Extracorporeal Cardiopulmonary Resuscitation Research Articles

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists. In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures. The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Predicting survival with scales for in-hospital extracorporeal cardiopulmonary resuscitation

Abstract Funding Acknowledgements None. Background Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue option in cardiac arrest (CA) refractory to advanced life support. Patient selection is challenging, and anecdotal scores are specific to this situation. Purpose Our objective was to analyse the usefulness of different scales used in shock and venoarterial extracorporeal membrane oxygenator (VA-ECMO) support in in-hospital ECPR. Methods Retrospective analysis of consecutive ECPR cases in a referal center. The ECPR alert includes in-hospital cardiologist/intensivist, on-call interventional cardiologist/cardiac surgeon for cannulation, and on-call perfusionist. We analysed hospital survival based on our own and other literature-based mortality scales calculated prior to VA-ECMO implantation: SCAI, INTERMACS, CardShock, CSS, SAVE-ECMO, RESCUE-IHCA. Results Out of 222 VA-ECMO implanted, we included 66 ECPR cases between 2014-oct 2023. Baseline, admission and ECPR characteristics are collected in the table. Overall in-hospital survival was 16.7% (n=11) (cerebral performance cathegory 1-2). We developed a sumative mortality scale including factors related to survival in our population and the literature (lactate &amp;gt;10.05, &amp;gt;60 minutes CA, peripheral arterial disease (PAD), and on-call time for ECPR alert activation) (figure A). This scale was significantly related to survival to discharge (figure A). Regarding the scales and their association with survival, only RESCUE-IHCA showed a trend towards statistical significance (16 [15] points in survivors vs 19 [15] in died patients, p=0.096). The remaining scores showed no relationship with survival to discharge: SAVE-ECMO -15,73±4.8 in survivors vs -14,07±4.1 in died patients (p= 0.301), CSS 10,09±1.9 vs 10.40±2.7 (p=0.651), CardShock 4.82±1.3 vs 5.27±1.2 (p=0.287). INTERMACS (all patients 1) and SCAI classification (all patients stage E) are not valid for discriminating survival in this situation. We compared the scales using the ROC curve for hospital survival, and we found that our own scale had the best discriminatory ability (Figure B). Conclusions Scales developed for shock or VA-ECMO support were not significantly related to survival in patients undergoing in-hospital ECPR. The specific ECPR scale RESCUE-IHCA, and our own scale developed in this population showed better discriminatory ability in survival to discharge.Table.Baseline, admission and ECPRFigure.A: Own scale. B: ROC curves

Risk of sepsis after extracorporeal cardiopulmonary resuscitation in patients with refractory cardiogenic shock from the RESCUE registry

Abstract Funding Acknowledgements None. Objectives It is known that the incidence of sepsis is higher in patients receiving extracorporeal membranous oxygenation (ECMO). In particular, extracorporeal cardiopulmonary resuscitation (ECPR) is performed in emergency situations, which may increase the likelihood of non-aseptic management compared to routine procedures. So, we investigated the association of ECPR and incidence of sepsis in patients with refractory cardiogenic shock (CS). Background Pre- and post-ECPR sepsis are associated with increased mortality, and it is known that the occurrence of sepsis after ECPR is higher than in conventional cardiopulmonary resuscitation (CPR). However, it is not well known whether ECPR has a higher incidence of sepsis than ECMO insertion in non-CPR conditions. Method The SMART-RESCUE study is a multi-center, retrospective and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1,247 patients with CS were enrolled from 12 major centers in Korea. The incidence of sepsis was compared by dividing into two groups according to whether or not ECPR was performed. Patients with ECMO duration less than 48 hours were excluded. Result Total of 231 patients(mean age 59.46 years, men 67.70%, mead follow-up duration 136.5 days) were analyzed into ECPR group(n=95, 60.7 ± 13.0 years, men 75.8%) and non-ECPR group(n=136, 58.6 ± 15.5 years, men 65.4%) respectively. ECPR group showed lower SBP, lower DBP, lower HR, more shock caused by ischemia, more smoking, lower LVEF, higher Hb, higher serum Na, lower AST, higher Peak troponin I, higher vasoactive inotropic score, higher ICMP portion. After 1:1 propensity score matching corrected for height, SBP, DBP, Hb, initial pump flow, Na, ICMP, vasoactive inotropic score, difference remained in SBP, DBP, HR, cause of shock. Sepsis incidence was 7.4%. The risk for sepsis incidence was not different between two groups(7.4% vs 6.3%, adjusted OR 1.18, 95% CI 0.38-3.65, p=0.774). Conclusion ECPR procedure does not increase sepsis compared to ECMO insertion not in CPR state in patients with cardiogenic shock. Keyword: Extracorporeal membrane oxygenation, cardiopulmonary resuscitation, sepsis, cardiogenic shockBaseline characteristicsAdjusted outcomes

