Clinical scenario

You are the arrest team leader for a 56 year old patient that has just been brought in by emergency ambulance. He collapsed suddenly in the town centre, but had early, effective bystander CPR. Fourteen minutes have elapsed since and he remains in VF despite three prehospital DC shocks. A single additional DC shock at 360 J restores sinus rhythm with an output.

Your ICU collegue informs you four days later that this patient has severe anoxic brain damage and is unlikely to be discharged from hospital. You feel that failure has been snatched from the jaws of success and wonder whether some other intervention, such as cardiopulmonary bypass support, might have improved his chances of functional survival.

Three part question

In [patients with cardiac arrest refactory to ACLS intervention] is [institution of cardiopulmonary bypass] of any benefit in [improving survival and neurological function]?

Search strategy

Medline 1966-03/04 using the OVID interface. [exp Heart Arrest/OR exp life support care/OR cardiac arrest.mp OR cardiac massage.mp OR CPR.mp] AND [exp Cardiopulmonary Bypass/OR Cardiopulmonary Bypass.mp OR cardiopulmonary support.mp] LIMIT to human AND English language.

Search outcome

Altogether 387 papers were found one of which was a review summarising 35 papers. Eight papers not included in this review were also found. Thus nine relevant papers are summarised in the table 3.

Comment(s)

There is a large variability in the reported papers. The prior clinical status of the patient is one very important factor in determining survival, as a patient with known coronary arterial disease arresting in the catheter lab will clearly have a superior survival to an out of hospital arrest with unknown pathology. However, some studies relied only on cardiopulmonary bypass and gradually weaned the patient after a number of hours, whereas other investigators immediately took the patient to the catheter lab to establish a diagnosis or to theatre for a definitive procedure. In addition there were differences in technique in the method of cardiopulmonary bypass. One important difference is whether the venous return adequately drains the right atrium, as failure to do this will cause the heart to distend and cause pulmonary oedema.

CLINICAL BOTTOM LINE

Around 15%–25% of selected patients who suffer witnessed cardiac arrest and who are not responsive to ACLS resuscitation may be successfully resuscitated with the assistance of cardiopulmonary bypass.