Tag: FOAMed

ECMO infographics (& more)

Optimal site for providing extracorporeal cardio-pulmonary resuscitation ECPR in out-of-hospital cardiac arrest? maybe in the hospital, in the cath-lab better! here notes from the talk given by Jan Belohlavek, EuroELSO president, at EuroELSO2019 meeting: not ECLS alone, but a comprehensive approach including ECMO, with high quality bystander CPR/high quality ACLS, may have an impact on logistics for OHCA patients; we have technology but we still need to define proper patients & optimize logistics: randomized studies are absolutely necessary. Everything else is just an emotional bias. Visual abstract by @foamecmo
See you at EuroELSO2020 Congress, next May 6-8 2020 in London! register here

Perfect prime for ECMO circuit?? We take care for neonates, pediatrics, growing number of adult patients… there is no gold standard that defines ideal prime, as no prime is going to fit all these populations, and sometimes is a race against time!
here some notes freely based on the talk by Christine Franciscovich at 2019 ELSO Conference:
clear & blood priming, and factors to be considered when choosing
dilutional hematocrit calculation
additives options: calcium, albumin, heparin, NaHcO3…
lab/ABG on prime
graphics by Velia Marta Antonini @foamecmo

Update on COVID-19: from epidemiology to clinical characteristics, & some recommendations

Report of the World Health Organization (WHO)-China Joint Mission on Coronavirus Disease 2019:
– major findings about virus, outbreak, transmission dynamics, disease progression/severity, the China response and knowledge gaps;
– recommendations in five major areas to inform the ongoing response in China and globally, for countries with imported cases and/or outbreaks of COVID-19, for uninfected countries, for the public, and for the international community;
– main signs and symptoms, clinical case management and infection prevention and control. There are no specific antiviral or immune modulating agents proven (or recommended) to improve outcomes. All patients are monitored by regular pulse oximetry. The guidelines include supportive care by clinical category (mild, moderate, severe & critical), as well as the role of investigational treatments such as chloroquine phosphate, lopinavir/ritonavir, alpha interferon, ribavirin, arbidol. The application of intubation/invasive mechanical ventilation and ECMO in critically ills can improve survival; clearly, though ECLS is very resource consumptive, any health system would need to carefully weigh the benefits.
Full text open access at http://bit.ly/2uF3L7o

Clinical characteristics of COVID-19 disease in China, data regarding 1099 patients with laboratory-confirmed COrona VIrus Disease 2019 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in China on The New England Journal of Medicine: most of patients received diagnosis of pneumonia 91.1%; ARDS diagnosed in 3.4%, and shock in 1.1%; 5.0% of cases were admitted to the ICU, 2.3% underwent invasive mechanical ventilation, ECMO performed in 5 patients (0.5%) with severe disease, 1.4% died. On admission, the degree of severity categorized as nonsevere in 926 patients and severe in 173;.in patients with severe disease presence of any coexisting illness more common, and older age vs nonsevere cases (median of 7 years).
Systemic glucocorticoids given to 18.6% (44.5% if severe disease, 13.7% nonsevere). . Median duration of hospitalization 12 days.
Open access full text on NEJM.

Characteristics of & main lessons from COVID-19 Coronavirus outbreak in China: summary of a report of 72314 cases (data from Chinese CDC), with comparison of COVID-19 with SARS and MERS, and response to the novel Coronavirus epidemic.
Here some of the key findings:
age: 87%: 30-79 years, 1% respectively 10-19 & <10 years
spectrum of disease (confirmed cases): 81% mild, 14% severe, 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction or failure)
case-fatality rate (confirmed cases): 2.3%, 14.8% in patients aged ≥80 years, 49.0% in critical cases.
Next steps? As global society is more interconnected than ever, and emerging pathogens do not respect geopolitical boundaries, proactive investment in public health infrastructure & capacity crucial to effectively respond to epidemics; persisting in improving international surveillance, cooperation, coordination, & communication, is critical to be better prepared to respond to future new public health threats. Full text open access on JAMA.
Also check the epidemiological characteristics of outbreak COVID-19 on China CDC Weekly.

