Refractory In-hospital Cardiac Arrest Research Articles

Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation.

The aim of this study was to develop and validate a score to accurately predict the probability of death for adult extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20% to 40%. Adult patients with extracorporeal membrane oxygenation for IHCA (ECPR) were identified from the American Heart Association GWTG-R (Get With the Guidelines-Resuscitation) registry. A multivariate survival prediction model and score were developed to predict hospital death. Findings were externally validated in a separate cohort of patients from the Extracorporeal Life Support Organization registry who underwent ECPR for IHCA. A total of 1,075 patients treated with ECPR were included. Twenty-eight percent survived to discharge in both the derivation and validation cohorts. A total of 6 variables were associated with in-hospital death: age, time of day, initial rhythm, history of renal insufficiency, patient type (cardiac vs noncardiac and medical vs surgical), and duration of the cardiac arrest event, which were combined into the RESCUE-IHCA (Resuscitation Using ECPR During IHCA) score. The model had good discrimination (area under the curve: 0.719; 95% CI: 0.680-0.757) and acceptable calibration (Hosmer and Lemeshow goodness of fit P=0.079). Discrimination was fair in the external validation cohort (area under the curve: 0.676; 95% CI: 0.606-0.746) with good calibration (P=0.66), demonstrating the model's ability to predict in-hospital death across a wide range of probabilities. The RESCUE-IHCA score can be used by clinicians in real time to predict in-hospital death among patients with IHCA who are treated with ECPR.

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest: A retrospective cohort study

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results. ResultsAmong the 137 patients (67.9% men; median [IQR] age, 54 [43–62] years; low-flow duration, 45 [30–70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25–53) versus 50 (35–80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts. ConclusionSurvival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.

The first year of experience with an extracorporeal resuscitation program for refractory in-hospital cardiac arrest

The first year of experience with an extracorporeal resuscitation program for refractory in-hospital cardiac arrest

Cardiopulmonary Resuscitation With Percutaneous ECMO in Refractory In-hospital Cardiac Arrest: A Single-center Experience.

Cardiopulmonary Resuscitation With Percutaneous ECMO in Refractory In-hospital Cardiac Arrest: A Single-center Experience.

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest

Despite recent improvement in cardiac arrest management, in-hospital cardiac arrest (IHCA) remains associated with poor outcome. Whereas its usefulness for out-of-hospital cardiac arrest seems poor, extracorporeal cardiopulmonary resuscitation (e-CPR; i.e. veno-arterial extracorporeal membrane oxygenation (VA-ECMO) under cardiopulmonary resuscitation) could be a life-saving strategy for refractory IHCA. To describe the characteristics and outcomes of refractory IHCA patients supported by e-CPR in our institution. Retrospective cohort study of data prospectively collected. All patients implanted with a VA-ECMO for refractory IHCA from 2007 to 2017 were included. VA-ECMO was implanted at the cardiac arrest site by trained cardiac surgeons from our mobile circulatory assistance unit. After ECMO implantation, patients were all referred and managed in our ICU. A 1-yr follow-up phone call was given to each survivor. During the study period, 97 patients (mean age 50.9 ± 14.8 yrs) received e-CPR for refractory IHCA. 80.4% of IHCA had a cardiac origin. VA-ECMO was implanted in our ICU for 37% of them, in the cardiology department for 30%, in another hospital for 23%. Survival rate was 19.6% at hospital discharge, 15% at 1-yr follow-up, with a 1-yr CPC score of 1 [1–2]. Main causes of in-ICU deaths were multiple organ failure (71%) and post-anoxic encephalopathy (12%). Compared to 1-yr non-survivors, 1-yr survivors had similar no- and low-flow, their initial rhythm was more frequently shockable (69.2% versus 33.8%, respectively, P = 0.03) and their day-1 SOFA score was significantly lower (13 [10–14] versus 15 [12–17], respectively, P = 0.02). e-CPR in refractory IHCA is associated with a 15% 1-yr survival rate. Survivors have a good 1-year CPC score. Next step is to determine prognosis factors to select the patients the most likely to benefit from this technique.

A CONTEMPORARY REVIEW OF EXTRACORPOREAL MEMBRANE OXYGENATION FOR CARDIAC ARRESTS IN THE CARDIAC CATHETERIZATION LABORATORY

