Optimal loop duration during the provision of in-hospital advanced life support (ALS) to patients with an initial non-shockable rhythm

Background

In advanced life support (ALS), time-cycled “loops” of chest compressions form the basis of action. However, the provider must compromise between interrupting compressions and detecting a change in cardiac rhythm. An “optimal” loop duration would best balance these choices. The current international CPR guidelines recommend 2-min loop durations. The aim of this study was to investigate the “optimal” loop duration in patients with initial asystole or pulseless electrical activity (PEA).

Materials and methods

Detailed defibrillator recordings from 249 in-hospital cardiac arrests at the University of Chicago Medicine (Chicago, IL) and St. Olav University Hospital (Trondheim, Norway) were analysed. The clinical states of asystole, PEA, ventricular fibrillation/-tachycardia (VF/VT) and return of spontaneous circulation (ROSC) were annotated along the time axis. PEA and asystole were combined as a single state for the analysis of state development. The probability of staying in PEA/asystole over time was estimated non-parametrically. In addition, to distinguish between initial and secondary PEA/asystole, the latter was defined by the transition from VF/VT or ROSC.

Results

Among patients with initial PEA (n = 179), 25% and 50% of patients had left PEA/asystole after 4 and 9 min of ALS efforts, respectively. The corresponding time points for patients with initial asystole (n = 70) were 7.3 and 13.3 min, respectively. The probability of transition from secondary PEA/asystole to ROSC or VF/VT varied between 10% and 20% in each 2–4 min interval.

Conclusion

The “optimal” first loop duration may be 4 min in initial PEA and 6–8 min in initial asystole. If secondary PEA/asystole is encountered, 2-min loop duration seems appropriate.     

Overcoming barriers to in-hospital cardiac arrest documentation

AIMS: (1) To describe the introduction of standardised cardiac arrest documentation to Auckland City Hospital, highlighting how barriers to using the Utstein template were overcome. (2) To determine the adequacy of documentation of cardiac arrest time intervals. METHOD: A retrospective audit of cardiac arrest documentation for a 3-year period following the introduction of a standard documentation form. RESULTS: There was an initial improvement in use of the template (29% (95%CI 22-37%) to 88% (95%CI 82-92%), p<0.001) after identification of barriers and implementation of tailored strategies. Use of the template declined (77%, 95%CI 69-84%, p=0.023) after the key facilitator left the hospital. Time interval documentation ranged from 66% (95%CI 54-77%) for tracheal intubation to 91% (95%CI 80-93%) for first dose of adrenaline (epinephrine). CONCLUSIONS: Designated 'hands-off' senior clinicians were required for accurate documentation of time intervals. Time interval documentation was sub-optimal and further efforts are required to improve this. Transfer of ownership beyond the key facilitator was integral to sustainability of the process. Future reports of in-hospital cardiac arrest outcomes should include baseline information on the adequacy of documentation of time intervals.     

255例院前心搏骤停患者心肺复苏影响因素分析

目的了解6年来心肺复苏(CPR)现状,分析其影响因素,研究如何提高CPR水平。方法对本院2001-01～2007-01院前发生的255例心搏骤停(cardiacarrest,CA)患者的资料进行分析,比较自主循环恢复(ROSC)成功组和失败组的CPR开始时间、CPR持续时间、除颤次数、肾上腺素用量等。结果全部病例ROSC成功率为38.03%,脑复苏成功率仅为2.74%。两组CPR开始时间(从心脏停搏至CPR开始时间)、人工气道开始建立时间、是否安装临时起搏器、肾上腺素用量比较差异有统计学意义(P≤0.01),在CPR持续时间、除颤次数方面比较差异无统计学意义(P>0.05)。CPR成功率与CPR开始时间和急救水平高低有密切关系。结论CA患者CPR成功率较低,与"生命链"未彻底落实及急救水平低有关。普及全民急救知识,加强完善急救医疗体系建设,是提高CPR成功率的关键措施。     

Recurrent ventricular fibrillation during advanced life support care of patients with prehospital cardiac arrest