WHO Critical Care Training Short Course for SARI

The World Health Organization has launched a free open access course, the WHO Critical Care Training Short Course for Severe Acute Respiratory Infection (SARI), including content on clinical management of patients with a severe acute respiratory infection, intended for clinicians working in ICUs in low and middle-income countries involved in critical care management of adult and pediatric patients with severe forms of SARI, including severe pneumonia, ARDS, sepsis and septic shock, during outbreaks of influenza virus (seasonal) human infection due avian influenza virus (H5N1, H7N9), MERS-CoV, nCoV or other emerging respiratory viral epidemics.
Visit OpenWHO to enrol and take the course. Here a list of the topics covered by the course:
introduction to the 2019nCoV and infection prevention for patients with Severe Acute Respiratory Infections (SARI);
clinical syndromes and pathophysiology of sepsis and ARDS;
triage and early recognition of patients with SARI, with role-playing scenarios;
monitoring patients with SARI;
differential diagnosis, specimen collection and diagnostic tests for SARI;
oxygen Therapy;
antimicrobial therapy and its modification after diagnostic test interpretation;
how to deliver targeted resuscitation for sepsis and septic shock;
mechanical ventilation: how to deliver lung-protective MV in ARDS;
sedation: how to manage pain, agitation and delirium;
best practices to prevent complications;
weaning from mechanical ventilation;
quality in critical care;
pandemic preparedness and ethical considerations.

Additional details and enrolment at OpenWHO

Imaging in 2019nCov infection

Early recognizing imaging features of novel Coronavirus infection: mandatory for promptly implement treatment/support strategies, but also for isolating case and performing an effective public health monitoring/response; some open access paper have been published on Radiology, starting with a series reviewing chest CT scans of symptomatic patients infected with 2019-nCoV, with emphasis on identifying & characterizing the most common findings, including bilateral pulmonary parenchymal ground-glass & consolidative pulmonary opacities, sometimes with rounded morphology and peripheral lung distribution. Notably, cavitation, discrete pulmonary nodules, pleural effusions, lymphadenopathy reported as absent. In seven over eight subjects, follow-up imaging (during study time window) often demonstrated mild or moderate progression of disease as manifested by increasing extent and density of opacities. Open access full text
Key points for radiologists in this related editorial, suggesting to consider in the proper clinical setting, 2019-nCoV as a possible diagnosis as detecting bilateral ground-glass opacities or consolidation at chest imaging (but normal chest CT scan does not exclude the diagnosis!): keep an high level of suspicion and collect detailed potential exposure/travel history. Open access full text

Additional cases, same journal, with interesting CT scans images/movie at
link & link

ECMO year in review: ECPR

Let’s start with the American Heart Association focused update on Advanced Cardiac Life Support – ACLS, with recommendations on the use of advanced airways, vasopressors, extracorporeal during cardiac arrest; about ECMO assisted cardio-pulmonary resuscitation: there is insufficient evidence to recommend routine use of ECPR, but may be considered for selected patients as rescue therapy when conventional CPR is failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD). Read full recommendations, open access! Also available the Update on Pediatric Advanced Life Support & the Focused update on neonatal resuscitation!

Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, Del Rios M, Cabañas JG, Link MS, Kurz MC, Chan PS, Morley PT, Hazinski MF, Donnino MW.
Abstract. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e881-e894. link

Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e904-e914. link

Escobedo MB, Aziz K, Kapadia VS, Lee HC, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin JG. 2019 American Heart Association Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e922-e930. link

Extracorporeal cardiopulmonary resuscitation: editorial with example of ECPR protocol for intra-hospital cardiac arrest to streamline the decision-making process leading to the involvement of #ECLS team, efficiently & consistently gather relevant info needed arrive at a consensus, prepare for initiating ECMO support.

Han JJ, Hoenisch K, Bermudez C. Designing an Extracorporeal Cardiopulmonary Resuscitation Protocol: It Is Time to Address Quality. ASAIO J. 2019 Aug;65(6):533-534. open access (with full algorithm access) link

The INCEPTION trial: early INitiation of extraCorporeal lifE suPporT in refractory Ohca, aiming to determine the clinical benefit for the use of #ECPR in patients with refractory out-of-hospital cardiac arrest presenting with VF/VT, and evaluating the feasibility & cost-effectiveness of #ECMO assisted cardio-pulmonary resuscitation. Read details about the trial design & current status.

