Endovascular resuscitation (EVR) describes a collection of novel therapies that aim to bridge patients in shock states or cardiac arrest to definitive treatment, through a combination of haemorrhage control and mechanical circulatory support. The last half-decade has seen landmark trials report on several techniques and adoption is growing despite controversies around risk, efficacy and implementation. As leaders in resuscitation, it is essential that emergency physicians understand the principles and practice of endovascular techniques to advocate for the critically unwell patients that may benefit from EVR and be engaged in future implementation.This practice review aims to provide emergency physicians with an overview of EVR, based around case scenarios of out-of-hospital cardiac arrest and non-compressible haemorrhage. We review the rationale for EVR in these conditions and describe the critical initial step of vascular access. We then describe the physiology, technique, efficacy and safety of three escalating interventions: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion and extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (ECPR) is considered infeasible in patients with traumatic cardiac arrest (TCA). We conducted a systematic literature review applying a multi-layered search strategy to summarise and meta-analyse published evidence on the use of ECPR in TCA patients. We focused on TCA occurring during the pre-hospital and early in-hospital phase approximately corresponding to the first six hours following injury. Nine studies (retrospective study, n = 4; case series, n = 2; case report, n = 3) including 84 TCA patients undergoing ECPR were identified. All ECPR procedures were performed in-hospital. The median age was 39 (29–51) years. Two patients (2

Introduction:Survival rates for cardiac arrest remain low. Extracorporeal cardiopulmonary resuscitation (ECPR) may offer a survival advantage in carefully selected patients. There is limited published data on ECPR in the UK and therefore this study aims to describe the last 11 years provision and outcomes of ECPR in the UK. Methods:This was a multicentre retrospective cohort study in the UK. Centres offering Extracorporeal membrane oxygenation (ECMO) as a potential support in the UK were identified at the first UK ECPR Summit. All centres were asked to submit data on their veno-arterial (VA) ECMO and ECPR patients between 1st January 2012 and 31st December 2022. Results:Over the 11-year period, 2117 patients received VA-ECMO in the UK with 963 survivors at 6 months (45.5%). Of these there were 302 ECPR runs with 92 survivors (30.5%). ECPR contributed to 14.3% of the total VA ECMO runs, with wide between-centre variation ranging from 5.4% to 73.3%. Centres provided a detailed dataset for 129 of the 172 consecutive ECPR cases for a 5-year period to 31st December 2022. The mean (SD) age was 46 ± 5 years, 77% were male and 48.9% presented with a shockable rhythm. The leading cause of cardiac arrest was ischaemic heart disease (45%). Only 14% achieved transient or sustained return of spontaneous circulation prior to initiation of ECMO flow, with mean time CPR to full ECMO flow of 52.5 ± 17.1 min. Percutaneous cannulation was performed in 85.3% of cases, with 51.9% of these procedures taking place in the cardiac catheter laboratory. Conclusion:In an UK cohort of VA ECMO and ECPR patients, the survival rates were comparable to other international registries. The variation in practice highlights the need to explore and address inequity of access to ECMO and ECPR services.