Real-world clinical outcome related to veno-arterial extracorporeal membranous oxygenator: a single-center experience

Abstract Funding Acknowledgements None. Background Veno-arterial extracorporeal membranous oxygenator (VA-ECMO) is one of the most powerful devices that rapidly restore sufficient organ perfusion in patients with cardiogenic shock. Despite abundant experiences of successful resuscitation with VA-ECMO, evidences for clinical benefit of VA-ECMO are still lacking. Purpose We summarised clinical outcomes related to VA-ECMO and investigated predictors regarding survival at discharge. Methods Patients who treated with peripheral VA-ECMO between 2006 and 2022 were included from a Hospital in South Korea. Eligible patients were analysed in stratification with ECMO initiation year (year 2006–2010, year 2011–2016, and year 2017–2022). Survival status at discharge were investigated. Results Among total of 693 patients included, 223 (32.2%) were survived at discharge. Survivors had stayed in hospital for median 28 (19–52) days. The overall volume of ECMO initiation (86 runs vs. 250 runs vs. 357 runs) and the rate of extracorporeal CPR (3.5% vs. 18.4% vs. 38.1%) have increased over time. The median duration of VA-ECMO treatment has increased over time (52.6 hours vs. 63.6 hours vs. 85.8 hours). The serum lactate test has been performed more frequently over time (15.1% vs. 79.6% vs. 99.2%). Among 470 patients who died in the index hospitalization, 154 (32.8%) patients died in the first 24 hours after initiation of VA-ECMO. In a multivariate regression model, age over 70 (OR, 0.54; 95% CI, 0.32–0.89), extracorporeal CPR (OR, 0.42; 95% CI, 0.24–0.71), and lactate level ≥8.0 mmol/L (OR, 0.24; 95% CI, 0.15–0.37) were associated with unfavorable outcome while hemoglobin was a predictor of favorable clinical outcome (OR, 1.16; 95% CI, 1.07–1.25). Conclusion The volume of VA-ECMO has increased and clinical severity has also become higher than before. The rate of survival at discharge after VA-ECMO treatment remains stable; however, the rate of patients who died in the first 24 hours is still high. Age, extracorporeal CPR, hemoglobin and lactate levels were predictors of clinical outcome after VA-ECMO treatment.

The Role of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Intraoperative Cardiac Arrest

The Role of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Intraoperative Cardiac Arrest

Management and outcome of high-risk pulmonary embolism in intensive care units: results from a retrospective single-center analysis

