Resuscitation For Refractory Cardiac Arrest Research Articles

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.

Perioperative Extracorporeal Cardiopulmonary Resuscitation in Adult Patients: A Review for the Perioperative Physician.

The use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest has grown rapidly over the previous decade. Considerations for the implementation and management of extracorporeal cardiopulmonary resuscitation are presented for the perioperative physician.

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

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

Abstract 244: Geospatial Access to Extracorporeal Membrane Oxygenation in the United States

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a form of complete cardiopulmonary support which has been associated with improved survival in both severe acute respiratory distress syndrome and refractory cardiac arrest. ECMO is a resource-intensive therapy limited to specialized centers in urban environments, restricting its availability in suburban and rural areas. We examined the proportion of the U.S. population within a 15-minute, 30-minute, and 45-minute drivetime area to an ECMO-capable center. Methods: Using geographic information systems (GIS), we created shapefiles with polygons representing 15, 30, and 45-minute drivetime areas to ECMO-capable centers. Census block group centroids were then overlaid to determine the proportion of the population with access to ECMO-capable centers. Results: We found that 22%, 52%, and 67% of the U.S. population live within 15, 30, and 45 minutes of ECMO-capable centers, respectively. One hundred and ten million people, more than one third of the U.S. population, live further than 45 minutes away from an ECMO-capable center. Puerto Rico, Wyoming, North Dakota, and Alaska have 0% population access. Texas, California, and Florida have the highest number of people with low access (9, 8, and 5 million, respectively). Conclusion: Population access to ECMO-capable centers in the U.S. is highly variable and limits time-dependent interventions, which are essential for successful deployment of extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest. Our GIS model can be used for future planning of ECMO systems to optimize access for the U.S. population or to comparatively evaluate proposals to improve access.

104 Extracorporeal CardioPulmonary Resuscitation in Refractory Cardiac Arrest: Two Experimental Models and A Systematic Review

104 Extracorporeal CardioPulmonary Resuscitation in Refractory Cardiac Arrest: Two Experimental Models and A Systematic Review

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in Australia: a narrative review.

Extracorporeal cardiopulmonary resuscitation (ECPR) in patients with prolonged or refractory out-of-hospital cardiac arrest (OHCA) is likely to be beneficial when used as part of a well developed emergency service system. ECPR is technically challenging to initiate and resource-intensive, but it has been found to be cost-effective in hospital-based ECPR programs. ECPR expansion within Australia has thus far been reactive and does not provide broad coverage or equity of access for patients. Newer delivery strategies that improve access to ECPR for patients with OHCA are being trialled, including networked hospital-based ECPR and pre-hospital ECPR programs. The efficacy, scalability, sustainability and cost-effectiveness of these programs need to be assessed. There is a need for national collaboration to determine the most cost-effective delivery strategies for ECPR provision along with its place in the OHCA survival chain.

A qualitative analysis of physician decision making in the use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest

Aim of StudyTo prepare for the design of future randomized clinical trials of extracorporeal cardioupulmonary resuscitation (ECPR), we sought to understand physician beliefs regarding the use of ECPR and subsequent management, among physicians who already perform ECPR, as these physicians would be likely to be involved in many planned ECPR trials. MethodsWe performed 12 semi-structured interviews of physicians who already perform ECPR across a variety of medical specialties, centers and geographic regions, but all with 10–50+ cases of ECPR experience. We qualitatively analyzed these interview to identify key characteristics of their experience using ECPR, the tensions involved in patient identification, the complications of subsequent management, and their willingness to enroll potential ECPR patients in randomized trials of ECPR. ResultsPhysicians who routinely perform ECPR have strong beliefs regarding the use of ECPR, and typically have protocols they follow, though they are willing to break these protocols to cannulate young or healthy patients, or patients with immediate pre-hospital CPR and shockable rhythms. We found that physicians lacked equipoise to randomize these types of patients to continued conventional CPR. Future RCTs might be successful in enrolling older patients, younger patients without immediate pre-hospital care/bystander CPR, or patients with obvious comorbidities. ConclusionsRCTs for ECPR will need to avoid targeting patients in whom physicians feel strongly compelled to do ECPR or not do ECPR, instead identifying the middle range of patients in whom the physicians consider ECPR reasonable, but not required or contraindicated.