Importance:Hemorrhage is the most common cause of preventable death after injury. Most deaths occur early, in the prehospital phase of care. Objective:To establish whether prehospital zone 1 (supraceliac) partial resuscitative endovascular balloon occlusion of the aorta (Z1 P-REBOA) can be achieved in the resuscitation of adult trauma patients at risk of cardiac arrest and death due to exsanguination. Design, Setting, and Participants:This was a prospective observational cohort study (Idea, Development, Exploration, Assessment and Long-term follow-up [IDEAL] 2A design) with recruitment from June 2020 to March 2022 and follow-up until discharge from hospital, death, or 90 days evaluating a physician-led and physician-delivered, urban prehospital trauma service in the Greater London area. Trauma patients aged 16 years and older with suspected exsanguinating subdiaphragmatic hemorrhage, recent or imminent hypovolemic traumatic cardiac arrest (TCA) were included. Those with unsurvivable injuries or who were pregnant were excluded. Of 2960 individuals attended by the service during the study period, 16 were included in the study. Exposures:ZI REBOA or P-REBOA. Main Outcomes and Measures:The main outcome was the proportion of patients in whom Z1 REBOA and Z1 P-REBOA were achieved. Clinical end points included systolic blood pressure (SBP) response to Z1 REBOA, mortality rate (1 hour, 3 hours, 24 hours, or 30 days postinjury), and survival to hospital discharge. Results:Femoral arterial access for Z1 REBOA was attempted in 16 patients (median [range] age, 30 [17-76] years; 14 [81%] male; median [IQR] Injury Severity Score, 50 [39-57]). In 2 patients with successful arterial access, REBOA was not attempted due to improvement in clinical condition. In the other 14 patients (8 [57%] of whom were in traumatic cardiac arrest [TCA]), 11 successfully underwent cannulation and had aortic balloons inflated in Z1. The 3 individuals in whom cannulation was unsuccessful were in TCA (failure rate = 3/14 [21%]). Median (IQR) pre-REBOA SBP in the 11 individuals for whom cannulation was successful (5 [46%] in TCA) was 47 (33-52) mm Hg. Z1 REBOA plus P-REBOA was associated with a significant improvement in BP (median [IQR] SBP at emergency department arrival, 101 [77-107] mm Hg; 0 of 10 patients were in TCA at arrival). The median group-level improvement in SBP from the pre-REBOA value was 52 (95% CI, 42-77) mm Hg (P < .004). P-REBOA was feasible in 8 individuals (8/11 [73%]) and occurred spontaneously in 4 of these. The 1- and 3-hour postinjury mortality rate was 9% (1/11), 24-hour mortality was 27% (3/11), and 30-day mortality was 82% (9/11). Survival to hospital discharge was 18% (2/11). Both survivors underwent early Z1 P-REBOA. Conclusions and Relevance:In this study, prehospital Z1 P-REBOA is feasible and may enable early survival, but with a significant incidence of late death. Trial Registration:ClinicalTrials.gov Identifier: NCT04145271.

AnaesthesiaEarly View Editorial Out-of-hospital cardiac arrest: pathways for extracorporeal cardiopulmonary resuscitation in the United Kingdom Benjamin Stretch, Corresponding Author Benjamin Stretch [email protected] orcid.org/0000-0001-6282-9410 Department of Anaesthesia, Barts Healthcare NHS Trust, London, UK Queen Mary University of London, London, UK Correspondence to: Benjamin Stretch Email: [email protected]Search for more papers by this authorBen Singer, Ben Singer orcid.org/0000-0002-9985-3198 Department of Anaesthesia, Barts Healthcare NHS Trust, London, UK Queen Mary University of London, London, UKSearch for more papers by this author Benjamin Stretch, Corresponding Author Benjamin Stretch [email protected] orcid.org/0000-0001-6282-9410 Department of Anaesthesia, Barts Healthcare NHS Trust, London, UK Queen Mary University of London, London, UK Correspondence to: Benjamin Stretch Email: [email protected]Search for more papers by this authorBen Singer, Ben Singer orcid.org/0000-0002-9985-3198 Department of Anaesthesia, Barts Healthcare NHS Trust, London, UK Queen Mary University of London, London, UKSearch for more papers by this author First published: 16 May 2024 https://doi.org/10.1111/anae.16316 1 Department of Anaesthesia, Barts Healthcare NHS Trust, London, UK 2 Queen Mary University of London, London, UK Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. 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Objective Nonshockable cardiac arrest rhythms have demonstrably poor outcomes. Pseudo-pulseless electrical activity (PEA), a subset of PEA in which visible cardiac contractility is present, is being described more frequently in recent literature. Physiology suggests that presence of cardiac motion even without a palpable pulse is energetically more favorable than true PEA, which is more like asystole. Therefore, we hypothesize that there is an increase in the survivability of PEA compared with asystole which may in part be due to a subset of pseudo-PEA. Methods A PICOST research question was generated which guided the composition of a systematic review and meta-analysis in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Results A total of 494,355 patients were identified from 12 pieces of literature. Meta-analyses revealed an overall increased survivability of PEA compared with asystole (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.52-2.86). When differentiating between location of arrest, PEA was more survivable in both in-hospital cardiac arrest and out-of-hospital cardiac arrest than asystole (out-of-hospital cardiac arrest OR 4.17, 95% CI 3.78-4.60, and in-hospital cardiac arrest OR 1.60, 95% CI 1.42-1.79). Finally, when comparing neurological outcome of PEA with asystole, PEA was more favorable (OR 3.32, 95% CI 1.39-7.94). Conclusion Pseudo-PEA may be one of the explanations attributed to better outcomes of PEA, especially neurological, due to the presence of cerebral and coronary flow. The presence of PEA likely requires evidence-based tailored management with presence of pseudo-PEA being more like a profound shock state. More evidence is required to investigate the true incidence of pseudo-PEA and its outcomes compared with true PEA.

