ReviewExtracorporeal life support in the emergency department: A narrative review for the emergency physician
Introduction
Respiratory and cardiac failure are commonly seen in the emergency department (ED), and emergency physicians are required to provide initial resuscitative therapy for these life-threatening conditions. When severe, these conditions are associated with a high mortality and can be a therapeutic challenge for the emergency physician. Conventional therapies available in the ED for respiratory failure include endotracheal intubation and mechanical invasive and non-invasive ventilation. Available options are more limited for cardiac failure. Supportive pharmacologic therapy is either the sole therapy or serves as a bridge to more definitive therapies available in the cardiac interventional or surgical suites. For cases when conventional therapies prove inadequate, more advanced therapies must be considered [1,2].
One therapeutic option for these selected cases that is becoming increasingly available to the emergency physician is extracorporeal life support (ECLS). Safe and effective ECLS requires specialized medical expertise and a trained staff [[3], [4], [5]] but currently is within the therapeutic realm of the emergency physician. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and miniaturization of extracorporeal devices have simplified ECLS for deployment in a variety of settings, including the ED [6,7]. Early stabilization in the ED provides a bridge to support the critically ill patient and enables diagnosis and intervention for emergency patients who otherwise may not survive [1,2,[7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]].
This paper introduces the current state of ECLS and recommendations for its application in disease categories experienced by emergency physicians. Available support devices that are capable of rapid priming and deployment are discussed. Additionally, current practices are provided, including indications, contraindications, complications, and outcomes that are applicable to emergency physicians, nurses, and ECLS specialists. This paper also aims to delineate best practices and outline the infrastructure and procedures required for the safe and effective implementation of ECLS. Experience with the emergency use of ECLS has been described in several nonrandomized studies, case series, and case reports [2,7,8,10,[19], [20], [21]]. The intention of this discussion is also to suggest the potential use of ECLS in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in the ED setting. Differences among hospital organizations and their regulations may require variations of this model.
Section snippets
Description
ECLS provides temporary support of circulation and/or gas exchange to replace heart or lung function as a bridge to recovery or other long-term support. The principal application modes of ECLS are veno-arterial (V-A) and veno-venous (V-V) (Fig. 1, Fig. 2, Fig. 3). V-A ECLS is aimed at supporting cardiac or combined cardiopulmonary failure, whereas V-V ECLS targets respiratory support in which cardiovascular function is not severely compromised. The veno-arterial-venous hybrid mode (V-AV), which
Indications for ECLS
Indications for ECLS in the ED cover a spectrum of conditions that are characterized by acute cardiac and/or pulmonary failure and have an expectation of reversibility or the potential to transition to long-term support devices (Table 1, Suppl. 1). Early stabilization with ECLS in the ED can provide time for diagnostic evaluation and/or urgent procedures. A more controlled approach to evaluation and management may allow for better informed diagnoses or selection of optimal therapeutic
Contraindications
Several conditions have been identified to be of such high risk and/or low benefit that extracorporeal support is considered contraindicated (Table 1). Patients in these conditions require individual consideration to balance these risks with the potential benefit of initiating support.
In the context of cardiac arrest, ECPR is not offered if the no-flow duration is unknown or prolonged to the extent that brain recovery is doubtful. Patients with end-stage heart or lung failure are not candidates
Cannulation and circuit management
Cannulation is the most challenging aspect of initiating ECLS in emergency situations. Two approaches to vessel access are percutaneous insertion and surgical cutdown [72,74]. Each approach has advantages and disadvantages, and the selection for a given patient depends on the experience of the cannulating operator, the body habitus of the patient, and additional anatomical (peripheral vascular disease jeopardizing limb perfusion) or functional (need for central cannulation for high flow)
Anticoagulation
Heparin is the default anticoagulant for ECLS, and it is administered intravenously at 100 IU/kg once the vessels have been controlled with guidewires; the estimated dose of heparin is 5000 IU, except in cases requiring heparin-free conditions such as hemorrhagic shock. Management of the circuit includes the maintenance of anticoagulation - a major concern in patients with either excessive clotting or hemorrhagic complications. Monitoring anticoagulation can be achieved using the activated
Intrahospital transport
Intra- or interhospital transport should provide the same level of support and quality of care during transport as the patient would receive in an appropriate ICU while on ECLS. Emergency equipment should be readily available to replace the ECLS system in scenarios of sudden malfunction. This equipment should include an uninterruptable electrical power supply, backup components of the ECLS system (such as a mechanical backup drive for the pump) and supplies for all circuit components. All ECLS
Complications of ECLS
Cannulation for extracorporeal support is a procedure with risk of injury to major vascular structures, hemorrhage, and cardiac injury, including perforation. The risk of percutaneous cannulation can be minimized by pre-cannulation ultrasound imaging for vessel sizing and anatomical aberrancy, ultrasound-guided needle and guidewire insertion, and fluoroscopic imaging of guidewire advancement and cannula insertion.
Due to the need for anticoagulation, ECLS entails a risk of bleeding from both
General logistics and organization of the ECLS team in the ED
There are no definitive data regarding the estimated number of ECLS candidates, and the number will vary greatly by center based on the center’s expertise (e.g., whether the center is a trauma center or a cardiac center) and patient population. The number of cannulations per ED visit is highly dependent on the perceived indications for ECLS, the experience of the center and the availability of resources, especially during off hours. Outcome data and selection factors have been reported by
Outcomes and survival
Kim performed a retrospective analysis of a prospective cohort and a meta-analysis comparing extracorporeal cardiopulmonary resuscitation (ECPR) with conventional cardiopulmonary resuscitation (CCPR) [18]. The beneficial effects of ECPR on patient outcomes were analyzed according to the time interval, location of arrest (OHCA and in-hospital cardiac arrest (IHCA)), and predefined population inclusion criteria (witnessed arrest, initial shockable rhythm, cardiac etiology of the arrest, and
Conclusions
Emergent ECLS plays an increasing role in the ED for selected indications in the face of life-threatening conditions in which the alternative is a poor outcome or certain death. ECLS in the ED provides a bridge to recovery, definitive therapy, intervention or surgery and requires an appropriately organized and trained staff, equipment resources and logistical planning. Close cooperation between pre-hospital emergency medical services, the ICU, the in-house ECLS program, the ED, and inpatient
Conflicts of interest
Dr. Brodie is currently the co-chair of the Trial Steering Committee for the VENT-AVOID trial sponsored by ALung Technologies, he was previously on the medical advisory boards of ALung Technologies and Kadence. All compensation for these activities is paid to Columbia University. He is also currently consulting for Baxter.
Dr. Lorusso is Principal Investigator of the PERSIST-AVR Study sponsored by LIVANOVA and received honoraria as a PI and for presentations (part of the consulting fee goes to
Acknowledgments
Dr. Belohlavek acknowledges partial funding support from a research grant from the Internal Grant Agency Ministry of Health, Czech Republic NT13225-4/2012. This funding has no involvement in the writing of the manuscript; and in the decision to submit the manuscript for publication.
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2021, ResuscitationCitation Excerpt :Extracorporeal CPR (eCPR) is defined by the ELSO (Extracorporeal Life Support Organization) as the application of rapid-deployment veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to provide circulatory support in patients in whom conventional CPR is unsuccessful in achieving sustained ROSC.361 The use of eCPR has increased for both IHCA and OHCA in recent years.362–365 The 2019 ILCOR CoSTR informed by a systematic review made the following recommendation:242,244,366