Extracorporeal cardiopulmonary resuscitation for adult cardiac arrest patients

Cardiac arrest is a major cause of unexpected death in developed countries, and patients with cardiac arrest generally have a poor prognosis. Despite the use of conventional cardiopulmonary resuscitation (CPR), few patients could achieve return of spontaneous circulation (ROSC). Even if ROSC was achieved, some patients showed re-arrest and many survivors were unable to fully resume their former lifestyles because of severe neurological deficits. Safar et al reported the effectiveness of emergency cardiopulmonary bypass in an animal model and discussed the possibility of employing cardiopulmonary bypass as a CPR method. Because of progress in medical engineering, the system of veno-arterial extracorporeal membrane oxygenation (ECMO) became small and portable, and it became easy to perform circulatory support in cardiac arrest or shock patients. Extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to be superior to conventional CPR in in-hospital cardiac arrest patients. Veno- arterial ECMO is generally performed in emergency settings and it can be used to perform ECPR in patients with out-of-hospital cardiac arrest. Although there is no sufficient evidence to support the efficacy of ECPR in patients with out-of-hospital cardiac arrest, encouraging results have been obtained in small case series.     

体外心肺复苏技术在成人心搏骤停抢救中的应用

目的 回顾性总结应用体外心肺复苏(E-CPR)技术救治成人心搏骤停患者的临床经验.方法 2005年7月至2009年7月,有11例心源性心搏骤停成人患者(男7例,女4例,年龄24～71岁)经常规心肺复苏(CPR)抢救10～15 min无法有效恢复自主循环,而采用E-CPR技术抢救.7例心脏手术后患者在CPR抢救同时自原胸骨切口先建立升主动脉-右心房常规体外循环辅助,再转为体外膜肺氧合(ECMO)辅助;4例患者在CPR抢救同时直接经股动、静脉置管建立ECMO辅助.结果 11例患者CPR时间30～90 min,平均(51±14)min,10例患者可恢复自主心律.11例患者ECMO辅助时间2～223 h,中位时间126 h.6例患者成功撤离ECMO辅助,但存活出院率为36.4%(4/11).2例患者在ECMO辅助的同时加用主动脉内球囊反搏术(IABP),1例存活.3例患者因合并肾功能衰竭而需血液滤过治疗.结论 E-CPR为抢救危重的心搏骤停患者提供了一个新的手段.如何有效评估和选择病例,及时开始救治以提高成功率,值得进一步研究.     

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution.MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10 min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n = 40) or CPR plus extracorporeal CPR (E-CPR, n = 20) were compared.ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90 ± 49.6 min vs 34.3 ± 17.7 min, p = 0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p = 0.0009), and good neurological function at discharge (40.0% vs 7.5%, p = 0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p = 0.1512) at discharge and (50% vs 20%, p = 0. 0998) at 1 year after discharge.ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.     

RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest

There is a growing interest in using point-of-care transesophageal echocardiography (TEE) during cardiac arrest. TEE is effective at identifying the etiology of sudden cardiovascular collapse and guiding management during the resuscitation. In selected patients with refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) can be considered. ECPR requires percutaneous vascular access for the implantation of veno-arterial extracorporeal membrane oxygenation circuit. We present a case of prolonged cardiac arrest in which rescue TEE was pivotal in narrowing the differential diagnosis, monitoring of mechanical chest compression performance, and guiding cannulation for ECPR.     

体外膜肺氧合在心肺脑复苏中的应用

目的 探讨体外膜肺氧合(extlacorporeal membrane oxygenation,ECMO)在心脏骤停患者中的治疗作用及应用价值.方法 回顾分析2002年6月至2007年6月期间,本院急诊和重症监护室应用体外膜肺氧合(ECMO)治疗的心脏骤停15例患者,按照美国心脏学会<2005年心肺复苏和心血管急救国际指南>的标准诊治方案进行救治,同时行体外膜肺氧合(ECMO)治疗.采用治疗前后自身对照的方法,监测ECMO治疗前、ECMO治疗后10 min、1 h、6 h、12 h、24 h,患者的心率、平均动脉压、中心静脉压(eve);并抽取桡动脉血检测动脉血氧分压、二氧化碳分压、血氧饱和度、酸碱度、动脉血乳酸含量等指标;统计数据以((x)±s)表示,采用SPSS 10.0统计软件包进行t检验,以P<0.05为差异具有统计学意义;同时就患者的神经性后遗症进行了观察和描述.结果 平均动脉压在ECMO治疗后10min比ECMO治疗前明显升高(P<0.01),ECMO治疗后1 h比ECMO治疗后10 min有所升高(P<0.05);CVP在ECMO治疗后10 min比ECMO治疗前,ECMO治疗后1 h比ECMO治疗后10 min有所降低(P<0.05);经ECMO治疗后10 min动脉血氧分压、血氧饱和度较ECMO治疗前明显上升(P<0.01),pH明显升高(P<0.01),动脉血乳酸含量明显降低(P<0.01).15例患者中,11例康复出院,其中5例完全康复,没有后遗症,2例有部分记忆障碍,无躯体后遗症;2例有精神障碍,2例有肢体偏瘫.结论 ECMO治疗可辅助心脏维持有效的血液循环,明显改善低氧血症,为大脑提供稳定的氧合血灌流,对心肺脑复苏有利.     

