Emergency Extracorporeal Life Support Research Articles

The efficacy of venous-arterial membrane oxygenation for emergency extracorporeal life support: results from a single-center large series over 6 years.

The efficacy of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in supporting cardio-pulmonary resuscitation for cardiac arrest is still debated. This study aimed to evaluate the outcome of patients treated with VA-ECMO positioned according to different clinical indications. The method is retrospective data analysis from patients admitted to a tertiary referral center for VA-ECMO in 6 years. The study population was divided into three groups based on the VA-ECMO indication: patients with refractory cardiac arrest (CA group), cardiogenic shock after return of spontaneous circulation (CS-ROSC group), and cardiogenic shock without cardiac arrest (CS group). Seventy-nine patients underwent emergency VA-ECMO, 49 patients (62.0%) were in the CA group, 14 (17.7%) in the CS-ROSC group, and 16 patients (20.3%) in the CS group. The overall survival at 28 days was different between the three groups (6.1% in the CA group, 64.2% in the CS-ROSC group, and 50.0% in the CS group, p < 0.001) and remained significant at 12months (p < 0.001). Furthermore, the Cerebral Performance Category at 12months differed between groups with good outcomes in 4.1% of patients in CA, 50.0% in CS-ROSC, and 31.2% in CS groups (p < 0.001). In the studied population, emergency VA-ECMO had negligible efficacy in refractory cardiac arrest, while it was correlated with a good outcome in cardiogenic shock after cardiac arrest, such as in cardiogenic shock alone. Patients with ROSC appear to benefit from VA-ECMO in the setting of persistent shock at rates comparable to cardiogenic shock patients who never sustained cardiac arrest.

The Efficacy of Venous-Arterial Membrane Oxygenation for Emergency Extracorporeal Life Support: Results from a Single-Center Large Series Over 6-Years

The Efficacy of Venous-Arterial Membrane Oxygenation for Emergency Extracorporeal Life Support: Results from a Single-Center Large Series Over 6-Years

ECPR and resuscitative ECMO: A detailed look at emergent extracorporeal life support

ECPR and resuscitative ECMO: A detailed look at emergent extracorporeal life support

Extracorporeal Life Support in Myocardial Infarction-Induced Cardiogenic Shock: Weaning Success

Outcome data of patients with acute myocardial infarction (AMI)-induced cardiogenic shock (CS) receiving extracorporeal life support (ECLS) are sparse. A consecutive series of 106 patients with AMI-induced CS receiving ECLS was evaluated regarding ECLS weaning success, hospital mortality, and long-term outcome. The Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) risk score was applied, and multivariable Cox regression analysis was performed. Mean patient age was 58.2 ± 11.2 years, and 78.3% were men. In 34 patients (32.1%), ECLS was implemented during ongoing cardiopulmonary resuscitation. De novo AMI was present in 58 patients (54.7%), and percutaneous coronary intervention complications were causative among 48 patients (45.3%). Multivessel coronary artery disease was diagnosed among 73.6% with mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) scores of 30.8 ± 4.8. Actuarial survival was 54.4% at 30 days, 42.2% at 1 year, and 38.0% at 5 years and was significantly higher among patients with low and intermediate IABP-SHOCK II risk scores at ECLS onset (log-rank P= .017). ECLS weaning with curative intention after a mean perfusion time of 6.6 ± 5.1 days was feasible in 51 patients (48.1%) and more likely among patients with complete revascularization (P= .026). Multivariable Cox regression analysis identified complete revascularization (hazard ratio, 2.38; 95% confidence interval, 1.1 to 5.1; P= .028) and absence of relevant mitral regurgitation at ECLS discontinuation (hazard ratio, 2.71; 95% confidence interval, 1.2 to 6.0; P= .014) to be associated with beneficial long-term survival after ECLS discontinuation. Emergency ECLS is a valuable option among patients with AMI-induced CS with low and intermediate IABP-SHOCK II risk scores. ECLS weaning is manageable, but additional revascularization of all nonculprit lesions is mandatory after ECLS implementation.