AIM OF THE STUDY: The response of recurrent episodes of ventricular fibrillation (VF) to defibrillation shocks has not been systematically studied. We analyzed outcomes from countershocks delivered for VF during advanced life support (ALS) care of patients with out-of-hospital cardiac arrest. METHODS: Cohort of patients with prehospital cardiac arrest presenting with VF, treated by ALS ambulance staff following ERC Guidelines 2000. Biphasic defibrillators provided shocks increasing from 200 to 360J. Recorded signals were analyzed to determine, for each shock, if VF was terminated and if a sustained organized rhythm was restored within 60s. RESULTS: In 465 of the 467 patients enrolled, the initial VF episode was terminated within three shocks: 92%, 61%, and 83% responded to 200J first, 200J second and 360J third shocks, respectively. VF recurred in 48% of patients within 2min of the first episode, and in 74% sometime during prehospital care. In the 175 patients experiencing five or more VF episodes, single shock VF termination dropped from the first to the fifth episode (90-80%, p<0.001) without change in transthoracic impedance, yet the proportion returning to organized rhythms increased (11-42%, p<0.0001). CONCLUSIONS: Repeated refibrillation is common in patients with VF cardiac arrest. The likelihood of countershocks to terminate VF declines for repeated episodes of VF, yet shocks that terminate these episodes result increasingly in a sustained organized rhythm.     

Characteristics and outcome among 14,933 adult cases of in-hospital cardiac arrest: A nationwide study with the emphasis on gender and age

Aim

To investigate characteristics and outcome among patients suffering in-hospital cardiac arrest (IHCA) with the emphasis on gender and age.

Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation

Extracorporeal life support has been used as an extension of conventional cardiopulmonary resuscitation (CPR). However, the appropriate indications for extracorporeal CPR (ECPR) including the duration of CPR are unknown. We present a case of a male, 37-year-old out-of-hospital cardiac arrest patient who received prolonged CPR followed by ECPR. Despite advanced cardiac life support, he did not regain a sustained spontaneous circulation and had recurrent ventricular fibrillation (VF) during the prolonged CPR. VF was unresponsive to CPR, defibrillation, adrenaline (epinephrine), and antiarrhythmics. The CPR time before ECPR was approximately 2h. During extracorporeal life support, the VF did not recur and percutaneous coronary angioplasty was achieved. Ultimately, the patient was discharged without neurological complications. Although cardiac arrest occurred out-of-hospital and CPR was performed for a long time, a patient might be a candidate for ECPR if perfusing rhythms are restored transiently but not successfully maintained due to recurrent VF. ECPR may be used for VF unresponsive to standard CPR techniques.     

Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner

For patients who present with an out-of-hospital refractory cardiac arrest, in-hospital extracorporeal life-support (ECLS) initiation represents an alternative therapy which allows significant survival. We describe here the first case of out-of-hospital ECLS implantation in a patient presenting with a refractory cardiac arrest during a road race. ECLS was initiated within the MICU ambulance 60 min after cardiac arrest and enabled restoration of cardiac output to 4.5 l min⁻¹. Coronarography revealed a severe isolated stenosis of the right coronary artery, which was treated by angioplasty. The cardiogenic shock resolved progressively, enabling ECLS weaning within 48 h, while renal, hepatic, and respiratory functions recovered simultaneously.     

Eleven years of experience with extracorporeal cardiopulmonary resuscitation for paediatric patients with in-hospital cardiac arrest

Purpose

The study aims to describe 11 years of experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital paediatric cardiac arrest in a university affiliated tertiary care hospital.

Methods

Paediatric patients who received extracorporeal membrane oxygenation (ECMO) during active extracorporeal cardiopulmonary resuscitation (ECPR) at our centre from 1999 to 2009 were included in this retrospective study. The results from three different cohorts (1999–2001, 2002–2005 and 2006–2009) were compared. Survival rates and neurological outcomes were analysed. Favourable neurological outcome was defined as paediatric cerebral performance categories (PCPC) 1, 2 and 3.