Assessment of outcomes and differences between in- and out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal life support

Aim

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) for in-hospital cardiac arrest (IHCA) patients has been assigned a low-grade recommendation in current resuscitation guidelines. This study compared the outcomes of IHCA and out-of-hospital cardiac arrest (OHCA) patients treated with ECLS.

Methods

A total of 77 patients were treated with ECLS. Baselines characteristics and outcomes were compared for 38 IHCA and 39 OCHA patients.

Results

The time interval between collapse and starting ECLS was significantly shorter after IHCA than after OHCA (25 (21-43) min versus 59 (45-65) min, p < 0.001). The weaning rate from ECLS (61% versus 36%, p = 0.03) and 30-day survival (34% versus 13%, p = 0.03) were higher for IHCA compared with OHCA patients. IHCA patients had a higher rate of favourable neurological outcome compared to OHCA patients, but the difference was not statistically significant (26% versus 10%, p = 0.07). Kaplan-Meier analysis showed improved 30-day and 1-year survival for IHCA patients treated with ECLS compared to OHCA patients who had ECLS. However, multivariate stepwise Cox regression model analysis indicated no difference in 30-day (odds ratio 0.94 (95% confidence interval 0.68-1.27), p = 0.67) and 1-year survival (0.99 (0.73-1.33), p = 0.95).

Conclusion

CPR with ECLS led to more favourable patient outcomes after IHCA compared with OHCA in our patient group. The difference in outcomes for ECLS after IHCA and OHCA disappeared after adjusting for patient factors and the time delay in starting ECLS.     

Refractory Anaphylactic Shock Requiring Emergent Venoarterial Extracorporeal Membrane Oxygenation in the Emergency Department: A Case Report

Venoarterial extracorporeal membrane oxygenation is a viable salvage intervention for patients who experience cardiopulmonary arrest or profound shock from any cause. Acute anaphylactic shock is a rare cause of cardiac arrest. We present a case of a 35-year-old male who experienced cardiac arrest owing to anaphylactic shock while receiving general anesthesia for a routine outpatient surgical procedure. Traditional advanced cardiac life support therapies were provided by paramedics en route to the emergency department of a suburban, community-based hospital. Maximal medical management including endotracheal intubation, intravenous steroids, intravenous crystalloid fluid administration, intravenous vasoactive medications, and high-quality cardiopulmonary resuscitation was provided. Although return of spontaneous circulation was achieved, profound cardiogenic shock persisted. Venoarterial extracorporeal membrane oxygenation was initiated by the emergency department provider and nursing team. The patient survived, was neurologically intact, had full recovery, and was discharged home several days later. We have extensive experience with venoarterial extracorporeal membrane oxygenation, and this case exemplifies the value of an established emergency department extracorporeal membrane oxygenation program in managing all causes of cardiac arrest or refractory shock.     

体外心肺复苏启动前因素对患者预后的影响

目的:分析体外心肺复苏（extracorporeal cardiopulmonary resuscitation,ECPR）启动前因素对患者预后的影响,以探讨ECPR的干预时机和改进策略。方法:回顾性分析2018年7月至2021年4月在湖南师范大学附属第一医院（湖南省人民医院）行ECPR的29例患者。按患者是否存活出院分为生存组( n=13)及死亡组( n=16),分析两组常规心肺复苏（conventional cardiopulmonary resuscitation,CCPR）时间（开始心肺复苏到体外膜肺氧合运转的时间）、ECPR前初始心律、院外及院内心搏骤停的构成比、外院转运病例构成比。按CCPR时间分为≤45 min组、45~60 min组及>60 min组分别比较其出院存活率及持续自主循环恢复（sustained return of spontaneous circulation,ROSC）率。本院院内心搏骤停患者按心搏骤停（cardiac arrest,CA）发生地点分为本科室亚组和其他科室亚组,比较其存活率。 结果:29例患者总体生存率44.83%,体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）平均辅助时长114（33.5,142.5） h,CCPR平均时长60（44.5,80） min。生存组ECMO辅助时间（140.15±44.80）h较死亡组长（ P=0.001）,生存组CCPR时间明显低于死亡组（ P=0.010）。初始心律为可除颤心律组生存率更高（ P=0.010）。OHCA较IHCA患者病死率高（ P=0.020）。外院转运病例病死率高于本院病例（ P=0.025）。CCPR时间≤45min、45~60 min、>60 min三组患者出院生存率依次递减（ P=0.001）,ROSC率依次递减（ P=0.001)。本院院内心搏骤停患者,CA发生地点在本科室（急诊医学科）组与其他科室组生存率差异无统计学意义（ P=0.54）。 结论:ECPR出院存活率高于国内外报道的CCPR存活率,ECPR对难治性心搏骤停是有效的。ECPR的预后跟CCPR时间、CA初始心律、CA发生地点明显相关,提高ECPR存活率需加强宣教及团队建设。     

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.     

