Pediatric ECPR as Bridge to Surgery: Successful Management of Refractory Cardiac Arrest in High‐Risk ICD Lead Extraction

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

BackgroundThe potential benefit of extracorporeal cardiopulmonary resuscitation (ECPR) compared to conventional CPR (CCPR) for patients with refractory cardiac arrest (CA) remains unclear.MethodsThis study is a retrospective analysis of a prospective database of CA patients, which includes all consecutive adult patients admitted to the Department of Intensive Care after CA between January 2012 and December 2017. The decision to initiate ECPR was made by the attending physician and ECPR performed by the ECPR team, which is composed of ICU physicians. A propensity score was derived using a logistic regression model, including characteristics that varied between groups with a p < 0.10 and were potentially related to outcome. Primary outcomes were survival to ICU discharge and favorable 3-month neurologic outcome, assessed by a Cerebral Performance Category (CPC) score of 1–2.ResultsFrom a total of 635 patients with CA during the study period (ECPR, n = 112), 80 ECPR patients were matched to 80 CCPR patients. The time from arrest to termination of CPR (i.e., return of spontaneous circulation [ROSC], extracorporeal membrane oxygenation [ECMO] initiation, or death) was 54 ± 22 and 54 ± 19 min in the ECPR and CCPR groups, respectively. ROSC rates were 77/80 (96%) for ECPR and 30/80 (38%) for CCPR (p < 0.001). Survival to ICU discharge was 18/80 (23%) vs. 14/80 (18%) in the ECPR and CCPR groups, respectively (p = 0.42). At 3 months, 17/80 (21%) ECPR patients and 9/80 (11%) CCPR patients had a favorable outcome (p = 0.11). Cox regression analysis stratified by matched pairs showed a significantly higher neurologic outcome rate in the ECPR group than in the CCPR group (log-rank test p = 0.003).ConclusionsECPR after CA may be associated with improved long-term neurological outcome.

42 Improving Patient Selection in International Pediatric ECPR Cohorts

Introduction: Prolonged chest compression (CC) pauses in cardiopulmonary resuscitation (CPR) are associated with worse survival during in-hospital cardiac arrests. Procedures necessary to gain access for extracorporeal CPR (ECPR) can potentially prolong CC pauses during extracorporeal membrane oxygenation (ECMO) cannulation. Implementation of targeted quality improvement initiatives to improve team communication may reduce CC pauses during pediatric ECPR. Methods: Baseline data from a pediatric intensive care unit (PICU) in a tertiary care children’s hospital demonstrated significantly longer CC pauses and lower CC fraction (CCF) during ECMO cannulation when compared to similar metrics pre-cannulation. An intervention designed to improve CC metrics during ECPR was implemented, including: 1. Sharing of baseline CC data with ECPR stakeholders 2. Standardization of counting CC pauses out loud to improve team awareness of pause length 3. Creation of a reporting aid to assist with ECPR documentation and 4. Interdisciplinary ECPR simulation sessions every other month to practice communication during cannulation. CC pause characteristics were compared pre- and post- intervention using unpaired t-tests. Results: Eleven ECPRs were analyzed pre-intervention and five ECPRs post-intervention. CC pause characteristics (mean duration of pauses, individual longest pause, and CCF) improved in both pre- and during ECMO cannulation epochs post-intervention when compared to their pre-intervention counterparts. During ECMO cannulation, mean length of CC pauses was 30 seconds (pre-intervention) vs 13 seconds (post-intervention) (p < 0.02). The longest CC pause during ECMO cannulation was 337 seconds (pre-intervention) compared with 69 seconds (post-intervention) (p = 0.03). CCF during ECMO cannulation pre-intervention and post-intervention was 68% vs 83% respectively (p = 0.03). Conclusions: CC pause metrics during the cannulation phase of pediatric ECPR improved significantly after quality improvement interventions including baseline CC data review, verbal communication of CC pause length and interdisciplinary ECPR simulations. Future aims include correlating CC pause characteristics with clinical outcomes.