Results

We identified 54 ECPR events. The survival rate to hospital discharge was 46% (25/54), and 21 (84%) of the survivors had favourable neurological outcomes.The duration of CPR was 39 ± 17 min in the survivors and 52 ± 45 min in the non-survivors (p = NS). The patients with pure cardiac causes of cardiac arrest had a survival rate similar to patients with non-cardiac causes (47% (18/38) vs. 44% (7/16), p = NS).The non-survivors had higher serum lactate levels prior to ECPR (13.4 ± 6.4 vs. 8.8 ± 5.1 mmol/L, p < 0.01) and more renal failure after ECPR (66% (19/29) vs. 20% (5/25), p < 0.01).The patients resuscitated between 2006 and 2009 had shorter durations of CPR (34 ± 13 vs. 78 ± 76 min, p = 0.032) and higher rates of survival (55% (16/29) vs. 0% (0/8), p = 0.017) than those resuscitated between 1999 and 2002.

Conclusions

In our single-centre experience with ECPR for paediatric in-hospital cardiac arrest, the duration of CPR has become shorter and outcomes have improved in recent years. Higher pre-ECPR lactate levels and the presence of post-ECPR renal failure were associated with increased mortality. The presence of non-cardiac causes of cardiac arrest did not preclude successful ECPR outcomes. The duration of CPR was not significantly associated with poor outcomes in this study.     

Prognosis in cardiac arrest

Cardiac arrest remains a common problem throughout the world. This article explores several factors that aid in determining prognosis after cardiac arrest. It is broadly divided into prearrest factors, intra-arrest factors, and postarrest factors. Prearrest factors predominantly concern the presence or absence of a shockable rhythm. Intra-arrest factors look at the partial pressure of end-tidal CO2 and the presence of cardiac standstill on ultrasound. Postarrest factors include early outcome measures as well as a more comprehensive algorithmic approach to predicting neurologic outcome.     

CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system

BACKGROUND: Cardiopulmonary resuscitation (CPR) quality during actual cardiac arrest has been found to be deficient in several recent investigations. We hypothesized that real-time feedback during CPR would improve the performance of chest compressions and ventilations during in-hospital cardiac arrest. METHODS: An investigational monitor/defibrillator with CPR-sensing and feedback capabilities was used during in-hospital cardiac arrests from December 2004 to December 2005. Chest compression and ventilation characteristics were recorded and quantified for the first 5 min of resuscitation and compared to a baseline cohort of arrest episodes without feedback, from December 2002 to April 2004. RESULTS: Data from 55 resuscitation episodes in the baseline pre-intervention group were compared to 101 resuscitations in the feedback intervention group. There was a trend toward improvement in the mean values of CPR variables in the feedback group with a statistically significant narrowing of CPR variable distributions including chest compression rate (104+/-18 to 100+/-13 min(-1); test of means, p=0.16; test of variance, p=0.003) and ventilation rate (20+/-10 to 18+/-8 min(-1); test of means, p=0.12; test of variance, p=0.04). There were no statistically significant differences between the groups in either return of spontaneous circulation or survival to hospital discharge. CONCLUSIONS: Real-time CPR-sensing and feedback technology modestly improved the quality of CPR during in-hospital cardiac arrest, and may serve as a useful adjunct for rescuers during resuscitation efforts. However, feedback specifics should be optimized for maximal benefit and additional studies will be required to assess whether gains in CPR quality translate to improvements in survival.     

参附注射液对家兔缺氧型心搏骤停-心肺复苏模型血清心肌肌钙蛋白T的影响

目的　探讨参附注射液 (SF)对家兔缺氧型心搏骤停 -心肺复苏 (CA -CPR)模型血清心肌肌钙蛋白T (cTnT)的影响。方法　普通家兔 30只 ,用夹闭气管法复制缺氧型CA -CPR模型 ,用随机数字表法随机分为SF组、纳洛酮组和生理盐水组 ,每组 10只。 3组在自主循环恢复后 8、 15、 2 2min分别静注SF、纳洛酮、生理盐水 ,并分时点检测血清cTnT值。结果　参附组cTnT值在复苏后 6 0、 12 0min明显低于生理盐水组 (P <0 0 5 )。结论　SF对CPR期间cTnT的升高有明显的抑制作用。     

