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.     

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:     

A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest

Background

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.

Methods

We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.

Results

The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20–50 min) vs. (50: 25–86 min); p = 0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p = 0.003), and the mean pH value was higher in the survivors’ group (p < 0.0001) compared to the non-survivors’ group. The CPR duration for the IHCA group (25: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).

Conclusions

CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.     

Devices used in cardiac arrest

Even the best conventional manual cardiopulmonary resuscitation (CPR) is highly inefficient, producing only a fraction of normal cardiac output. Over the past several decades, many therapeutic devices have been designed to improve on conventional CPR during cardiac arrest and increase the probability of survival. This article reviews several adjuncts and mechanical alternatives to conventional CPR for use during cardiac arrest. Recent clinical studies comparing conventional resuscitation techniques with the use of devices during cardiac arrest are reviewed, with a focus on clinical implications and directions for future research.     

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.     

Out-of-hospital extracorporeal life support for cardiac arrest-A case report

We report the use of out-of-hospital extracorporeal life support (ECLS) in cardiac arrest. We treated a 9-year-old girl with cardiac arrest after warm-water drowning with percutaneous venoarterial extracorporeal membrane oxygenation (ECMO) using a new portable Mini-ECMO system. A beating-heart circulation was reestablished on ECMO, but, unfortunately, our patient did not survive. This case shows that Mini-ECMO support can be used to restore an effective circulation and gas exchange in the out-of-hospital setting.     

Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: A Canadian observational experience

Background

Among patients with reversible conditions who sustain cardiac arrest, extracorporeal membrane oxygenation (ECMO) may support end organ perfusion while bridging to definitive therapy.

Methods

A single center retrospective review (February 2008–September 2013) of adults receiving ECMO for cardiac arrest ≥15 min duration refractory to conventional management (E-CPR) or profound cardiogenic shock following IHCA (E-CS) was conducted. The primary outcome was 30-day survival with good neurologic function defined as a cerebral performance category (CPC) of 1–2. Secondary outcomes included intensive care unit (ICU) and hospital length of say, duration of mechanical ventilation, and univariate predictors of 30-day survival with favorable neurologic function.

Results

Thirty-two patients (55 ± 11 years, 66% male) were included of which 22 (69%) received E-CPR and 10 (31%) received E-CS following return of spontaneous circulation (ROSC). Cardiac arrest duration was 48.8 ± 21 min for those receiving E-CPR and 25 ± 23 min for the E-CS group. Patients received ECMO support for 70.7 ± 47.6 h. Death on ECMO support occurred in 7 (21.9%) patients, while 7 (21.9%) were bridged to another form of mechanical circulatory support, and 18 (56.3%) were successfully decannulated. ICU length of stay was 7.5 [3.3–14] days and ICU survival occurred in 16 (50%) of patients. 30-Day survival was 5 (50%) in the E-CS group, 10 (45.4%) in the E-CPR group, and 15 (47%) overall. All survivors had CPC 1–2 neurologic status.

Conclusion

In this single center experience, the use of resuscitative ECMO was associated with neurologically favorable 30-day survival in 47% of patients with prolonged IHCA (H2012:172).     

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。     

Pulse pressure as a prognostic marker in patients receiving extracorporeal life support

Background

It is not easy to predict the prognosis of patients receiving extracorporeal life support (ECLS) because of the highly variable situation around its implementation. We evaluated the role of pulse pressure (PP), which is available on real-time basis, as a hemodynamic prognostic marker during ECLS.

Methods

From January 2009 to August 2011, data from 69 patients who were treated with ECLS for at least 6 h in a single center for any cause was collected. We calculated the mean PP over the first 6 h after ECLS implantation and examined if there was any correlation between mean PP and the study endpoints, in-hospital death and ECLS weaning failure.

Results

The causes of ECLS were of cardiac origin in 36 patients (52%). 27 patients (39.1%) weaned off ELCS and 13 patients (18.8%) survived to discharge. In Cox regression analysis (with age, Killip class ≥3, ECLS implementation during cardiopulmonary resuscitation (CPR), CPR duration, out-of-hospital arrest, initial laboratory results including blood gas analysis, initial systolic blood pressure (SBP), mean SBP over the first 6 h after ECLS implantation, mean PP over the first 6 h after ECLS implantation as independent variables), mean PP over the first 6 h after ECLS implantation (hazard ratio [95% confidence interval] = 0.96[0.94–0.98], P < 0.001) and out-of-hospital arrest (HR[95%CI] = 2.04[1.14–3.62], P = 0.02) were independent predictors of in-hospital mortality and mean PP over the first 6 h after ECLS implantation (HR[95% CI] = 0.95[0.93–0.98], P < 0.001) was the sole independent predictor of weaning failure.

Conclusion

Higher mean PP over the initial 6 h after ECLS implementation independently predicted successful weaning and survival. Our findings may help better predict and analyze prognosis in patients receiving ECLS.     

