Extracorporeal life support following out-of-hospital refractory cardiac arrest

Guen, Morgan Le; Nicolas-Robin, Armelle; Carreira, Serge; Raux, Mathieu; Leprince, Pascal; Riou, Bruno; Langeron, Olivier

doi:10.1186/cc9976

Cited by 262 publications

(172 citation statements)

References 37 publications

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“…In contrast, the use of ECLS in the management of OHCA remains a matter of debate with survival rates ranging from 4 to 29% (13,14). Le Guen et al reported survival of 4%, with a median low-flow of 120 min, in a cohort of 51 patients with RCA.…”

Section: Discussionmentioning

confidence: 99%

Comparable Outcome of Out‐of‐Hospital Cardiac Arrest and In‐Hospital Cardiac Arrest Treated With Extracorporeal Life Support

et al. 2017

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Extracorporeal life support (ECLS) has shown benefits in the management of refractory inhospital cardiac arrest (IHCA) by improving survival. Nonetheless, the results concerning out-of-hospital refractory cardiac arrests (OHCA) remain uncertain. The aim of our investigation was to compare survival between the two groups. We realized a single-center retrospective, observational study of all patients who presented IHCA or OHCA treated with ECLS between 2011 and 2015. Multivariate analysis was realized to determine independent factors associated with mortality. Over the 4-year period, 65 patients were included, 43 in the IHCA group (66.2%), and 22 (33.8%) in the OHCA group. The duration of low flow was significantly longer in the OHCA group (60 vs. 90 min, P 5 0.004). Survival to discharge from the hospital was identical in the two groups (27% in the OHCA group vs. 23% in the IHCA group, P 5 0.77). All surviving patients in the OHCA group had a cerebral performance categories score of 1-2. In multivariate analysis, we found that the initial lactate level and baseline blood creatinine were independently associated with mortality. We found comparable survival and neurological score in patients who presented IHCA and OHCA treated with ECLS. We believe that appropriate selection of patients and optimization of organ perfusion during resuscitation can lead to good results in patients with OHCA treated with ECLS. Key Words: Extracorporeal life support-Cardiac arrestCardiopulmonary resuscitation.Conventional management of cardiac arrest (CA) has evolved considerably in recent years, nevertheless mortality is still high (1,2). This is essentially related to the neurological prognosis and thus to cerebral damage due to ischemia and reperfusion injury. Given this, the management of CA should focus on maintaining effective circulation during the external cardiac massage and to manage adequately the return to spontaneous circulation.The use of extracorporeal life support (ECLS) for the management of in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) has been widely described (3). Nonetheless, doubts have been expressed about the usefulness of ECLS in OHCA (4). Indeed, rapid ECLS implementation is a major concern. However, in large towns with heavy traffic, timely implementation of ECLS and restoration of effective circulation is sometimes very long.To update our management practices and to determine the usefulness of ECLS in OHCA, we conducted a retrospective study of all IHCA and OHCA treated with ECLS to compare survival and the neurological prognosis of our patients.

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Section: Discussionmentioning

confidence: 99%

Comparable Outcome of Out‐of‐Hospital Cardiac Arrest and In‐Hospital Cardiac Arrest Treated With Extracorporeal Life Support

et al. 2017

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“…While there was some variability in time points of reported outcomes, the overall reported survival rate was 22%, including 13% having a good neurological recovery (CPC 1-2 or GOS 4-5, see Table 1). In addition to these short-term results, three studies 12,13,19 reported patient outcomes at 3 months with an overall survival rate of 21% (24/115), including 15% (17/115) having good neurological function and five studies 16,20,22,26,30 reported patient outcomes at 6 months with an overall survival rate of 16% (61/377), including 9% (34/377) having good neurological function.…”

Section: Discussionmentioning

confidence: 99%

“…Most of the included studies presented high risk of confounding bias and threats to external validity because of their observational design. However, the methodological quality assessment of the 20 included studies resulted in a rating of good for 14 studies [12][13][14][15][16]18,20,[22][23][24][25][26][27][28] and fair for the other 6 17,19,21,29-31 (see Table 1). …”

Section: Ecpr Studiesmentioning

confidence: 99%

“…The main exclusion criteria were the pre-existence of severe comorbidities, neurological disabilities, a valid do not attempt resuscitation order and the identification of a primary non-cardiac etiology (Table 2). • Catheter Lab + IABP: 1 study 17 • Catheter Lab + IABP + TTM: 9 studies [13][14][15][16][18][19][20]26,27 CPR, cardiopulmonary resuscitation; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; TTM, targeted temperature management, also known as therapeutic mild hypothermia; IABP, intra-aortic balloon pump.…”

Section: Patient Characteristicsmentioning

confidence: 99%

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Accuracy of Nasal Nitric Oxide Measurement as a Diagnostic Test for Primary Ciliary Dyskinesia: A Systematic Review and Meta-Analysis