Abstract Funding Acknowledgements None. Background High-risk pulmonary embolism (PE) patients are exposed to hemodynamic/multiorgan compromise including hypotension, cardiogenic shock and/or cardiac arrest (CA). Few data exist on management and outcome in patients admitted to intensive care units (ICU) with high-risk PE. Purpose We sought to analyse the epidemiology, management and outcome of patients admitted to ICU due to high-risk PE. Methods Retrospective monocentric analysis of adult patients with high-risk PE admitted from 2017 to 2023; COVID-19 patients were excluded. Demographic, clinical presentation, management and outcome data have been collected. Descriptive analysis comparing means adjusted for organ involvement severity and Cox regression were performed. Results 85 patients (55 male, 63±12 years old, BMI 29.06± 6) were included in the analysis. All patients received the diagnosis through the computed tomography angiography except 4 of them who underwent extra-corporeal cardiopulmonary resuscitation (eCPR) and the diagnosis was made with trans-oesophageal echocardiography. Overall mortality was 32%, eCPR rate was 9%. 92% were treated with adrenergic drugs (norepinephrine 78%, dobutamine 65%, epinephrine 35%); 7 patients required VA-ECMO due to CA. 42 patients received mechanical ventilation (MV) during the first 12 hours; those patients had higher rate of CS (p &amp;lt;0.001), higher lactates (mean difference 1.45±3.2; p &amp;lt;0.001), higher SOFA and SAPS II scores (respectively, mean difference 12.5±0.49 and 7.9±3.4; p 0.004). 75 patients underwent systemic thrombolysis. 10 patients with contraindication to systemic thrombolysis, underwent catheter directed thrombolysis (CDT); in 6 cases CDT was preceded by mechanical suction thrombectomy. Patients undertaking CDT had higher SOFA score at admission (mean difference 2.45±1.6; p 0.04), worsen creatinine (p &amp;lt;0.001), lower PaCO2 (mean difference -0.54±5.3; p 0.01), higher PaO2 (mean difference 28.7±6.5; p 0.009), higher bilirubin (mean difference 3.2±1.6; p &amp;lt;0.001) and lower systolic blood pressure (mean difference -6.8±3.36; p 0.01). At the Cox regression, higher lactates (HR 1.45 [0.40-0.99], p 0.004, panel A), lower glomerular filtration rate (HR 1.1 [1.02-1.09], p 0.001, panel B), higher bilirubin (HR 2.6 [1.20-6.03,] p 0.016), higher ALT (HR 1.07 [0.95-0.99], p 0.04), lower PaO2/FiO2 ratio (HR 1.1 [0.97-0.99], p 0.024, panel C), MV (HR 1.1 [0.78-7.58], p 0.04, panel D) and VA-ECMO (HR 2.5 [1.25-3.54], p 0.002) were associated with increased mortality; CDT was associated with lower mortality (HR 0.82 [0.68-1.89], p 0.04). Conclusions High-risk PE was burdened by high mortality. Signs of worsen organ failure and respiratory and mechanical support are associated with increased mortality. In this monocentric population the use of CDT was performed when systemic thrombolysis contraindicated and it was associated with favourable outcome, although the small sample (10%) should warn contextualization in results’ interpretation.

Bleeding and Thrombosis in Patients With Out-of-Hospital Ventricular Tachycardia/Ventricular Fibrillation Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation.

Extracorporeal cardiopulmonary resuscitation improves outcomes after out-of-hospital cardiac arrest. However, bleeding and thrombosis are common complications. We aimed to describe the incidence and predictors of bleeding and thrombosis and their association with in-hospital mortality. Consecutive patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest between December 2015 and March 2022 who met the criteria for extracorporeal cardiopulmonary resuscitation initiation at our center were included. Major bleeding was defined by the Extracorporeal Life Support Organization's criteria. Adjusted analyses were done to seek out risk factors for bleeding and thrombosis and evaluate their association with mortality. Major bleeding occurred in 135 of 200 patients (67.5%), with traumatic bleeding from cardiopulmonary resuscitation in 73 (36.5%). Baseline demographics and arrest characteristics were similar between groups. In multivariable analysis, decreasing levels of fibrinogen were independently associated with bleeding (adjusted hazard ratio [aHR], 0.98 per every 10 mg/dL rise [95% CI, 0.96-0.99]). Patients who died had a higher rate of bleeds per day (0.21 versus 0.03, P<0.001) though bleeding was not significantly associated with in-hospital death (aHR, 0.81 [95% CI. 0.55-1.19]). A thrombotic event occurred in 23.5% (47/200) of patients. Venous thromboembolism occurred in 11% (22/200) and arterial thrombi in 15.5% (31/200). Clinical characteristics were comparable between groups. In adjusted analyses, no risk factors for thrombosis were identified. Thrombosis was not associated with in-hospital death (aHR, 0.65 [95% CI, 0.42-1.03]). Bleeding is a frequent complication of extracorporeal cardiopulmonary resuscitation that is associated with decreased fibrinogen levels on admission whereas thrombosis is less common. Neither bleeding nor thrombosis was significantly associated with in-hospital mortality.