Bol ME, Suverein MM, Lorusso R, Delnoij TSR, Brandon Bravo Bruinsma GJ, Otterspoor L6, Kuijpers M, Lam KY, Vlaar APJ, Elzo Kraemer CV, van der Heijden JJ, Scholten E, Driessen AHG, Montero Cabezas JM, Rittersma SZH, Heijnen BG, Taccone FS, Essers B, Delhaas T, Weerwind PW, Roekaerts PMHJ, Maessen JG, van de Poll MCG. Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: Design and rationale of the INCEPTION trial. Am Heart J. 2019 Apr;210:58-68. open access link

2CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion), multi-centre, prospective cohort study enrolled 12–70 years patients with refractory cardiac arrest, and reporting ECMO support in refractory cardiac arrest as feasible and associated with very good neurologically intact survival.

Dennis M, Forrest P, Bannon P, Scott S, Lowe D, Reynolds C, Burns B, Habig K, Nair P, Gattas D, Buscher H. The 2CHEER Study: (Mechanical CPR, Hypothermia, ECMO and Early Re-Perfusion) for Refractory Cardiac arrest. Heart, Lung & Circulation 2019 28:S322 link

High fidelity ECPR simulation training enables emergency teams to acquire/retain skills to rapidly & safely initiate ECMO support: this strategy could be valuable for institutions initiating ED-based ECPR programs or planning to participate in ECPR trials for Out-of-Hospital cardiac arrest.

Whitmore SP, Gunnerson KJ, Haft JW, Lynch WR, VanDyck T, Hebert C, Waldvogel J, Havey R, Weinberg A, Cranford JA, Rooney DM, Neumar RW.
Simulation training enables emergency medicine providers to rapidly and safely initiate extracorporeal cardiopulmonary resuscitation (ECPR) in a simulated cardiac arrest scenario. Resuscitation. 2019 May;138:68-73.
link

Outcomes, outcome prediction & neuroprognostication

Impact of medical management on prognostication after cardiac arrest, review focusing on target temperature management & extracorporeal life support. indications & implications of TTM, with shivering as most common complication, particularly during induction, attenuating benefits by increasing metabolism, and TTM induced sedatives/analgesics PK changes, potentially impacting on late awakening/prognostication. ECMO support… a therapeutic agent after cardiac arrest? suggested neuromonitoring tools for ECPR patients at key time-points, pre cannulation, to identify the salvageable cases, post-cannulation, to detect neuro-complications included brain death, & post-awakening. Withdrawal of life-sustaining treatments due to perceived poor neurological outcome remains most common cause of hospital death: a valuable multimodal prognostication scheme including novel biomarkers, quantitative measures of brain stem reflexes, POC cerebral perfusion monitoring tool after ROSC still needed!

Agarwal S, Morris N, Der-Nigoghossian C, May T, Brodie D. The Influence of Therapeutics on Prognostication After Cardiac Arrest. link

Cardiac arrest before VA ECMO support: initial (nonshockable) rhythm, metabolic state expressed as level of lactate just before venoarterial ECLS, and ischemic heart disease identified as independent risk factors of 90-day mortality by this observation at Karolinska University Hospital, and may be more important than rigid low-flow (CPR) time/age limits and absence of ROSC (not significant risk factors) when considering ECPR or ECMO in post-arrest cardiogenic shock.

Fux T, Holm M, Corbascio M, van der Linden J. Cardiac Arrest Prior to Venoarterial Extracorporeal Membrane Oxygenation: Risk Factors for Mortality. Crit Care Med. 2019 Jul;47(7):926-933. link

Extracorporeal CPR in refractory OHCA: 4% of out-of-hospital cardiac arrest supported with ECPR in this population-based prospective registry study of the Paris region. comparing survival at hospital discharge with and without ECPR and identifying factors associated with survival in ECMO CPR group. In the latter, factors reported as associated with hospital survival: initial shockable rhythm, transient ROSC before ECPR, and prehospital ECMO implementation. These may help in selecting patients.

Bougouin W, Dumas F, Lamhaut L, Marijon E, Carli P, Combes A, Pirracchio R, Aissaoui N, Karam N, Deye N, Sideris G, Beganton F, Jost D, Cariou A, Jouven X; Sudden Death Expertise Center investigators. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J. 2019 Oct 31. link

Outcomes after ECMO assisted CPR ECPR in pediatric in-hospital cardiac arrest reported by linking two national registries, the American Heart Association Get With the Guidelines—Resuscitation and the ELSO – registries: encouraging results! Noncardiac diagnoses, preexisting renal failure, longer time from onset of the CPR event to ECLS initiation, and adverse events during the ECMO run are associated with worse outcomes.

