Improved Survival With Extracorporeal Cardiopulmonary Resuscitation Despite Progressive Metabolic Derangement Associated With Prolonged Resuscitation

Abstract

Background: The likelihood of neurologically favorable survival declines with prolonged resuscitation. However, the ability of extracorporeal cardiopulmonary resuscitation (ECPR) to modulate this decline is unknown. Our aim was to examine the effects of resuscitation duration on survival and metabolic profile in patients who undergo ECPR for refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest. Methods: We retrospectively evaluated survival in 160 consecutive adults with refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest treated with the University of Minnesota (UMN) ECPR protocol (transport with ongoing cardiopulmonary resuscitation [CPR] to the cardiac catheterization laboratory for ECPR) compared with 654 adults who had received standard CPR in the amiodarone arm of the ALPS trial (Amiodarone, Lidocaine, or Placebo Study). We evaluated the metabolic changes and rate of survival in relation to duration of CPR in UMN-ECPR patients. Results: Neurologically favorable survival was significantly higher in UMN-ECPR patients versus ALPS patients (33% versus 23%; P =0.01) overall. The mean duration of CPR was also significantly longer for UMN-ECPR patients versus ALPS patients (60 minutes versus 35 minutes; P <0.001). Analysis of the effect of CPR duration on neurologically favorable survival demonstrated significantly higher neurologically favorable survival for UMN-ECPR patients compared with ALPS patients at each CPR duration interval <60 minutes; however, longer CPR duration was associated with a progressive decline in neurologically favorable survival in both groups. All UMN-ECPR patients with 20 to 29 minutes of CPR (8 of 8) survived with neurologically favorable status compared with 24% (24 of 102) of ALPS patients with the same duration of CPR. There were no neurologically favorable survivors in the ALPS cohort with CPR ≥40 minutes, whereas neurologically favorable survival was 25% (9 of 36) for UMN-ECPR patients with 50 to 59 minutes of CPR and 19% with ≥60 minutes of CPR. Relative risk of mortality or poor neurological function was significantly reduced in UMN-ECPR patients with CPR duration ≥60 minutes. Significant metabolic changes included decline in pH, increased lactic acid and arterial partial pressure of carbon dioxide, and thickened left ventricular wall with prolonged professional CPR. Conclusions: ECPR was associated with improved neurologically favorable survival at all CPR durations <60 minutes despite severe progressive metabolic derangement. However, CPR duration remains a critical determinate of survival.

Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

“…Excluding these patients from ECPR effectively results in a higher survival compared to patients receiving conventional CCPR. Especially the age criteria are quite stringent, and therefore likely affect the apparent survival [42], given the average age of the CPR population [43]. Moreover, the nding that we found substantially less heterogeneity in survival rates between studies than a systematic review of the CCPR literature [1,2] also supports the hypothesis that this is a selected population.…”

“…Evidence in the literature suggests that a longer time to ECMO time is associated with lower bene t of ECPR [48][49][50][51]. Bartos et al suggest the association between time to ECMO and survival is explained by the metabolic derangements, which develop during prolonged low-ow time, leading to a worse outcome [52]. In our meta-analysis, this association between time to ECMO and survival is not found.…”

Erweiterte Reanimationsmaßnahmen: die extrakorporale kardiopulmonale Reanimation

“…Diese negativen Aspekte können bei der In-Hospital-Methode unter Inkaufnahme der verlängerten "Collapse-tostart-eCPR-Zeit" vermieden werden. Es gibt zwar Hinweise, dass die prähospitale Versorgung mit eCPR aufgrund der kürzeren Low-Flow-Zeit mit einer höheren Überlebensrate assoziiert sein könnte [7]. Es ist aber noch nicht abschließend geklärt, ob diese Methode allein zu empfehlen ist.…”

Neuron-Specific Enolase Levels in Adults Under Venoarterial Extracorporeal Membrane Oxygenation

“…Venoarterial extracorporeal membrane oxygenation (ECMO) is an effective technique to provide emergency mechanical support for patients with refractory cardiogenic shock, with hospital discharge survival rates of 40% ( 1 ). In patients requiring ECMO during extracardiopulmonary resuscitation (ECPR), survival with satisfactory neurologic outcome is observed in less than 35% of cases ( 2 – 4 ). Neurologic complications during venoarterial ECMO are reported in 15% of adult patients and are associated with morbidity and mortality ( 5 – 7 ).…”