Treatment strategies for patients with out-of-hospital cardiac arrest associated with traumatic brain injury: A case series

IntroductionCollapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). We aimed to investigate the clinical characteristics and treatment strategies for patients with OHCA and TBI. MethodsWe analyzed a consecutive cohort of patients with intrinsic OHCA retrospectively treated between January 2011 and December 2021 at a single critical care center, and presented a case series of seven patients. Patients with collapse-related TBI were examined for the causes and situations of cardiac arrest, laboratory data, radiological images, targeted temperature management (TTM), coronary angiography (CAG), percutaneous coronary intervention (PCI), and extracorporeal cardiopulmonary resuscitation (ECPR). ResultsOf the 197 patients with intrinsic OHCA, 7 (3.6%) had TBI (age range: 49–70 years; 6 men). All seven patients presented with ventricular fibrillation in the initial electrocardiograms, with four refractory cases treated with ECPR. All patients underwent CAG under heparinization, and four underwent PCI with antiplatelet administration. Initial head computed tomography indicated an intracranial hemorrhage (ICH) in three patients. ICH appeared or was exacerbated in six patients after CAG with or without PCI, except in one who underwent delayed PCI. All patients displayed elevated plasma D-dimer levels, and four underwent neurosurgical procedures. Four patients survived (three with cerebral performance category [CPC] 2, one with CPC 3) and three died; two had hypoxic-ischemic brain injury and one had severe TBI. ConclusionDelayed ICH occurred frequently. Individualized management is required based on the extent of brain and cardiac damage, including optimal TTM, PCI procedures, and antiplatelet medications. Early detection of ICH and emergency treatment are critical for multi-disciplinary collaboration.

Extracorporeal cardiopulmonary resuscitation for patients with refractory out-of-hospital cardiac arrest: a propensity score matching, observational study.

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly performed as an adjunct to conventional cardiopulmonary resuscitation (CCPR) for refractory out-of-hospital cardiac arrest (OHCA). However, the specific benefits of ECPR concerning survival with favorable neurological outcomes remain uncertain. This study aimed to investigate the potential advantages of ECPR in the management of refractory OHCA. We conducted a retrospective cohort study involved OHCA patients between January 2016 and May 2021. Patients were categorized into ECPR or CCPR groups. The primary endpoint assessed was survival with favorable neurological outcomes, and the secondary outcome was survival rate. Multivariate logistic regression analyses, with and without 1:2 propensity score matching, were employed to assess ECPR's effect. In total, 1193 patients were included: 85underwent ECPR, and 1108 received CCPR. Compared to the CCPR group, the ECPR group exhibited notably higher survival rate (29.4% vs. 2.4%; p < 0.001). The ECPR group also exhibited a higher proportion of survival with favorable neurological outcome than CCPR group (17.6% vs. 0.7%; p < 0.001). Multivariate logistic regression analysis demonstrated that ECPR correlated with increased odds of survival with favorable neurological outcome (adjusted odds ratio: 13.57; 95% confidence interval (CI) 4.60-40.06). Following propensity score matching, the ECPR group showed significantly elevated odds of survival with favorable neurological outcomes (adjusted odds ratio: 13.31; 95% CI 1.61-109.9). This study demonstrated that in comparison to CCPR, ECPR may provide survival benefit and increase the odds of favorable neurological outcomes in selected OHCA patients.

Cost-effectiveness of ECPR versus CCPR in OHCA; A pre-planned, trial-based economic evaluation.

When out-of-hospital cardiac arrest (OHCA) becomes refractory, extracorporeal cardiopulmonary resuscitation (ECPR) is a potential option to restore circulation and improve the patient's outcome. However, ECPR requires specific materials and highly skilled personnel, and it is unclear whether increased survival and health-related quality of life (HRQOL) justify these costs. This cost-effectiveness study was part of the INCEPTION study, a multicenter, pragmatic randomized trial comparing hospital-based ECPR to conventional CPR (CCPR) in patients with refractory OHCA in 10 cardiosurgical centers in the Netherlands. We analyzed healthcare costs in the first year and measured HRQOL using the EQ-5D-5L at 1, 3, 6, and 12 months. Incremental cost-effectiveness ratio's (ICER), cost-effectiveness planes, and acceptability curves were calculated. Sensitivity analyses were performed for per-protocol and as-treated subgroups as well as imputed productivity loss in deceased patients. In total 132 patients were enrolled: 62 in the CCPR and 70 in the ECPR group. The difference in mean costs after one year was €5,109 (95%CI -7,264-15,764). Mean QALY after one year was 0.15 in the ECPR group and 0.11 in the CCPR group, resulting in an ICER of €121,643 per additional QALY gained. The acceptability curve shows that at a willingness-to-pay threshold of €80.000, the probability of ECPR being cost-effective compared to CCPR is 36%. Sensitivity analysis showed increasing ICER in the per-protocol and as-treated groups and lower probabilities of acceptance. Hospital-based ECPR in refractory OHCA has a low probability of being cost-effective in a trial-based economic evaluation.

