Emergency Department Cardiopulmonary Bypass in the Treatment of Human Cardiac Arrest

doi:10.1378/chest.113.3.743

Chest

Volume 113, Issue 3, March 1998, Pages 743-751

https://doi.org/10.1378/chest.113.3.743 Get rights and content

Objective

To study the use of emergency department (ED) femoro-femoral cardiopulmonary bypass (CPB) in the resuscitation of medical cardiac arrest patients.

Design

Prospective, uncontrolled trial.

Setting

Urban academic ED staffed with board-certified emergency physicians (EPs).

Participants

Ten patients with medical cardiac arrest unresponsive to standard therapy.

Interventions

Femoro-femoral CPB instituted by EPs.

Results

The time of cardiac arrest prior to CPB (mean±SD) was 32.0±13.6 min. The cardiac output while on CPB was 4.09±1.03 L/min with an average of 229±111 min on bypass. All 10 patients had resumption of spontaneous cardiac activity while on CPB. Seven of these were weaned from CPB with intrinsic spontaneous circulation. Of these, six patients were transferred from the ED to the operating room for cannula removal and vessel repair while the other patient died in the ED soon after discontinuing CPB. Mean survival was 47.8±44.7 h in the six patients leaving the ED. Although these patients had successful hemodynamic resuscitation, there were no long-term survivors.

Conclusion

CPB instituted by EPs is feasible and effective for the hemodynamic resuscitation of cardiac arrest patients unresponsive to advanced cardiac life support therapy. Future efforts need to focus on improving long-term outcome.

Section snippets

Materials and Methods

This study was approved by the Human Rights Committee (Institutional Review Board) of Henry Ford Hospital, Detroit. Patients with either out-of-hospital cardiac arrest or emergency department (ED) cardiac arrest that was unresponsive to ACLS therapy were considered for entry into the study. Patients were eligible for enrollment if they met the following criteria: (1) age older than 14 years and younger than 65 years; (2) witnessed cardiac arrest of ≦30 min for age younger than 40 years and <20

Results

Thirteen patients were originally considered for entry into the study. Cannulation was unsuccessful in three of these patients. This cannulation failure was related to inability to advance the venous cannulas in all three patients. Positioning the patient in reverse Trendelenburg position alleviated this problem. Results from the 10 patients who were successfully placed on CPB will be presented. A representative case (case 5 from Table 1) is presented below for illustrative purposes.

Discussion

CPB has been used with success to resuscitate animals in models of prolonged cardiac arrest.11, 12, 13 In a clinically relevant out-of-hospital cardiac arrest scenario in dogs, Levine et al¹¹ demonstrated significant improvement in long-term neurologic outcome in animals treated with CPB vs standard ACLS after 4 min of VF followed by 30 min of CPR. Several groups have studied the clinical role of CPB as a resuscitative tool14, 15, 16, 17, 18, 19, 20, 21, 22 with varying results. The variance in

Conclusion

CPB instituted by EPs is feasible and effective for the hemodynamic resuscitation of cardiac arrest patients unresponsive to ACLS therapy. With increased awareness of the postresuscitation disease and therapy aimed at alleviating ischemia-reperfusion injury on both an organ-specific and total body basis, more success with CPB as a resuscitative tool may be expected.

Acknowledgments

The authors thank all the ED personnel for their support and help in conducting this study and to Roy Eisiminger, CCP, CCT, for his expertise in operating the CPB unit.

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2020, Annals of Emergency Medicine
The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation.
Improving cannulation time for extracorporeal life support in refractory cardiac arrest of presumed cardiac cause – Comparison of two percutaneous cannulation techniques in the catheterization laboratory in a center without on-site cardiovascular surgery
2018, Resuscitation
Citation Excerpt :
When appropriate resuscitation does not restore spontaneous circulatory function, patients are declared deceased unless life-saving measures such as veno-arterial extracorporeal membrane oxygenator (vaECMO) devices are used [6]. VaECMO devices are supplanting circulatory and pulmonary function and are connected to the patient through arterial and venous cannulae inserted in refractory CA patients in the femoral vessels under cardiopulmonary resuscitation [6,7]. The insertion of the vaECMO cannulae can be performed by surgical technique using femoral dissection [3–5,8,9] or by percutaneous technique under ultrasound guidance or in the catheterization laboratory under fluoroscopic guidance [10–14].
Cardiac arrest (CA) without return of spontaneous circulation can be treated with veno-arterial extracorporeal membrane oxygenation (vaECMO) implemented surgically or percutaneously. We performed a study assessing time for vaECMO percutaneous cannulation in the catheterization laboratory.
Single-centre retrospective study in a University hospital without on-site cardiovascular surgery, including patients aged >18 receiving vaECMO for out- or in-hospital refractory CA of presumed cardiac cause between 2010 and 2016, cannulated by interventional cardiologists. Cannulation time using anatomic landmarks vessel puncture and conventional wires (first period) was compared with ultrasound guidance puncture and stiff wires (second period). Data are expressed as medians (interquartile range) and percentages.
Forty-six patients were included, age 56 (49–62), 34 in the first period. Shockable initial rhythm occurred in 29 (63%), 36 (78%) had ischemic heart disease and 26 (57%) acute myocardial infarction (AMI). Out-of-hospital refractory CA occurred in 27 (59%) patients. Time from out-of-hospital refractory CA to admission was 100 (80–118) min.
Cannulation was successful in 42 (91%) patients. Cannulation time was 14 (10–21) min, 17 (12–26) (first) and 8 (6–12) min (second period), p < 0.001. Survival to discharge was 9%. In out-of-hospital versus in-hospital, time from CA to vaECMO was 120 (115–140) versus 82 (58–102) min, p = 0.011, survival was 7% (two patients) versus 11% (two patients), p = 0.35 respectively. All survivors had shockable initial rhythm.
In these refractory CA patients with high prevalence of AMI and good feasibility of percutaneous vaECMO in the catheterization laboratory, cannulation time was shorter using ultrasound guidance and stiff wires.
A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis
2017, Resuscitation
Out of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies.
We consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30 min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20 min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28.
A total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20 min (p < 0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P < 0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2.
Our data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
2015, Resuscitation
Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest
2014, Resuscitation
Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.
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.
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.
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.
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
2013, Resuscitation
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.
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.
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.

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: revision accepted August 20.

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Chest

Clinical Investigations in Critical CareEmergency Department Cardiopulmonary Bypass in the Treatment of Human Cardiac Arrest

Objective

Design

Setting

Participants

Interventions

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Acknowledgments

Ann Emerg Med

J Neurol Sci

Am J Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

Ann Thorac Surg

Ann Emerg Med

Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation

Am J Emerg Med

Predicting outcome of in-hospital CPR

Crit Care Med

Clinical Investigations in Critical Care
Emergency Department Cardiopulmonary Bypass in the Treatment of Human Cardiac Arrest