AIM:Sub30 study is an open-label, prospective, single-arm feasibility study with the primary objective of assessing the logistics, feasibility, and safety of ECPR delivery in a pre-hospital setting for refractory out-of-hospital cardiac arrest patients in London, United Kingdom. RESULTS:Forty-three eligible patients were identified by London Ambulance Service over 27 trial recruitment days during a 13-month study period resulting in the despatch of the pre-hospital ECPR team to 18 patients. Five patients met full criteria and were cannulated for ECPR. All patients were male with a median age of 61 years and received ECPR full flows at a mean of 47 min (range 37-59 min) from initial collapse after a median travel time to scene of 14 min (range 3-20 min). No patient met the primary outcome measure of being established on pre-hospital ECPR within 30 min of the call to the emergency services. Out of 5 patients, 3 patients had treatment withdrawn and 2 survived to hospital discharge (both CPC score 3 and modified Rankin Score (mRS) score 4 and 5 respectively). METHODS:Open-label, single-arm, feasibility, prospective study. CONCLUSIONS:Whilst our study did not meet primary outcome of achieving full ECPR flow within 30-minute of collapse, it demonstrated safe, timely and effective delivery of ECPR with comparable survival rates by pre-hospital teams in a large metropolitan city and this has potential to improve outcomes in refractory out-of-hospital cardiac arrest patients.

BACKGROUND:A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program. METHODS:A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale). RESULTS:35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance. CONCLUSIONS:We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.

BACKGROUND:Out-of-hospital cardiac arrest carries a poor prognosis with survival less than 10% in many patient cohorts. Survival is inversely associated with duration of resuscitation as external chest compressions do not provide sufficient blood flow to prevent irreversible organ damage during a prolonged resuscitation. Extracorporeal membrane oxygenation (ECMO) instituted during cardiac arrest can provide normal physiological blood flows and is termed Extracorporeal Cardio-Pulmonary Resuscitation (ECPR). ECPR may improve survival when used with in-hospital cardiac arrests. This possible survival benefit has not been replicated in trials of out-of-hospital cardiac arrests, possibly because of the additional time it takes to transport the patient to hospital and initiate ECPR. Pre-hospital ECPR may shorten the time between cardiac arrest and physiological blood flows, potentially improving survival. It may also mitigate some of the neurological injury that many survivors suffer.METHODS:Sub30 is a prospective six patient feasibility study. The primary aim is to test whether it is possible to institute ECPR within 30 ​min of collapse in adult patients with refractory out of hospital cardiac arrest (OHCA). The secondary aims are to gather preliminary data on clinical outcomes, resource utilisation, and health economics associated with rapid ECPR delivery in order to plan any subsequent clinical investigation or clinical service. On study days a dedicated fast-response vehicle with ECPR capability will be tasked to out-of-hospital cardiac arrests in an area of London served by Barts Heart Centre. If patients suffer a cardiac arrest refractory to standard advanced resuscitation and meet eligibility criteria, ECPR will be started in the pre-hospital environment.DISCUSSION:Delivering pre-hospital ECPR within 30 ​min of an out-of-hospital cardiac arrest presents significant ethical, clinical, governance and logistical challenges. Prior to conducting an efficacy study of ECPR the feasibility of timely and safe application must be demonstrated first. Extensive planning, multiple high-fidelity multiagency simulations and a unique collaboration between pre-hospital and in-hospital institutions will allow us to test the feasibility of this intervention in London. The study has been reviewed, refined and endorsed by the International ECMO Network (ECMONet).TRIAL REGISTRATION:Clinicaltrials. gov NCT03700125, prospectively registered October 9, 2018.

