Elsevier

Resuscitation

Volume 83, Issue 11, November 2012, Pages 1331-1337
Resuscitation

Clinical paper
A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest

https://doi.org/10.1016/j.resuscitation.2012.07.009Get rights and content

Abstract

Background

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.

Methods

We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.

Results

The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). 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: 20–50 min) vs. (50: 25–86 min); 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: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).

Conclusions

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.

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.

References (35)

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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.

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