Patients who sustain refractory in-hospital cardiac arrest (IHCA) with severe cardiopulmonary compromise in the cardiac catheterization laboratory have an extremely low survival. Despite early revascularization to infarct-related coronary artery, mortality rates vary between 80-90%. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be lifesaving and is increasingly used in patients with reversible conditions who sustain refractory cardiac arrest or profound cardiogenic shock. The primary objective was to determine the characteristics and outcomes of patients receiving VA-ECMO in cardiac catheterization laboratory following IHCA or hemodynamic collapse. Secondary objectives included determination of 30-day mortality and identification of univariate predictors of 30-day survival. Between 2010 and 2016, all consecutive adults who received VA-ECMO in the cardiac catheterization laboratory at a single tertiary care center were retrospectively reviewed. Refractory cardiac arrest was defined as those who required ECMO cannulation during active cardiopulmonary resuscitation or those with profound cardiogenic shock post return of spontaneous circulation (ECPR-ROSC). Data collection information included baseline demographics, comorbid cardiovascular risk factors, referral diagnosis, etiology of cardiac arrest, procedural characteristics and in and out of hospital outcomes. A total of 41 ECMO cannulations (57-66, 18 males) occurred in the cardiac catheterization laboratory between July 2010 and April 2016. The baseline cardiovascular risk factors between survivors and non-survivors were relatively similar (Table 1). Overall, the majority of cases were related to cardiogenic shock secondary to an acute coronary syndrome (Table 1). None of the patients who suffered a mechanical complication secondary to an ACS survived. Procedural complications such as aortic dissections, pulmonary artery and atrial rupture accounted for 10% of the ECMO cannulations and had a 75% (n=3) associated mortality. 30-day survival for the entire cohort was 43.9% (Figure 1). There was no difference from time to cannulation between those that survived 30 days and those that did not survive. There was no difference in the complications rate between those that survived and those that did not survive ECMO cannulation. However, ECMO site bleeding was increased in those that did not survive. In the evolving field of mechanical support, VA-ECMO is becoming increasingly available as a temporizing measure for patients with refractory shock or cardiac arrest. Our study shows that patients with ACS or procedural complication in the catheterization lab who develop IHCA or profound cardiogenic shock benefit from VA-ECMO. VA-ECMO cannulation demonstrates an impressive 30-day survival in a patient cohort which has extremely high mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Extracorporeal Cardiopulmonary Resuscitation with Therapeutic Hypothermia for Prolonged Refractory In-hospital Cardiac Arrest.

Background and ObjectivesWe identified the impact of extracorporeal cardiopulmonary resuscitation (ECPR) followed by therapeutic hypothermia on survival and neurologic outcome in patients with prolonged refractory in-hospital cardiac arrest (IHCA).MethodsWe enrolled 16 adult patients who underwent ECPR followed by therapeutic hypothermia between July 2011 and December 2015, for IHCA. Survival at discharge and cerebral performance category (CPC) scale were evaluated.ResultsAll patients received bystander cardiopulmonary resuscitation (CPR); the mean CPR time was 66.5±29.9 minutes, and the minimum value was 39 minutes. Eight patients (50%) were discharged alive with favorable neurologic outcomes (CPC 1–2). The mean follow-up duration was 20.1±24.3 months, and most deaths occurred within 21 days after ECPR; thereafter, no deaths occurred within one year after the procedure.ConclusionECPR followed by therapeutic hypothermia could be considered in prolonged refractory IHCA if bystander-initiated conventional CPR is performed.

Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis.

Extracorporeal life support (ECLS) has shown encouraging survival rates in patients with in-hospital cardiac arrest; however, its routine use is still controversial. We compared the survival of patients with in-hospital cardiac arrest receiving conventional cardiopulmonary resuscitation (CCPR) to that of patients with ECLS as an adjunct to cardiopulmonary resuscitation (ECPR). A total of 353 patients with in-hospital cardiac arrest (272 CCPR and 52 ECPR) were included in this retrospective, propensity score-adjusted (1:1 matched), single-centre study. Primary endpoints were survival at 30 days, long-term survival and neurological outcome defined by the cerebral performance categories score. In the unmatched groups patients undergoing ECPR initially had significantly higher APACHE II scores ( P=0.03), increased norepinephrine dosages ( P=0.03) and elevated levels of creatine kinase ( P<0.0001), creatinine ( P=0.04) and lactate ( P=0.02) before cardiopulmonary resuscitation compared with those undergoing CCPR. After equalising these parameters significant differences were observed in short and long-term survival, favouring ECPR over CCPR (27% vs. 17%; P=0.01 (short-term) and 23.1% vs. 11.5%; P=0.008 (long-term); median follow-up duration after discharge 1136 days (interquartile range 823-1416)). There was no significant difference in the incidence of a cerebral performance categories score of 1 or 2 between the matched groups (CCPR 66.7% vs. ECPR 83.3%; P=0.77). ECLS implantation was the only significant and independent predictor of mortality in multivariate Cox regression analysis (hazard ratio 0.57, 95% confidence interval 0.35-0.90; P=0.02). In our cohort of cardiovascular patients ECPR was associated with better short- and long-term survival over CCPR, with a good neurological outcome in the majority of the patients with refractory in-hospital cardiac arrest.

Oxigenación con membrana extracorpórea venoarterial en reanimación cardiopulmonar intrahospitalaria como puente a trasplante cardiaco

ObjectiveTo evaluate the functional and neurological outcome of patients in whom extracorporeal cardiopulmonary resuscitation E-CPR was used as a bridge to heart transplantation. DesignThis is a retrospective, observational study. ParticipantsAn evaluation was performed on adult patients who were treated with extracorporeal life support for cardiopulmonary arrest between 2007 and 2014. ResultsFrom 2007 to 2014, 168 patients received some form of extracorporeal support (112 neonatal or pediatric and 56 adults). From the adult group, 45 (80%) had a cardiac mechanical support (45 V-A ECMO, three short-term VADs, and one long-term VAD). Among this group, 15 received the support as E-CPR, and in 9 patients it was used as a bridge to heart transplantation. In the use of E-CPR as a bridge to heart transplantation, the median age was 56, the mean time of CPR before full flow was 54±15min, and the median duration of ECMO support before heart transplant was 1.5 days. Of the 6 out of 9 patients transplanted (66%), 5 of 6 survived with good functional and neurological outcome. An intention-to-treat analysis showed an overall survival of 55% (5 of 9). ConclusionThe use of E-CPR for the management of refractory in-hospital cardiac arrest in patients with severely impaired left ventricular systolic function, candidates for heart transplant, may increase the likelihood of survival to hospital discharge without neurological sequelae.