Biomarkers for neuroprognostication after standard versus extracorporeal cardiopulmonary resuscitation – A sub-analysis of Prague-OHCA study

BackgroundLimited evidence exists for prognostic performance of biomarkers in patients resuscitated from out-of-hospital cardiac arrest (OHCA) with extracorporeal CPR (ECPR). We hypothesized that (1) the time course and (2) prognostic performance of biomarkers might differ between CPR and ECPR in a sub-analysis of Prague-OHCA study. MethodsPatients received either CPR (n = 164) or ECPR (n = 92). The primary outcome was favorable neurologic survival at 180 days [cerebral performance category (CPC) 1–2]. Secondary outcomes included biomarkers of neurologic injury, inflammation and hemocoagulation. ResultsFavorable neurologic outcome was not different between groups: CPR 29.3% vs. ECPR 21.7%; p = 0.191. Biomarkers exhibited similar trajectories in both groups, with better values in patients with CPC 1–2. Procalcitonin (PCT) was higher in ECPR group at 24–72 h (all p < 0.01). Neuron-specific enolase (NSE), C-reactive protein and neutrophil-to-lymphocyte ratio did not differ between groups. Platelets, D-dimers and fibrinogen were lower in ECPR vs. CPR groups at 24–72 h (all p < 0.001). ROC analysis (24–48–72 h) showed the best performance of NSE in both CPR and ECPR groups (AUC 0.89 vs. 0.78; 0.9 vs. 0.9; 0.91 vs. 0.9). PCT showed good performance specifically in ECPR (0.72 vs. 0.84; 0.73 vs. 0.87; 0.73 vs. 0.86). Optimal cutoff points of NSE and PCT were higher in ECPR vs. CPR. ConclusionsBiomarkers exhibited similar trajectories although absolute values tended to be higher in ECPR. NSE had superior performance in both groups. PCT showed a good performance specifically in ECPR. Additional biomarkers may have modest incremental value. Prognostication algorithms should reflect the resuscitation method.

Fluid balance during acute phase extracorporeal cardiopulmonary resuscitation and outcomes in OHCA patients: a retrospective multicenter cohort study.

The association between fluid balance and outcomes in patients who underwent out-of-hospital cardiac arrest (OHCA) and received extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. We aimed to examine the above relationship during the first 24 h following intensive care unit (ICU) admission. We performed a secondary analysis of the SAVE-J II study, a retrospective multicenter study involving OHCA patients aged ≥ 18 years treated with ECPR between 2013 and 2018 and who received fluid therapy following ICU admission. Fluid balance was calculated based on intravenous fluid administration, blood transfusion, and urine output. The primary outcome was in-hospital mortality. The secondary outcomes included unfavorable outcome (cerebral performance category scores of 3-5 at discharge), acute kidney injury (AKI), and need for renal replacement therapy (RRT). Overall, 959 patients met our inclusion criteria. In-hospital mortality was 63.6%, and the proportion of unfavorable outcome at discharge was 82.0%. The median fluid balance in the first 24 h following ICU admission was 3673 mL. Multivariable analysis revealed that fluid balance was significantly associated with in-hospital mortality (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.02-1.06; p < 0.001), unfavorable outcome (OR, 1.03; 95% CI, 1.01-1.06; p = 0.005), AKI (OR, 1.04; 95% CI, 1.02-1.05; p < 0.001), and RRT (OR, 1.05; 95% CI, 1.03-1.07; p < 0.001). Excessive positive fluid balance in the first day following ICU admission was associated with in-hospital mortality, unfavorable outcome, AKI, and RRT in ECPR patients. Further investigation is warranted.

Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report.

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT. A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure. Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.

A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study

BackgroundThe likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients.MethodsThe ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18–50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months.DiscussionThe ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment.Trial registrationClinicaltyrials.gov under NCT04620070, registration date 3 November 2020.

