Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Research Articles

Quality improvement developments following pediatric resuscitation and veno-arterial extracorporeal membrane oxygenation support due to a massive intentional antidepressant overdose

Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (ECPR) is the act of placing a patient on bypass at the bedside while simultaneously carrying out life-sustaining interventions such as chest compressions or epinephrine administration. This involves a team of physicians, nurses, respiratory therapists, pharmacists, extracorporeal membrane oxygenation (ECMO) trained staff, and other health professionals who must focus on cardiopulmonary resuscitation (CPR), cannulation, and initiating ECMO flow at the same time. ECPR may be considered when traditional CPR does not achieve return of spontaneous circulation (ROSC) in a patient. Limitations when thinking about using ECPR for a patient include location, timing from arrest to CPR initiation, as well as CPR initiation to successfully on bypass, trained staff available to begin the cannulation process, and pauses in compressions during surgery. We analyzed a pediatric patient who required ECPR after an intentional drug overdose. Gaps identified in this case prompted us to assess our ECPR protocol. Through the development and use of multidisciplinary ECPR simulations, our team discovered areas of quality improvement and put those findings into practice.

Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review.

Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.

Potential role for extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) during in-hospital cardiac arrest in Australia: A nested cohort study

ObjectiveThis study aims to evaluate the characteristics and outcomes of patients who fulfilled extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) selection criteria during in-hospital cardiac arrest (IHCA). DesignThis is a nested cohort study. SettingCode blue data were collected across seven hospitals in Australia between July 2017 and August 2018. ParticipantsParticipants who fulfilled E-CPR selection criteria during IHCA were included. Main outcome measuresReturn of spontaneous circulation and survival and functional outcome at hospital discharge. Functional outcome was measured using the modified Rankin scale, with scores dichotomised into good and poor functional outcome. ResultsTwenty-three (23/144; 16%) patients fulfilled E-CPR selection criteria during IHCA, and 11/23 (47.8%) had a poor outcome. Patients with a poor outcome were more likely to have a non-shockable rhythm (81.8% vs. 16.7%; p = 0.002), and a longer duration of CPR (median 12.5 [5.5, 39.5] vs. 1.5 [0.3, 2.5] minutes; p < 0.001) compared to those with a good outcome. The majority of patients (18/19 [94.7%]) achieved sustained return of spontaneous circulation within 15 minutes of CPR. All five patients who had CPR >15 minutes had a poor outcome. ConclusionApproximately one in six IHCA patients fulfilled E-CPR selection criteria during IHCA, half of whom had a poor outcome. Non-shockable rhythm and longer duration of CPR were associated with poor outcome. Patients who had CPR for >15 minutes and a poor outcome may have benefited from E-CPR. The feasibility, effectiveness and risks of commencing E-CPR earlier in IHCA and among those with non-shockable rhythms requires further investigation.

Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit

Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population. To investigate incidence, trends, and factors associated with IHCA and mortality in children with cardiac disease in the ICU. A systematic review was conducted using PubMed, Web of Science, EMBASE, and CINAHL, from inception to September 2021. Observational studies on IHCA in pediatric ICU patients with cardiac disease were selected (age cutoffs in studies varied from age ≤18 y to age ≤21 y). Quality of studies was assessed using the National Institutes of Health Quality Assessment Tools. Data on incidence, mortality, and factors associated with IHCA or mortality were extracted by 2 independent observers. Random-effects meta-analysis was used to compute pooled proportions and pooled ORs. Metaregression, adjusted for type of study and diagnostic category, was used to evaluate trends in incidence and mortality. Primary outcomes were incidence of IHCA and in-hospital mortality. Secondary outcomes were proportions of patients who underwent extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) and those who did not achieve return of spontaneous circulation (ROSC). Of the 2574 studies identified, 25 were included in the systematic review (131 724 patients) and 18 in the meta-analysis. Five percent (95% CI, 4%-6%) of children with cardiac disease in the ICU experienced IHCA. The pooled in-hospital mortality among children who experienced IHCA was 51% (95% CI, 42%-59%). Thirty-nine percent (95% CI, 29%-51%) did not achieve ROSC; in centers with ECMO, 22% (95% CI, 14%-33%) underwent ECPR, whereas 22% (95% CI, 12%-38%) were unable to be resuscitated. Both incidence of IHCA and associated in-hospital mortality decreased significantly in the last 20 years (both P for trend < .001), whereas the proportion of patients not achieving ROSC did not significantly change (P for trend = .90). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, prearrest mechanical ventilation or ECMO, and higher surgical complexity were associated with increased incidence of IHCA and mortality odds. This systematic review and meta-analysis found that 5% of children with cardiac disease in the ICU experienced IHCA. Decreasing trends in IHCA incidence and mortality suggest that education on preventive interventions, use of ECMO, and post-arrest care may have been effective; however, there remains a crucial need for developing resuscitation strategies specific to children with cardiac disease.