INTRODUCTION:Extracorporeal cardiopulmonary resuscitation (ECPR) is an internationally recognised treatment for refractory cardiac arrest, with evidence of improved outcomes in selected patient groups from cohort studies and case series. In order to establish the clinical need for an in-hospital extracorporeal cardiopulmonary resuscitation service at a tertiary cardiac centre, we analysed the inpatient cardiac arrest database for the previous 12 months.METHODS:Evidence-based inclusion criteria were used to retrospectively identify the number of patients potentially eligible for extracorporeal cardiopulmonary resuscitation over a 12-month period.RESULTS:A total of 261 inpatient cardiac arrests were analysed with 21 potential extracorporeal cardiopulmonary resuscitation candidates meeting the inclusion criteria (1.75 patients per month, or 8% of inpatient cardiac arrests (21/261)). The majority (71%) of these cardiac arrests occurred outside of normal working hours. Survival-to-discharge within this sub-group with conventional cardiopulmonary resuscitation was 19% (4/21).CONCLUSION:Sufficient numbers of refractory inpatient cardiac arrests occur to justify an extracorporeal cardiopulmonary resuscitation service, but a 24-h on-site extracorporeal membrane oxygenation team presents a significant financial and logistical challenge.

There is increasing interest in the potential use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the prehospital setting to stabilise patients in refractory cardiac arrest.1 VA-ECMO involves draining blood through a cannula sited in a large vein and passing it through a pump and a membrane oxygenator before returning it under pressure through another cannula sited in a large artery. It can therefore be used to temporarily replace the function of the heart and lungs. When VA-ECMO is used to manage refractory cardiac arrest, it is termed extracorporeal cardiopulmonary resuscitation (ECPR). Out-of-hospital cardiac arrest patients have poor outcomes,2 3 not least because it takes time to package and transport them to heart attack centres. By bringing VA-ECMO into the prehospital environment, it is hoped that vital organ perfusion can be re-established more quickly in a refractory cardiac arrest, preventing irreversible hypoxic organ damage and potentially improving out-of-hospital cardiac arrest survival rates that remain very low. Prehospital ECPR is fraught with difficulties and potential complications,4 many of which can be prepared for by simulation. Unfortunately, there are no cost-effective, commercially available manikins designed for ECPR. Previous attempts at simulating prehospital ECPR have used separate manikins for the dichotomous elements of cardiopulmonary resuscitation (CPR) and extracorporeal membrane oxygenation (ECMO); however, this significantly reduces the fidelity of the exercise. In-hospital ECMO manikins often have to forego the use of …

Background Injured patients are at risk of developing acute kidney injury (AKI), which is associated with increased morbidity and mortality. The aim of this study is to describe the incidence, timing, and severity of AKI in a large trauma population, identify risk factors for AKI, and report mortality outcomes. Methods A prospective observational study of injured adults, who met local criteria for trauma team activation, and were admitted to a UK Major Trauma Centre. AKI was defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression and Cox proportional hazard modelling was used to analyse parameters associated with AKI and mortality. Results Of the 1410 patients enrolled in the study, 178 (12.6%) developed AKI. Age; injury severity score (ISS); admission systolic blood pressure, lactate and serum creatinine; units of Packed Red Blood Cells transfused in first 24 hours and administration of nephrotoxic therapy were identified as independent risk factors for the development of AKI. Patients that developed AKI had significantly higher mortality than those with normal renal function (47/178 [26.4%] versus 128/1232 [10.4%]; OR 3.09 [2.12 to 4.53]; p<0.0001). After adjusting for other clinical prognostic factors, AKI was an independent risk factor for mortality. Conclusions AKI is a frequent complication following trauma and is associated with prolonged hospital length of stay and increased mortality. Future research is needed to improve our ability to rapidly identify those at risk of AKI, and develop resuscitation strategies that preserve renal function in trauma patients.

INTRODUCTION:The probability of surviving a cardiac arrest remains low. International resuscitation guidelines state that extracorporeal cardiopulmonary resuscitation (ECPR) may have a role in selected patients suffering refractory cardiac arrest. Identifying these patients is challenging. This project systematically reviewed the evidence comparing the outcomes of ECPR over conventional-CPR (CCPR), before examining resuscitation-specific parameters to assess which patients might benefit from ECPR.METHOD:Literature searches of studies comparing ECPR to CCPR and the clinical parameters of survivors of ECPR were performed. The primary outcome examined was survival at hospital discharge or 30 days. A secondary analysis examined the resuscitation parameters that may be associated with survival in patients who receive ECPR (no-flow and low-flow intervals, bystander-CPR, initial shockable cardiac rhythm, and witnessed cardiac arrest).RESULTS:Seventeen of 948 examined studies were included. ECPR demonstrated improved survival (OR 0.40 (0.27-0.60)) and a better neurological outcome (OR 0.10 (0.04-0.27)) over CCPR during literature review and meta-analysis. Characteristics that were associated with improved survival in patients receiving ECPR included an initial shockable rhythm and a shorter low-flow time. Shorter no-flow, the presence of bystander-CPR and witnessed arrests were not characteristics that were associated with improved survival following meta-analysis, although the quality of input data was low. All data were non-randomised, and hence the potential for bias is high.CONCLUSION:ECPR is a sophisticated treatment option which may improve outcomes in a selected patient population in refractory cardiac arrest. Further comparative research is needed clarify the role of this potential resuscitative therapy.