Bembea MM, Ng DK3, Rizkalla N, Rycus P, Lasa JJ, Dalton H, Topjian AA, Thiagarajan RR, Nadkarni VM, Hunt EA; American Heart Association’s Get With The Guidelines – Resuscitation Investigators. Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries. Crit Care Med. 2019 Apr;47(4):e278-e285. link

ECMO assisted vs conventional CPR in Cardiac Arrest: significantly higher occurrence of long-term favorable neurological outcome with ECPR (almost 50% relative increase of good neuro-recovery).

Patricio D, Peluso L, Brasseur A, Lheureux O, Belliato M, Vincent JL, Creteur J, Taccone FS. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. Crit Care. 2019 Jan 28;23(1):27. open access link

ECMO assisted cardiopulmonary resuscitation for patients presenting with VF or pulseless VT found to be highly cost-effective (providing higher survival rate) vs ECPR if presenting rhythm asystole or PEA, borderline cost-effective (costing about twice as much), a retrospective observation.

Kawashima T, Uehara H, Miyagi N, Shimajiri M, Nakamura K, Chinen T, Hatano S, Nago C, Chiba S, Nakane H, Gima Y. Impact of first documented rhythm on cost-effectiveness of extracorporeal cardiopulmonary resuscitation. Resuscitation. 2019 Jul;140:74-80. link

Neurobehavioral outcomes & factors associated with survival 1 year after in-hospital cardiac arrest for children who received ECPR, secondary analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital THAPCA-IH trial: findings support American Heart Association & ILCOR recommendations to consider ECMO assisted CPR in children with cardiac disease.

Meert KL, Guerguerian AM, Barbaro R, Slomine BS, Christensen JR, Berger J, Topjian A, Bembea M7, Tabbutt S, Fink EL, Schwartz SM, Nadkarni VM, Telford R, Dean JM, Moler FW; Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Extracorporeal Cardiopulmonary Resuscitation: One-Year Survival and Neurobehavioral Outcome Among Infants and Children With In-Hospital Cardiac Arrest. Crit Care Med. 2019 Mar;47(3):393-402. open access link

& related editorial MacLaren G, Hoskote. Resuscitating Hearts and Minds: 1-Year Outcomes Following Extracorporeal Membrane Oxygenation for Cardiac Arrest. Crit Care Med. 2019 Mar;47(3):476-477. link

TTM on ECLS after OHCA: does this combination poses an excessive risk on pts? an Euro ELSO annual conference survey, supporting the statement that the use of outcome-enhancing targeted temperature management strategies is considerably variable; therefore, further studies weighting the risk of hypothermia-mediated relevant bleeding vs potential neuroprotective benefits of TTM on ECPR are needed.

Rolfes C, Muellenbach RM, Lepper PM, Spangenberg T, Swol J, Lorusso R, Weber K, Foerstner S, Lotz C, Belohlavek J. Targeted temperature management in patients undergoing extracorporeal life support after out-of-hospital cardiac arrest: an EURO-ELSO 2018 annual conference survey. Perfusion. 2019 Nov;34(8):714-716. link

Hyperoxemia & mortality in extracorporeal cardiopulmonary resuscitation ECPR after OHCA: additional data from this retrospective study underline the potential toxicity of high O2 dose, suggesting an optimal management of oxygenation, strictly controlling O2 administration after the initiation of ECMO assisted CPR in refractory out-of-hospital cardiac arrest is crucial.

Halter M, Jouffroy R, Saade A, Philippe P, Carli P, Vivien B. Association between hyperoxemia and mortality in patients treated by eCPR after out-of-hospital cardiac arrest. Am J Emerg Med. 2019 Jul 8. link

Which partial pressure of CO2 during ECMO CPR? Rapid PaCO2 drop may occur soon after ECPR initiation, & as relationship between Pre/Post ML PCO2 is not consistent/predictable, sweep gas flow should be adjusted based on PaCO2 avoiding sudden CO2 removal.

Morris KP, Brincat E, Sanz I, Scholefield BR. Which partial pressure of carbon dioxide during extracorporeal cardiopulmonary resuscitation (ECPR)? Resuscitation. 2019 May;138:42-43. link

According to this registry study, reporting strong correlation between hospital survival and arterial pH (no such correlation with paCO2), it might be reasonable to correct both respiratory and metabolic acidosis in ECPR patients.