The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation.

Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.

Interprofessional Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Simulations Aimed at Decreasing Actual Cannulation Times: A Longitudinal Study.

Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process. During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data. Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations. We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.

Long-Term Survival and Quality of Life in Non-Surgical Adult Patients Supported with Veno-Arterial Extracorporeal Oxygenation.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for hemodynamic support is on the rise. Not much is known about the impact of extracorporeal membrane oxygenation (ECMO) and its complications on long-term survival and quality of life. In this single-center, cross-sectional study, we evaluated the survival and quality of life in patients treated with VA ECMO between May 2009 and July 2019. Follow-up was conducted between November 2019 and January 2020. Overall, 118 patients were evaluated in this study. Of the 37 patients who were alive at hospital discharge, 32 answered the EuroQol-5 dimensional-5-level questionnaire (EQ-5D-5L). For patients discharged alive from the hospital, mean survival was 8.1 years, 8.4 years for cardiogenic shock, and 5.0 years for patients with refractory cardiac arrest. EQ-5D-5L index value of ECMO survivors was not significantly different from the general age-matched population. Neurologic complications and major bleeding during index hospitalization limit long-term quality of life. Patients treated with VA ECMO have high in-hospital mortality, with extracorporeal membrane oxygenation cardio-pulmonary resuscitation patients being at higher risk of early death. However, once discharged from the hospital, most patients remain alive with a reasonable quality of life.

Role of the emergency department in implementing an extracorporeal membrane oxygenation cardiopulmonary resuscitation.

The Royal Brisbane and Women's Hospital has introduced an extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (E-CPR) service with collaboration between ED and ICU teams for refractory cardiac arrest patients. E-CPR is potentially beneficial to patients who do not gain return of spontaneous circulation after conventional advanced cardiac life support treatments, provided specific demographic and biochemical inclusion criteria are met. A joint ICU and ED decision is reached to commence ECMO flow. We discuss our rationale to use the ED and the emergency physician role in leading the multidisciplinary team, with ICU leading the cannulation team. The development of ED processes and the increased availability of this intervention can significantly impact the survivability of refractory cardiac arrest with good neurological outcomes.

Effect of hospital case volume on clinical outcomes of patients requiring extracorporeal membrane oxygenation: a territory-wide longitudinal observational study

BackgroundThe utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable.MethodsAll adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. “High-volume” centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while “low-volume” centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers.ResultsA total of 911 patients received extracorporeal membrane oxygenation—297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61–1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54–1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46).ConclusionsIn a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.

Cardiac Catheter Laboratory Utilisation Following Introduction of an Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (e-CPR) Programme for Out-of-Hospital Cardiac Arrest

