Further studies are needed to better investigate bleeding and coagulopathy in these patients. Interventions that reduce these complications may improve outcome.
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The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO). To describe the characteristics of all patients with 2009 influenza A(H1N1)-associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes. An observational study of all patients (n = 68) with 2009 influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009. Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival. Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) Pao(2)/fraction of inspired oxygen (Fio(2)) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H(2)O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO. During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)-associated respiratory failure, one-third of whom received ECMO. These ECMO-treated patients were often young adults with severe hypoxemia and had a 21% mortality rate at the end of the study period.
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Background: Out of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care. Methods: This paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines. Primary outcome: 6 months survival with good neurological outcome (Cerebral Performance Category 1-2). Secondary outcomes will include 30 day neurological and cardiac recovery. Discussion: Authors introduce and offer a protocol of a proposed randomized study comparing a combined "hyperinvasive approach" to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future. ETHICS AND REGISTRATION: The protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under ClinicalTrials.gov identifier: NCT01511666.
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The aim of this paper was to conduct a systematic review of the published literature to address the question: "In pre-hospital adult cardiac arrest (asystole, pulseless electrical activity, pulseless Ventricular Tachycardia and Ventricular Fibrillation), does the use of mechanical Cardio-Pulmonary Resuscitation (CPR) devices compared to manual CPR during Out-of-Hospital Cardiac Arrest and ambulance transport, improve outcomes (e.g. Quality of CPR, Return Of Spontaneous Circulation, Survival)". Databases including PubMed, Cochrane Library (including Cochrane database for systematic reviews and Cochrane Central Register of Controlled Trials), Embase, and AHA EndNote Master Library were systematically searched. Further references were gathered from cross-references from articles and reviews as well as forward search using SCOPUS and Google scholar. The inclusion criteria for this review included manikin and human studies of adult cardiac arrest and anti-arrhythmic agents, peer-review. Excluded were review articles, case series and case reports. Out of 88 articles identified, only 10 studies met the inclusion criteria for further review. Of these 10 articles, 1 was Level of Evidence (LOE) 1, 4 LOE 2, 3 LOE 3, 0 LOE 4, 2 LOE 5. 4 studies evaluated the quality of CPR in terms of compression adequacy while the remaining six studies evaluated on clinical outcomes in terms of return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge and Cerebral Performance Categories (CPC). 7 studies were supporting the clinical question, 1 neutral and 2 opposing. In this review, we found insufficient evidence to support or refute the use of mechanical CPR devices in settings of out-of-hospital cardiac arrest and during ambulance transport. While there is some low quality evidence suggesting that mechanical CPR can improve consistency and reduce interruptions in chest compressions, there is no evidence that mechanical CPR devices improve survival, to the contrary they may worsen neurological outcome.
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Extracorporeal life support (ECLS) has recently shown encouraging results in the resuscitation of in-hospital (IH) refractory cardiac arrest. We assessed the use of ECLS following out-of-hospital (OH) refractory cardiac arrest. We evaluated 51 consecutive patients who experienced witnessed OH refractory cardiac arrest and received automated chest compression and ECLS upon arrival in the hospital. Patients with preexisting severe hypothermia who experienced IH cardiac arrest were excluded. A femorofemoral ECLS was set up on admission to the hospital by a mobile cardiothoracic surgical team. Fifty-one patients were included (mean age, 42 ± 15 years). The median delays from cardiac arrest to cardiopulmonary resuscitation and ECLS were, respectively, 3 minutes (25th to 75th interquartile range, 1 to 7) and 120 minutes (25th to 75th interquartile range, 102-149). Initial rhythm was ventricular fibrillation in 32 patients (63%), asystole in 15 patients (29%) patients and pulseless rhythm in 4 patients (8%). ECLS failed in 9 patients (18%). Only two patients (4%) (95% confidence interval, 1% to 13%) were alive at day 28 with a favourable neurological outcome. There was a significant correlation (r = 0.36, P = 0.01) between blood lactate and delay between cardiac arrest and onset of ECLS, but not with arterial pH or blood potassium level. Deaths were the consequence of multiorgan failure (n = 43; 47%), brain death (n = 10; 20%) and refractory hemorrhagic shock (n = 7; 14%), and most patients (n = 46; 90%) died within 48 hours. This poor outcome suggests that the use of ECLS should be more restricted following OH refractory cardiac arrest.