Emergency extracorporeal life support and ongoing resuscitation: a retrospective comparison for refractory out-of-hospital cardiac arrest

BackgroundIn refractory cardiac arrest, with cardiopulmonary resuscitation (CPR) for more than 30 min, chances of survival are small. Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for certain patients with cardiac...

Technical assist devices : Perspectives and new developments

The development of technical assist devices in the context of cardiopulmonary resuscitation (CPR) reaches back to the early roots of modern resuscitation research. This article covers the subjects of extracorporeal CPR (ECPR), including extracorporeal life support (ECLS), emergency ECLS (EECLS) and mechanical resuscitation devices. Specifically, the potential use of active compression-decompression CPR (ACD-CPR), impedance threshold devices (ITD) and capnography as additional measures during resuscitation are described in detail. Furthermore, the article presents acompact preview of the potential future developments of technical aids in the field of life support and postresuscitation care.

The incidence of “load&go” out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: A one-year review

BackgroundThe outcome of patients after out-of-hospital cardiac arrest (OHCA) is poor and gets worse after prolonged resuscitation. Recently introduced attempts like an early installed emergency extracorporeal life support (E-ECLS) in patients with persisting cardiac arrest at the emergency department (ED) are tried. The “Vienna Cardiac Arrest Registry” (VICAR) was introduced August 2013 to collect Utstein-style data. The aim of this observational study was to identify the incidence of patients which fulfil “load&go”-criteria for E-ECLS at the ED. MethodsVICAR was retrospectively analyzed for following criteria: age <75 years; witnessed OHCA; basic life support; ventricular fibrillation/ventricular tachycardia; no return-of-spontaneous-circulation (ROSC) within 15min of advanced-life-support, which were supposed as potential optimal criteria for “load&go” plus successful E-ECLS treatment at the ED. The observation period was from August 1, 2013 to July 31, 2014. ResultsOver 948 OHCA patients registered during the study period; data were exploitable for 864 patients. Of all patients, “load&go”-criteria were fulfilled by 55 (6%). However, 96 (11%) were transported with on-going CPR to the ED. Of these 96 patients, only 16 (17%) met the “load&go”-criteria. Similarly, among the 96 patients, 12 adults were treated with E-ECLS at the ED, with only 5 meeting the criteria. Among these 12 patients, favourable neurological outcome (CPC 1/2) was obtained in 1 patient without criteria. ConclusionFurther promotion of these criteria within the ambulance crews is needed. May be these criteria could serve as a decision support for emergency physicians/paramedics, which patients to transport with on-going CPR to the ED for E-ECLS.

Inverted-Takotsubo cardiomyopathy: severe refractory heart failure in poly-trauma patients saved by emergency extracorporeal life support.

The sequelae of severe poly-trauma may include myocardial dysfunction followed by acute heart failure and death. Inverted-Takotsubo cardiomyopathy (ITC) is a variant of stress cardiomyopathy, characterized by a contractile abnormality with extensive left ventricular circumferential dyskinesia or akinesia with a hyperkinetic apex. We report our experience with refractory cardiogenic shock and/or cardiac arrest, treated with extracorporeal life support. From June 2008 to December 2011, we treated 4 adult poly-trauma patients (3 men, 1 woman, mean age: 27.7 ± 13.5 years, mean ISS score 53.2 ± 15.9) with veno-arterial (V-A) extracorporeal life support for cardiopulmonary failure/cardiac arrest refractory to conventional treatment, due to inverted-Takotsubo cardiomyopathy. We used a miniaturized extracorporeal life support (ECLS) device. ITC myocardial dysfunction appeared 15.4 ± 11.6 h after intensive care unit admission and rapidly evolved to refractory cardiopulmonary failure and cardiac arrest (within 4.8 ± 2.5 h of the onset). At ECLS, initiation median pH was 7.12 ± 0.14 (6.91-7.25), median lactate was 6.7 ± 2.8 (4-10) mmol/l and median vasoactive-inotropic score was 192.1 ± 50.6 µg/kg/min. Tissue perfusion improved significantly within 4 h on ECLS. Cardiac function improved gradually but consistently. Initial median ejection fraction was 14.2 ± 4.7% and median global longitudinal strain test was -7.4 ± 4.7. At complete cardiac recovery, they were 62.73 ± 7.8 and -18.43 ± 2.4%, respectively. After that, 2 patients survived and were sent to neurological rehabilitation before hospital discharge. In the other 2 cases, post-traumatic cerebral death occurred and they underwent organ explantation. Rapid heparin-free ECLS may improve outcome in the most severe cases of poly-traumatized patients demonstrating refractory inverted-Takotsubo cardiomyopathy.