Refractory out-of-hospital cardiac arrest (r-OHCA) is associated with globally poor outcomes. Highly selected r-OHCA cases may be suitable for invasive, resource intensive interventions such as extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR). We sought to further understand whether ECPR implementation would have unintended effects on cardiac catheterisation laboratory (CCL) utilisation. This was an analysis of a prospective adult OHCA registry and Utstein-based outcome reporting with two distinct ‘pre’ and ‘post’ cohorts. The setting was a tertiary centre in Sydney, Australia. The pre-ECPR cohort comprised consecutive OHCA patients between 2016 and 2019 (prior to an ECPR program), and the post-ECPR cohort from mid-2020 and mid-2021 (post implementation of an ECPR program). There were 248 patients in the pre-ECPR cohort and 51 in the post-ECPR cohort. The groups had similar baseline characteristics. Sustained return of spontaneous circulation (ROSC) was obtained in 61 (24.6%) (pre) and 12 (23.5%) (post) OHCAs, respectively (p=0.86). Pre-ECPR, 47 (77%) received CCL during admission versus 8 (67%) post-ECPR (p=0.55). Early CCL (<24 h) was performed in 34 (56%) pre-ECPR patients versus 8 (67%) post-ECPR (p=0.57). In patients receiving early CCL, time from OHCA to CCL arrival was 188.38 min (SD 176.6) for pre-ECPR versus 130.38 min (SD 91.9) for the post-ECPR cohort (p=0.38). ECPR was attempted in 6/51 OHCA cases but only 1 patient survived to CCL. ECPR implementation did not appear to lead to unintended delayed to CCL interventions. All patients attending CCL post-ECPR implementation did so within 24 hours [[1]Yannopoulos D. Bartos J. Raveendran G. Walser E. Connett J. Murray T.A. et al.Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.Lancet. 2020; 396: 1807-1816Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar].

Potential Role for Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (E-CPR) Following In-Hospital Cardiac Arrest in Australia: A Nested Cohort Study

Potential Role for Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (E-CPR) Following In-Hospital Cardiac Arrest in Australia: A Nested Cohort Study

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

ObjectiveTo assess the feasibility of delivering extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out‐of‐hospital cardiac arrests (OHCA) by low volume extracorporeal membrane oxygenation (ECMO) centers and to explore pre‐ECPR predictors of survival.MethodsBetween 2016 and 2020, we studied 21 ECPR patients admitted in 2 tertiary ECMO centers in Liège, Belgium. Our ECPR protocol was based on 6 prehospital criteria (no flow < 3 minutes, low flow < 60 minutes, initial shockable rhythm, end‐tidal CO2 > 15 mmHg, age < 65 years, and absence of comorbidities). A dedicated training, prehospital checklist and call number for 24/7 ECMO team assistance were implemented. Hemodynamics and blood gases on admission also were assessed.ResultsTwenty‐one (28%) out of 75 refractory OHCA patients referred were treated by ECPR, with a hospital survival rate of 43% (n = 9/21), comparable to ECPR results from the international extracorporeal life support organization registry. Transient return of spontaneous circulation before ECPR (89% in survivors vs 17% in non‐survivors, P = 0.002) and higher initial serum bicarbonate (med [P25‐P75] 14.0 [10.6–15.2] vs 7.5 [3.7–10.5] mmol/L, P = 0.019) or lower initial base deficit (14.9 [11.9–18.2] vs 21.6 [17.9–28.9] mmol/L, P = 0.039) were associated with a more favorable outcome.ConclusionIn low volume ECMO centers, the implementation of a specific ECPR protocol for refractory OHCA patients is feasible and provides potential clinical benefit. Highly selective inclusion criteria seem essential to select candidates for ECPR. Initial serum bicarbonate and base deficit integrating cumulative cell failure may be relevant pre‐ECMO prognostic factors and require larger‐scale evaluation.

Obesity is not a contraindication to veno-arterial extracorporeal life support.