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Currently emergency medical services (EMS) that provide advanced cardiac life support (ACLS) at scene do not routinely transport out-of-hospital cardiac arrest (OHCA) patients without sustained return of spontaneous circulation (ROSC). This is due to logistical difficulties and historical poor outcomes. However, new technology for mechanical chest compression, has made transport to hospital safer and extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) enabling further intervention, may result in ROSC. We aimed to explore the characteristics and outcomes of patients with OHCA who were transported to hospital with ongoing CPR in the absence of ROSC, who might benefit from this new technology. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult OHCA with an initial shockable rhythm between 2003 and 2012. There were 5593 OHCA meeting inclusion criteria. Analysis was performed on 3095 (55%) of patients who did not achieve sustained ROSC in the field. Of these only 589 (20%) had ongoing CPR to hospital. There was a significant decline in rates of transport over the study period. Predictors of transport with ongoing CPR included younger patients, decreased time to first shock and intermittent ROSC prior to transport. Survival to hospital discharge occurred in 52 (9%) of patients who had ongoing CPR to hospital. In an EMS that provides ACLS at scene, patients without ROSC in the field who receive CPR to hospital have poor outcomes. Developing a system which provides safe transport with ongoing CPR to a hospital that provides ECPR, should be considered.
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We describe a one-year experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) associated with intra-arrest hypothermia and normoxemia. Since January 1(st) 2012, ECPR has been applied in our hospital to all patients less than 65 years of age and without major co-morbidities who develop refractory cardiac arrest (CA) with bystander CPR. Over a one-year period of observation, we recorded 28-day survival with intact neurological outcome and the rate of organ donation. During the observational period, 24 patients were treated with ECPR, with a median age of 48 years. Ten patients had IHCA. Acute coronary syndrome and/or major arrhythmias were the main cause of arrest. Intra-arrest cooling was used in 17 patients; temperature on ECMO initiation in these patients was 32.9 (32-34( °C. The time from collapse to ECPR was 58min (45-70( and was shorter in survivors than in non-survivors (41min (39-58( vs. 60min (55-77(, p=0.059). Non-survivors were more likely to have coagulopathy and received more blood transfusions. Six patients (25%) survived with good neurological outcome at day 28. Four patients with irreversible brain damage had organ function suitable for donation. ECPR provided satisfactory survival rates with good neurologic recovery in refractory CA for both IHCA and OHCA. ECMO may help rapidly stabilize systemic haemodynamic status and restore organ function.
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Objective: Although measures of functional status are often advocated when assessing short-term survival following cardiac arrest, little is known about how these measures predict long-term prognosis. We sought to determine whether the Cerebral Performance Category (CPC) was associated with long-term outcome following resuscitation from out-of-hospital cardiac arrest. Design: The study was a retrospective cohort investigation of adults who suffered out-of-hospital cardiac arrest in the study community between January 1, 2001 and December 31, 2009, and were successfully resuscitated and discharged alive from the hospital following the event. The CPC at the time of hospital discharge was ascertained through review of the hospital record. The primary outcome was survival following hospital discharge. Survival status was determined using state and national death indexes. We used Kaplan-Meier curves and Cox regression to evaluate the association between CPC and survival. Main results: Among the 980 eligible subjects, 606 of 980 (62%) had a CPC of 1; 227 of 980 (23%) had a CPC of 2; 97 of 980 (10%) had a CPC of 3; and 50 of 980 (5%) had a CPC of 4. There were 336 deaths during 3,713 person-years of follow-up. Overall, 1-year survival was 82% and 5-year survival was 64%. Favorable CPC predicted better long-term prognosis. Compared with CPC 1, the relative risk of survival was 0.61 (0.47-0.80) for CPC 2, 0.43 (0.31-0.59) for CPC 3, and 0.10 (0.06-0.15) for CPC 4. Conclusions: The CPC at hospital discharge is a useful surrogate measure of long-term survival and can be an informative tool for programmatic evaluation and research of resuscitation.
Article
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a critical resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best available national data on heart disease, stroke, and other cardiovascular disease-related morbidity and mortality and the risks, quality of care, use of medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited >10 500 times in the literature, based on citations of all annual versions. In 2012 alone, the various Statistical Updates were cited ≈3500 times (data from Google Scholar). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas, as well as increasing the number of ways to access and use the information assembled. For this year's edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year. This year's edition includes a new chapter on peripheral artery disease, as well as new data on the monitoring and benefits of cardiovascular health in the population, with additional new focus on evidence-based approaches to changing behaviors, implementation strategies, and implications of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Update.