Bemtgen X, Schroth F, Wengenmayer T, Biever PM, Duerschmied D, Benk C, Bode C, Staudacher DL.How to treat combined respiratory and metabolic acidosis after extracorporeal cardiopulmonary resuscitation? Crit Care. 2019 May 21;23(1):183. open access link

Early and 24h post-ROSC oxygenation status & Pao2/Fio2 ratio in pts treated with #ECMO assisted CPR #ECPR post CA is associated with both neuro-outcome & survival: closely monitor both during the early postcardiac arrest care. According to the results of this study optimal Pao2 range 77-220mmHg.

Chang WT, Wang CH, Lai CH, Yu HY, Chou NK, Wang CH, Huang SC, Tsai PR, Chou FJ, Tsai MS, Huang CH, Ko WJ, Chen WJ, Chen YS. Optimal Arterial Blood Oxygen Tension in the Early Postresuscitation Phase of Extracorporeal Cardiopulmonary Resuscitation: A 15-Year Retrospective Observational Study. Crit Care Med. 2019 Nov;47(11):1549-1556. link

Coagulation in refractory cardiac arrest treated with ECMO assisted CPR: derangements are frequent & may have important consequences for ECPR management of anticoagulation and blood product transfusion; presence of DIC diagnostic criteria should be considered among prognostic factors in this population, results from a single high-volume center experience.

Ruggeri L, Franco A, Alba AC, Lembo R, Frassoni S, Scandroglio AM, Calabrò MG, Zangrillo A, Pappalardo F. Coagulation Derangements in Patients With Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation. J Cardiothorac Vasc Anesth. 2019 Jul;33(7):1877-1882. link

Development of a new a risk prediction score for early neuro-prognosis of ECPR patients (nECPR) using independent predictors and interaction between age & low-flow time (model based on a retrospective analysis).

Ryu JA, Chung CR, Cho YH, Sung K, Jeon K, Suh GY, Park TK, Lee JM, Song YB, Hahn JY, Choi JH, Choi SH, Gwon H5, Carriere KC, Ahn J, Yang JH. Neurologic Outcomes in Patients Who Undergo Extracorporeal Cardiopulmonary Resuscitation. Ann Thorac Surg. 2019 Sep;108(3):749-755. link

Routinely perform a full-body CT scan in all ECPR patients?? may be reasonable… in this observation, a relevant number of clinically significant CT findings is reported after ECMO assisted cardiopulmonary resuscitation. Early detection of intracranial pathologies or iatrogenic complications by full-body CT scans, reported as associated with poor prognosis, could potentially influence further management, and eventually early limitation of care. In the study, multiple rib fractures (common, 65% of cases, supposedly related to vigorous conventional CPR efforts) appears not associated with poor outcome. PS: ECMO cannula malposition detected in 6% of patients!

Zotzmann V, Rilinger J, Lang CN, Duerschmied D, Benk C, Bode C, Wengenmayer T, Staudacher DL. Early full-body computed tomography in patients after extracorporeal cardiopulmonary resuscitation (eCPR). Resuscitation. 2019 Dec 4. link

ECMO support in cardiac arrest: early initiation of ECLS (within 46′) found to be associated with favourable neurological outcome in patients suffering from CA caused by cardiac events in this single center experience ECPR.

Komeyama S, Takagi K, Tsuboi H, Tsuboi S, Morita Y, Yoshida R, Kanzaki Y, Nagai H, Ikai Y, Furui K, Tsuzuki, Shibata N, Yoshioka N, Yamauchi R, Sugiyama H, Morishima I.The Early Initiation of Extracorporeal Life Support May Improve the Neurological Outcome in Adults with Cardiac Arrest due to Cardiac Events. Intern Med. 2019 May 15;58(10):1391-1397. open access link

Evaluating predictive value of NSE in patients on ECMO implemented for cardiogenic shock post cardio-pulmonary resuscitation or to support ECPR: neuron-specific-enolase is a still valuable tool after even on ECLS; serial measurements provided the highest specificity in this observation.