Obesity may complicate the peripheral cannulation and delivery of veno-arterial extracorporeal life support (ECLS). With rising global body mass indices (BMI), obesity is becoming increasingly prevalent in severe cardiogenic shock yet its impact on outcomes is not well described. This study sought to examine the relationship between BMI and veno-arterial ECLS outcomes to better inform clinical decision-making. All cardiogenic shock patients undergoing peripheral veno-arterial ECLS at our institution from March 2008 to January 2019 were retrospectively analysed (n = 431). Patients were divided into 4 groups, BMI 17.5-24.9, 25-29.9, 30-34.9 and ≥35 kg/m2, and compared on clinical outcomes. Multivariable logistic regression was performed to identify variables associated with survival to discharge, the primary outcome of interest. The median BMI was 28.3 kg/m2 (interquartile range 24.8-32.6) with a range of 17.0-69.1 kg/m2. Obese patients achieved significantly lower percentages of predicted flow rates compared with BMI < 25 kg/m2 patients though did not differ in their lactate clearances. Patients with BMI ≥35 kg/m2 had similar complication rates to the other cohorts but were more likely to require continuous veno-venous haemodialysis (51% vs 25-40% in other cohorts, P = 0.002). Overall survival to discharge was 48% (n = 207/431) with no differences between the cohorts (P = 0.92). Patients with BMI ≥35 kg/m2 had considerably lower survival (10%) in extracorporeal membrane oxygenation cardiopulmonary resuscitation compared with the other groups (P = 0.17). On multivariable logistic regression, BMI was not significantly associated with failure to survive to discharge. In conclusion, with the rising global prevalence of obesity, the results of our study suggest that clinicians need not treat obesity as a negative prognostic factor in cardiogenic shock requiring ECLS.

Pediatric cardiopulmonary resuscitation quality during intra-hospital transport

AimTo evaluate pediatric cardiopulmonary resuscitation (CPR) quality during intra-hospital transport to facilitate extracorporeal membrane oxygenation (ECMO)-CPR (ECPR). We compared chest compression (CC) rate, depth, and fraction (CCF) between the pre-transport and intra-transport periods. MethodsObservational study of children <18 years with either in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) who underwent transport between two care locations within the hospital for ECPR and who had CPR mechanics data available. Descriptive patient and arrest characteristics were summarized. The primary analysis compared pre- to intra-transport CC rate, depth, and fraction. A secondary analysis compared the proportion of pre- versus intra-transport 60-s epochs meeting guideline recommendations for rate (100–120/min), depth (≥4 cm for infants; ≥5 cm for children ≥1 year), and CCF (≥0.80). ResultsSeven patients (four IHCA; three witnessed OHCA) met eligibility criteria. Six (86%) patients survived the event and two (28%) survived to hospital discharge. Median transport CPR duration was 7 [IQR 5.5, 8.5] minutes. There were no differences in pre- vs. intra-transport CC rate (115 [113, 118] vs. 118 [114, 127] CCs/minute; p = 0.18), depth (3.2 [2.7, 4.4] vs. 3.6 [2.5, 4.6] cm; p = 0.50), or CCF (0.89 [0.82, 0.90] vs. 0.92 [0.79, 0.97]; p = 0.31). Equivalent proportions of 60-s CPR epochs met guideline recommendations between pre- and intra-transport (rate: 66% vs. 57% [p = 0.22]; depth: 14% vs. 19% [p = 0.39]; CCF: 80% vs. 75% [p = 0.43]). ConclusionsPediatric CPR quality was maintained during intra-hospital patient transport, suggesting that it is reasonable for ECPR systems to incorporate patient transport to facilitate ECMO cannulation.

Use of extracorporeal membrane oxygenation in postcardiotomy pediatric patients: parameters affecting survival