体外膜肺氧合在抢救危重心脏病患者心搏骤停中的作用

目的观察体外膜肺氧合对危重心脏患者心搏骤停后常规心肺复苏困难者的治疗效果。方法本院自2005年9月至2006年5月行体外膜肺氧合(ECMO)治疗危重心脏病患者37例,回顾性分析其中11例发生心搏骤停实施常规心肺复苏无效或复苏后持续低心排而行ECMO循环辅助患者的病历资料。结果5例为心脏术后患者,其中3例心肺复苏(CPR)的同时紧急建立体外循环再次手术,之后因低心排而行ECMO。7例患者床旁建立ECMO,ECMO支持治疗(134．0±113．0)h。8例顺利停机,6例存活出院,其中2例经心脏移植后出院。3例不能顺利脱机者由于ECMO辅助期间循环功能恶化,并最终死于多器官功能衰竭。ECMO期间出现的并发症包括出血、神经精神系统异常、肢体缺血坏死和多脏器功能不全。结论ECMO可以为心搏骤停的患者提供最快的心肺功能支持,为赢得抢救时机和提高抢救质量提供了又一途径,在危重患者心肺复苏中具有良好的疗效。     

体外膜肺氧合治疗用于心肺复苏的临床研究

目的 总结体外膜肺氧合（ECMO）治疗对于常规心肺复苏（CPR）困难患者的临床治疗经验。方法 自2005-09-2006-05我院进行ECMO治疗37例患者，其中11例心脏骤停后实施电除颤和心脏按压等CPR措施无效或自主循环恢复后持续低心排而行ECMO循环辅助。结果 8例顺利停机，6例存活恢复出院，其中2例行心脏移植后康复出院。3例不能顺利撤机者在ECMO辅助期间由于循环功能恶化，最终因多器官功能衰竭死亡。顺利撤机和存活出院的患者治疗前乳酸水平较低。ECMO治疗后乳酸清除率较快（P〈0．05）。ECMO期间出现的并发症包括出血、神经精神系统异常、肢体缺血坏死和多脏器功能不全。4例患者因膜肺出现血浆渗漏而更换膜肺。结论 ECMO可为危重心脏病患者心脏骤停后复苏困难时提供心肺功能支持，提高危重心脏病患者CPR的存活率。CPR后动脉血乳酸值和ECMO治疗后乳酸清除率可以预测患者预后。     

成人体外心肺复苏患者神经功能预后相关指标的预测价值研究

目的探讨成人体外心肺复苏（ECPR）患者神经功能预后相关指标的判断价值。 方法回顾性分析2018年1月至2021年4月于南京医科大学第一附属医院急诊科接受ECPR治疗的69例心脏骤停患者。根据患者出院时脑功能表现分级（CPC）评分将69例患者分为预后良好组（26例,CPC评分1 ~ 2分）和预后不良组（43例,CPC评分3 ~ 5分）。所有患者均于体外生命支持建立后24 h内接受头颅CT检查,测定其灰质/白质比例（GWR）。记录所有患者的一般资料及72 h内血清神经元特异性烯醇化酶（NSE）峰值水平。采用Spearman相关分析探讨基底节GWR与NSE水平的相关性,并采用受试者工作特征（ROC）曲线评价相关指标对ECPR患者神经功能预后的判断价值。 结果预后不良组心脏骤停患者基底节GWR [1.15（1.10,1.22）vs. 1.26 （1.22,1.28）,Z = 4.576,P < 0.001]较预后良好组显著降低,而体外膜肺氧合建立后72 h内血清NSE峰值[205.80（105.00,370.00）μg/L vs. 41.25（31.96,52.07）μg/L,Z = 5.910,P < 0.001]显著升高。Spearman相关分析结果显示,基底节GWR与NSE水平呈显著负相关（r = -0.685,P < 0.001）。ROC曲线分析结果显示,基底节GWR [曲线下面积（AUC）= 0.831,95%置信区间（CI）（0.735,0.926）,P < 0.001]及NSE 72 h内峰值[AUC = 0.926,95%CI（0.859,0.992）,P < 0.001]均对心脏骤停患者神经功能不良预后具有预测价值。基底节GWR < 1.18时,其预测神经功能不良预后的敏感度和特异度分别为62.8%和92.3%。ECMO建立后72 h内NSE峰值> 79.49 μg/L时,其预测不良预后的敏感度为83.7%,特异度为100%。 结论ECPR患者24 h内头颅CT提示GWR降低、72 h内NSE水平升高可作为预测神经功能预后不良的有效手段。     