Recognizing the causes of in-hospital cardiac arrest — A survival benefit

BackgroundThe in-hospital emergency team (ET) may or may not recognize the causes of in-hospital cardiac arrest (IHCA) during the provision of cardiopulmonary resuscitation (CPR). In a previous 4.5-year prospective study, this rate of recognition was found to be 66%. The aim of this study was to investigate whether survival improved if the cause of arrest was recognized by the ET.MethodsThe difference in survival if the causes were recognized versus not recognized was estimated after propensity score matching patients from these two groups.ResultsOverall survival to hospital discharge was 25%. After propensity score matching, the benefit of recognizing the cause regarding 1-hour survival of the episode was 29% (p < 0.01), and 19% regarding hospital discharge, respectively. Variables commonly known to affect the outcome after cardiac arrest were found to be balanced between the two groups. The largest difference was found in patients with non-cardiac causes and non-shockable presenting rhythms. Patient records and pre-arrest clinical symptoms were the information sources most frequently utilized by the ET to establish the causes of arrest.ConclusionsPatients suffering an IHCA showed a substantial survival benefit if the causes of arrest were recognized by the ET. Patient records and pre-arrest clinical symptoms were the sources of information most frequently utilized in these instances.     

Causes of in-hospital cardiac arrest – Incidences and rate of recognition

Background and methodsDo emergency teams (ETs) consider the underlying causes of in-hospital cardiac arrest (IHCA) during advanced life support (ALS)? In a 4.5-year prospective observational study, an aetiology study group examined 302 episodes of IHCA. The purpose was to investigate the causes and cause-related survival and to evaluate whether these causes were recognised by the ETs.ResultsIn 258 (85%) episodes, the cause of IHCA was reliably determined. The cause was correctly recognised by the ET in 198 of 302 episodes (66%). In the majority of episodes, cardiac causes (156, 60%) or hypoxic causes (51, 20%) were present. The cause-related survival was 30% for cardiac aetiology and 37% for hypoxic aetiology.The initial cardiac rhythm was pulseless electrical activity (PEA) in 144 episodes (48%) followed by asystole in 70 episodes (23%) and combined ventricular fibrillation/ventricular tachycardia (VF/VT) in 83 episodes (27%). Seventy-one patients (25%) survived to hospital discharge. The median delay to cardiopulmonary resuscitation (CPR) was 1 min (inter-quartile range 0–1 min).ConclusionsVarious cardiac and hypoxic aetiologies dominated. In two-thirds of IHCA episodes, the underlying cause was correctly identified by the ET, i.e. according to the findings of the aetiology study group.     

Chest compression depth and survival in out-of-hospital cardiac arrest

Aim

Outcomes from out-of-hospital cardiac arrest (OHCA) may improve if rescuers perform chest compressions (CCs) deeper than the previous recommendation of 38–51 mm and consistent with the 2010 AHA Guideline recommendation of at least 51 mm. The aim of this study was to assess the relationship between CC depth and OHCA survival.

Methods

Prospective analysis of CC depth and outcomes in consecutive adult OHCA of presumed cardiac etiology from two EMS agencies participating in comprehensive CPR quality improvement initiatives. Analysis: Multivariable logistic regression to calculate adjusted odds ratios (aORs) for survival to hospital discharge and favorable functional outcome.

Results

Among 593 OHCAs, 136 patients (22.9%) achieved return of spontaneous circulation, 63 patients (10.6%) survived and 50 had favorable functional outcome (8.4%). Mean CC depth was 49.8 ± 11.0 mm and mean CC rate was 113.9 ± 18.1 CC min⁻¹. Mean depth was significantly deeper in survivors (53.6 mm, 95% CI: 50.5–56.7) than non-survivors (48.8 mm, 95% CI: 47.6–50.0). Each 5 mm increase in mean CC depth significantly increased the odds of survival and survival with favorable functional outcome: aORs were 1.29 (95% CI 1.00–1.65) and 1.30 (95% CI 1.00–1.70) respectively.