Extracorporeal membrane oxygenation, ECMO, cardiac arrest, refractory cardiac arrest, V fib, ventricular fibrillation, CPR, cardiopulmonary resuscitation, ECPR, extracorporeal cardiopulmonary resuscitation, ACLS, advanced cardiac life support, HOCM, hypertrophic obstructive cardiomyopathy, critical care, emergency medicine.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. Quaternary care children's hospital. Pediatric patients undergoing ECPR. None. Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

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.

Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pediatric patients with refractory cardiac arrest

Post-cardiac arrest survivals remain low despite the effort of cardiopulmonary resuscitation. Utilization of extracorporeal membrane oxygenation during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation) can provide immediate cardiovascular support and potentially improve outcomes of patients with cardiac arrest requiring cardiopulmonary resuscitation. There is renewed interest in the use of extracorporeal cardiopulmonary resuscitation due to improved outcomes over the years. Extracorporeal membrane oxygenation data between 2010 and 2018 were reviewed. Patients with extracorporeal membrane oxygenation placed under cardiopulmonary resuscitation were identified, and demographics, extracorporeal membrane oxygenation survival, survival to discharge, and neurological recovery were retrospectively analyzed with institutional review board approval. Among 230 cases of extracorporeal membrane oxygenation, 34 (21 males and 13 females, age of 49 ± 13 years) underwent extracorporeal cardiopulmonary resuscitation. The mean duration of extracorporeal membrane oxygenation support after extracorporeal cardiopulmonary resuscitation was 8.3 ± 7.9 days. Extracorporeal membrane oxygenation mortality among extracorporeal cardiopulmonary resuscitation patients was 32% (11/34) and hospital survival was 38% (13/34), which are similar to standard cardiac extracorporeal membrane oxygenation (extracorporeal membrane oxygenation survival 62% and hospital survival 39% in cardiac extracorporeal membrane oxygenation). Among the extracorporeal membrane oxygenation death after extracorporeal cardiopulmonary resuscitation, the majority was due to neurological injury (73%, 8/11); 8/34 extracorporeal membrane oxygenation survival rate and 30-day survival rate were 63% and 25% in early half of study (2010-2014) and have improved to 70% and 60% in late half of study (2014-2018). Over years of experience with extracorporeal membrane oxygenation, the outcome of the extracorporeal cardiopulmonary resuscitation has been improving and appears to exceed those of traditional methods, despite limited sample size. Neurological complications still need to be addressed in order for survival and outcomes to improve.

Background: Prolonged conventional cardiopulmonary resuscitation (C-CPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to C-CPR. However, the indication and optimal duration to switch from C-CPR to E-CPR are not well established. In addition, the opportunities to develop teamwork skills and expertise to mitigate risks are few. We thus developed the implementation protocol for the E-CPR simulation program, and investigated whether the faster deployment of extracorporeal membrane oxygenation (ECMO) improves the neurological outcome in patients with refractory OHCA. Methods: A total of 42 consecutive patients (age 58±16 years, male ratio 90%, and initial shockable rhythm 64%) received E-CPR (3% of OHCA) during the study period. Among them, 32 (76%) were deployed ECMO during the pre-intervention time period (Pre: from January 2012 to September 2017), whereas 10 (24%) were deployed during the post-intervention time period (Post: October 2017 to May 2019). We compared the door to E-CPR time, collapse to E-CPR time, 30-day mortality, and favorable neurological outcome (Cerebral Performance Categories 1, 2) between the two periods. Results: There was no significant difference in age, the rates of male sex and shockable rhythm, and the time form collapse to emergency room admission between the two periods. The door to E-CPR time and the collapse to E-CPR time were significantly shorter in the post-intervention period compared to the pre-intervention period (Pre: 39 min [IQR; 30-50] vs. Post: 29 min [IQR; 22-31]; P=0.007, Pre: 76 min [IQR; 58-87] vs. Post: 59 min [IQR; 44-68]; P=0.02, respectively). The 30-day mortality was similar between the two periods (Pre: 88% vs. Post: 80%; P=0.6). In contrast, the rate of favorable neurological outcome at the time of discharge was significantly higher in post-intervention period (Pre: 0% vs. Post: 20%; P=0.01) compared to the pre-intervention period. Conclusion: A comprehensive simulation-based training for E-CPR seems to improve the neurological outcome in patients with refractory OHCA patients.