Hyperoxia during extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest is associated with severe circulatory failure and increased mortality

BackgroundHigh levels of arterial oxygen pressures (PaO2) have been associated with increased mortality in extracorporeal cardiopulmonary resuscitation (ECPR), but there is limited information regarding possible mechanisms linking hyperoxia and death in this setting, notably with respect to its hemodynamic consequences. We aimed therefore at evaluating a possible association between PaO2, circulatory failure and death during ECPR.MethodsWe retrospectively analyzed 44 consecutive cardiac arrest (CA) patients treated with ECPR to determine the association between the mean PaO2 over the first 24 h, arterial blood pressure, vasopressor and intravenous fluid therapies, mortality, and cause of deaths.ResultsEleven patients (25%) survived to hospital discharge. The main causes of death were refractory circulatory shock (46%) and neurological damage (24%). Compared to survivors, non survivors had significantly higher mean 24 h PaO2 (306 ± 121 mmHg vs 164 ± 53 mmHg, p < 0.001), lower mean blood pressure and higher requirements in vasopressors and fluids, but displayed similar pulse pressure during the first 24 h (an index of native cardiac recovery). The mean 24 h PaO2 was significantly and positively correlated with the severity of hypotension and the intensity of vasoactive therapies. Patients dying from circulatory failure died after a median of 17 h, compared to a median of 58 h for patients dying from a neurological cause. Patients dying from neurological cause had better preserved blood pressure and lower vasopressor requirements.ConclusionIn conclusion, hyperoxia is associated with increased mortality during ECPR, possibly by promoting circulatory collapse or delayed neurological damage.

Survival outcomes of in-hospital cardiac arrest in pediatric patients in the USA.

We report on in-hospital cardiac arrest outcomes in the USA. The data were obtained from the National (Nationwide) Inpatient Sample datasets for the years 2000-2017, which includes data from participating hospitals in 47 US states and the District of Columbia. We included pediatric patients (< 18 years of age) with cardiac arrest, and we excluded patients with no cardiopulmonary resuscitation during the hospitalization. Primary outcome of the study was in-hospital mortality after cardiac arrest. A multivariable logistic regression was performed to identify factors associated with survival. A total of 20,654 patients were identified, and 8226 (39.82%) patients survived to discharge. The median length of stay and cost of hospitalization were significantly higher in the survivors vs. non-survivors (LOS 18 days vs. 1 day, and cost $187,434 vs. $45,811, respectively, p < 0.001). In a multivariable model, patients admitted to teaching hospitals, elective admissions, and those admitted on weekdays had higher survival (aOR=1.19, CI: 1.06-1.33; aOR=2.65, CI: 2.37-2.97; and aOR=1.17, CI: 1.07-1.27, respectively). There was no difference in mortality between patients with extracorporeal cardiopulmonary resuscitation (E-CPR) and those with conventional cardiopulmonary resuscitation. E-CPR patients were likely to have congenital heart surgery (51.0% vs. 20.8%).Conclusion: We highlighted the survival predictors in these events, which can guide future studies aimed at improving outcomes in pediatric cardiac arrest. What is Known: • In-hospital cardiac arrest occurs in 2-6% of pediatric intensive care admissions. • Cardiac arrests had a significant impact on hospital resources and a significantly high mortality rate. What is New: • Factors associated with higher survival rates in patients with cardiac arrest: admission to teaching hospitals, elective admissions, and week-day admissions. • The use of rescue extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest has increased by threefold over the last two decades.