We aimed to investigate the risk factors affecting survival after extracorporeal membrane oxygenation use in pediatric postcardiotomy patients. One hundred thirty-three consecutive patients who underwent surgery for congenital heart disease who needed extracorporeal membrane oxygenation support were retrospectively analyzed. In all, 3,082 patients were operated, of which 140 patients (4.54% of the total number of operations) needed extracorporeal membrane oxygenation. Eighty (60.1%) patients were successfully weaned and 51 (38.3%) patients were discharged. Of the 50 patients discharged during the mean follow-up period of 34.8 (0-192.4) months, 6 (12%) patients died. The extracorporeal membrane oxygenation support was instituted in 29 (21.8%) patients for extracorporeal membrane oxygenation cardiopulmonary resuscitation, in 44 (33.1%) patients due to the inability to be separated from cardiopulmonary bypass, in 19 (14.3%) patients due to respiratory failure, and in 41 patients due to low cardiac output syndrome. Eighty patients (60.2%) were successfully weaned from extracorporeal membrane oxygenation support. The remaining 53 (39.8%) patients died on extracorporeal membrane oxygenation. Mortality was observed in 29 (21.8%) of the 80 patients in the successful weaning group, while the remaining 51 (38.3%) patients were discharged from the hospital. Multivariate analysis showed that double-ventricular physiology increased the rate of successful weaning (odds ratio: 3.4, 95% confidence interval lower: 1.5 and upper: 8, p = 0.004) and prolonged extracorporeal membrane oxygenation durations were a risk factor in successful weaning (odds ratio: 0.9, 95% confidence interval lower: 0.8 and upper: 0.9, p = 0.007). The parameters affecting mortality were the presence of syndrome (odds ratio: 3.8, 95% confidence interval lower: 1.0 and upper: 14.9, p = 0.05), single-ventricular physiology (odds ratio: 5.3, 95% confidence interval lower: 1.8 and upper: 15.3, p = 0.002), and the need for a second extracorporeal membrane oxygenation (odds ratio: 12.9, 95% confidence interval lower: 1.6 and upper: 104.2, p = 0.02). While 1-year survival was 15.2% and 3-year survival was 12.1% in patients with single-ventricular physiology, the respective survival rates were 43.9% and 40.8%. Parameters affecting mortality after extracorporeal membrane oxygenation support in pediatric postcardiotomy patient group were the presence of a syndrome, multiple runs of extracorporeal membrane oxygenation, and single-ventricular physiology. Timing of extracorporeal membrane oxygenation initiation, appropriate patient selection, appropriate reintervention or reoperation for patients with correctable pathology, the use of an appropriate cannulation strategy in single-ventricle patients, management of shunt flow, and appropriate interventions to reduce the incidence of complications play key roles in improving survival.

ICU nurses and ecpr

Introduction: Mortality from refractory cardiac arrest is greater than 90%. Survival may be significantly improved with Extracorporeal Membrane Oxygenation Cardio Pulmonary Resuscitation (ECPR). Objectives: To enable ICU nurses to participate in the ECPR team by preparing the ECPR trolley and/or console. Additional goals: maintain 66% ECPR accreditation following May 2016; plan ECPR nursing training at approximately 2 per month; and maintain ECPR outcomes comparable to reported rates. Methods: Training for nurses commenced May 2015. There were 10 planned sessions employing didactic explanations and simulated demonstrations. From 2016 to 2019 there were approximately two sessions per month booked. Additional hig- fidelity multidisciplinary simulations were provided by the Simulation Coordinator involving ED, Ambulance and Interventional Cardiology staff. Audits of ECMO outcomes were conducted biannually with comparisons made to international registries and literature. Results: By May 2016 greater than 66% of ECMO nurses had been accredited for ECPR. This rate was maintained and is currently 69/84 (82%). Of the planned education sessions from 2015 to 2018; the following were respectively documented as achieved 4/10, 13/23, 10/18 and 13/21. ECPR outcome from 2015-2018 was 39% survival to hospital discharge. Accredited ICU ECPR nurses were assigned every day to the ECPR team and attend ECPR emergency calls as they occurred. Conclusion: It is feasible for ICU nurses to participate as valuable members of the ECPR team. Whilst the potential numbers of patients in NSW who may require ECPR per year for refractory cardiac arrest may remain relatively low (i.e approximately 130/yr) it appears that the possible improvement in survival outcome for this group may be significantly increased from dismal to around 30%. The ICU ECMO ECPR nurse's role in assisting with this survival benefit for the patient is an important part of the function of the team.

Extracorporeal membrane oxygenation cardiopulmonary resuscitation, a luxury we cannot afford missing: a narrative review

Extracorporeal membrane oxygenation (ECMO) was introduced into practice since more than four decades to support patients with advanced yet potentially reversible cardiopulmonary failure. Following several prospective clinical trials, ECMO is considered a widely accepted support modality in severe neonatal respiratory failure and in pediatric cardiac failure, particularly in the perioperative environment. Compared with conventional CPR, ECPR provides higher level of cardiac output support and several potential advantages including a higher rate of successful ROSC, support of post-resuscitation cardiogenic shock while arranging and performing coronary interventions and maintaining organ perfusion during recovery of native cardiac output.

