Abstract 208: A Comprehensive Simulation-Based Training for E-CPR Improves the Neurological Outcome in Patients With Refractory Out-Of-Hospital Cardiac Arrest

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

Favourable neurological outcome in patients with out-of-hospital cardiac arrest (OHCA) vary across countries. Different advanced resuscitation strategies such as extracorporeal cardiopulmonary resuscitation (ECPR) might have impact on long-term neurological outcome. However, this remains unclear in Switzerland. This retrospective single-centre observational study included all patients with OHCA transported by the local emergency medical services to a large Swiss academic hospital between 1 January 2015 and 31 December 2023. Data were collected before and after the implementation of the local ECPR programme for patients with refractory OHCA on 01 May 2018. The primary outcome was 1-year favourable neurological outcome, defined as Cerebral Performance Categories 1 and 2. Secondary outcomes included 30-day favourable neurological outcome, characteristics and survival of patients treated with ECPR, and factors associated with non-survival among all OHCA patients. A total of 578 patients with OHCA were transported to the hospital. Favourable neurological survival at 1 year was 16.8% (95%-CI, 12.1-22.4%) before and 21.5% (95%-CI, 17.4-26.1%) after the ECPR programme implementation. Hazard ratios for overall survival were 2.19 for patients with a non-shockable initial rhythm, 1.02 for older age and 1.68 for unwitnessed OHCA. Of all transported patients, 16.8% (n = 97, n = 31 before vs. n = 66 after) met local ECPR criteria. In total 34 patients with refractory OHCA were treated with ECPR, all assessable survivors had favourable 1-year neurological outcomes. This observational study on patients sustaining OHCA transferred to a large Swiss hospital showed 1 year favourable outcome in 19.7% (95%-CI: 16.6-23.2%). Among ECPR patients, all five survivors had a favourable neurological outcome at 1 year. No association was found between implementing an ECPR programme for patients with refractory OHCA and 1 year favourable neurological outcome. However, the effect might be underestimated given the low incidence of ECPR. https://www.clinicaltrials.gov, identifier NCT03759210.

IntroductionProlonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR.MethodsThis study is a retrospective analysis based on a prospective cohort. We included patients ≥ 18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group.ResultsOf 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥ 21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥ 60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome.ConclusionsECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥ 21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has the potential to improve neurological outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA), offering an alternative to conventional cardiopulmonary resuscitation (CCPR). However, its effectiveness in OHCA remains controversial despite advancements in resuscitation techniques. Methods: This retrospective single-center study compared neurological outcomes and 30-day survival between ECPR and CCPR patients from January 2014 to January 2022. Patients aged 18-75 with witnessed OHCA, minimal no flow and low flow times, and cardiac arrests occurring at home or in public places were included. All patients were transported directly to our institution, a tertiary medical center serving the southeastern region of Seoul, where extracorporeal membrane oxygenation implantation was consistently performed in the emergency department. Neurological outcomes were assessed using Cerebral Performance Category scores, with good outcomes defined as scores of 1-2. Statistical analyses included logistic regression models and Kaplan-Meier survival curves, adjusted for confounders using inverse probability of treatment weighting. Results: ECPR was associated with significantly better neurological outcomes than CCPR (p < 0.001). Factors predicting poor outcomes included older age and longer low flow times, while male sex and shockable rhythms were protective. No significant difference was found in 30-day survival between the ECPR and CCPR groups, although a trend toward better survival was noted with ECPR. Conclusions: ECPR may improve neurological outcomes in patients with refractory OHCA compared to CCPR, although it does not significantly affect 30-day survival. Further studies are necessary to validate these findings and explore the long-term impacts of ECPR.