Abstract P398: Sex Differences in Stroke Frequency in Extracorporeal Cardio-Pulmonary Resuscitation for Refractory Cardiac Arrest

Introduction: Extracorporeal cardio-pulmonary resuscitation (ECPR) is being used more frequently for refractory cardiac arrest (rCA). Stroke remains a key determinant of outcomes in patients receiving ECPR. No studies have yet analyzed sex differences in the frequency of stroke in patients with rCA treated with ECPR. Methods: Retrospective analysis of ECPR cases for rCA identified in the Extracorporeal Life Support Organization (ELSO) International Registry. Age, sex, race/ethnicity and vascular risk factors were included. Stroke was defined as “Ischemic Stroke” and “Intracranial Hemorrhage” as detected by neuroimaging. Statistical analysis: level of significance was set to p≤0.05. To assess sex differences comparative tests were used as appropriate. Results: From 1992 to 2020 a total of 7,460 adult cases of ECPR for rCA were identified; 2,276 (30%) women vs. 5,184 (69%) men; Mean age 50.3 years (±SD 17) in women vs. 54.7 years (±SD 14) in men, (p&lt;0.001). There was no significant difference in hypertension, diabetes, and atrial fibrillation frequency between men and women. Coronary artery disease was more frequent in men than women, 960 (18.5%) vs. 333 (14.6%) respectively (p&lt;0.001). Intracranial hemorrhage occurred in 165 (2.2%) patients in the overall cohort, more frequently in women than men, 69 (3.0%) vs. 96 (1.8%) respectively (p=0.013). Ischemic Stroke occurred in 367 (4.9%) of the overall cohort and more frequently in men than women, 272 (5.2%) vs. 95 (4.1%) respectively (p =0.049). In-hospital mortality occurred in 89 (92.7%) men and 59 (85.5%) women with intracranial hemorrhage (p=0.133), and in 226 (83%) men and 76 (80%) women with ischemic stroke (p=0.497). Conclusions: This is the first study evaluating sex-related differences in the frequency of stroke in patients with ECPR from the largest contemporary ELSO registry. Women were younger than men at the time of rCI and had more intracranial hemorrhages. Men were older and had more ischemic strokes. Morality was high when stroke was present. Our study has implications for future development of sex-targeted treatment strategies when implementing ECPR to reduce neurological complications and to improve outcome.

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: a scoping review.

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is an emerging concept in cardiac arrest and cardiopulmonary resuscitation. Recent research has documented a significant improvement in favorable outcomes, notable survival to discharge, and neurologically intact survival.ObjectivesThe present study undertakes a scoping review to summarize the available evidence by assessing the use of ECPR, compared with no ECPR or the standard of care, for adult patients who sustain cardiac arrest in any setting, in studies which record survival and neurologic outcomes.MethodsThis review followed the PRISMA extension for scoping reviews (PRISMA‐ScR) guidelines. Four online databases were used to identify papers published from database inception to July 12, 2020. We selected 23 observational studies from Asia, Europe, and North America that used survival to discharge or neurologically intact survival as a primary or secondary endpoint variable in patients with cardiac arrest refractory to standard treatment.ResultsTwenty‐three observational studies were included in the review. Eleven studies were of out‐of‐hospital cardiac arrest, 7 studies were of in‐hospital cardiac arrest, and 5 studies included mixed populations. Ten studies reported long‐term favorable neurological outcomes (ie, Cerebral Performance Category score of 1 – 2 at 3 months [n = 3], 6 months [n = 3], and 1 year [n = 4]), of which only 4 had statistical significance at 5% significance levels. Current knowledge is mostly drawn from single‐center observations, with most of the evidence coming from case series and cohort studies, hence is prone to publication bias. No randomized control trials were included.ConclusionsThis scoping review highlights the need for high‐quality studies to increase the level of evidence and reduce knowledge gaps to change the paradigm of care for patients with shock‐refractory cardiac arrest.

Practice parameters of extracorporeal cardio-pulmonary resuscitation for refractory cardiac arrest in Germany. A nation-wide survey by the eCPR/ECMO working group of the German resuscitation council

Aim: Extracorporeal cardiopulmonary resuscitation, eCPR is increasingly becoming available as a therapy option in refractory in- or out-of-hospital cardiac arrest (IHCA or OHCA), respectively. To further assess the current state and practices of eCPR in Germany, we conducted a survey among 99 institutions by the eCPR/ECMO working group of the German Resuscitation Council.