Risk Factors for Major Adverse Events after Surgical Closure of Ventricular Septal Defect in Patients Less than 1 Year of Age: A Single-Center Retrospective.

ObjectiveTo reveal the risk factors that can lead to a complicated course and an increased morbidity in patients < 1 year old after surgical ventricular septal defect (VSD) closure.MethodsWe reviewed a consecutive series of patients who were admitted to our institution for surgical VSD closure who were under one year of age, between 2015 and 2018. Mechanical ventilation (MV) time > 24 hours, intensive care unit (ICU) stay longer than three days, and hospital stay longer than seven days were defined as “prolonged”. Unplanned reoperation, complete heart block requiring a permanent pacemaker implantation, sudden circulatory arrest, and death were considered as significant major adverse events (MAE).ResultsVSD closure was performed in 185 patients. The median age was five (1-12) months. There was prolonged MV time in 54 (29.2%) patients. Four patients (2.2%) required permanent pacemaker implantation. Hemodynamically significant residual VSD was observed in six (3.2%) patients. Extracorporeal membrane oxygenation-cardiopulmonary resuscitation was performed in one (0.5%) patient. Small age (< 4 months) (P-value<0.001) and prolonged cardiopulmonary bypass time (P=0.03) were found to delay extubation and to prolong MV time. Low birth weight at the operation was associated with MAE (P=0.03).ConclusionHigher body weight during operation had a reducing effect on the MAE frequency and shortened the MV duration, ICU stay, and hospital stay. As a conclusion, for patients who are scheduled to undergo VSD closure, body weight should be taken into consideration.

Extracorporeal membrane oxygenation in cardiac arrest.

The survival of cardiac arrest patients is dependent on the efficient and timely application of the chain of survival. This includes early identification of cardiac arrest and activation of the emergency response system, high-quality cardiopulmonary resuscitation (CPR), rapid defibrillation, basic and advanced medical services, and advanced life support and post-cardiac arrest care. However, some patients may be refractory to these measures. Extracorporeal membrane oxygenation CPR (ECPR), otherwise known as extracorporeal life support, offers an alternative to such refractory cardiac arrest cases. As hospitals have limited resources, it is important to devise effective patient selection methods, and improve our understanding and experience of ECPR to ensure the best outcome. It is also vital to understand that ECPR constitutes only one component of post-cardiac arrest care, which includes other aspects such as therapeutic hypothermia and early perfusion for best patient outcome.

Extracorporeal membrane oxygenation for rescuing 12 children with acute fulminant myocarditis

Objective: To summarize clinical experience of using extracorporeal membrane oxygenation (ECMO) in rescuing children with acute fulminant myocarditis (AFM). Method: Data of 12 children with acute fulminate myocarditis (6 boys and 6 girls, median age 8.3 (0.6, 13.0) years, median weight 33.1 (6, 61) kg) who were rescued with ECMO in Children's Hospital, Zhejiang University from September 2009 to August 2015 were analyzed retrospectively. The analysis focused on the intervene timing of ECMO for the cardiogenic shock and hypoperfusion caused by heart failure and(or) lethal arrhythmia and the essentials of ECMO cardiopulmonary resuscitation(ECPR) for cardiac arrest in pediatric AFM were summarized. Result: The median ECMO duration was 110(22, 240) h. Ten cases survived and 2 were dead of the total of 12 patients. Six ECPR patients survived and 2 were dead in the total of 8 ECPR patients. The complication of 10 survivors were cannula site bleeding (3 cases), hypernatremia and intracranial hemorrhage (1 case), limping (1 case), hoarse voice (1 case), and cerebral injury (1 case). Conclusion: The key points of improving ECMO rescuing outcome for the AFM children are grasping the ECMO intervene timing and training skilled ECMO team. For ECPR patients, keeping effective chest compressions resuscitation is the key to achieve survival and improve the quality of life.