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。     

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.     

Neurologic complications and neurodevelopmental outcome with extracorporeal life support

Extracorporeal life support is used to support patients of all ages with refractory cardiac and/or respiratory failure. Extracorporeal membrane oxygenation (ECMO) has been used to rescue patients whose predicted mortality would have otherwise been high. It is associated with acute central nervous system (CNS) complications and with long- term neurologic morbidity. Many patients treated with ECMO have acute neurologic complications, including seizures, hemorrhage, infarction, and brain death. Various pre-ECMO and ECMO factors have been found to be associated with neurologic injury, including acidosis, renal failure, cardiopulmonary resuscitation, and modality of ECMO used. The risk of neurologic complication appears to vary by age of the patient, with neonates appearing to have the highest risk of acute central nervous system complications. Acute CNS injuries are associated with increased risk of death in a patient who has received ECMO support. ECMO is increasingly used during cardiopulmonary resuscitation when return of spontaneous circulation is not achieved rapidly and outcomes may be good in select populations. Economic analyses have shown that neonatal and adult respiratory ECMO are cost effective. There have been several intriguing reports of active physical rehabilitation of patients during ECMO support that is well tolerated and may improve recovery. Although there is evidence that some patients supported with ECMO appear to have very good outcomes, there is limited understanding of the long-term impact of ECMO on quality of life and long-term cognitive and physical functioning for many groups, especially the cardiac and pediatric populations. This deserves further study.     

Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest

Aim

We describe a 1-year experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) associated with intra-arrest hypothermia and normoxemia.

Methods

Since January 1st 2012, ECPR has been applied in our hospital to all patients less than 65 years of age and without major co-morbidities who develop refractory cardiac arrest (CA) with bystander CPR. Over a 1-year period of observation, we recorded 28-day survival with intact neurological outcome and the rate of organ donation.

Results

During the observational period, 24 patients were treated with ECPR, with a median age of 48 years. Ten patients had IHCA. Acute coronary syndrome and/or major arrhythmias were the main cause of arrest. Intra-arrest cooling was used in 17 patients; temperature on ECMO initiation in these patients was 32.9 °C [32–34]. The time from collapse to ECPR was 58 min [45–70] and was shorter in survivors than in non-survivors (41 min [39–58] vs. 60 min [55–77], p = 0.059). Non-survivors were more likely to have coagulopathy and received more blood transfusions. Six patients (25%) survived with good neurological outcome at day 28. Four patients with irreversible brain damage had organ function suitable for donation.

Conclusion

ECPR provided satisfactory survival rates with good neurologic recovery in refractory CA for both IHCA and OHCA. ECMO may help rapidly stabilise systemic haemodynamic status and restore organ function.     

Full recovery of an avalanche victim with profound hypothermia and prolonged cardiac arrest treated by extracorporeal re-warming

Survival of hypothermic avalanche victims with cardiac arrest is rare. This report describes full recovery of a 29-year-old backcountry skier completely buried for 100 min at 3.0m (9.8 ft) depth. On extrication he was unconscious, but breathing spontaneously into an air pocket; core body temperature measured 22.0 degrees C (71.6 degrees F). He was intubated and ventilated on site. Ventricular fibrillation commenced during helicopter transportation, whereby chest compression was lacking for 15 min. At the nearest hospital continuous cardiopulmonary resuscitation was initiated, but defibrillation failed. Tympanic core body temperature measurement confirmed life-threatening hypothermia of 21.7 degrees C (71.1 degrees F) and serum K(+) was 4.3 mmol/l, necessitating transferral to a hospital with cardiopulmonary bypass facilities. Defibrillation finally succeeded following re-warming, by femoral veno-arterial bypass, to 34.5 degrees C (94.1 degrees F). Total duration of cardiac arrest was 150 min. The patient developed pulmonary oedema, treated by extracorporeal membrane oxygenation, but progressed well and was discharged from hospital on day 17, fit to resume professional and social activities. Follow-up cerebral magnetic resonance imaging 2 years after avalanche burial demonstrated only minimal changes attributable to unrelated, prior cranial trauma. Extensive neurological and psychological investigations gave excellent results. This report confirms previous literature that an air pocket with patent airways is essential for survival of a completely buried avalanche victim after 35 min and endorses the recommended management strategies of the International Commission for Mountain Emergency Medicine ICAR MEDCOM. In particular, all hypothermic victims extricated with an air pocket and free airways must be treated optimistically, even despite prolonged cardiac arrest. This remarkable case documents the fastest drop in core temperature ever recorded during snow burial, namely 9.0 degrees C (16.2 degrees F)/h, and the second-lowest reversible core temperature in avalanche literature.     