What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR.MethodsThis retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests.ResultsThe mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021–3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289–4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907–5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907–5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092–3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161–0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration.ConclusionThese findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.

Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study.

Hyperoxemia is common and associated with poor outcome during veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. However, little is known about practical daily management of oxygenation. Then, we aim to describe sweep gas oxygen fraction (FSO2), postoxygenator oxygen partial pressure (PPOSTO2), inspired oxygen fraction (FIO2), and right radial arterial oxygen partial pressure (PaO2) between day 1 and day 7 of peripheral VA ECMO support. We also aim to evaluate the association between oxygenation parameters and outcome. In this retrospective multicentric study, each participating center had to report data on the last 10 eligible patients for whom the ICU stay was terminated. Patients with extracorporeal cardiopulmonary resuscitation were excluded. Primary endpoint was individual mean FSO2 during the seven first days of ECMO support (FSO2mean (day 1-7)). Between August 2019 and March 2022, 139 patients were enrolled in 14 ECMO centers in France, and one in Switzerland. Among them, the median value for FSO2mean (day 1-7) was 70 [57; 79] % but varied according to center case volume. Compared to high volume centers, centers with less than 30 VA-ECMO runs per year were more likely to maintain FSO2 ≥ 70% (OR 5.04, CI 95% [1.39; 20.4], p = 0.017). Median value for right radial PaO2mean (day 1-7) was 114 [92; 145] mmHg, and decreased from 125 [86; 207] mmHg at day 1, to 97 [81; 133] mmHg at day 3 (p < 0.01). Severe hyperoxemia (i.e. right radial PaO2 ≥ 300 mmHg) occurred in 16 patients (12%). PPOSTO2, a surrogate of the lower body oxygenation, was measured in only 39 patients (28%) among four centers. The median value of PPOSTO2mean (day 1-7) value was 198 [169; 231] mmHg. By multivariate analysis, age (OR 1.07, CI95% [1.03-1.11], p < 0.001), FSO2mean (day 1-3)(OR 1.03 [1.00-1.06], p = 0.039), and right radial PaO2mean (day 1-3) (OR 1.03, CI95% [1.00-1.02], p = 0.023) were associated with in-ICU mortality. In a multicentric cohort of cardiogenic shock supported by VA ECMO, the median value for FSO2mean (day 1-7) was 70 [57; 79] %. PPOSTO2 monitoring was infrequent and revealed significant hyperoxemia. Higher FSO2mean (day 1-3) and right radial PaO2mean (day 1-3) were independently associated with in-ICU mortality.

Organ donation after extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in a metropolitan cardiac arrest centre in Milan, Italy

IntroductionExtracorporeal cardiopulmonary resuscitation (ECPR) may improve survival in refractory out-of-hospital cardiac arrest (OHCA) but also expand the donor pool as these patients often become eligible for organ donation. Our aim is to describe the impact of organ donation in OHCA patients treated with ECPR in a high-volume cardiac arrest centre. MethodsRate of organ donation (primary outcome), organs harvested, a composite of patient survival with favourable neurological outcome or donation of ≥ 1 solid organ (ECPR benefit), and the potential total number of individuals benefiting from ECPR (survivors with favourable neurological outcome and potential recipients of one solid organ) were analysed among all-rhythms refractory OHCA patients treated with ECPR between January 2013–November 2022 at San Raffaele Hospital in Milan, Italy. ResultsAmong 307 adults with refractory OHCA treated with ECPR (95% witnessed, 66% shockable, low-flow 70 [IQR 58–81] minutes), 256 (83%) died during hospital stay, 33% from brain death. Donation of at least one solid organ occurred in 58 (19%) patients, 53 (17%) after determination of brain death and 5 (1.6%) after determination of circulatory death, contributing a total of 167 solid organs (3.0 [IQR 2.5-4.0] organs/donor). Overall, 196 individuals (29 survivors with favourable neurological outcome and 167 potential recipients of 1 solid organ) possibly benefited from ECPR. ECPR benefit composite outcome was achieved in 87 (28%) patients. Solid organ donation decreased from 19% to 16% in patients with low-flow < 60 minutes and to 11% with low-flow < 60 minutes and initial shockable rhythm. ConclusionsWhen ECPR fails in patients with refractory OHCA, organ donation after brain or circulatory death can help a significant number of patients awaiting transplantation, enhancing the overall benefit of ECPR. ECPR selection criteria may affect the number of potential organ donors.