Introduction: Previous studies have shown an association between hyperoxemia and mortality in out-of-hospital cardiac arrest (OHCA) patients after cardiopulmonary resuscitation (CPR); however, the evidence is lacking in patients receiving extracorporeal CPR (ECPR). Hypothesis: To test the hypothesis that hyperoxemia is associated with poor neurological outcome in patients treated by ECPR. Methods: The Japanese Association for Acute Medicine - OHCA (JAAM-OHCA) Registry is a multicenter, prospective, observational registry including 34,754 OHCA patients between 2014 and 2017. Patients who had been resuscitated and survived 24 hours after OHCA and had a PaO 2 levels above 60 mmHg were included. Eligible patients were divided into 2 groups by each 2 definition according to the PaO 2 levels measured from arterial blood gas analysis 24-h after the ECPR, (1) High-level of PaO 2 (H-PaO 2 , n=242) as PaO 2 ≥ 157 mmHg (median) and control (n=211) as 60 &lt; PaO 2 &lt; 157 mmHg, (2) hyperoxemia (HO, n=80) as PaO 2 ≥ 300 mmHg and control (n=373) as 60 &lt; PaO 2 &lt; 300 mmHg. The primary and secondary outcomes were the favorable neurological outcome, defined as Cerebral Performance Categories (CPC) Scale 1-2, and survival at 30 days after OHCA, respectively. Results: Out of 34,754 patients with OHCA, 453 patients with ECPR were included. The number of CPC 1-2 was significantly lower in the H-PaO 2 and HO group compared with each control group (H-PaO 2 : 17.4% vs. 33.2%; Odds ratio [OR] 0.42; 95% confidence interval [CI] 0.27-0.66; P&lt;0.0001, HO: 8.8% vs. 28.2%; OR 0.24; 95% CI 0.11-0.55; P&lt;0.001). The 30-day survival was lower in these high oxygen groups (H-PaO 2 : 39.3% vs. 57.4%; OR 0.48; 95% CI 0.33-0.70; P&lt;0.0001, HO: 25.0% vs. 52.6%; OR 0.30; 95% CI 0.17-0.52; P&lt;0.0001). After adjusting for potential confounders, the H-PaO 2 and HO were associated with unfavorable neurological outcomes (adjusted OR, H-PaO 2 ; 2.71; 95% CI 1.16-6.30; P=0.021, HO; 5.76; 95% CI 1.30-25.4; P=0.021). The H-PaO 2 and HO were also associated with poor 30-day survival (adjusted OR, H-PaO 2 ; 2.28; 95% CI 1.13-4.60; P=0.021, HO; 3.75; 95% CI 1.28-11.0; P=0.016). Conclusions: Hyperoxemia was associated with worse neurological outcomes in OHCA patients with ECPR.

Background: Extracorporeal CPR (E-CPR) has been utilized as a rescue strategy for cardiac arrest (CA) patients unresponsive to conventional CPR. Although the time from cardiac arrest to starting extracorporeal membrane oxygenation (ECMO) is known as a predictor for a good outcome, the opportunities to establish the E-CPR initiation flow are limited. Objective: We developed a protocol for the E-CPR simulation program and investigated whether the faster deployment of ECMO improves the neurological outcome and mortality in patients with refractory CA. Methods: In this single-center observational study, we enrolled 140 consecutive patients who received E-CPR from January 2012 to May 2020. E-CPR simulation training was carried out twice a year with the participation of doctors and co-medicals using a mock vascular model to practice ECMO cannulation and initiation since October 2017. 86 patients received E-CPR in the pre-simulation period (from January 2012 to September 2017), and 54 received in the post-simulation period (October 2017 to May 2020). We assessed the 30-day survival rate and the rate of the Cerebral Performance Category grades 1 and 2 as favorable neurological prognosis. Results: No significant difference in age, the rate of the male sex, witnessed CA, by-stander CPR, shockable rhythm at the initial contact, acute coronary syndrome (ACS) as a cause of CA, and out of hospital CA (OHCA). The collapse to ECMO placement time (CTET) was significantly shorter in the post-simulation group compared to the pre-simulation group (44 min [IQR; 27-74] vs. 32 min [IQR; 15-46]; P&lt;0.01). The rate of 30-day survival and favorable neurological outcome was significantly higher in the Post-simulation group compared to the pre-simulation group (16% vs. 20%; P=0.02, 9% vs. 13%; p=0.03, respectively). Cox regression analysis including data on the age, male sex, OHCA, initial shockable rhythm, ACS, and CTET revealed that CTET was significantly associated with the 30-day mortality (HR for 5 minutes increase, 1.12 [95%CI; 1.07-1.16]; p&lt;0.01). Conclusion: A regular comprehensive simulation-based E-CPR training improves the 30-day mortality and the neurological outcome in patients with refractory CA as a result of the shortening of the ECMO deployment.

Extracorporeal cardiopulmonary resuscitation (ECPR) with extracorporeal membrane oxygenation is a more promising treatment for out-of-hospital cardiac arrest (OHCA) than conventional cardiopulmonary resuscitation (CCPR). However, previous studies that compared ECPR and CCPR included mixed groups of patients with or without target temperature management (TTM). In this study, we compared the neurological outcomes of OHCA between ECPR and CCPR with TTM in all patients. We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. Witnessed adult cases of cardiogenic OHCA treated with TTM were eligible for this study. We used univariate and multivariable analyses in all eligible patients to compare the neurological outcomes after ECPR or CCPR. We also conducted propensity score analyses of all patients and according to the interval from witnessed OHCA to reaching the target temperature (IWT) of ≤600, ≤480, ≤360, ≤240, and ≤120 minutes. We analyzed 1146 cases. The propensity score analysis did not show a significant difference in favorable neurological outcomes (defined as a Glasgow-Pittsburgh Cerebral Performance Category of 1-2 at 1 month after collapse) between EPCR and CCPR (odds ratio: OR 4.683 [95% confidence interval: CI 0.859-25.535], p = 0.747). However, ECPR was associated with more favorable neurological outcomes in patients with IWT of ≤600 minutes (OR 7.089 [95% CI 1.091-46.061], p = 0.406), ≤480 minutes (OR 10.492 [95% CI 1.534-71.773], p = 0.0168), ≤360 minutes (OR 17.573 [95% CI 2.486-124.233], p = 0.0042), ≤240 minutes (OR 38.908 [95% CI 5.045-300.089], p = 0.0005), and ≤120 minutes (OR 200.390 [95% CI 23.730-1692.211], p < 0.001). This study revealed significant differences in the neurological outcomes between ECPR and CCPR in patients with TTM whose IWT was ≤600 minutes.