Evaluating the potential impact of an emergency department extracorporeal resuscitation (ECPR) program: a health records review.

Extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program. This retrospective health records review included patients aged 18-75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both "liberal" and "restrictive" ECPR criteria were defined and applied to our cohort. A total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31-53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR. At our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Cost and Quality of Life Analysis of Extracorporeal Cardiopulmonary Resuscitation for Refractory Cardiac Arrest

Aims: The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest (ECPR) has increased exponentially. ECPR is a resource intensive service and its cost effectiveness has yet to be demonstrated. We sought to complete a cost analysis with modelling of cost effectiveness and quality of life outcomes. Methods: Using data on all Extracorporeal Cardiopulmonary Resuscitation (ECPR) patients at two ECMO centres in Sydney, Australia; we completed a costing analysis of ECPR patients. A Markov model of cost, quality of life and survival outcomes was developed to examine cost per QALY estimates and incremental cost effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) was completed to assess the probability of cost effectiveness for base case and variations. Results: Sixty-two ECPR patients were analysed; mean age of 51.9 ± 13.6 years, 38 (61%) were in hospital cardiac arrests (IHCA). Twenty-five patients (40%) survived to hospital discharge; all with a Cerebral Performance Category (CPC) of 1 or 2. The mean cost per ECPR patient was AUD 75,165 (€50,535; ± AUD 75,737). Over 10 years ECPR was estimated to add a mean gain of 3.0 Quality Adjusted Life Years (QALYs) per patient with an incremental cost effectiveness ratio (ICER) of AUD 25,212 (€16,890) per QALY, increasing to 4.0 QALYs and an ICER of AUD 18,829 (€12,614) over a 15-year survival scenario. Mean cost per QALY did not differ significantly by OHCA or IHCA. Conclusion: ECMO support for refractory cardiac arrests is cost effective and compares favourably to accepted cost effectiveness thresholds.

Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: A two center observational study

BackgroundCardiac arrest (CA) due to pulmonary embolism (PE) is associated with low survival rates and poor neurological outcomes. We examined whether Extracorporeal Cardiopulmonary Resuscitation (ECPR) improves the outcomes of patients who suffer from CA due to massive PE. MethodsWe retrospectively included 39 CA patients with proven or strongly suspected PE in two hospitals in the Netherlands, in a ‘before/after’-design. 20 of these patients were treated with Conventional Cardiopulmonary Resuscitation (CCPR) and 19 patients with ECPR. ResultsThe main outcomes of this study were ICU survival and favourable neurological outcome, defined as Cerebral Performance Category (CPC) score 1–2. The ICU survival rate in CCPR patients was 5% compared to 26% in ECPR patients (p<0.01). Survival with favourable neurological outcome was present in 0/20 (0%) CCPR patients compared to 4/19 (21%) of the ECPR patients (p<0.05). ConclusionECPR seems a promising treatment for cardiac arrest patients due to (suspected) massive pulmonary embolism compared to conventional CPR, though outcomes remain poor.

Health related quality of life after extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest

BackgroundRecent data identifies extracorporeal cardio-pulmonary resuscitation (eCPR) as a potential addendum of conventional cardiopulmonary-resuscitation (cCPR) in highly specified circumstances and selected patients. However, consented criteria indicating eCPR are lacking. Therefore we provide first insights into the health-related quality of life (HRQoL) outcomes of patients treated with eCPR in a real world setting. MethodsRetrospective single-center experience of 60 consecutive patients treated with eCPR between 01/2014 and 06/2016 providing 1-year survival- and HRQoL data obtained through the Short-Form 36 Survey (SF-36) after refractory out-of-hospital- (OHCA) and in-hospital cardiac arrest (IHCA) of presumed cardiac etiology. ResultsResuscitation efforts until initiation of eCPR averaged 66 ± 35 min and 63.3% of the patients suffered from OHCA. Fifty-five (91.7%) of the overall events were witnessed and bystander-CPR was performed in 73.3% (n = 44) of cases. Cause of arrest was dominated by acute myocardial infarction (AMI, 66.7%) and initial rhythm slightly outbalanced by ventricular fibrillation/tachycardia (VF/VT 53.3%). 12-month survival was 31%. Survivors experienced more often bystander-CPR (p = .001) and a shorter duration of cCPR (p = .002). While mid-term survivors’ perceived HRQoL was compromised compared to controls (p ≦ .0001 for PF, RP, RE and BP; p = .007 for GH; p = .016 for SF; p = .030 for MH; p = .108 for VT), scores however resembled HRQoL of subjects on hemodialysis, following cardiogenic shock or pulmonary failure treated with extracorporeal membrane oxygenation (ECMO). ConclusionsWhile HRQoL scores of our survivors ranged markedly below controls, compared to patients on chronic hemodialysis, following ECMO for cardiogenic shock or pulmonary failure most of the discrepancies ameliorated. Thus, successfull eCPR in properly selected patients does translate into an encouraging HRQoL approximating chronic renal failure.