Survival from out-of-hospital cardiac arrest (OHCA) has remained low despite advances in resuscitation science. Hospital-based extra-corporeal cardiopulmonary resuscitation (ECPR) is a novel use of an established technology that provides greater blood flow and oxygen delivery during cardiac arrest than closed chest compressions. Hospital-based ECPR is currently offered to selected OHCA patients in specialized centres. The interval between collapse and restoration of circulation is inversely associated with good clinical outcomes after ECPR. Pre-hospital delivery of ECPR concurrent with conventional resuscitation is one approach to shortening this interval and improving outcomes after OHCA. This article examines the background and rationale for pre-hospital ECPR; summarises the findings of a literature search for published evidence; and considers candidate selection, logistics, and complications for this complex intervention.

Take-Home MessageIn refractory out-of-hospital cardiac arrest patients, initial shockable cardiac rhythm, shorter cardiopulmonary resuscitation (CPR) duration, higher admission arterial pH, and lower admission serum lactate level may help predict favorable outcome after extracorporeal CPR.MethodsData SourcesData sources included MEDLINE (2000 to 2016), references of relevant articles and previously published reviews, and experts in the field for article recommendations or unpublished work.Study SelectionObservational and experimental studies (≥10 subjects) of extracorporeal CPR during cardiac arrest and a case mix of at least 50% out-of-hospital cardiac arrest were used. Studies comparing extracorporeal CPR and conventional CPR were excluded.Data Extraction and SynthesisTwo investigators extracted data after independently assessing each study for methodological quality, using the Quality in Prognosis Studies tool. Using random-effects models, the authors calculated summary estimates of prespecified clinical variables and their association with favorable outcome (favorable neurologic status [or survival for studies that did not assess neurologic status] at the longest available follow-up interval). In refractory out-of-hospital cardiac arrest patients, initial shockable cardiac rhythm, shorter cardiopulmonary resuscitation (CPR) duration, higher admission arterial pH, and lower admission serum lactate level may help predict favorable outcome after extracorporeal CPR. Data sources included MEDLINE (2000 to 2016), references of relevant articles and previously published reviews, and experts in the field for article recommendations or unpublished work. Observational and experimental studies (≥10 subjects) of extracorporeal CPR during cardiac arrest and a case mix of at least 50% out-of-hospital cardiac arrest were used. Studies comparing extracorporeal CPR and conventional CPR were excluded. Two investigators extracted data after independently assessing each study for methodological quality, using the Quality in Prognosis Studies tool. Using random-effects models, the authors calculated summary estimates of prespecified clinical variables and their association with favorable outcome (favorable neurologic status [or survival for studies that did not assess neurologic status] at the longest available follow-up interval). Tabled 1Summary estimates for pooled data.Clinical VariableSummary EstimateNo. Studies (Subjects)Result (95% CI)Heterogeneity (I2), %AgeMean difference∗Difference between subjects with and without favorable outcome.8 (n=411)–0.4 y (–4.5 to 3.7)19Female sexSummary odds ratio†Association between clinical variable and favorable outcome.6 (n=130)OR 1.75 (0.93 to 3.31)0Bystander CPRSummary odds ratio†Association between clinical variable and favorable outcome.8 (n=479)OR 2.81 (0.95 to 8.32)64Shockable initial cardiac rhythmSummary odds ratio†Association between clinical variable and favorable outcome.10 (n=617)OR 2.20 (1.30 to 3.72)0Low-flow duration‡Interval from CPR initiation to extracorporeal CPR.Summary geometric mean ratio†Association between clinical variable and favorable outcome.6 (n=316)0.90 (0.81 to 0.99)0Baseline arterial pH§Measured before or immediately after starting extracorporeal CPR.Mean difference∗Difference between subjects with and without favorable outcome.9 (n=392)0.12 (0.03 to 0.22)76Baseline serum lactate§Measured before or immediately after starting extracorporeal CPR.Mean difference∗Difference between subjects with and without favorable outcome.8 (n=354)–3.52 mmol/L (–5.05 to –1.99)51CI, Confidence interval; OR, odds ratio.∗ Difference between subjects with and without favorable outcome.† Association between clinical variable and favorable outcome.‡ Interval from CPR initiation to extracorporeal CPR.