Perceptions on Specialist Palliative Care Involvement During and After Cardiopulmonary Resuscitation: A Qualitative Study

IMPORTANCE: Cardiopulmonary resuscitation (CPR) is an exceptional physical situation and may lead to significant psychological, spiritual, and social distress in patients and their next of kin. Furthermore, clinicians might experience distress related to a CPR event. Specialist palliative care (sPC) integration could address these aspects but is not part of routine care. OBJECTIVES: This study aimed to explore perspectives on sPC integration during and after CPR. A needs assessment for sPC, possible triggers indicating need, and implementation strategies were addressed. DESIGN, SETTING, AND PARTICIPANTS: A multiprofessional qualitative semistructured focus group study was conducted in a German urban academic teaching hospital. Participants were clinicians (nursing staff, residents, and consultants) working in the emergency department and ICUs (internal medicine and surgical). ANALYSIS: The focus groups were recorded and subsequently transcribed. Data material was analyzed using the content-structuring content analysis according to Kuckartz. RESULTS: Seven focus groups with 18 participants in total were conducted online from July to November 2022. Six main categories (two to five subcategories) were identified: understanding (of palliative care and death), general CPR conditions (e.g., team, debriefing, and strains), prognosis (e.g., preexisting situation, use of extracorporeal support), next of kin (e.g., communication, presence during CPR), treatment plan (patient will and decision-making), and implementation of sPC (e.g., timing, trigger factors). CONCLUSIONS: Perceptions about the need for sPC to support during and after CPR depend on roles, areas of practice, and individual understanding of sPC. Although some participants perceive CPR itself as a trigger for sPC, others define, for example, pre-CPR-existing multimorbidity or complex family dynamics as possible triggers. Suggestions for implementation are multifaceted, especially communication by sPC is emphasized. Specific challenges of extracorporeal CPR need to be explored further. Overall, the focus groups show that the topic is considered relevant, and studies on outcomes are warranted.

Impact of center volume on in-hospital mortality in adult patients with out‑of‑hospital cardiac arrest resuscitated using extracorporeal cardiopulmonary resuscitation: a secondary analysis of the SAVE-J II study

Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11–20 sessions per year), or low-volume (< 11 sessions per year). The primary outcome was survival rate at the time of discharge. Patient characteristics and outcomes were compared among the three groups. Moreover, a multivariable-adjusted logistic regression model was applied to study the impact of center ECPR volume. A total of 1740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P = 0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P = 0.003) and low-volume centers (adjusted odds ratio 0.983; P = 0.006). The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure.Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Sex-Related Differences in Utilization and Outcomes of Extracorporeal Cardio-Pulmonary Resuscitation for Refractory Cardiac Arrest.

Sparse data exist on sex-related differences in extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (rCA). We explored the role of sex on the utilization and outcomes of ECPR for rCA by retrospective analysis of the Extracorporeal Life Support Organization (ELSO) International Registry. The primary outcome was in-hospital mortality. Exploratory outcomes were discharge disposition and occurrence of any specific extracorporeal membrane oxygenation (ECMO) complications. From 1992 to 2020, a total of 7,460 adults with ECPR were identified: 30.5% women; 69.5% men; 55.9% Whites, 23.7% Asians, 8.9% Blacks, and 3.8% Hispanics. Women's age was 50.4 ± 16.9 years (mean ± standard deviation) and men's 54.7 ± 14.1 (p < 0.001). Ischemic heart disease occurred in 14.6% women vs. 18.5% men (p < 0.001). Overall, 28.5% survived at discharge, 30% women vs. 27.8% men (p = 0.138). In the adjusted analysis, sex was not associated with in-hospital mortality (odds ratio [OR] = 0.93 [confidence interval {CI} = 0.80-1.08]; p = 0.374). Female sex was associated with decreased odds of neurologic, cardiovascular, and renal complications. Despite being younger and having fewer complications during ECMO, women had in-hospital mortality similar to men. Whether these findings are driven by biologic factors or disparities in health care warrants further investigation.