Conventional Conventional Cardiopulmonary Resuscitation Research Articles

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: an overview of current practice and evidence.

Cardiac arrest (CA) is acommon and potentially avoidable cause of death, while constituting asubstantial public health burden. Although survival rates for out-of-hospital cardiac arrest (OHCA) have improved in recent decades, the prognosis for refractory OHCA remains poor. The use of veno-arterial extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) is increasingly being considered to support rescue measures when conventional cardiopulmonary resuscitation (CPR) fails. ECPR enables immediate haemodynamic and respiratory stabilisation of patients with CA who are refractory to conventional CPR and thereby reduces the low-flow time, promoting favourable neurological outcomes. In the case of refractory OHCA, multiple studies have shown beneficial effects in specific patient categories. However, ECPR might be more effective if it is implemented in the pre-hospital setting to reduce the low-flow time, thereby limiting permanent brain damage. The ongoing ON-SCENE trial might provide adefinitive answer regarding the effectiveness of ECPR. The aim of this narrative review is to present the most recent literature available on ECPR and its current developments.

Abstract 243: Comparing the Effectiveness of Extracorporeal and Conventional Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: An Updated Systematic Review and Meta-Analysis

Background: Cardiac arrest is a leading cause of death worldwide, with out-of-hospital cardiac arrest (OHCA) presenting unique challenges in terms of timely and effective treatment. Conventional Cardiopulmonary Resuscitation (CPR) remains the standard intervention; however, the emerging use of Extracorporeal Cardiopulmonary Resuscitation (ECPR) and its potential for superior hemodynamic support necessitates a comprehensive comparison of these interventions in the context of OHCA to guide resuscitation practices. Aim: This study aims to compare ECPR and conventional CPR in patients experiencing OHCA. Methods: We searched several databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) until May 2023. Studies that compared ECPR and conventional CPR in OHCA were included in the analysis. The outcomes assessed included in-hospital mortality following admission, return of spontaneous circulation (ROSC), 30-day mortality, and positive neurological recovery at discharge. Data analysis was performed using a random-effects model, with Relative Risk (RR) computed for each outcome. All statistical analyses were performed using R software (version 4.0.3) with metafor and meta packages. Results: We included a total of 5 studies totaling 8,632 patients (4,315 in the ECPR group and 4,317 in the conventional CPR group). The analysis revealed no significant difference between ECPR and conventional CPR in terms of in-hospital mortality (RR 0.95, 95% Confidence Interval (CI) 0.88 to 1.03, P=0.19, I2=60%) and ROSC (RR 1.01, 95% CI 0.97 to 1.05, P=0.58, I2=0%). However, ECPR was associated with a significant reduction in 30-day mortality (RR 0.93, 95% CI 0.91 to 0.95, P<0.01, I2=0%). No significant improvement was found in positive neurological recovery at discharge with ECPR compared to conventional CPR (RR 1.25, 95% CI 0.80 to 1.93, P=0.33, I2=16%). Conclusion: This study highlights the potential of ECPR in reducing 30-day mortality compared to conventional CPR in OHCA cases, although its effectiveness in other outcomes, such as in-hospital mortality and neurological recovery, remains inconclusive. Given the observed heterogeneity among the studies, further high-quality studies are needed.

Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature.

The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.

Association between Case Volumes of Extracorporeal Life Support and Clinical Outcome in Out-of-Hospital Cardiac Arrest

Aim Extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) is increasing. There is little evidence identifying the association between hospital ECLS case volumes and outcomes in different populations receiving ECLS or conventional cardiopulmonary resuscitation (CPR). The goal of this investigation was to identify the association between ECLS case volumes and clinical outcomes of OHCA patients. Methods This cross-sectional observational study used the National OHCA Registry for adult OHCA cases in Seoul, Korea between January 2015 and December 2019. If the ECLS volume during the study period was >20, the institution was defined as a high-volume ECLS center. Others were defined as low-volume ECLS centers. Outcomes were good neurologic recovery (cerebral performance category 1 or 2) and survival to discharge. We performed multivariate logistic regression and interaction analyses to assess the association between case volume and clinical outcome. Results Of the 17,248 OHCA cases, 3,731 were transported to high-volume centers. Among the patients who underwent ECLS, those at high-volume centers had a higher neurologic recovery rate than those at low-volume centers (17.0% vs. 12.0%), and the adjusted OR for good neurologic recovery was 2.22 (95% confidence interval (CI): 1.15–4.28) in high-volume centers compared to low-volume centers. For patients who received conventional CPR, high-volume centers also showed higher survival-to-discharge rates (adjusted OR of 1.16, 95%CI: 1.01–1.34). Conclusions High-volume ECLS centers showed better neurological recovery in patients who underwent ECLS. High-volume centers also had better survival-to-discharge rates than low-volume centers for patients not receiving ECLS.

Refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta-analysis of randomized trials.

In adults with refractory out-of-hospital cardiac arrest, when conventional cardiopulmonary resuscitation (CPR) alone does not achieve return of spontaneous circulation, extracorporeal CPR is attempted to restore perfusion and improve outcomes. Considering the contrasting findings of recent studies, we conducted a meta-analysis of randomized controlled trials to ascertain the effect of extracorporeal CPR on survival and neurological outcome. Pubmed via MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched up to February 3, 2023, for randomized controlled trials comparing extracorporeal CPR versus conventional CPR in adults with refractory out-of-hospital cardiac arrest. Survival with a favorable neurological outcome at the longest follow-up available was the primary outcome. Among four randomized controlled trials included, extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome at the longest follow-up available for all rhythms (59/220 [27%] vs. 39/213 [18%]; OR=1.72; 95% CI, 1.09-2.70; p=0.02; I2 = 26%; number needed to treat of 9), for initial shockable rhythms only (55/164 [34%] vs. 38/165 [23%]; OR=1.90; 95% CI, 1.16-3.13; p=0.01; I2 = 23%; number needed to treat of 7), and at hospital discharge or 30 days (55/220 [25%] vs. 34/212 [16%]; OR=1.82; 95% CI, 1.13-2.92; p=0.01; I2 = 0.0%). Overall survival at the longest follow-up available was similar (61/220 [25%] vs. 34/212 [16%]; OR=1.82; 95% CI, 1.13-2.92; p=0.59; I2 = 58%). Extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome in adults with refractory out-of-hospital cardiac arrest, especially when the initial rhythm was shockable. PROSPERO CRD42023396482.

Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: An interrupted time series analysis

AimIn this study, we examine the impact of a trauma-focused resuscitation protocol on survival outcomes following adult traumatic out-of-hospital cardiac arrest (OHCA). MethodsWe included adult traumatic OHCA patients aged >16 years occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation (CPR). The effect of the new protocol on survival outcomes was assessed using adjusted interrupted time series regression. ResultsOver the study period, paramedics attempted resuscitation on 996 patients out of 3,958 attended cases. Of the treated cases, 672 (67.5%) and 324 (32.5%) occurred during pre-intervention and intervention periods, respectively. The frequency of almost all trauma interventions was significantly higher in the intervention period, including external haemorrhage control (15.7% vs 7.6; p-value <0.001), blood administration (3.8% vs 0.2%; p-value <0.001), and needle thoracostomy (75.9% vs 42.0%; p-value <0.001). There was also a significant reduction in the median time from initial patient contact to the delivery of needle thoracostomy (4.4 min vs 8.7 min; p-value <0.001) and splinting (8.7 min vs 17.5 min; p-value = 0.009). After adjustment, the trauma-focused resuscitation protocol was not associated with a change in the level of survival to hospital discharge (adjusted odds ratio [AOR] 0.98; 95% confidence interval [CI]: 0.11−8.59), event survival (AOR 0.82; 95% CI: 0.33–2.03), or prehospital return of spontaneous circulation (AOR 1.30; 95% CI: 0.61–2.76). ConclusionDespite an increase in trauma-based interventions and a reduction in the time to their administration, our study did not find a survival benefit from a trauma-focused resuscitation protocol over initial conventional CPR. However, survival was low with both approaches.

ECMO in Cardiac Arrest: A Narrative Review of the Literature.

Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Variations in chest compression time, ventilation time and rescuers' heart rate during conventional cardiopulmonary resuscitation in trained male rescuers.