P58: Monitoring of hydroxychloroquine and its metabolites after a massive ingestion: Are there contributive to poisoned patient management in the intensive care unit?

Aims Hydroxychloroquine (HCQ) is a safe drug currently prescribed for the treatment of chronic autoimmune disorders. However, severe cases have been reported after massive overdoses in humans. A sensitive and specific LC-MS/MS method was developed for the simultaneous quantitation of HCQ and its major metabolites, desethylhydroxychloroquine (DHCQ), desethylchloroquine (DCQ) and bisdesethylchloroquine (BDCQ) in human whole blood. The assay was used to the quantitation of HCQ and its metabolites in one severe non-fatal poisoning. Relevance of HCQ monitoring is further discussed in order to evaluate its contribution to the management of acute poisonings. Case report and analytical procedure A 25-year-old woman was admitted to the intensive care unit (ICU) 1.5 h after the ingestion of 6 g of HCQ in a suicidal attempt. She developed life-threatening cardiovascular failure, which required emergent extracorporeal life support. Blood samples were regularly collected and the timecourse of HCQ and metabolites concentrations was studied from 4 hours after HCQ ingestion up to recovery. Briefly, 400 μL of HCQ-D4 in methanol were mixed to 100 μL of samples and centrifuged for 10 minutes at 13000 rpm. Hundred L of supernatant were then mixed to 100 μL of acidified water and 10 μL were injected in the LC-MS/MS system. Analytes were eluted on a 50 × 3 mm 3 μm Hypersil Gold aQ column (Thermo, USA). Detection was achieved using a Quantum Ultra triple-quadrupole mass spectrometer (Thermo, USA) with an electrospray ionization source in positive ion mode, using multiple reaction monitoring. Results The assay, fully validated according to European Medicines Agency's guidelines, was linear in a dynamic range of 25–2000 ng/mL for all compounds and was suitable for drug monitoring and overdoses with levels of HCQ up to 20000 ng/mL after appropriate dilution. It was successfully used to measure HCQ and its metabolites in the whole blood samples of our female poisoned patient. Blood HCQ concentration was 19500 ng/mL on ICU admission and slowly decreased to 2225 ng/mL on day 9. Blood concentrations of the metabolites were significantly less elevated than HCQ and decreased from 1123 to 182, 465 to 109 and 91 to 36 ng/mL for DHCQ, DCQ and BDCQ, respectively. All measurements of HCQ and its metabolites were modeled simultaneously using ADAPT5 software. Half-life of HCQ (8.7 h) was lower to those reported in the literature (Jordan et al , Clin Toxicol, 1999), which could be explained by alterations in its pharmacokinetics related to the extracorporeal circulation. Conclusions and perspectives A selective and sensitive LC-MS/MS method was developed to quantify HCQ and its metabolites in human whole blood. The assay was suitable to cases of overdoses with expected elevated concentrations and used to the study of HCQ toxicokinetics after a massive ingestion. A short review of the cases of HCQ poisonings admitted in the ICU showed that elevated blood HCQ concentrations on admission at the early phase of the intoxication were associated with serious cardiovascular toxicity requiring intensive supportive care. Blood HCQ concentrations seem correlated with poisoning severity on ICU admission and daily monitoring of HCQ concentrations useful to optimize patient management and evaluate the final outcome. However, further studies are still needed to investigate the exact role of HCQ metabolites in acute intoxications and chronic treatments as well as the contribution of measuring their respective concentrations in blood.