Outcomes of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in adult cardiac surgery patients

BackgroundThe role of extracorporeal cardiopulmonary resuscitation (ECPR) in adult cardiac surgery patients with refractory cardiac arrest is uncertain. We hypothesized that ECPR would be associated with better than expected outcomes in this group of patients. MethodsWe conducted a single-center retrospective cohort study of adult cardiac surgery patients who underwent ECPR for refractory cardiac arrest during a 6-year period (2010 to 2015). In-hospital mortality, survival at last follow-up, and cerebral performance category (CPC) were examined as outcomes, and potential risk factors for mortality were explored. ResultsTwenty-three patients underwent ECPR when spontaneous circulation did not return with conventional resuscitation. Thirty-day mortality was 65.2%, and in-hospital mortality was 69.6%. Six of the 23 patients (26.1%) were discharged with a favorable neurologic outcome, defined as CPC 1 or 2. Most patients who died had multiple organ dysfunction syndrome (43.8%), and a smaller number had severe brain injury (25.0%). Kaplan-Meier survival analysis suggested age as a critical factor affecting survival (P = .04, log-rank test). ConclusionsECPR may have a role in younger adult cardiac surgery patients who experience refractory cardiac arrest. Future studies are needed to identify patients who will benefit most from ECPR.

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in children after cardiac surgery.

Objective:Extracorporeal membrane oxygenation (ECMO) is used to provide cardiorespiratory support during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation; ECPR) unresponsive to conventional methods. In this study, the results of ECPR in a cardiac arrest setting after cardiac surgery in children were analyzed.Methods:In this retrospective cohort study, between November 2010 and June 2014, 613 congenital heart operations were performed by the same surgical team. Medical records of all the patients who experienced cardiac arrest and ECPR in an early postoperative period (n=25; 4%) were analyzed. Their ages were between 2 days and 4.5 years (median: 3 months). Sixteen patients had palliative procedures. In 88% of the patients, cardiac arrest episodes occurred in the first 24 h after operation. Mechanical support was provided by cardiopulmonary bypass only (n=10) or by ECMO (n=15) during CPR.Results:The CPR duration until commencing mechanical support was <20 min in two patients, 20–40 min in 11 patients, and >40 min in 12 patients. Eleven patients (44%) were weaned successfully from ECMO and survived more than 7 days. Five of them (20%) could be discharged. The CPR duration before ECMO (p=0.01) and biventricular physiology (p=0.022) was the key factor affecting survival. The follow-up duration was a mean of 15±11.9 months. While four patients were observed to have normal neuromotor development, one patient died of cerebral bleeding 6 months after discharge.Conclusion:Postoperative cardiac arrest usually occurs in the first 24 h after operation. ECPR provides a second chance for survival in children who have had cardiac arrest. Shortening the duration of CPR before ECMO might increase survival rates. (Anatol J Cardiol 2017; 17: 328-33)

High-dose intravenous nitroglycerin during cardiopulmonary resuscitation for refractory cardiac arrest

High-dose intravenous nitroglycerin during cardiopulmonary resuscitation for refractory cardiac arrest