Conclusion

Deeper chest compressions were associated with improved survival and functional outcome following OHCA. Our results suggest that adhering to the 2010 AHA Guideline-recommended depth of at least 51 mm could improve outcomes for victims of OHCA.     

The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest

BackgroundOut-of hospital cardiac arrest (OHCA) is associated with significant mortality. Therapeutic hypothermia is one of the few interventions that have been shown to increase post-arrest survival as well as enhance neurologic recovery. Despite clinical guidelines recommending the use of therapeutic hypothermia (TH) following cardiac arrest, utilization rates by physicians remain low. We hypothesized that the development of a multi-disciplinary emergency cardiac arrest response team (eCART) would enhance therapeutic hypothermia utilization in the emergency department for OHCA.Methods and resultsAn eCART (emergency department cardiac arrest response team) was created at a single site academic urban emergency department. The eCART team consisted of a physician hypothermia consultant, a cardiologist, a clinical pharmacist, a respiratory therapist and a chaplain. These providers were notified by page prior to the arrival of an OHCA patient and responded to the ED in person or by phone to support the resuscitation. Analysis of pre- and post-intervention data demonstrated a significant increase in the rate of TH utilization (64% to 96%). There was a non-significant decrease in the time to target temperature.ConclusionsThe creation of a coordinated, multi-disciplinary care team, providing real-time support for OHCA patients increased TH utilization in an emergency department.     

Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest – A report from the American Heart Association Get With The Guidelines®-Resuscitation

BackgroundDespite limited recommendations for using sodium bicarbonate (SB) during cardiopulmonary resuscitation (CPR), we hypothesized that SB continues to be used frequently during pediatric in-hospital cardiac arrest (IHCA) and that its use varies by hospital-specific, patient-specific, and event-specific characteristics.MethodsWe analyzed 3719 pediatric (<18 years) index pulseless CPR events from the American Heart Association Get With The Guidelines-Resuscitation database from 1/2000 to 9/2010.ResultsSB was used in 2536 (68%) of 3719 CPR events. Incidence of SB use between 2000 and 2005 vs. 2006 and 2010 was 71.1% vs. 66.2% (P = 0.002). The primary outcome was survival to discharge. Secondary outcomes included 24-h survival and neurologic outcome. Multivariable logistic regression analyzed the association between SB use and outcomes. SB had increased use an ICU location, metabolic/electrolyte disturbance, prolonged CPR, pVT/VF, and concurrently with other pharmacologic interventions. Adjusting for confounding factors, SB use was associated with decreased 24-h survival (aOR 0.83, 95% CI: 0.69, 0.99) and decreased survival to discharge (aOR 0.80; 95% CI: 0.65, 0.97). Inclusion of metabolic/electrolyte abnormalities, hyperkalemia, and toxicologic abnormalities only (n = 674), SB use was not associated with worse outcomes or unfavorable neurologic outcome.ConclusionsSB is used frequently during pediatric pulseless IHCA, yet there is a significant trend toward less routine use over the last decade. Because SB is more likely to be used in an ICU, with prolonged CPR, and concurrently with other pharmacologic interventions; its use during CPR may be associated with poor prognosis due to an association with “last ditch” efforts of resuscitation rather than causation.     

The impact of airway management on quality of cardiopulmonary resuscitation: An observational study in patients during cardiac arrest

Background

Minimising interruptions in chest compressions is associated with improved survival from cardiac arrest. Current in-hospital guidelines recommend continuous chest compressions after the airway is secured on the premise that this will reduce no flow time. The aim of this study was to determine the effect of advanced airway use on the no flow ratio and other measures of CPR quality.

