Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR)

Abstract

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) support under extracorporeal cardiopulmonary resuscitation (eCPR) is the last option and may be offered to selected patients. Several factors predict outcome in these patients, including initial heart rhythm, comorbidities, and bystander cardiopulmonary resuscitation (CPR). We evaluated outcomes of all VA-ECMO patients treated within the last 5 years at our center in respect to low-flow duration during CPR.MethodsWe report retrospective registry data on all patients with eCPR treated at a university hospital between October 2010 and May 2016.ResultsA total of 133 patients (mean age 58.7 ± 2.6 years, Simplified Acute Physiology Score II score at admission 48.1 ± 3.4) were included in the analysis. The indication for eCPR was either in-hospital or out-of-hospital cardiac arrest without return of spontaneous circulation (n = 74 and 59, respectively). There was a significant difference in survival rates between groups (eCPR in-hospital cardiac arrest [IHCA] 18.9%, eCPR out-of-hospital cardiac arrest [OHCA] 8.5%; p < 0.042). Mean low-flow duration (i.e., duration of mechanical CPR until VA-ECMO support) was 59.6 ± 5.0 minutes in all patients and significantly shorter in IHCA patients than in OHCA patients (49.6 ± 5.9 vs. 72.2 ± 7.4 minutes, p = 0.001). Low-flow time strongly correlated with survival (p < 0.001) and was an independent predictor of mortality.ConclusionsTime to full support is an important and alterable predictor of patient survival in eCPR, suggesting that VA-ECMO therapy should be established as fast as possible in the selected patients destined for eCPR.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1744-8) contains supplementary material, which is available to authorized users.

Effect of interplay between age and low-flow duration on neurologic outcomes of extracorporeal cardiopulmonary resuscitation

“…Studies have shown that both advanced age and prolonged LFDs are associated with poor neurologic outcomes [3, 4, 13]; therefore, both are generally considered contraindications for ECMO use in CPR [24]. However, whether relatively young patients with long LFDs or elderly patients with relatively short LFDs have acceptable chances of survival after ECPR has not been studied.…”

“…Several studies have shown that prolonged LFDs are significantly associated with poor hospital outcomes for ECPR [3, 4], with an approximate survival rate of only 10–17% if LFDs exceed 60 min. Animal experiments have indicated that old and young animals present different degrees of neuroinflammation and apoptosis reaction after brain ischemic damage [5, 6].…”

Managing Traps and Pitfalls During Initial Steps of an ECMO Retrieval Program Using a Miniaturized Portable System: What Have We Learned From the First Two Years?

“…Despite the fact that this difference did not reach statistical significance probably due to our small patient cohort, our initial experience shows that minimization of launching and travel time to the referring center in cases of cardiac arrest is of vital priority for providing expected results. Larger studies can confirm the essential role of keeping low‐flow time as low as possible as it represents an independent predictor of mortality strongly correlating with survival .…”

Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR)

“…Zum gegenwärtigen Zeitpunkt erscheint es trotzdem nicht gerechtfertigt, die eCPR für Patienten ohne defibrillierbaren Rhythmus kategorisch auszuschließen. Der prognostische Wert der Low-flow-Zeit wurde sowohl für den innerklinischen Kreislaufstillstand als auch den außerklinischen Herzstillstand bereits dokumentiert [19,27]. Insbesondere der Faktor Zeit scheint eine bedeutende Rolle einzunehmen.…”

“…In einer japanischen Registerstudie konnte gezeigt werden, dass die strikte Einhaltung der "collapse to start eCPR" <40 min und "collapse to coronary reperfusion" <60 min mit dem besten prognostischen Outcome einherging [28]. Auch in Städ-ten mit einem bereits etablierten eCPRProgramm lag die Low-flow-Zeit bis zur ECLS-Unterstützung bei über 70 min, was es in Zukunft in Analogie zur Behandlung des ST-Strecken-HebungsInfarkts zu reduzieren gilt [17,27] [30].…”