ObjectiveThis study was conducted to determine why rescuers could maintain adequate chest compression depth for longer periods during conventional cardiopulmonary resuscitation (CPR).MethodsVarious CPR parameters, including average compression depth (ACD), average compression rate, average ventilation time (AVT), and rescuers’ heart rates were recorded in real-time when 20 health care providers performed 10 minutes of conventional CPR during a simulation experiment.ResultsThe ACD was maintained above 50 mm and was not significantly different during 19 consecutive CPR cycles. The average compression rate increased from 114.9±10.0/min (2nd cycle) to 120.1±13.8/min (18th cycle) (P=0.007), and the AVT increased from 8.7±1.5 seconds (3rd cycle) to 10.1±2.6 seconds (18th cycle) (P=0.002). The rescuers’ heart rates also increased gradually for 10 min; however, they increased rapidly and were highest during the ventilation phase. Their heart rates then decreased and were lowest during the early chest compression phases of each CPR cycle. Decreases in heart rates were significant in all CPR cycles (average decrease: 14.5±4.5 beats/min, P<0.001).ConclusionThe ACD was maintained adequately during 10 minutes of conventional CPR. However, the AVT increased significantly during the 10-minute period. The rescuers’ heart rates increased and decreased throughout all CPR cycles. These results showed that the ventilation phase might play a role as a resting period and be a reason for the maintenance of adequate chest compression depth for prolonged periods during conventional CPR.

Abstract 171: Developing an ECPR Program for Out of Hospital Cardiac Arrest

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a novel treatment for cardiac arrest that is refractory to conventional cardiopulmonary resuscitation (CPR). As part of a quality improvement initiative we sought to develop a program at our institution. Hypothesis: ECPR is a feasible and effective alternative means of resuscitation for patients in refractory cardiac arrest. Methods: We developed a multidisciplinary ECPR team consisting of staff from Emergency Medical Services (EMS), Emergency Department, Cardiology, Cardiac Surgery and Critical Care Medicine. Patients with an out of hospital cardiac arrest (OHCA) refractory to medical treatment were identified by EMS and brought to our institution if they met our program selection criteria. The patient was cannulated in the Emergency Department or Catheterization Laboratory, then underwent coronary angiogram with intervention if applicable and was transferred to cardiothoracic intensive care unit (ICU) for further care. Results: From October 1 st 2015 to March 31 st 2018, a total of 1165 out of hospital cardiac arrests occurred, of which five met criteria for our study. Median age was 47 [IQR 32-53] and four were men. Most common arrest rhythm was VF (80%), one patient had ST elevation on EKG. Time from arrest to initiation of ECMO was 63 [IQR 59-69] min with 5 [IQR 3-6] defibrillations and 6 [IQR 6-7] doses of epinephrine administered. Four patients were successfully cannulated (80%). Cannulation time was 21 [IQR 16-33] min, with one patient achieving ROSC during cannulation. All patients underwent angiography, with two patients receiving coronary intervention (40%). ECMO duration was 48 [IQR 38-68] hours and length of stay was 2 [IQR 2-8] days. All patients had an initial Pittsburgh Cardiac Arrest Category of 4. Two patients (40%) survived to hospital discharge with good neurologic function. Conclusions: ECPR is a potentially life-saving alternative treatment to conventional CPR that is feasible in our patient population.

Clinical application of abdominal lifting and compression cardiopulmonary resuscitation method for treatment of patients with cardiac arrest

To investigate the clinical application of rhythmic abdominal lifting and compression cardiopulmonary resuscitation (ALC-CPR) in cardiac arrest (CA) patients with conventional cardiopulmonary resuscitation (CPR) contraindication (chest rib fracture, chest trauma, etc.). The clinical data of patients with CA in emergency department of Hefei Second People's Hospital from June 2015 to December 2016 were analyzed retrospectively, and the patients with weights 40-150 kg and CA≤20 minutes, and resuscitated with ALC-CPR were selected. The vital signs and blood gas analysis indexes of patients before resuscitation and 30 minutes after return of spontaneous circulation (ROSC, after successful resuscitation) were recorded. A total of 19 patients with CA were treated with CPR-LW1000 type ALC-CPR apparatus for resuscitation, and with 12 males, 7 females; the age ranged from 43 to 87 years, and the average age was (70.32±13.49) years; there were 4 cases of heart disease, and 15 cases of non-heart disease. Compared with before resuscitation, the heart rate [HR (bpm): 115.05±21.70 vs. 0], mean arterial pressure [MAP (mmHg, 1 mmHg = 0.133 kPa): 66.05±11.69 vs. 0], pulse oxygen saturation (SpO2: 0.928±0.057 vs. 0.417±0.118), pH value (7.05±0.23 vs. 6.80±0.28), arterial oxygen partial pressure [PaO2 (mmHg): 65.42±19.11 vs. 42.42±10.78], HCO3- (mmol/L: 19.22±2.77 vs. 17.18±3.76) were significantly improved after successful resuscitation (all P < 0.05), and arterial blood carbon dioxide partial pressure (PaCO2) was decreased after successful resuscitation (mmHg: 53.72±13.23 vs. 57.66±14.86, P > 0.05). Rhythmic ALC-CPR has obvious clinical value for CA patients with conventional CPR contraindication.