Schrage B, Rübsamen N, Becher PM, Roedl K, Söffker G, Schwarzl M, Dreher A, Schewel J, Ghanem A, Grahn H, Lubos E, Bernhardt A, Kluge S, Reichenspurner H, Blankenberg S, Spangenberg T, Westermann D. Neuron-specific-enolase as a predictor of the neurologic outcome after cardiopulmonary resuscitation in patients on ECMO. Resuscitation. 2019 Mar;136:14-20. link

Emergency physician-initiated & managed resuscitative ECMO: in this single-center experience, EPs implemented & managed ED #ECPR demonstrates promising clinical outcomes with limited downstream inpatient resource utilization.

Shinar Z, Plantmason L, Reynolds J, Dembitsky W, Bellezzo J, Ho C, Glaser D, Adamson R. Emergency Physician-Initiated Resuscitative Extracorporeal Membrane Oxygenation. J Emerg Med. 2019 Jun;56(6):666-673. open access link

Most promising candidates for ECMO assisted CPR among patients with refractory OHCA might be those with sustained VF/ pVT before extracorporeal support; patients with conversion from VF/pVT to PEA/asystole before ECPR might be unlikely to experience favorable neurological outcomes.

Nakashima T, Noguchi T, Tahara Y, Nishimura K, Ogata S, Yasuda S, Onozuka D, Morimura N, Nagao K, Gaieski DF, Asai Y, Yokota H, Nara S, Hase M, Atsumi T, Sakamoto T; SAVE-J Group. Patients With Refractory Out-of-Cardiac Arrest and Sustained Ventricular Fibrillation as Candidates for Extracorporeal Cardiopulmonary Resuscitation - Prospective Multi-Center Observational Study. Circ J. 2019 Apr 25;83(5):1011-1018. open access link

Effectiveness (& cost-effectiveness) of ECPR

Extracorporeal cardiopulmonary resuscitation: effective vs conventional CPR for adults in cardiac arrest?? Data presented in this open access systematic literature review & meta-analysis suggest that, in selected patients, ECPR could increase rate of survival to discharge & number of neurologically intact survivors; factors associated with improved outcome: initial shockable rhythm & short low-flow time. We still need high-quality evidence to support ECMO assisted resuscitation, but lot clinical trials are ongoing, which will hopefully provide some answers.

Twohig CJ, Singer B, Grier G, Finney SJ. A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest. J Intensive Care Soc. 2019 Nov;20(4):347-357. link

Extracorporeal Cardio-Pulmonary Resuscitation in IHCA: a study aiming to estimate cost-effectiveness of this strategy to support in-hospital cardiac arrest management. Authors apply a decision tree & Markov model constructed based on current literature, and report evaluation according to the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines for this population. ECPR appears cost-effective from a healthcare perspective, considering conventional WTP thresholds between 50-100,000 €/$; authors suggest identifying patients who could benefit most, and long-term effects of ECPR, as goals for future investigations… Waiting for the results of the (at least) 5 ongoing RCTs!

Gravesteijn BY, Schluep M, Voormolen DC, van der Burgh AC, Dos Reis Miranda D, Hoeks SE, Endeman H. Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model. Resuscitation. 2019 Oct;143:150-157. Open access  link 

A cost analysis with modelling of cost effectiveness and quality of life outcomes of patients who have undergone ECPR, reporting ECMO support in refractory cardiac arrests as cost effective and favourably comparing to accepted cost effectiveness thresholds. Over 10 years ECPR was estimated to add a mean gain of 3.0 Quality Adjusted Life Years (QALYs) per patient. Mean cost per QALY did not differ significantly by OHCA or IHCA.

Dennis M, Zmudzki F, Burns B, Scott S, Gattas D, Reynolds C, Buscher H, Forrest P; Sydney ECMO Research Interest Group. Cost effectiveness and quality of life analysis of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Resuscitation. 2019 Jun;139:49-56. link

Cost-Utility of extracorporeal cardiopulmonary resuscitation ECPR in the setting of refractory cardiac arrest: according to this evaluation, calculated cost-utility is largely within the threshold considered cost-effective in the United States; results appears comparable to the cost-effectiveness of heart Tx for end-stage heart failure.

Bharmal MI, Venturini JM, Chua RFM, Sharp WW, Beiser DG, Tabit CE, Hirai T, Rosenberg JR, Friant J, Blair JEA, Paul JD, Nathan S, Shah AP. Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest. Resuscitation. 2019 Mar;136:126-130. link

Pulmonary embolism

ECPR important rescue strategy in fulminant PE as intraarrest thrombolysis fails: although bleeding concern, potential life-saving benefits of ECMO assisted CPR overcome hemorrhagic risks. Here a case rep; what the best approach? preparing for ECLS during early administration of thrombolytics to be prepared for eventual failure or implementing ECMO as primary intervention?