Shapiro

Josephson

Rosenfeld³

et al. 2017

Annals ATS

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a b s t r a c tAim: Extracorporeal resuscitation during cardiopulmonary resuscitation (ECPR) deploys rapid cardiopulmonary bypass to sustain oxygenated circulation until the return of spontaneous circulation (ROSC). The purpose of this systematic review is to address the defining elements and outcomes (quality survival and organ donation) of currently active protocols for ECPR in refractory out-of-hospital cardiac arrest (OHCA) of cardiac origin in adult patients. The results may inform policy and practices for ECPR and help clarify the corrresponding intersection with deceased organ donation. Methods: We searched Medline, Embase, Cochrane and seven other electronic databases from 2005 to 2015, with no language restrictions. Internal validity and the quality of the studies reporting outcomes and guidelines were assessed. The review was included in the international prospective register of systematic reviews (Prospero, CRD42014015259). Results: One guideline and 20 outcome studies were analyzed. Half of the studies were prospective observational studies assessed to be of fair to good methodological quality. The remainder were retrospective cohorts, case series, and case studies. Ages ranged from 16 to 75 years and initial shockable cardiac rhythms, witnessed events, and a reversible primary cause of cardiac arrest were considered favorable prognostic factors. CPR duration and time to hospital cannulation varied considerably. Coronary revascularization, hemodynamic interventions and targeted temperature management neuroprotection were variable. A total of 833 patients receiving this ECPR approach had an overall reported survival rate of Abbreviations: ECPR, extracorporeal resuscitation; ROSC, return of spontaneous circulation; OHCA, out-of-hospital cardiac arrest; CPC, cerebral performance category; GOS, Glasgow Outcome Scale; LOE, level of evidence; ILCOR, International Liaison Committee on Resuscitation; RCTs, randomized controlled trials; TTM, targeted temperature management; IABP, intra-aortic balloon pump; DBD, donation after brain death; cDCD, controlled donation after circulatory determination of death; ELSO, extracorporeal life support organization. I. Ortega-Deballon et al. / Resuscitation 101 (2016) 12-20 13 22%, including 13% with good neurological recovery. Additionally, 88 potential and 17 actual deceased organ donors were identified among the non-survivor population in 8 out of 20 included studies. Study heterogeneity precluded a meta-analysis preventing any meaningful comparison between protocols, interventions and outcomes. Conclusions: ECPR is feasible for refractory OHCA of cardiac origin in adult patients. It may enable neurologically good survival in selected patients, who practically have no other alternative in order to save their lives with quality of life, and contribute to organ donation in those who die. Large, prospective studies are required to clarify patient selection, modifiable outcome variables, risk-benefit and cost-effectiveness.

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“…Conversely, in patients with an out-of-hospital witnessed cardiac arrest who remain in refractory arrest, a single-center study reported extremely poor outcomes, even when ECMO was initiated very early (median time, 120 minutes), with only 4% of patients surviving to hospital discharge with a favorable neurological prognosis. 13 …”

Section: Clinical Evidencementioning

confidence: 99%

Extracorporeal Membrane Oxygenation in Adults With Cardiogenic Shock

et al. 2015

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A 28-year-old previously healthy woman was brought to the hospital after out-of-hospital resuscitated cardiac arrest attributable to ventricular fibrillation. On the evening of presentation, she was found unconscious at home by family members. Bystander cardiopulmonary resuscitation (CPR) was immediately initiated. The patient was defibrillated in the field by emergency medical response providers with return of spontaneous circulation. She aspirated during intubation in the field, and arrived to the hospital in shock, with blood pressure 88/71 mm Hg on norepinephrine 20 μg/min and vasopressin 0.04 U/min. She did not have purposeful movements, and therapeutic hypothermia was initiated in the Emergency Department. She had a metabolic acidosis and concomitant type I acute respiratory failure, with PaO 2 66 mm Hg on volume-cycled assist/control mode with tidal volumes of 400 cc, FiO 2 1.0, positive end-expiratory pressure 10 cm H 2 O, and a respiratory rate of 26 breaths/min. Her ECG did not demonstrate stigmata of ischemia or infarction. However, a type I Brugada pattern was noted in leads V1 and V2 before cooling.Over the ensuing several hours, vasopressor requirements escalated. A SwanGanz catheter demonstrated severely depressed cardiac index and elevated pulmonary capillary wedge pressure. She remained severely hypoxic despite maximal ventilator support. Chest x-ray showed diffuse bilateral pulmonary infiltrates, consistent with severe aspiration pneumonitis. PaO 2 decreased to 49 mm Hg despite increased positive end-expiratory pressure and chemical paralysis, meeting Berlin criteria for severe acute respiratory distress syndrome. 1 Options for percutaneous hemodynamic support were considered (including extracorporeal membrane oxygenation [ECMO] or percutaneous ventricular assist device [VAD], such as Impella and TandemHeart), and the patient was placed on veno-arterial ECMO (VA ECMO) for both hemodynamic and respiratory rescue 6 hours after presentation.Cardiopulmonary bypass was first developed in 1954 to facilitate openheart surgery and used successfully 1 year later. 2,3 Although substantially different from early cardiopulmonary bypass systems, ECMO evolved from cardiopulmonary bypass and provides prolonged cardiopulmonary support outside of the operating suite. With increasing technological advances and safety, the uses of ECMO have expanded, with increasing interest as combined shortterm circulatory and respiratory support in patients with cardiogenic shock. 4 Although potentially life-saving, ECMO is invasive, complex, resource intensive, and can be associated with serious complications. This Clinician Update will introduce ECMO technology, review indications and contraindications, discuss management, including maintaining and weaning support, and underscore potential complications.

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Extracorporeal life support following out-of-hospital refractory cardiac arrest

Abstract: Introduction: Extracorporeal life support (ECLS) has recently shown encouraging results in the resuscitation of inhospital (IH) refractory cardiac arrest. We assessed the use of ECLS following out-of-hospital (OH) refractory cardiac arrest.

Cited by 262 publications

References 37 publications

Comparable Outcome of Out‐of‐Hospital Cardiac Arrest and In‐Hospital Cardiac Arrest Treated With Extracorporeal Life Support

Comparable Outcome of Out‐of‐Hospital Cardiac Arrest and In‐Hospital Cardiac Arrest Treated With Extracorporeal Life Support

Accuracy of Nasal Nitric Oxide Measurement as a Diagnostic Test for Primary Ciliary Dyskinesia: A Systematic Review and Meta-Analysis

Extracorporeal Membrane Oxygenation in Adults With Cardiogenic Shock

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