Successful Management of Fulminant Pulmonary Embolism Using a Novel Portable Extracorporeal Life Support System

A 46-year-old man presented to the emergency room with pain in his left leg, dyspnea, and general cyanosis. During examination he collapsed and required resuscitation. Under suspicion of pulmonary embolism, a new portable "click 'n run" extracorporeal life support system (LIFEBRIDGE-B(2)T [Medizintechnik AG, Ampfing, Germany]) was implanted by the femoral vessels under resuscitation within 15 minutes of presentation. The patient was stabilized, despite severe decompensation (pH, 6.8), and could be transferred for a computed tomographic scan, which confirmed massive pulmonary embolism. Still connected to the life support system, the patient was transferred to the operating room. After a pulmonary thrombectomy was performed, the patient recovered without any organ dysfunction. A portable emergency extracorporeal life support may change clinical practice in the treatment of patients with severe hemodynamic deterioration at emergency care hospitals.

Successful Treatment of Acute Fulminant Myocarditis with Double Sets of Extracorporeal Membrane Oxygenation: Report of a Case and Review of the Literature

We report a case of acute fulminant myocarditis (AFM) with cardiogenic shock and hemodynamic collapse. We performed emergency extracorporeal life support (ECLS) with right femoral venoarterial cannulation by Seldinger procedure. Because of poor systemic perfusion over the upper trunk with low O₂ saturation due to inadequate venous return, a second ECLS was applied 16 hours after the first ECLS with right subclavian venoarterial cannulation by cut-down procedure. Total flow of both ECLS sets can achieve a flow of up to 6-8 l/min without massive destruction of blood cells. Combined with supportive intravenous immunoglobulin (IVIG) treatment, cardiac function recovered well and the ECLS sets were removed one-by-one. Follow-up studies one year after admission showed good cardiac systolic function and no sequelae of AFM.

Extracorporeal life support in severe drug intoxication: a retrospective cohort study of seventeen cases

IntroductionCardiovascular failure is the leading cause of death in severe acute drug intoxication. In this setting, we report the feasibility, complications, and outcome of emergency extracorporeal life support (ECLS) in refractory shock or cardiac arrest following a drug overdose.MethodsThis is a retrospective cohort study of 17 patients admitted over a 10-year period for prolonged cardiac arrest or refractory shock following a drug overdose and not responding to optimal conventional treatment. Patients were evaluated in the medical ICU and cardiovascular surgery department of a university hospital. ECLS implantation used a centrifugal pump connected to a hollow-fiber membrane oxygenator and was performed in the operating room (n = 13), intensive care unit (n = 3), or emergency department (n = 1). ECLS was employed for refractory shock and prolonged cardiac arrest in 10 and 7 cases, respectively.ResultsThe mean duration of external cardiac massage was 101 ± 55 minutes. Fifteen patients had ingested cardiotoxic drugs, including 11 cases of drugs with membrane stabilizing activity. Time from hospital admission to initiation of ECLS was 6.4 ± 7.0 hours. Time to ECLS implant was 58 ± 11 minutes. The mean ECLS flow rate was 3.45 ± 0.45 L/min. The average ECLS duration was 4.5 ± 2.4 days. Early complications included limb ischemia (n = 6), femoral thrombus (n = 1), cava inferior thrombus (n = 1), and severe bleeding at the site of cannulation (n = 2). Fifteen patients were weaned off ECLS support and 13 (76%) were discharged to hospital without sequelae.ConclusionsBased on our experience, we consider ECLS as a last resort, efficient, and relatively safe therapeutic option in this population. However, the uncontrolled nature of our data requires careful interpretation.