Thind GS, Hanane T, Bribriesco A, Yun J, Anandamurthy B, Latifi M, Unai S, Krishnan S. Extracorporeal cardiopulmonary resuscitation in a patient with fulminant pulmonary embolism refractory to intraarrest thrombolysis. Perfusion. 2019 Jul 21:267659119862932. link

2019 European Society of Cardiology Guidelines for the diagnosis & management of acute pulmonary embolism developed in collaboration with the European Respiratory Society. Temporary use of mechanical cardiopulmonary support, mostly veno-arterial ECMO may be considered, and may be helpful in combination with surgical embolectomy or catheter-directed treatment, in patients with high-risk PE and refractory circulatory collapse or cardiac arrest. Survival of critically ill patients has been described in a number of case series, but no RCTs in the setting of high-risk PE have been conducted to date.

Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory. Eur Respir J. 2019 Oct 9;54(3). Open access link

Extracorporeal support or ECPR in massive pulmonary embolism: veno-arterial ECMO able to save lives and extend time for definitive treatment if implemented in a timely manner, as reported in this series of patients suffering form circulatory collapse or cardiac arrest due to PE; a trained ECMO team need to be involved & alerted in all cases suspected for massive PE.

Kjaergaard B, Kristensen JH, Sindby JE, de Neergaard S, Rasmussen BS. Extracorporeal membrane oxygenation in life-threatening massive pulmonary embolism. Perfusion. 2019 Feb 17:267659119830014. link

May Extracorporeal Cardiopulmonary Resuscitation improve the outcomes of patients who suffer from CA due to massive PE? yes, according to this before-after study! ECPR seems promising treatment to support patients with refractory cardiac arrest due to (suspected) massive pulmonary embolism compared to conventional CPR (26 vs 5%, with no favourable neurological outcome in CCPR patients compared to 21% of the ECMO patients, p < 0.05), even if outcomes remain poor.

Mandigers L, Scholten E, Rietdijk WJR, den Uil CA, van Thiel RJ, Rigter S, Heijnen BGADH, Gommers D, Dos Reis Miranda D. Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: A two center observational study. Resuscitation. 2019 Mar;136:8-13. link

Accidental hypothermia

Looking for reliable cut-off values for identification of hypothermic avalanche victims with reversible OHCA at admission for extracorporeal assisted rewarming to allocate ECLS resources increasing survivors: serum potassium accurately predicted survival, combined serum K+ 7 mmol/L & core temperature 30°C achieved lowest overtriage rate/highest PPV; presence of vital signs at the time of extrication strongly associated with survival open access.

Brugger H, Bouzat P, Pasquier M, Mair P, Fieler J, Darocha T, Blancher M, de Riedmatten M, Falk M, Paal P, Strapazzon G, Zafren K, Brodmann Maeder M. Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: A retrospective multi-centre study. Resuscitation. 2019 Jun;139:222-229. open access link

Hypothermia outcome prediction after ECLS for hypothermic cardiac arrest: may the HOPE score replace serum K+ as triage tool when considering ECMO assisted rewarming of a hypothermic CA victim? first external validation.

Pasquier M, Rousson V, Darocha T, Bouzat P, Kosiński S, Sawamoto K, Champigneulle B, Wiberg S, Wanscher MCJ, Brodmann Maeder M, Paal P, Hugli O. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score. Resuscitation. 2019 Jun;139:321-328. link

ECMO support to improve outcomes in accidental hypothermia with no vital signs? veno-arterial ECLS associated with higher survival & favourable neurological outcomes compared with conventional CPR alone in this cohort, according to the results of this large nationwide observation.

Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H. Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study. Resuscitation. 2019 Nov;144:27-32. link

Severe hypothermia? Promising outcomes (hospital survival = 89% with excellent neuro-recovery) for veno-arterial ECMO in this case series from an established high-volume ECMO & #CPR European center, comparing severely hypothermic patients rewarmed on VA-ECLS with hypothermic patients rewarmed conservatively. Except for mildly lower temperature in the ECMO group and presence of refractory cardiac arrest, previously published prognostic indicators (arterial lactate level, pH, plasmatic K) did not differ between the two groups.