ECPR in the cath lab

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is the rapid deployment of extracorporeal membrane oxygenation (ECMO) – or cardiopulmonary bypass – to provide immediate cardiovascular support for patients who have cardiac arrest unresponsive to conventional cardiopulmonary resuscitation (CPR) measures. There is improved survival with isolated cardiac lesions. 1 Cardiac disease (adjusted for confounding factors) was associated with improved survival when compared with non-cardiac diseases (odds ratio 6.3, 2.01–19.80). 2 Conventional CPR versus ECPR has a lower survival to discharge 8.2–22% and about 6–11% for critically ill patients. The survival of out-of-hospital cardiac arrest is less than 3%. 3 The long-term survival is 53% with ECPR versus 17% with conventional CPR. 4 ECPR in witnessed in-hospital cardiac arrest in areas of advanced life support system and effective CPR with single organ dysfunction with minimum time elapse in logistics like ECPR in cath lab is associated with much bet...

Extracorporeal membrane oxygenation for refractory cardiac arrest.

Extracorporeal cardiopulmonary resuscitation (ECPR) is the use of rapid deployment venoarterial (VA) extracorporeal membrane oxygenation to support systemic circulation and vital organ perfusion in patients in refractory cardiac arrest not responding to conventional cardiopulmonary resuscitation (CPR). Although prospective controlled studies are lacking, observational studies suggest improved outcomes compared with conventional CPR when ECPR is instituted within 30–60 min following cardiac arrest. Adult and pediatric patients with witnessed in-hospital and out-of-hospital cardiac arrest and good quality CPR, failure of at least 15 min of conventional resuscitation, and a potentially reversible cause for arrest are candidates. Percutaneous cannulation where feasible is rapid and can be performed by nonsurgeons (emergency physicians, intensivists, cardiologists, and interventional radiologists). Modern extracorporeal systems are easy to prime and manage and are technically easy to manage with proper training and experience. ECPR can be deployed in the emergency department for out-of-hospital arrest or in various inpatient units for in-hospital arrest. ECPR should be considered for patients with refractory cardiac arrest in hospitals with an existing extracorporeal life support program, able to provide rapid deployment of support, and with resources to provide postresuscitation evaluation and management.

Early Coronary Reperfusion Facilitates Return of Spontaneous Circulation and Improves Cardiovascular Outcomes After Ischemic Cardiac Arrest and Extracorporeal Resuscitation in Pigs.

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is widely proposed for the treatment of refractory cardiac arrest. It should be associated with coronary angiography if coronary artery disease is suspected. However, the prioritization of care remains unclear in this situation. Our goal was to determine whether coronary reperfusion should be instituted as soon as possible in such situations in a pig model.Methods and ResultsAnesthetized pigs were instrumented and submitted to coronary artery occlusion and ventricular fibrillation. After 5 minutes of untreated cardiac arrest, conventional cardiopulmonary resuscitation (CPR) was started. Fifteen minutes later, ECPR was initiated for a total duration of 240 minutes. Animals randomly underwent either early or late coronary reperfusion at 20 or 120 minutes of ECPR, respectively. This timing was adapted to the kinetic of infarct extension in pigs. Return of spontaneous circulation was determined as organized electrocardiogram rhythm with systolic arterial pressure above 80 mm Hg. During conventional CPR, hemodynamic parameters were not different between groups. Carotid blood flow then increased by 70% after the onset of ECPR in both groups. No animal (0 of 7) elicited return of spontaneous circulation after late reperfusion versus 4 of 7 after early reperfusion (P=0.025). The hemodynamic parameters, such as carotid blood flow, were also improved in early versus late reperfusion groups (113±20 vs 43±17 mL/min after 240 minutes of ECPR, respectively; P=0.030), along with infarct size decrease (71±4% vs 84±2% of the risk zone, respectively; P=0.013).ConclusionsEarly reperfusion improved hemodynamic status and facilitated return of spontaneous circulation in a porcine model of ischemic cardiac arrest treated by ECPR.

