Elsevier

Resuscitation

Volume 85, Issue 11, November 2014, Pages 1527-1532
Resuscitation

Clinical Paper
Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest

https://doi.org/10.1016/j.resuscitation.2014.08.028Get rights and content

Abstract

Background

Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.

Objective

We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.

Methods

Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.

Conclusion

ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.

Introduction

Extracorporeal life support (ECLS) has been used in cardiac surgery since the 1950s and has subsequently been applied to patients outside of the operating room with cardiopulmonary failure. A number of ECLS case series have demonstrated successful treatment of refractory respiratory failure, poisoning, cardiac arrest, and cardiogenic shock 1, 2, 3, 4, 5, 6, 7.

Japanese case reports of application of ECLS to patients with refractory cardiac arrest have appeared in journals since the mid-1980s. These cases were recently reviewed and summarized in Resuscitation 8. The first English language reports of ECLS for refractory cardiac arrest were published in the late 1990s 4, 9. In 2000, physicians at the University of Michigan documented their experience with 1000 consecutive patients treated with ECLS for a variety of indications including cardiac arrest and cardiogenic shock as well as the scientific and logistical evolution of their program 1. Since this time, a handful of centers both in the United States and internationally have documented success with using ECLS for cardiogenic shock or cardiac arrest refractory to traditional therapies 2, 10, 11, 12, 13, 14. Data from pediatrics and neonatology are most promising, with one study documenting 40% neurologically-intact survival among children who suffered in-hospital cardiac arrest 15.

A large randomized trial of ECLS for cardiac arrest has not yet been completed. Several analyses comparing cardiac arrest patients treated with ECLS and matched cohorts have demonstrated benefit 12, 16, 17. A small but growing body of literature supports deployment of ECLS in the emergency department (ED) for selected cases of refractory out-of-hospital cardiac arrest 10, 11, 12. The experiences from a few selected centers appear promising, but controversy still exists about the wide-spread adoption of ECLS as well as its cost-effectiveness, feasibility, and efficacy for cardiac arrest 18.

We aim to describe our institution's experience implementing ECLS as a rescue strategy in adult patients with out-of-hospital cardiac arrests and in the ED. Our primary outcome was survival to hospital discharge.

Section snippets

Study design

This is an analysis of consecutively enrolled patients in a prospective registry from July 1, 2007 to April 1, 2014. This study was approved by the Institutional Review Board of the University of Pennsylvania.

Setting

This investigation was conducted at the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC). HUP is an urban, academic, adult, quaternary referral center with 70,000 annual ED visits, 772 beds, 39,000 annual admissions, and a Level 1 trauma center.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, 42% were white (42% were black and 16% were other races). (Table 2) Eight patients (31%) had preexisting cardiac disease defined as documented history of coronary artery disease, dysrhythmia, or congestive heart failure. Of these, one patient had previously undergone cardiac transplantation. Three patients had a history of malignancy, but only one was undergoing active treatment. Nine patients (35%)

Discussion

We aimed to demonstrate that ECLS is feasible as a rescue strategy for both out-of-hospital and ED cardiac arrest, and may be a useful tool in properly selected patients. Its implementation requires significant interdisciplinary collaboration and is resource intensive, but it may be a useful adjunct among patients who have failed traditional resuscitative therapies.

ECLS has grown widely as a rescue therapy for a variety of indications. The Extracorporeal Life Support Organization (ELSO)

Conflict of interest statement

No conflicts of interest to declare.

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