§ Measured before or immediately after starting extracorporeal CPR. Open table in a new tab CI, Confidence interval; OR, odds ratio. The authors identified 816 potential studies, of which 15 met inclusion criteria (841 subjects): 11 enrolled only subjects with out-of-hospital cardiac arrest and 4 enrolled mixed populations with prevalence of out-of-hospital cardiac arrest from 51% to 71%. Confounding was a universal source of bias across all studies, given the observational nature of this literature. Other risks of bias for included studies were mostly low to moderate. Specific clinical and laboratory variables were associated with favorable outcome after extracorporeal CPR (Table). Heterogeneity varied greatly across predictors of interest (range 0% to 76%). Included studies were each conducted at single centers in Japan, South Korea, western Europe, or the United States. Common themes in extracorporeal CPR subject selection include younger age, witnessed collapse, shorter low-flow durations, and the absence of major comorbidities, but there was variability between studies in the restriction of extracorporeal CPR for subjects with specific initial cardiac rhythms, precise duration of low-flow time, and suspected causes of cardiac arrest. Because of investigator reluctance to share raw data, this meta-analysis was limited by the use of published aggregate data as opposed to individual subject data. Extracorporeal CPR is a therapeutic option for select cases of cardiac arrest refractory to traditional resuscitation techniques.1Callaway C.W. Soar J. Aibiki M. et al.Advanced Life Support Chapter CollaboratorsPart 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.Circulation. 2015; 132: S84-S145Crossref PubMed Scopus (243) Google Scholar Observational evidence demonstrates the feasibility of extracorporeal CPR and its association with survival compared with historical controls or matched control patients for whom it was not available.2Ouweneel D.M. Schotborgh J.V. Limpens J. et al.Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis.Intensive Care Med. 2016; 42: 1922-1934Crossref PubMed Scopus (300) Google Scholar In populations enriched with cardiac cause of cardiac arrest, extracorporeal CPR is associated with a 14% (95% confidence interval 2% to 25%) absolute increase in 30-day survival and a 13% (95% confidence interval 7% to 20%) absolute increase in 30-day favorable neurologic outcome compared with conventional therapy.2Ouweneel D.M. Schotborgh J.V. Limpens J. et al.Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis.Intensive Care Med. 2016; 42: 1922-1934Crossref PubMed Scopus (300) Google Scholar Most guidelines conditionally recommend extracorporeal CPR in select patients under certain clinical circumstances when the cause of cardiac arrest is potentially reversible.1Callaway C.W. Soar J. Aibiki M. et al.Advanced Life Support Chapter CollaboratorsPart 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.Circulation. 2015; 132: S84-S145Crossref PubMed Scopus (243) Google Scholar Given the burden of resources, logistics, equipment, and training, institutions implementing extracorporeal CPR should do so in a rational manner with optimal chance to benefit patients. There is wide variation in outcome after extracorporeal CPR for out-of-hospital cardiac arrest, in part from the lack of validated criteria for candidate selection.3Ortega-Deballon I. Hornby L. Shemie S.D. et al.Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: a systematic review of international practices and outcomes.Resuscitation. 2016; 101: 12-20Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Identifying prognostic factors is essential to guiding initial treatment decisions, and this systematic review succinctly summarizes baseline clinical variables associated with favorable outcome after extracorporeal CPR (Table). Of the 4 variables associated with favorable outcome, initial cardiac rhythm and low-flow duration had strikingly absent heterogeneity, suggesting these are uniquely important when extracorporeal CPR candidates are selected. Despite their heterogenicity, baseline arterial pH and lactate are plausible surrogates for the degree of ischemic insult or effect of conventional resuscitation. Yet unanswered questions persist: the interaction between no-flow and low-flow durations is uncertain, the optimal combination of prognostic factors to select candidates is unclear, nonrandomized comparisons between extracorporeal CPR and matched controls will never eliminate selection bias, and it remains unknown whether some extracorporeal CPR subjects would have survived with traditional resuscitation alone.4Callaway CW, Sunde K. Extracorporeal cardiopulmonary resuscitation probably good, but adoption should not be too fast and furious! Emerg Med J. 2017;34:275-276.Google Scholar At least 4 experimental studies of extracorporeal CPR are in progress that will be key in addressing these remaining questions.5ClinicalTrials.gov. Search of: ecpr. Available at: https://clinicaltrials.gov/ct2/results?term=ecpr&Search=Search. Accessed March 16, 2017.Google Scholar