Clinical state transitions during advanced life support (ALS) in in-hospital cardiac arrest

Background

When providing advanced life support (ALS) in cardiac arrest, the patient may alternate between four clinical states: ventricular fibrillation/tachycardia (VF/VT), pulseless electrical activity (PEA), asystole, and return of spontaneous circulation (ROSC). At the end of the resuscitation efforts, either death has been declared or sustained ROSC has been obtained. The aim of this study was to describe and analyze the clinical state transitions during ALS among patients experiencing in-hospital cardiac arrest.

Methods and results

The defibrillator files from 311 in-hospital cardiac arrests at the University of Chicago Hospital (IL, USA) and St. Olav University Hospital (Trondheim, Norway) were analyzed (clinicaltrials.gov: NCT00920244). The transitions between clinical states were annotated along the time axis and visualized as plots of the state prevalence according to time. The cumulative intensity of the state transitions was estimated by the Nelson–Aalen estimator for each type of state transition, and for the intensities of overall state transitions. Between 70% and 90% of patients who eventually obtained sustained ROSC had progressed to ROSC by approximately 15–20 min of ALS, depending on the initial rhythm. Patients behaving unstably after this time period, i.e., alternating between ROSC, VF/VT and PEA, had a high risk of ultimately being declared dead.

Conclusions

We provide an overall picture of the intensities and patterns of clinical state transitions during in-hospital ALS. The majority of patients who obtained sustained ROSC obtained this state and stabilized within the first 15–20 min of ALS. Those who continued to behave unstably after this time point had a high risk of ultimately being declared dead.     

Feasibility of initiating extracorporeal life support during mechanical chest compression CPR: a porcine pilot study

Background

Recently, portable extracorporeal membrane oxygenation (ECMO) machines have become commercially available. This creates the potential to utilize extracorporeal life support (ECLS) for the treatment of sudden cardiac arrest in the emergency department, and potentially in the out-of-hospital setting.

Objective

We sought to determine the feasibility of installing the ECMO circuit during delivery of mechanical chest compression CPR.

Methods

We used 5 mixed-breed domestic swine with a mean mass of 26.0 kg. After induction of anesthesia, animals were instrumented with micromanometer-tipped transducers placed in the aorta and right atrium via the left femoral artery and vein. Ventricular fibrillation (VF) was induced electrically with a transthoracic shock and left untreated for 8 min. Then, mechanical chest compressions were begun (LUCAS, Jolife, Lund, Sweden) and manual ventilations were performed to maintain ETCO₂ between 35 and 45 Torr. Compressions continued until ECMO flow was started. Ten minutes after induction of VF, drugs were given (epinephrine, vasopressin, and propranolol). ECMO installation was started via cutdown on the right external jugular vein and right femoral artery for placement of venous and arterial catheters while chest compressions continued. ECMO installation start time varied from 17 to 30 min after start of compressions and continued until ECG indicated a shockable rhythm. First rescue shocks were given at 22, 32, 35, 44, and 65 min.

Results

ECMO was successfully installed in all five animals without incident. It was necessary to briefly discontinue chest compressions during the most delicate part of inserting the catheters into the vessels. ECMO also allowed for very rapid cooling of the animals and facilitated post-resuscitation hemodynamic support. Only the 65-min animal did not attain return of spontaneous circulation (ROSC).

Conclusion

Mechanical chest compression may be a suitable therapeutic bridge to the installation of ECMO and does not interfere with ECMO catheter placement.     

Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest

Background

Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.

Objective

We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.

Methods

Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.

Conclusion

ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.     

Safety and feasibility of prehospital extra corporeal life support implementation by non-surgeons for out-of-hospital refractory cardiac arrest

Background

Extra corporeal life support (ECLS) has been recently introduced in the treatment of refractory cardiac arrest (CA). Several studies have assessed the use of ECLS in refractory CA once the patients reach hospital. The time between CA and the implementation of ECLS is a major prognostic factor for survival. The main predictive factor for survival is ECLS access time. Pre hospital ECLS implementation could reduce access time. We therefore decided to assess the feasibility and safety of prehospital ECLS implementation (PH-ECLS) in a pilot study.

Methods and results

From January 2011 to January 2012, PH-ECLS implementation for refractory CA was performed in 7 patients by a PH-ECLS team including emergency and/or intensivist physicians and paramedics. Patients were included prospectively and consecutively if the following criteria were met: they had a witnessed CA; CPR was initiated within the first 5 min of CA and/or there were signs of life during CPR; an PH-ECLS team was available and absence of severe comorbidities. ECLS flow was established in all patients. ECLS was started 22 min (±6) after the incision, and 57 min (±21) after the onset of advanced cardiovascular life support (ACLS). In one patient, ECLS was stopped for 10 min due to an accidental decannulation. One patient survived without sequelae. Three patients developed brain death.

Conclusions

This pilot study suggests that PH-ECLS performed by non-surgeons is safe and feasible. Further studies are needed to confirm the time saved by this strategy and its potential effect on survival.