Methods

Consecutive adult patients who sustained an in-hospital cardiac arrest were enrolled in this prospective observational study. The quality of CPR was measured using the Q-CPR device (Phillips, UK) before and after an advanced airway device (endotracheal tube [ET] or laryngeal mask airway [LMA]) was inserted. Patients receiving only bag-mask ventilation were used as the control cohort. The primary outcome was no flow ratio (NFR). Secondary outcomes were chest compression rate, depth, compressions too shallow, compressions with leaning, ventilation rate, inflation time, change in impedance and time required to successfully insert airway device.

Results

One hundred patients were enrolled in the study (2008–2011). Endotracheal tube and LMA placement took similar durations (median 15.8 s (IQR 6.8–19.4) vs LMA median 8.0 s (IQR 5.5–15.9), p = 0.1). The use of an advanced airway was associated with improved no flow ratios (endotracheal tube placement (n = 50) improved NFR from baseline median 0.24 IQR 0.17–0.40) to 0.15 to (IQR 0.09–0.28), p = 0.012; LMA (n = 25) from median 0.28 (IQR 0.23–0.40) to 0.13 (IQR 0.11– 0.19), p = 0.0001). There was no change in NFR in patients managed solely with bag valve mask (BVM) (n = 25) (median 0.29 (IQR 0.18–0.59) vs median 0.26 (IQR 0.12–0.37), p = 0.888). There was no significant difference in time taken to successfully insert the airway device between the two groups.

Conclusion

The use of an advanced airway (ETT or LMA) during in-hospital cardiac arrest was associated with improved no flow ratio. Further studies are required to determine the effect of airway devices on overall patient outcomes.     

Alterations of soluble L- and P-selectins during cardiac arrest and CPR

Objective: To investigate the relationship between cytokines and the inflammatory responses in patients with out-of-hospital cardiac arrest, we examined the changes of cytokines as well as alterations in the markers of neutrophil activation, platelet and endothelial activation, and endothelial injury. Design: Prospective, cohort study. Setting: General intensive care unit of a tertiary care center. Patients and participants: 26 out-of-hospital cardiac arrest patients were classified into two groups: those who achieved return of spontaneous circulation (ROSC) (n = 10) and those with no ROSC (n = 16). Eight normal healthy volunteers served as control subjects. Measurements and results: Serial levels of soluble L-selectin (sL-selectin), soluble P-selectin (sP-selectin), neutrophil elastase, and soluble thrombomodulin were measured during and after cardiopulmonary resuscitation (CPR). Serial levels of tumor necrosis factor α (TNFα) and interleukin-1β (IL-1β) were also measured. We could not find any elevations in either cytokine during the study period. In both groups, sP-selectin levels were significantly higher than those in control subjects from the time of arrival at the emergency department to 24 h after admission. sL-selectin levels in the two groups were markedly lower compared to those in control subjects at all sampling points. In patients with ROSC, cardiac arrest and CPR led to an increase in the levels of neutrophil elastase and soluble thrombomodulin that peaked 6 h or 24 h after arrival at the emergency department. No statistical differences in the levels of the two selectins, neutrophil elastase, and soluble thrombomodulin between the two groups were found during CPR. Conclusions: Out-of-hospital cardiac arrest and CPR induces platelet, neutrophil, and endothelial activation and is associated with endothelial injury. Inflammatory cytokines may not have an important role in human whole-body ischemia-reperfusion injury. Received: 2 November 1998 Final revision received: 3 March 1999 Accepted: 26 March 1999     

Bacteremia following cardiac arrest and cardiopulmonary resuscitation

After but of hospital CPR thirty three resuscitated patients were studied for bacteremic complications. Thirteen patients (39%) had two or more positive blood cultures during the twelve hours following CPR. Source of superinfection was a central venous catheter in one case (staphylococcus). The twelve other bacteremic patients had fetid diarrhea a few hours after admission. The same organism were found in blood and faeces (streptococcus D, Escherichia coli, Pseudomonas aeruginosa, acinetobacter, enterobacter). Mesenteric ischemia caused by a low cardiac output may explain the diarrhea and the intestinal origin of the septicemia. All patients (12 cases) with diarrhoea and bacteremia died. Patients who recovered without neurologic sequelae (4 cases) had never been septic and never had diarrhea.     

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

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