Predictors of survival following extracorporeal cardiopulmonary resuscitation in patients with acute myocardial infarction-complicated refractory cardiac arrest in the emergency department: a retrospective study
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Abstract:
This study aimed to identify the determinant factors for clinical outcomes and survival rates of patients with cardiac arrest (CA) concurrent with acute myocardial infarction (AMI) who underwent extracorporeal cardiopulmonary resuscitation (ECPR) using extracorporeal membrane oxygenation (ECMO).We retrospectively evaluated 37 patients admitted to our emergency department between January 2006 and August 2012 for AMI-induced CA treated with ECPR during ongoing continuous chest compressions.Mean patient age was 61.4 ± 11.3 years, and 27 patients (73%) were men. Mean CPR time was 50.8 ± 35.4 min. Door-to-ECMO and door-to-balloon times were 84.4 ± 55.3 and 98.4 ± 56.8 min, respectively. Mean ECMO time was 106.4 ± 84.7 h; nine (24%) patients died within 24 h after ECMO initiation. Twelve (32%) patients were weaned off ECMO, seven (19%) of whom survived >30 days after ECMO removal; all except one had Cerebral Performance Category Grade 1. Of the patients who survived, 5 of them were able to be discharged. In multivariate analysis, statistical significance was only observed in door-to-ECMO time ≤60 min (OR, 6.0; 95% CI, 1,177-852.025; p = 0.033).We conclude that ECMO insertion within 60 min of the arrival of patients with AMI and CA at the ED appears to be a good option for maintaining myocardial and systemic perfusion, thereby increasing the survival rate of these patients.Keywords:
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Extracorporeal life support (ECLS) is used for patients in isolated or combined cardiopulmonary failures. The use of ECLS to rescue patients with cardiac arrest that is refractory to conventional cardiopulmonary resuscitation has been shown to improve survival in many patient populations. Increasing recognition of the survival benefit associated with extracorporeal cardiopulmonary resuscitation (ECPR) has led to increased use of ECPR during the past decade. This review provides an overview of ECPR utilization; population-based clinical outcomes, resource utilization and costs associated this advanced form of life support therapy.
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When patients deteriorate after decannulation from extracorporeal membrane oxygenation (ECMO), a second run of extracorporeal support may be considered. However, repeat cannulation can be difficult and poor outcomes associated with multiple ECMO runs are a concern. The aim of this study was to evaluate outcomes and identify factors associated with survival and mortality in cases of multiple runs of extracorporeal membrane oxygenation.Retrospective cohort analysis of the Extracorporeal Life Support Organization Registry.The Extracorporeal Life Support Organization's registry was queried for neonates, children, and adults receiving 2 or more runs of ECMO during the same hospitalization, for any indication, from 1998 to 2015.1,818 patients from the Extracorporeal Life Support Organization Registry.Of the 1,818 patients, 1,648 underwent 2 runs and 170 underwent 3 or more runs of ECMO. The survival to discharge rate was 36.7% for 2 runs and 29.4% for 3 or more runs. No significant differences in survival were detected in analysis by decade of ECMO run (p = 0.21). Pediatric patients had less mortality than adults (OR: 0.45, 95%CI: 0.24-0.82). Cardiac support on the first run portrayed worse mortality than pulmonary support regardless of final run indication (OR:1.38, 95%CI: 1.09-1.75). Across all age groups, patients receiving pulmonary support on the last run tended to have higher survival rates regardless of support type on the first run. The only first run complication independently predictive of mortality on the final run was renal complications (OR: 1.60, 95%CI: 1.28-1.99).Though the use of multiple runs of ECMO is growing, outcomes remain poor for most cohorts. Survival decreases with each additional run. Patients requiring additional runs for a pulmonary indication should be considered prime candidates. Renal complications on the first run significantly increases the risk of mortality on subsequent runs, and as such, careful consideration should be applied in these cases.
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Objectives: Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) help in bridging critical cardiopulmonary situations. Although some experience has been gained over the last years, many patients supported by either device cannot be weaned from it. We aimed to find determinants of survival.