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Background: During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. Methods: Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. Findings: 31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021). Interpretation: Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. Funding: American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.
Article
Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients. We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012. The mean CPR duration was 40min (20-70min). The mean ECLS support duration was 49h (12-92h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20-50min) vs. (50: 25-86min); p=0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p=0.003), and the mean pH value was higher in the survivors' group (p<0.0001) compared to the non-survivors' group. The CPR duration for the IHCA group (25: 20-50min) was shorter compared to the OHCA group (70: 55-110min; p<0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p<0.02). CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.
Article
Extracorporeal cardiopulmonary resuscitation (ECPR) refers to emergent percutaneous veno-arterial cardiopulmonary bypass to stabilize and provide temporary support of patients who suffer cardiopulmonary arrest. Initiation of ECPR by emergency physicians with meaningful long-term patient survival has not been demonstrated. To determine whether emergency physicians could successfully incorporate ECPR into the resuscitation of patients who present to the emergency department (ED) with cardiopulmonary collapse refractory to traditional resuscitative efforts. A three-stage algorithm was developed for ED ECPR in patients meeting inclusion/exclusion criteria. We report a case series describing our experience with this algorithm over a 1-year period. 42 patients presented to our ED with cardiopulmonary collapse over the 1-year study period. Of these, 18 patients met inclusion/exclusion criteria for the algorithm. 8 patients were admitted to the hospital after successful ED ECPR and 5 of those patients survived to hospital discharge neurologically intact. 10 patients were not started on bypass support because either their clinical conditions improved or resuscitative efforts were terminated. Emergency physicians can successfully incorporate ED ECPR in the resuscitation of patients who suffer acute cardiopulmonary collapse. More studies are necessary to determine the true efficacy of this therapy.
Article
Survival rates after out-of-hospital cardiac arrest (OHCA) continue to be poor. Recent evidence suggests that a more aggressive approach to postresuscitation care, in particular combining therapeutic hypothermia with early coronary intervention, can improve prognosis. We performed a single-center review of 125 patients who were resuscitated from OHCA in 2 distinct treatment periods, from 2002 to 2003 (control group) and from 2007 to 2009 (contemporary group). Patients in the contemporary group had a higher prevalence of cardiovascular risk factors but similar cardiac arrest duration and prehospital treatment (adrenaline administration and direct cardioversion). Rates of cardiogenic shock (48% vs 41%, p = 0.2) and decreased conscious state on arrival (77% vs 86%, p = 0.2) were similar in the 2 cohorts, as was the incidence of ST-elevation myocardial infarction (33% vs 43%, p = 0.1). The contemporary cohort was more likely to receive therapeutic hypothermia (75% vs 0%, p <0.01), coronary angiography (77% vs 45%, p <0.01), and percutaneous coronary intervention (38% vs 23%, p = 0.03). This contemporary therapeutic strategy was associated with better survival to discharge (64% vs 39%, p <0.01) and improved neurologic recovery (57% vs 29%, p <0.01) and was the only independent predictor of survival (odds ratio 5.5, 95% confidence interval 1.2 to 26.2, p = 0.03). Longer resuscitation time, presence of cardiogenic shock, and decreased conscious state were independent predictors of poor outcomes. In conclusion, modern management of OHCA, including therapeutic hypothermia and early coronary angiography is associated with significant improvement in survival to hospital discharge and neurologic recovery.
Article
We investigated whether the survival of patients with inhospital cardiac arrest could be extended by extracorporeal cardiopulmonary resuscitation supported with extracorporeal membrane oxygenation compared with those of conventional cardiopulmonary resuscitation. : A retrospective, single-center, observational study. A tertiary care university hospital. We retrospectively analyzed a total of 406 adult patients with witnessed inhospital cardiac arrest receiving cardiopulmonary resuscitation for >10 mins from January 2003 to June 2009 (85 in the extracorporeal cardiopulmonary resuscitation group and 321 in the conventional cardiopulmonary resuscitation group). None. The primary end point was a survival discharge with minimal neurologic impairment. Propensity score matching was used to balance the baseline characteristics and cardiopulmonary resuscitation variables that could potentially affect prognosis. In the matched population (n = 120), the survival discharge rate with minimal neurologic impairment in the extracorporeal cardiopulmonary resuscitation group was significantly higher than that in the conventional cardiopulmonary resuscitation group (odds ratio of mortality or significant neurologic deficit, 0.17; 95% confidence interval, 0.04-0.68; p = .012). In addition, there was a significant difference in the 6-month survival rates with minimal neurologic impairment (hazard ratio, 0.48; 95% confidence interval, 0.29-0.77; p = .003; p <.001 by stratified log-rank test). In the subgroup based on cardiac origin, extracorporeal cardiopulmonary resuscitation also showed benefits for survival discharge (odds ratio, 0.19; 95% confidence interval, 0.04-0.82; p = .026) and 6-month survival with minimal neurologic impairment (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97; p = .038; p = .013 by stratified log-rank test). Extracorporeal cardiopulmonary resuscitation showed a survival benefit over conventional cardiopulmonary resuscitation in patients who received cardiopulmonary resuscitation for >10 mins after witnessed inhospital arrest, especially in cases with cardiac origins.