体外膜肺氧合在成人心脏手术术后心力衰竭治疗中的应用

目的:观察体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)对成人心脏手术术后心力衰竭患者的治疗效果,探讨在此类患者应用ECMO的适应证。方法:自2006年11月—2007年1月,对3例成人心脏术后心力衰竭的患者进行ECMO支持治疗,均采用股动-静脉插管。ECMO期间维持血流动力学和呼吸指标稳定。结果:ECMO时间平均102.3h。3例患者心功能改善、均顺利脱机。1例康复出院,1例脱机31d后因严重肺部感染死亡,1例脱机5d后因心律失常死亡。结论:ECMO是治疗成人心脏术后心功能衰竭的有效方法,但需正确掌握适应证,合理选择患者。     

78例体外心肺复苏患者的临床特点回顾性分析

目的:总结体外膜肺氧合辅助心肺复苏患者(extracorporeal cardiopulmonary resuscitation, ECPR)的临床特点并分析临床结局的影响因素。方法:回顾性纳入2015年03月至2020年12月南京医科大学第一附属医院(江苏省人民医院)急诊医学科收治的ECPR患者78例。根据患者的临床结局分为存活组和死亡组。分别比较两组的基本资料,CPR资料及ECPR启动前实验室检验。结果:共纳入ECPR患者78例,男性51例,女性27例,存活23例,其中男性10例,女性13例。组间患者年龄、体质量指数、基础疾病(高血压病、糖尿病、冠心病)均差异无统计学意义(均 P>0.05)。存活组男性患者比例低于死亡组( P=0.017)。同时存活组患者SAVE（survival after veno-arterial ECMO）评分显著高于死亡组[(-1.57±4.15) vs. (-9.36±5.36), P<0.001]。存活组中旁观者心肺复苏比例高于死亡组( P=0.014)。存活组ECPR启动前存活组血清AST、ALT、Cr水平均低于死亡组( P<0.05)。二分类多因素Logistic回归分析结果显示旁观者心肺复苏( OR=0.114,95% CI: 0.015~0.867, P=0.036)和SAVE评分( OR=0.625,95% CI: 0.479~0.815, P=0.001)是预测ECPR患者ICU死亡的独立危险因素。 结论:单中心资料显示ECPR是救治呼吸心搏骤停患者的有效手段,旁观者心肺复苏、SAVE评分是预测ECPR患者ICU死亡的独立危险因素。     

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A review of the Japanese literature

Aim

Although favourable outcomes in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest have been frequently reported in Japanese journals since the late 1980s, there has been no meta-analysis of ECPR in Japan. This study reviewed and analysed all previous studies in Japan to clarify the survival rate of patients receiving ECPR.

Material and methods

Case reports, case series and abstracts of scientific meetings of ECPR for out-of-hospital cardiac arrest written in Japanese between 1983 and 2008 were collected. The characteristics and outcomes of patients were investigated, and the influence of publication bias of the case-series studies was examined by the funnel-plot method.

Results

There were 1282 out-of-hospital cardiac arrest patients, who received ECPR in 105 reports during the period. The survival rate at discharge given for 516 cases was 26.7 ± 1.4%. The funnel plot presented the relationship between the number of cases of each report and the survival rate at discharge as the reverse-funnel type that centred on the average survival rate. In-depth review of 139 cases found that the rates of good recovery, mild disability, severe disability, vegetative state, death at hospital discharge and non-recorded in all cases were 48.2%, 2.9%, 2.2%, 2.9%, 37.4% and 6.4%, respectively.

Conclusions

Based on the results of previous reports with low publication bias in Japan, ECPR appears to provide a higher survival rate with excellent neurological outcome in patients with out-of-hospital cardiac arrest.     

Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest

Cardiopulmonary resuscitation (CPR) guidelines assume that cardiac arrest victims can be treated with a uniform chest compression (CC) depth and a standardized interval administration of vasopressor drugs. This non-personalized approach does not incorporate a patient's individualized response into ongoing resuscitative efforts. In previously reported porcine models of hypoxic and normoxic ventricular fibrillation (VF), a hemodynamic-directed resuscitation improved short-term survival compared to current practice guidelines. Skilled in-hospital rescuers should be trained to tailor resuscitation efforts to the individual patient's physiology. Such a strategy would be a major paradigm shift in the treatment of in-hospital cardiac arrest victims.