Extracorporeal Life Support in Severe Propranolol and Verapamil Intoxication

Combined poisoning with calcium-channel blockers and beta-blockers is usually associated with severe heart failure. This report shows the effectiveness of emergency extracorporeal life support in treating life-threatening simultaneous propranolol and verapamil intoxication. A 15-year-old girl presented in cardiogenic shock after alcohol consumption and a propranolol and verapamil overdose; plasma concentrations: propranolol, 0.53 m/mL; verapamil, 1.06 mg/mL. She was successfully resuscitated with extracorporeal life support. Therapeutic plasma exchange was initiated. Extracorporeal support was discontinued 70 hours later. The patient made a full recovery. Simultaneous verapamil and propranolol overdoses can cause severe hemodynamic compromise and arrest of electrical and mechanical function of the heart. Emergency extracorporeal life support can successfully maintain vital organ blood flow and allows time for drug metabolism, redistribution, and removal. Therapeutic plasma exchange may reduce the time of emergency extracorporeal life support. Emergency extracorporeal life support should be considered early in cases of near-fatal intoxications with cardiodepressive drugs.

Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest

To report the feasibility, complications, and outcomes of emergency extracorporeal life support (ECLS) in refractory cardiac arrests in medical intensive care unit (ICU). Prospective cohort study in the medical ICU in a university hospital in collaboration with the cardiosurgical team of a neighboring hospital. Seventeen patients (poisonings: 12/17) admitted over a 2-year period for cardiac arrest unresponsive to cardiopulmonary resuscitation (CPR) and advanced cardiac life support, without return of spontaneous circulation. ECLS femoral implantation under continuous cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane oxygenator. Stable ECLS was achieved in 14 of 17 patients. Early complications included massive transfusions (n=8) and the need for surgical revision at the cannulation site for bleeding (n=1). Four patients (24%) survived at medical ICU discharge. Deaths resulted from multiorgan failure (n=8), thoracic bleeding(n=2), severe sepsis (n=2), and brain death (n=1). Massive hemorrhagic pulmonary edema during CPR (n=5) and major capillary leak syndrome (n=6) were observed. Three cardiotoxic-poisoned patients (18%, CPR duration: 30, 100, and 180 min) were alive at 1-year follow-up without sequelae. Two of these patients survived despite elevated plasma lactate concentrations before cannulation (39.0 and 20.0 mmol/l). ECLS was associated with a significantly lower ICU mortality rate than that expected from the Simplified Acute Physiology Score II (91.9%) and lower than the maximum Sequential Organ Failure Assessment score (>90%). Emergency ECLS is feasible in medical ICU and should be considered as a resuscitative tool for selected patients suffering from refractory cardiac arrest.

Extracorporeal Life Support for Massive Pulmonary Embolism

Massive pulmonary embolism is frequently lethal because of acute irreversible pulmonary and cardiac failure. Extracorporeal life support (ECLS) has been used for cardiopulmonary failure in our institution since 1988, and we reviewed our experience with its use in the management of massive pulmonary emboli. We reviewed our complete experience with ECLS for massive pulmonary emboli from January 1992 through December 2005. The records of 21 patients were examined and data extracted. During the study period, 21 patients received ECLS for massive pulmonary emboli. All patients were on vasoactive drugs, acidemic, and hypoxic at the time of institution of ECLS. Eight were in active cardiac arrest. Five were trauma patients, eight had recently undergone an operation, and six had a hypercoagulable disorder. Nineteen of the 21 patients were cannulated for venoarterial bypass and two were placed on venovenous bypass. The average duration of support for survivors was 5.4 days, ranging from 5 hours to 12.5 days. Emboli resolved with anticoagulation in 10 of 13 survivors and 4 of 13 survivors underwent surgical pulmonary embolectomy. Catastrophic neurologic events were the most common cause of mortality in our series; four patients died from intracranial hemorrhage. The overall survival rate was 62% (13/21). We conclude that emergent ECLS provides an opportunity to improve the prognosis of an otherwise near-fatal condition, and should be considered in the algorithm for management of a massive pulmonary embolism in an unstable patient.