Abstract 14267: Clinical Characteristics of Patients With Out-of-hospital Cardiac Arrest Caused by Ventricular Fibrillation due to Acute Coronary Syndromes Who Responded to Extracorporeal Cardiopulmonary Resuscitation

Background: Extracorporeal cardiopulmonary resuscitation (ECRP) have been reported to be effective in patients with out-of-hospital cardiac arrest (OHCA) associated with an initial rhythm of ventricular fibrillation (VF) caused by acute coronary syndromes (ACS) refractory to conventional cardiopulmonary resuscitation (CPR). However, the clinical characteristics of patients who best respond to ECRP remain unclear. Methods: Between 2008 and 2012, we prospectively collected Utstein-style data at 46 institutions on 454 consecutive patients with OHCA aged 20 to 74 years had an initial rhythm of VF and arrived at the hospital within 45 minutes after the onset of cardiac arrest. They did not respond to conventional CPR given for more than 15 minutes after hospital arrival and received combination therapy with ECPR, percutaneous coronary intervention (PCI), intra-aortic balloon pumping (IABP), and therapeutic hypothermia (TH). ACS was diagnosed on emergency coronary angiography or clinical course in 133 patients. These patients were classified according to whether neurologic outcomes at 6 months, i.e., good outcome group (cerebral performance category [CPC] = 1 to 2) or poor outcome group (CPC = 3 to 5). Demographic characteristics were compared between two groups. Results: Among the 133 ACS patients given ECPR, good neurologic outcomes at 6 months in 14 (11%) patients, but not in 119 (89%) patients. There were no significant differences of age, the rate of witnessed arrest, bystander CPR, TH and time from hospital arrival to PCPS start between the 2 groups. Good outcome group had a shorter time from cardiac arrest to hospital arrival (24.9± 8.6 vs. 29.5± 10.1 min, p=0.03) and time from cardiac arrest to PCPS start (44 ± 8.8 vs. 53.7 ± 15.9 min, p=0.01) than poor outcome group. Conclusions: Our results suggest that shortening the interval from cardiac arrest until PCPS start, especially until hospital arrival, may improve neurologic outcomes in patients with refractory VF caused by ACS.

Resistance to conventional cardiopulmonary resuscitation in witnessed out-of-hospital cardiac arrest patients with shockable initial cardiac rhythm

BackgroundShockable initial cardiac rhythm is a key predictor of survival after out-of-hospital cardiac arrest (OHCA). However, not all patients with shockable OHCA achieve return of spontaneous circulation (ROSC) via conventional cardiopulmonary resuscitation (CPR). Therefore, we retrospectively analyzed patients with witnessed OHCA and shockable initial cardiac rhythm to identify the resistance factors for conventional CPR. MethodsWe retrospectively analyzed consecutive patients with witnessed OHCA and shockable initial cardiac rhythm who were admitted to our hospital between October 2009 and October 2014. We then compared the baseline characteristics, pre-hospital clinical course, and causes of the cardiopulmonary arrest among patients who achieved ROSC via conventional CPR and patients who did not achieve ROSC via conventional CPR and underwent extracorporeal CPR (ECPR). ResultsA total of 85 patients achieved ROSC via conventional CPR (non-ECPR group) and 40 patients did not achieve ROSC via conventional CPR and underwent ECPR (ECPR group). Among these 125 patients, 113 had known causes for their cardiopulmonary arrest, including 66 cases (53%) of acute myocardial infarction (AMI). There were no significant differences in the causes of arrest between the non-ECPR and ECPR cases. However, among the 66 cases of AMI (43 non-ECPR and 23 ECPR), the rate of non-recanalization during the initial coronary angiography was significantly higher among the ECPR cases (non-ECPR: 58% vs. ECPR: 87%; p=0.03). ConclusionsThe major cause of witnessed OHCA with shockable initial cardiac rhythm was AMI, and resistance to conventional CPR was related to continuous myocardial ischemia.

