Clinical paperA 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest☆
Introduction
Over the past decades, survival rate after cardiac arrest remains dismal despite important improvements in cardiopulmonary resuscitation (CPR).1, 2, 3 Several factors, including duration of resuscitation, initial cardiac rhythm, underlying primary disease, and age, may be related to the outcome.1, 4, 5 Investigators reported a decreased survival rate when the duration of CPR exceeds 10 min, and even more if it exceeds 30 min.1, 4 Hence, several mechanical devices and techniques have been developed to extend the accepted duration of CPR.1, 4, 6 Extracorporeal life support (ECLS) has been suggested as a therapeutic option in refractory cardiac arrest since 1976.7 However, the use of this technique remains limited and is confined to specialized centres and reserved for exceptional cases due to high complication rates (bleeding, thrombosis, haemolysis, severe infection, systemic emboli, ischemia, and renal insufficiency), high costs and difficult logistics. Recently, advances in ECLS technology and improvement of commercially available percutaneous cannulas make ECLS nowadays a more powerful resuscitation tool. Crucial technical innovations and ease of device implantation and transport allow location-independent stabilization and make necessary examinations and intervention possible. Several studies have shown rapid positive haemodynamic effects, increased frequency of return of spontaneous circulation, and improved survival with good neurological outcome when compared to conventional CPR.8, 9, 10, 11, 12 Recent studies have demonstrated that CPR using ECLS led to more favourable outcomes after in-hospital cardiac arrest (IHCA) compared with out-of-hospital cardiac arrest (OHCA).13, 14 Accordingly, an early insertion of ECLS to improve the prognosis of patients with prolonged CPR is essential.13, 14, 15
Preconditions for success are specialized surgical and perfusion techniques and a qualified and well-trained ECLS team. Since 2007, Regensburg University Medical Centre has a specialized rapid response ECLS team both for in-hospital and out-of-hospital ECLS implantation.16, 17, 18
This study summarizes our five-year experience with extracorporeal CPR using portable miniaturized ECLS systems in non-postcardiotomy patients with cardiac arrest.
Section snippets
Patient population
A retrospective review of our prospectively obtained database for ECLS devices implanted between January 2007 and January 2012 indicated 234 patients requiring ECLS support. We analysed a total of 85 non-postcardiotomy patients (age >18 years) with cardiac arrest receiving extracorporeal CPR using percutaneous ECLS. The remaining 149 patients were not eligible for following reasons; postcardiotomy patients requiring ECLS because they could not be weaned from cardiopulmonary bypass or due to
Basic data
The baseline characteristics, CPR variables, and outcome of the study population are shown in Table 1, Table 2. The cohort consisted of 24 women and 61 men with a median age of 57 (47–73) years. The mean Sequential Organ Failure Assessment (SOFA) score was 14 ± 5. Forty-eight patients (57%) received ECLS during continuous external cardiac massage. The remaining patients were successfully resuscitated to spontaneous circulation initially, but their condition subsequently deteriorated despite high
Discussion
The primary objective of our study was to present our five-year experience with extracorporeal CPR using portable miniaturized ECLS systems in non-postcardiotomy patients with cardiac arrest. This report is of particular interest because one third of the patients had OHCA with relatively long CPR duration in comparison with previously reported cases. The present retrospective analysis on 85 patients presenting refractory IHCA or OHCA and subjected to ECLS treatment has shown encouraged results
Limitations
Nevertheless, our report has some limitations. The retrospective data collection is a major limitation. The report is a single centre experience and the number of patients is relatively small without a control group without ECLS. The Utstein template criteria were not used.
Conclusion
Our experience suggests that CPR using modern ECLS systems should be established in the treatment of prolonged cardiac arrest with failing conventional CPR. Extracorporeal CPR may improve survival with good neurological outcome in selected patients. The outcome for OHCA using ECLS is worse compared with IHCA patients. Long CPR duration and low blood pH value were independent risk factor for mortality after extracorporeal CPR using ECLS. Therefore, the implementation of a rapid response ECLS
Conflict of interest statement
The authors declare no conflict of interest.
Acknowledgment
None.
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Hyperoxemia is Associated With Poor Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Rescued by Extracorporeal Cardiopulmonary Resuscitation: Insight From the Nationwide Multicenter Observational JAAM-OHCA (Japan Association for Acute Medicine) Registry
2022, Journal of Emergency MedicineCitation Excerpt :In contrast to our study, they included not only patients with OHCA, but also patients with in-hospital CA (IHCA) rescued by ECPR. It should be noted that patient characteristics, including age, underlying diseases, causes of CA, time courses of resuscitation, and mortality, are quite different between patients with OHCA and IHCA; thus, it is reasonable to examine the effects of exposure to hyperoxia on mortality in OHCA or IHCA separately (27,28). In addition, in contrast to the neurological outcome in our study, the primary outcome in their study was in-hospital mortality.
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2022, Cardiopulmonary Bypass: Advances in Extracorporeal Life SupportHow effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis
2022, American Journal of Emergency MedicineCitation Excerpt :We identified 1287 studies, reviewed 209 full text articles and included 44 for data extraction (Fig. 1). Eleven of the included studies were prospective [15,24-34], including two RCTs [15,33] and 33 were retrospective [35-66]; all studies reported either survival or CPC at hospital discharge. We determined that most of the studies included in our meta-analysis were of high quality, with a NOS rating of 7–9 or a low risk of bias per the Cochrane risk-of-bias assessment, as previously defined in the Quality Assessment section of this article (Table 1).
Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis
2020, Resuscitation PlusCitation Excerpt :Outcomes of early deployment of VA-ECMO as ECPR for IHCA or OHCA in prior research have varied greatly among a range of study designs that include case series, case-control, and cohort studies. This approach has been associated with a 2- to 4-fold (8.0%–15.0% to 30.0%–45.0%) increase in patient-centered outcomes, including survival to discharge and neurologically intact survival.16–54 An unexplored outcome of this approach is long-term neurologically intact survival in patients with cardiac arrest who respond poorly to the current standard of care.45–50
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.07.009.