Emergency extracorporeal life support for patients with near-fatal status asthmaticus

Extracorporeal life support (ECLS) was used to treat three patients with near-fatal status asthmaticus who did not respond to aggressive medical therapies and mechanical ventilation under controlled permissive hypercapnia. ECLS was instituted in patient 1 because Paco 2 was excessively high and pH was excessively low, in patient 2 because hypoxemia and shock were not responsive to treatment, and in patient 3 because of sustained severe hypotension. ECLS supported adequate gas exchange until pulmonary function improved, diminishing the need for mechanical ventilation and preventing pulmonary complications. Pulmonary dysfunction improved markedly after only 21 to 86 hours of ECLS. Aggressive medical treatments were continued during ECLS. Our findings indicate that ECLS is a useful method for preventing death in patients with near-fatal status asthmaticus.

Analysis of Clinical Trends in a Program of Emergent ECLS for Cardiovascular Collapse

Between June 1986 and October 1995, 81 patients were emergently resuscitated with a portable extracorporeal life support (ECLS) system. Venoarterial perfusion was achieved using a centrifugal pump (BioMedicus; Medtronic, Anaheim, CA) and a hollow fiber oxygenator (BARD in 56 patients; Medtronic heparin-bonded MAXIMA, [MAXIMA, Medtronic, Minneapolis, MN] in the last 25 patients. The ECLS system was used at various locations in the hospital with the setup, priming, and initiation of perfusion done by ECLS trained intensive care unit nurses. Clinical data in these patients were reviewed to analyze variables influencing survival and trends that develop as the authors' experience accumulated and the technology evolved. The indication for ECLS was cardiac arrest in 68 patients and refractory cardiogenic shock in 13 patients. Thirty-five patients (43.2%) survived > 24 hrs after termination of ECLS, whereas 20 patients (24.7%) are long-term survivors (> 30 days). The ECLS system permitted an additional therapeutic surgical intervention in 45 cases. Patients who had a surgically remediable problem were more likely to survive. Prolongation of cardiopulmonary resuscitation beyond 30 mins before initiation of ECLS correlated with a decreased likelihood of survival.

The determinant of severe cerebral dysfunction in patients undergoing emergency extracorporeal life support following cardiopulmonary resuscitation

We investigated the factors associated with cerebral dysfunction in patients undergoing extracorporeal life support (ECLS) following conventional advanced cardiac life support (ACLS). The subjects were 9 patients in whom ECLS was started following ACLS because of intractable cardiac arrest. We investigated whether the irreversibility of cerebral dysfunction during ECLS was related to the cardiopulmonary resuscitation (CPR) time, arterial pH and blood gases, hemoglobin concentration (Hb), peak arterial pressure (PAP) before the start of ECLS and total doses of epinephrine and sodium bicarbonate administered during CPR. Two of the 3 patients who recovered consciousness were weaned from ECLS and survived, while all 6 patients who did not recover from coma were not weaned and died. There was no difference in the CPR time, Hb and PAP before the start of ECLS along with total doses of epinephrine and sodium bicarbonate administered during CPR between the patients who recovered consciousness and those who did not. In addition, there was no difference in arterial pH and blood gases except the arterial oxygen tension (Pa o 2) between the groups. The Pa o 2 values before the start of ECLS in the patients who remained in coma ranged from 34 to 58 mmHg, whereas those in the patients who recovered consciousness ranged from 132 to 442 mmHg. The Pa o 2 values before the start of ECLS in the patients who remained in coma were less than 60 mmHg, whereas those in the patients who recovered consciousness were over 60 mmHg. The present study suggests that hypoxemia during CPR may play a major role in severe cerebral dysfunction in patients undergoing ECLS. Further investigations are needed to determine the relationship between severe cerebral dysfunction in patients undergoing ECLS and Pa o 2 during CPR.