Article
Although favourable outcomes in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest have been frequently reported in Japanese journals since the late 1980s, there has been no meta-analysis of ECPR in Japan. This study reviewed and analysed all previous studies in Japan to clarify the survival rate of patients receiving ECPR. Case reports, case series and abstracts of scientific meetings of ECPR for out-of-hospital cardiac arrest written in Japanese between 1983 and 2008 were collected. The characteristics and outcomes of patients were investigated, and the influence of publication bias of the case-series studies was examined by the funnel-plot method. There were 1282 out-of-hospital cardiac arrest patients, who received ECPR in 105 reports during the period. The survival rate at discharge given for 516 cases was 26.7±1.4%. The funnel plot presented the relationship between the number of cases of each report and the survival rate at discharge as the reverse-funnel type that centred on the average survival rate. In-depth review of 139 cases found that the rates of good recovery, mild disability, severe disability, vegetative state, death at hospital discharge and non-recorded in all cases were 48.2%, 2.9%, 2.2%, 2.9%, 37.4% and 6.4%, respectively. Based on the results of previous reports with low publication bias in Japan, ECPR appears to provide a higher survival rate with excellent neurological outcome in patients with out-of-hospital cardiac arrest.
Article
Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) for in-hospital cardiac arrest (IHCA) patients has been assigned a low-grade recommendation in current resuscitation guidelines. This study compared the outcomes of IHCA and out-of-hospital cardiac arrest (OHCA) patients treated with ECLS. A total of 77 patients were treated with ECLS. Baselines characteristics and outcomes were compared for 38 IHCA and 39 OCHA patients. The time interval between collapse and starting ECLS was significantly shorter after IHCA than after OHCA (25 (21-43)min versus 59 (45-65)min, p<0.001). The weaning rate from ECLS (61% versus 36%, p=0.03) and 30-day survival (34% versus 13%, p=0.03) were higher for IHCA compared with OHCA patients. IHCA patients had a higher rate of favourable neurological outcome compared to OHCA patients, but the difference was not statistically significant (26% versus 10%, p=0.07). Kaplan-Meier analysis showed improved 30-day and 1-year survival for IHCA patients treated with ECLS compared to OHCA patients who had ECLS. However, multivariate stepwise Cox regression model analysis indicated no difference in 30-day (odds ratio 0.94 (95% confidence interval 0.68-1.27), p=0.67) and 1-year survival (0.99 (0.73-1.33), p=0.95). CPR with ECLS led to more favourable patient outcomes after IHCA compared with OHCA in our patient group. The difference in outcomes for ECLS after IHCA and OHCA disappeared after adjusting for patient factors and the time delay in starting ECLS.
Article
Extracorporeal membrane oxygenation (ECMO) to support cardiopulmonary resuscitation (CPR) has been shown to improve survival in children and adults. We describe outcomes after the use of ECMO to support CPR (E-CPR) in adults using multiinstitutional data from the Extracorporeal Life Support Organization (ELSO) registry. Patients greater than 18 years of age using ECMO to support CPR (E-CPR) during 1992 to 2007 were extracted from the ELSO registry and analyzed. Two hundred and ninety-seven (11% of 2,633 adult ECMO uses) reports of E-CPR use in 295 patients were analyzed. Median age was 52 years (interquartile range [IQR], 35, 64) and most patients had cardiac disease (n = 221; 75%). Survival to hospital discharge was 27%. Brain death occurred in 61 (28%) of nonsurvivors. In a multivariate logistic regression model, pre-ECMO factors including a diagnosis of acute myocarditis (odds ratio [OR]: 0.18; 95% confidence interval [CI]: 0.05 to 0.69) compared with noncardiac diagnoses and use of percutaneous cannulation technique (OR: 0.42; 95% CI: 0.21 to 0.87) lowered odds of mortality, whereas a lower pre-ECMO arterial blood partial pressure of oxygen (Pao(2)) less than 70 mm Hg (OR: 2.7; 95% CI: 1.21 to 6.07) compared with a Pao(2)of 149 mm Hg or greater increased odds of mortality. The need for renal replacement therapy during ECMO increased odds of mortality (OR: 2.41; 95% CI: 1.34 to 4.34). The use of E-CPR was associated with survival in 27% of adults with cardiac arrest facing imminent mortality. Further studies are warranted to evaluate and better define patients who may benefit from E-CPR.