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Out-of-hospital cardiopulmonary arrest (OHCA) is highly lethal. Although overall survival is increasing, hospital discharge with good neurological prognosis remains low and highly variable. In some countries, protocols are being implemented, which include techniques in cardiopulmonary resuscitation, allowing a better neurological prognosis for those patients who undergo an OHCA. Following these new techniques and the incorporation of these new protocols already accepted in the guidelines of advanced cardiopulmonary resuscitation, we report a 54 years old male who presented an OHCA and received advanced cardiopulmonary by a professional team in situ. He was transferred to the emergency department, where optimal advanced resuscitation was continued, until the connection to extracorporeal cardiopulmonary support, with the aim of reestablishing blood flow, a technique known as cardiopulmonary resuscitation (ECPR: extracorporeal cardiopulmonary resuscitation). The patient was discharged from the hospital 25 days later.
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The prognosis of out-of-hospital cardiac arrest remains poor, especially for cardiopulmonary arrest patients in rural areas with longer transport duration to hospitals.In June 2016, we began providing prehospital extracorporeal life support using a mobile operating room for emergency surgery. We report two patients who survived after receiving prehospital extracorporeal cardiopulmonary resuscitation and were discharged. A patient with cardiopulmonary arrest from accidental hypothermia due to drowning survived with good neurological outcomes after on-site extracorporeal cardiopulmonary resuscitation immediately after rescue. The other patient who survived experienced cardiopulmonary arrest at his workplace, which was approximately 90 min from the center. Prehospital extracorporeal cardiopulmonary resuscitation shortened the cardiopulmonary arrest time by an estimated 30 min, and the patient survived until the hospital.Prehospital extracorporeal cardiopulmonary resuscitation has the potential to save lives in rural areas by reducing low-flow time.
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Patients in the UK who suffer an out-of-hospital cardiac arrest are treated with cardiopulmonary resuscitation in the pre-hospital environment. Current survival outcomes are low in out-of-hospital cardiac arrest. Extracorporeal cardiopulmonary resuscitation is a technique which is offered to patients in specialised centres which provides better blood flow and oxygen delivery than conventional chest compressions. Shortening the interval between cardiac arrest and restoration of circulation is associated with improved outcomes in extracorporeal cardiopulmonary resuscitation. Delivering extracorporeal cardiopulmonary resuscitation in the pre-hospital environment can shorten this interval, improving outcomes in out-of-hospital cardiac arrest. This article will review recently published studies and summarise studies currently being undertaken in pre-hospital extracorporeal cardiopulmonary resuscitation. It will also discuss the potential application of a pre-hospital extracorporeal cardiopulmonary resuscitation programme in the North East of England.
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Objective: To report survival outcomes and to identify factors associated with survival following extracorporeal cardiopulmonary resuscitation for in-hospital pediatric cardiac arrest. Design: Retrospective chart review, consecutive case series. Main Outcome Measure: Survival to hospital discharge. Results: During a 7-yr study period, there were 66 cardiac arrest events in 64 patients in which a child was cannulated for extracorporeal membrane oxygenation during active cardiopulmonary resuscitation with chest compressions. A total of 33 of 66 events (50%) resulted in the child being decannulated and surviving at least 24 hrs; 21 of 64 (33%) children undergoing extracorporeal cardiopulmonary resuscitation survived to hospital discharge. A total of 19 of 43 children with isolated heart disease compared with two of 21 children with other medical conditions survived to hospital discharge (p < .01). Pediatric Cerebral Performance Category and Pediatric Overall Performance Category were determined for survivors >2 months old. Five of ten extracorporeal cardiopulmonary resuscitation survivors >2 months old had no change in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category compared with admission. Three of six extracorporeal cardiopulmonary resuscitation patients who survived after receiving >60 mins of chest compressions before extracorporeal cardiopulmonary resuscitation had grossly intact neurologic function. During a 2-yr period in the same hospital, no patient who received >30 mins of cardiopulmonary resuscitation without extracorporeal cardiopulmonary resuscitation survived. In this case series, age, weight, or duration of chest compressions before extracorporeal cardiopulmonary resuscitation did not correlate with survival. Conclusions: Extracorporeal cardiopulmonary resuscitation can be used to successfully resuscitate selected children following refractory in-hospital cardiac arrest, and can be implemented during active cardiopulmonary resuscitation. Intact neurologic survival can sometimes be achieved, even when the duration of in-hospital cardiopulmonary resuscitation is prolonged. In this series, children with isolated heart disease were more likely to survive following extracorporeal cardiopulmonary resuscitation than were children with other medical conditions.
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