BackgroundTarget temperature management (TTM) is an effective component of treating out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation in conventional cardiopulmonary resuscitation. However, therapeutic hypothermia (32–34 °C TTM) is not recommended based on the results of recent studies. Extracorporeal cardiopulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation is another promising therapy for OHCA, but few studies have examined the effectiveness of ECPR with TTM. Therefore, we hypothesized that ECPR with TTM could have the effectiveness to improve the neurological outcomes for adults following witnessed OHCA, in comparison to ECPR without TTM.MethodsWe performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. We focused on adults who underwent ECPR for witnessed OHCA. We performed univariate (the Mann–Whitney U test and Fisher’s exact test), multivariable (logistic regression analyses), and propensity score analyses (the inverse probability of the treatment-weighting method) with to compare the neurological outcomes between patients with or without TTM, among all eligible patients, patients with a cardiogenic cause, and patients divided into subgroups according to the interval from collapse to pump start (ICPS) (> 30, > 45, or > 60 min).ResultsWe analyzed data for 977 patients. Among 471 patients treated with TTM, the target temperature was therapeutic hypothermia in 70%, and the median interval from collapse to target temperature was 249 min. Propensity score analysis showed a positive association between TTM and favorable neurological outcomes in all patients (odds ratio 1.546 [95% confidence interval 1.046–2.286], P = 0.029), and in patients with ICPS of > 30 or > 45 min, but not in those with ICPS of > 60 min. The propensity score analysis also showed a positive association between TTM and favorable neurological outcomes in patients with a cardiogenic cause (odds ratio 1.655 [95% confidence interval 1.096–2.500], P = 0.017), including in all ICPS subgroups (> 30, > 45, and > 60 min).ConclusionWithin patients who underwent ECPR following OHCA, ECPR with TTM could show the potential of improvement in the neurological outcomes, compared to ECPR without TTM.

trauma T he American Heart Association Resuscitation Science Symposium (ReSS) was held virtually from November 13 to 15, 2021. This report summarizes ReSS programming, including awards, special sessions, and workshops and scientific content organized by topic (ie, intra-arrest and postarrest care) and plenary session. Subsequent sections include special circumstances of arrest, survivorship, and new developments in mechanical circulatory support. Lastly, selected abstracts and laboratory science are summarized before a concluding year in review.

Hyperoxemia is Associated With Poor Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Rescued by Extracorporeal Cardiopulmonary Resuscitation: Insight From the Nationwide Multicenter Observational JAAM-OHCA (Japan Association for Acute Medicine) Registry

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used for cardiac arrest patients when conventional CPR is ineffective. While VA-ECMO sustains systemic perfusion, it also increases left ventricular (LV) afterload. The recent introduction of the transcatheter LV assist device, Impella, suggests benefits from its combination with VA-ECMO (ECPELLA), but the effectiveness of ECPELLA in E-CPR is still under investigation. Objective: This single-site cohort study aimed to evaluate the impact of ECPELLA versus VA-ECMO combined with intra-aortic balloon pump (IABP) in patients undergoing E-CPR. Method: We performed a retrospective review of 212 consecutive patients who underwent E-CPR at our institute from January 2012 to December 2023. After excluding 61 patients who received VA-ECMO alone, 151 patients were included in the study. These patients were divided into two groups: 67 in the ECPELLA group and 84 in the VA-ECMO with IABP group. We assessed the 90-day survival rate and favorable neurological outcomes, defined as a Cerebral Performance Categories (CPC) score of 1 or 2. Results: No significant differences were noted between the two groups regarding age, male ratio, coronary risk factors, initial shockable rhythm, acute coronary syndrome (ACS), out-of-hospital cardiac arrest (OHCA), and initial lactate levels. The ECPELLA group exhibited a significantly shorter time from cardiac arrest to VA-ECMO placement, known as low flow time (LFT) (35 min [IQR: 18-56] vs. 48 min [IQR: 24-73]; P=0.01), higher total MCS flow, and reduced catecholamine use during the first 72 hours, compared to the VA-ECMO with IABP group. Survival rates and favorable neurological outcomes at hospital discharge were significantly higher in the ECPELLA group (39% vs. 17%, P=0.002; 27% vs. 12%, P=0.02, respectively). The 90-day all-cause mortality was significantly lower in the ECPELLA group (P=0.003 by log-rank test). Multivariate Cox proportional hazard analysis, including age, shockable rhythm, ACS, OHCA, LFT, and ECPELLA, indicated that age (hazard ratio [HR] 1.02, 95% CI 1.01-1.04, P=0.004), LFT (HR 1.02, 95% CI 1.01-1.03, P&lt;0.001), and ECPELLA (HR 0.67, 95% CI 0.45-0.99, P=0.046) were significantly associated with 90-day all-cause mortality. Conclusion: ECPELLA was associated with improved 90-day mortality rates and neurological outcomes in patients who received E-CPR.

Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis

It remains unclear whether extracorporeal cardiopulmonary resuscitation (ECPR) could improve neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) compared with conventional cardiopulmonary resuscitation (CCPR). We conducted a systemic search for randomized controlled trials (RCTs) comparing the efficacy of ECPR versus CCPR for OHCA until February 2023. The main end points were 6-month survival, and 6-month and short-term (in-hospital or 30-day) survival with favorable neurological outcome, defined as a Glasgow-Pittsburg cerebral performance category (CPC) score of 1 or 2. We identified four RCTs including a total of 435 patients. In the included RCTs, the initial cardiac rhythms were ventricular fibrillation in most cases (75%). There was a tendency towards improved 6-month survival and 6-month survival with favorable neurological outcome in ECPR although it did not reach statistical significance [odds ratio (OR): 1.50; 95% confidence interval (CI): 0.67 to 3.36, I2 = 50%, and OR: 1.74; 95% CI: 0.86 to 3.51, I2 = 35%, respectively]. ECPR was associated with a significant improvement in short-term favorable neurological outcomes without heterogeneity (OR: 1.84; 95% CI: 1.14 to 2.99, I2 = 0%). Our meta-analysis of RCTs revealed that there was a tendency towards better mid-term neurological outcomes in ECPR and that ECPR was associated with a significant improvement in short-term favorable neurological outcomes compared with CCPR.

BackgroundThe prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR.MethodsWe included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002–2011.ResultsA total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n = 1285, 92%) or with refractory OHCA (n = 108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5–9] vs. 7 [5–10] min, p = 0.8; ROSC, 15 [9–22] vs. 27 [20–41] min, p < 0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2–5.8]; p < 0.001), witnessed OHCA (OR, 3.7 [2.0–7.1]; p < 0.001), shockable rhythm (OR, 3.0 [1.9–4.7]; p < 0.001), younger age (OR, 1.2 [1.1–1.2]; p < 0.001), and later calendar year (OR, 1.4 [1.2–1.6]; p < 0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p < 0.001). Four of 28 refractory OHCA patients with duration of resuscitation > 60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p = 0.7).ConclusionsSurvival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.

Signs of life (SOLs) during cardiac arrest (gasping, pupillary light reaction, or any form of body movement) are suggested to be associated with favorable neurologic outcomes in out-of-hospital cardiac arrest (OHCA). While data has demonstrated that extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in cases of refractory cardiac arrest, it is expected that other contributing factors lead to positive outcomes. This study aimed to investigate whether SOL on arrival is associated with neurologic outcomes in patients with OHCA who have undergone ECPR. Retrospective multicenter registry study. Thirty-six facilities participating in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan II (SAVE-J II). Consecutive patients older than 18 years old who were admitted to the Emergency Department with OHCA between January 1, 2013, and December 31, 2018, and received ECPR. None. Patients were classified into two groups according to the presence or absence of SOL on arrival. The primary outcome was a favorable neurologic outcome (Cerebral Performance Category 1 or 2) at discharge. Of the 2157 patients registered in the SAVE-J II database, 1395 met the inclusion criteria, and 250 (17.9%) had SOL upon arrival. Patients with SOL had more favorable neurologic outcomes than those without SOL (38.0% vs. 8.1%; p < 0.001). Multivariate analysis showed that SOL on arrival was independently associated with favorable neurologic outcomes (odds ratio, 5.65 [95% CI, 3.97-8.03]; p < 0.001). SOL on arrival was associated with favorable neurologic outcomes in patients with OHCA undergoing ECPR. In patients considered for ECPR, the presence of SOL on arrival can assist the decision to perform ECPR.