Feasibility of extracorporeal membrane oxygenation cardiopulmonary resuscitation by low volume centers in Belgium.

Background: Pediatric extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly utilized for cardiac arrests that do not respond to standard cardiopulmonary resuscitation (CPR), although multicenter data on outcomes remain scarce.This study evaluated trends, outcomes, and factors associated with survival in pediatric ECPR over a 10-year period.Methods: This multicenter retrospective study was conducted across 12 centers from 2012 to 2021.It included pediatric patients (<18 years) who underwent ECPR.Data were analyzed for period 1 (2012-2016) and period 2 (2017-2021), focusing on survival outcomes and factors associated with mortality.Results: Out of 754 extracorporeal membrane oxygenation (ECMO) cases, 206 (27.3%) involved ECPR.The number of annual ECPR cases decreased from 114 in period 1 to 92 in period 2. The survival rates to hospital discharge improved from 28.1% in period 1 to 34.8% in period 2, with notable improvements in post-cardiotomy survival (23.9% to 43.2%, p=0.032).Cardiac indications were the most common (93.2%), with 53.9% categorized as post-cardiotomy ECMO and 39.3% as cardiac-medical ECMO, the latter showing an increase over time.Among non-survivors, 62.7% died from incurable primary diseases, and 17.6% from hypoxic brain injury or cerebral edema.The median CPR duration before ECMO initiation was 60 minutes.Higher survival rates were observed for CPR durations 30 minutes (47.4% vs. 27.4%,p=0.016) and 60 minutes (38.0% vs. 23.4%,p=0.025).Dialysis for acute kidney injury, especially in post-cardiotomy cases, significantly increased the risk of mortality (p<0.001).Conclusion: Over the past decade, pediatric ECPR has demonstrated improved survival trends, particularly in post-cardiotomy cases.However, outcomes remain challenging.Early initiation of ECMO and optimized management are essential for increasing survival rates.

Extracorporeal cardiopulmonary resuscitation for acute aortic dissection during cardiac arrest: A nationwide retrospective observational study

To determine if development of an extracorporeal cardiopulmonary resuscitation simulation program reduced extracorporeal cardiopulmonary resuscitation times in real patients : Before-after study. Twenty-six bed pediatric cardiac ICU in a tertiary urban hospital. Forty-three cardiac patients (aged 1 d to 16 yr) who received extracorporeal cardiopulmonary resuscitation. An interdisciplinary team collaborated to define the roles and clarify responsibilities of each individual involved in extracorporeal cardiopulmonary resuscitation. An "ideal rapid deployment" was defined and tested using simulation sessions. This included a task analysis, role creation, and multidisciplinary simulations, including structured debriefings and video review and the creation of a master checklist. There were a total of 43 episodes of extracorporeal cardiopulmonary resuscitation during the study period, 16 (37%) of which occurred during the preintervention time period (from February 2009 to March 2010) and 27 (63%) during the postintervention time period (April 2010 to March 2013). The median deployment time in the preintervention time period was 51 minutes (interquartile range, 43-62 min), whereas the median deployment time in the postintervention time period was 40 minutes (interquartile range, 23-52 min) (p = 0.018). There are no standard guidelines of how a team should coordinate the efforts of nursing, physicians, extracorporeal membrane oxygenation specialists, surgeons, respiratory therapists, patient care technicians, and unit clerks to emergently execute this complex procedure. Because time is of the essence, it is essential to develop a highly functioning and well-coordinated team with a standardized method of the procedure, its documentation, and communication. Simulation accomplished this for our program. Following these simulation exercises, not only was there a subjectively observed improved coordination and smoother deployment of extracorporeal membrane oxygenation in real-life extracorporeal cardiopulmonary resuscitation, but we have also demonstrated a significantly faster deployment of extracorporeal membrane oxygenation as compared with the presimulation era.