Balik M, Porizka M, Matousek V, Brestovansky P, Svobodova E, Flaksa M, Rulisek J, Mlejnsky F, Hodkova G, Grus T, Vobruba V, Belohlavek J. Management of accidental hypothermia: an established extracorporeal membrane oxygenation centre experience. Perfusion. 2019 Apr;34(1_suppl):74-81. link

Interesting ECPR case reports

Prolonged cardiopulmonary resuscitation & low flow… contraindications for #ECLS?? here longest (to date!) duration for conventional CPR (>2h) followed by successful ECMO support in pediatric out-of-hospital, witnessed cardiac arrest OCHA, demonstrating unpredictability of outcomes, especially in a previously healthy children: ECPR can provide the chance of recovery even in the setting of an extremely long resuscitation. Patient has been discharged home with no impairment of cognitive abilities.

Deshpande SR, Vaiyani D, Cuadrado AR, McKenzie ED, Maher KO. Prolonged cardiopulmonary resuscitation and low flow state are not contraindications for extracorporeal support. Int J Artif Organs. 2019 Sep 23:391398819876940. link

ECPR & prolonged use of mechanical compression device to provide LV unloading in the setting of peripheral veno-arterial #ECMO: a combined support while correcting hypothermia, coagulopathy, acid-base abnormalities allowing for return of spontaneous circulation & successful neurologic outcome after hypothermic cardiac arrest, despite downtime greater than 100′: case rep… Hint! TEE guidance critical to optimize LUCAS position!

Trethowan B, Michaud C, Kumar A, Strotbaum A, Berjaoui W, Spurlock D. Veno-arterial extracorporeal membrane oxygenation and prolonged use of mechanical compression device combine for good outcome after hypothermic cardiac arrest: a case report. Journal Of Emergency And Critical Care Medicine, 3, jan. 2019. link

ECPR in prolonged refractory cardiac arrest + switch from veno-arterial to veno-venous configuration of ECMO as cardiogenic shock improved to support impaired lung function and weaning with full neuro-recovery, an interesting open access case from Japan!

Ichinohashi K, Natsukawa T, Ueda T, Sawano H, Hayashi Y, Shigeoka H, Kitazawa Y, Hiraide A. Unexpectedly Good Neurological Outcome after Prolonged Cardiac Arrest. OJEM Vol.7 No.1 , March 2019 link

Report of 2 cases of refractory cardiac arrest presenting with agonal breathing, both successfully resuscitated with favourable neurological outcome at discharge through ECLS, despite initial non-shockable rhythms (asystole & PEA)… look at the signs of life when considering criteria for ECPR!

Bunya N, Wada K, Yamaoka A, Kakizaki R, Katayama Y, Kasai T, Kyan R1, Murakami N, Kokubu N, Uemura S, Narimatsu E. The prognostic value of agonal respiration in refractory cardiac arrest: a case series of non-shockable cardiac arrest successfully resuscitated through extracorporeal cardiopulmonary resuscitation. Acute Med Surg. 2019 Feb 20;6(2):197-200. open access link

Would you consider ECPR in acute aortic dissection?? here, concerns about stopping veno-arterial ECMO support implementation upon identification of Type A AAD bit.ly/2Y9vnuz & case report triggering the discussion.

Kelly C, Ockerse P, Glotzbach JP, Jedick R, Carlberg M, Skaggs J, Morgan DE. Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation. Am J Emerg Med. 2019 Jun;37(6):1214.e5-1214.e6. link

Rescue TEE for monitoring mechanical chest compressions, improving cCPR quality & guiding ECPR cannulation in refractory cardiac arrest, increasing efficiency in implementing #ECMO. In pulseless patients, POCUS allows for vessel identification, decreasing complications of blind attempts & reducing time needed to obtain accesses, confirming sites prior to dilation cannulation, and may improve survival.

Giorgetti R, Chiricolo G, Melniker L, Calaf C, Gaeta T. RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest. J Clin Ultrasound. 2019 Dec 10. link

ECMOed Mission

The ECMO Education ECMOed Taskforce is an international consortium of health-care professionals dedicated to the development and delivery of high-quality ECMO educational activities. Primary to the mission is an international and collaborative approach to identifying and addressing ECMO educational needs. ECMOed seeks to be the guiding international and multi-professional commission within ELSO. We are committed to a collaborative approach to ECMO education with the goal of defining international standards applicable across the 5 ELSO chapters.