Outcome predictors in cardiopulmonary resuscitation facilitated by extracorporeal membrane oxygenation.

Cardiac arrest is the major cause of sudden death in developed countries. Extracorporeal cardiopulmonary resuscitation (ECPR) employs extracorporeal membrane oxygenation (ECMO) in patients without return of spontaneous circulation (ROSC) by conventional cardiopulmonary resuscitation (CPR). Aim of the current study was to assess short- and long-term outcome in patients treated with ECPR in our tertiary center and to identify predictors of outcome. We retrospectively collected data of all patients treated with ECPR at our institution from 2002 to 2013. Outcome was assessed according to patient records; good neurological outcome was defined as cerebral performance category 1 or 2. Quality of life data was collected using EQ-5 questionnaire. Uni- and multivariate analysis was applied to identify predictors of outcome. One-hundred and seventeen patients were included into the study. Weaning from ECMO was successful in 61 (52 %) patients. Thirty-day survival endpoint was achieved by 27 (23 %) patients. Good neurological outcome was present in 17 (15 %) patients. Multivariate analysis revealed baseline serum lactate as the strongest predictor of outcome, whereas age and out-of-hospital CPR did not predict outcome. The optimal lactate cut-off to discriminate outcome was determined at 4.6 mmol/l [HR 3.55 (2.29-5.49), p < 0.001, log-rank test]. ECPR represents a treatment option in patients without ROSC after conventional CPR rescuing 15 % of patients with good neurological outcome. Serum lactate may play a crucial role in patient selection for ECPR.

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution. MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n=40) or CPR plus extracorporeal CPR (E-CPR, n=20) were compared. ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90±49.6min vs 34.3±17.7min, p=0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p=0.0009), and good neurological function at discharge (40.0% vs 7.5%, p=0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p=0.1512) at discharge and (50% vs 20%, p=0. 0998) at 1 year after discharge. ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.

Venoarterial Extracorporeal Membrane Oxygenation in Adults With Cardiac Arrest.

Cardiac arrest (CA) is a major cause of morbidity and mortality worldwide. Despite the use of conventional cardiopulmonary resuscitation (CPR), rates of return of spontaneous circulation and survival with minimal neurologic impairment remain low. Utilization of venoarterial extracorporeal membrane oxygenation (ECMO) for CA in adults is steadily increasing. Propensity-matched cohort studies have reported outcomes associated with ECMO use to be superior to that of conventional CPR alone in in-hospital patients with CA. In this review, we discuss the mechanism, indications, complications, and evidence for ECMO in CA in adults.

Compressing with dominant hand improves quality of manual chest compressions for rescuers who performed suboptimal CPR in manikins

ObjectiveThe question of whether the placement of the dominant hand against the sternum could improve the quality of manual chest compressions remains controversial. In the present study, we evaluated the influence of dominant vs nondominant hand positioning on the quality of conventional cardiopulmonary resuscitation (CPR) during prolonged basic life support (BLS) by rescuers who performed optimal and suboptimal compressions. MethodsSix months after completing a standard BLS training course, 101 medical students were instructed to perform adult single-rescuer BLS for 8 minutes on a manikin with a randomized hand position. Twenty-four hours later, the students placed the opposite hand in contact with the sternum while performing CPR. Those with an average compression depth of less than 50 mm were considered suboptimal. ResultsParticipants who had performed suboptimal compressions were significantly shorter (170.2 ± 6.8 vs 174.0 ± 5.6 cm, P = .008) and lighter (58.9 ± 7.6 vs 66.9 ± 9.6 kg, P < .001) than those who performed optimal compressions. No significant differences in CPR quality were observed between dominant and nondominant hand placements for these who had an average compression depth of greater than 50 mm. However, both the compression depth (49.7 ± 4.2 vs 46.5 ± 4.1 mm, P = .003) and proportion of chest compressions with an appropriate depth (47.6% ± 27.8% vs 28.0% ± 23.4%, P = .006) were remarkably higher when compressing the chest with the dominant hand against the sternum for those who performed suboptimal CPR. ConclusionsChest compression quality significantly improved when the dominant hand was placed against the sternum for those who performed suboptimal compressions during conventional CPR.