Article
To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.
Article
The purpose of this study was to evaluate the efficacy of an alternative cardiopulmonary cerebral resuscitation (CPCR) using emergency cardiopulmonary bypass (CPB), coronary reperfusion therapy and mild hypothermia. Good recovery of patients with out-of-hospital cardiac arrest is still inadequate. An alternative therapeutic method for patients who do not respond to conventional CPCR is required. A prospective preliminary study was performed in 50 patients with out-of-hospital cardiac arrest meeting the inclusion criteria. Patients were treated with standard CPCR and, if there was no response, by emergency CPB plus intra-aortic balloon pumping. Immediate coronary angiography for coronary reperfusion therapy was performed in patients with suspected acute coronary syndrome. Subsequently, in patients with systolic blood pressure above 90 mm Hg and Glasgow coma scale score of 3 to 5, mild hypothermia (34 C for at least two days) was induced by coil cooling. Neurologic outcome was assessed by cerebral performance categories at hospital discharge. Thirty-six of the 50 patients were treated with emergency CPB, and 30 of 39 patients who underwent angiography suffered acute coronary artery occlusion. Return of spontaneous circulation and successful coronary reperfusion were achieved in 92% and 87%, respectively. Mild hypothermia could be induced in 23 patients, and 12 (52%) of them showed good recovery. Factors related to a good recovery were cardiac index in hypothermia and the presence of serious complications with hypothermia or CPB. The alternative CPCR demonstrated an improvement in the incidence of good recovery. Based upon these findings, randomized studies of this hypothermia are needed.
Article
Sudden cardiac death (SCD) is a major clinical and public health problem. United States (US) vital statistics mortality data from 1989 to 1998 were analyzed. SCD is defined as deaths occurring out of the hospital or in the emergency room or as "dead on arrival" with an underlying cause of death reported as a cardiac disease (ICD-9 code 390 to 398, 402, or 404 to 429). Death rates were calculated for residents of the US aged >/=35 years and standardized to the 2000 US population. Of 719 456 cardiac deaths among adults aged >/=35 years in 1998, 456 076 (63%) were defined as SCD. Among decedents aged 35 to 44 years, 74% of cardiac deaths were SCD. Of all SCDs in 1998, coronary heart disease (ICD-9 codes 410 to 414) was the underlying cause on 62% of death certificates. Death rates for SCD increased with age and were higher in men than women, although there was no difference at age >/=85 years. The black population had higher death rates for SCD than white, American Indian/Alaska Native, or Asian/Pacific Islander populations. The Hispanic population had lower death rates for SCD than the non-Hispanic population. From 1989 to 1998, SCD, as the proportion of all cardiac deaths, increased 12.4% (56.3% to 63.9%), and age-adjusted SCD rates declined 11.7% in men and 5.8% in women. During the same time, age-specific death rates for SCD increased 21% among women aged 35 to 44 years. SCD remains an important public health problem in the US. The increase in death rates for SCD among younger women warrants additional investigation.
Article
The Emergency Medical Response (EMR) program is a Victorian Government initiative in which fire fighters trained in cardiopulmonary resuscitation and equipped with automatic external defibrillators are dispatched to suspected cardiac arrests simultaneously with ambulance paramedics across metropolitan Melbourne. During the first 12 months (February 2000 to February 2001) of the expanded EMR program, 2942 events involved simultaneous dispatch of ambulance paramedics and fire fighters. In 430 events, patients had suffered a cardiac arrest of presumed cardiac cause, and resuscitation was attempted by the emergency medical services. Fire fighters provided the initial defibrillation to 41 (26.5%) patients presenting in ventricular fibrillation. Survival to hospital discharge for bystander-witnessed ventricular fibrillation cardiac arrests was 21.8%. The mean emergency services (fire and ambulance) response time to cardiac arrest patients was 6.03 (SD, 1.65) minutes. The mean time to defibrillation for ventricular fibrillation patients was 8.75 (SD, 2.07) minutes.