There is an increasing interest in using venoarterial extracorporeal membrane oxygenation (VA-ECMO) to manage out-of-hospital cardiac arrest, termed extracorporeal cardiopulmonary resuscitation (E-CPR).1 VA-ECMO, used in intensive care medicine for cardiorespiratory support, involves draining blood through a cannula sited in a large vein passage through a pump and a membrane oxygenator and returning it under pressure through another cannula sited in a large artery. The time between cardiac arrest and implementation of E-CPR is a major prognostic factor2 with data suggesting improved survival if instituted within 30 min.3 UK practice for out-of-hospital cardiac arrest involves advanced life support on scene for 20 min seeking return of spontaneous circulation and transport of appropriate patients to secondary care if initial efforts fail. Thus, if VA-ECMO is only commenced in hospital, eligible patients might not be stabilised until after 30 min, reducing the chance of neurologically intact survival. We performed a high-fidelity simulation to assess the possibility of implementing prehospital E-CPR for a simulated patient within 30 min of a call to emergency services and the logistics of transfer and handover to a heart attack centre. Our aim was to facilitate learning between prehospital, paramedic and ECMO teams to help coordinate future attempts at the intervention and plan a formal feasibility trial. We also hoped that this novel simulation would form a basis for future training in prehospital E-CPR. …

Introduction: The probability of surviving an out-of-hospital cardiac arrest remains low despite the introduction of novel therapies. Extracorporeal cardiopulmonary resuscitation (eCPR) may have a role to play in certain patients in whom conventional cardiopulmonary resuscitation (cCPR) is not successful, but the clarification of which patients remains unclear. This project systematically reviewed the evidence comparing the outcomes of eCPR over cCPR, before analysing which patients might benefit from eCPR to create a potential triage tool.

Aim: Estimate prevalence of ECPR-eligible subjects in a large, North American, multi-center cohort, describe natural history with conventional resuscitation, and predict optimal timing of transition to ECPR.Methods: Secondary analysis of clinical trial enrolling adults with non-traumatic OHCA. Primary outcome was survival to discharge with favorable outcome (mRS 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4-5), ROSC without survival (mRS 6), or without ROSC. We plotted subject accrual as a function of resuscitation duration (CPR onset to return of spontaneous circulation (ROSC) or termination of resuscitation), and estimated time-dependent probabilities of ROSC and mRS 0-3 at discharge. Adjusted logistic regression models tested the association between resuscitation duration and survival with mRS 0-3.Results: Of 11,368 subjects, 1237 (10.9%; 95% CI 10.3-11.5%) were eligible for ECPR, Of these, 778 (63%) achieved ROSC, 466 (38%) survived to discharge, and 377 (30%) had mRS 0-3 at discharge. Half with eventual mRS 0-3 achieved ROSC within 8.8 min (95% CI 8.3-9.2 min) of resuscitation, and 90% within 21.0 min (95% CI 19.1-23.7 min). Time-dependent probabilities of ROSC and mRS 0-3 declined over elapsed resuscitation, and the likelihood of additional cases with mRS 0-3 beyond 20 min was 8.4% (95% CI 5.9-11.0%). Resuscitation duration was independently associated with survival to discharge with mRS 0-3 (OR 0.95; 95% CI 0.92-0.97).Conclusion: Approximately 11% of subjects were eligible for ECPR. Only one-third survived to discharge with favorable outcome. Performing 9-21 min of conventional resuscitation captured most ECPR-eligible subjects with eventual mRS 0-3 at hospital discharge. (C) 2017 Elsevier B.V. All rights reserved.