Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis

Bjertnæs, Lars J.; Hindberg, Kristian; Næsheim, Torvind; Суборов, Е. В.; Reierth, Eirik; Kirov, Mikhail Y.; Лебединский, К.М.; Tveita, Torkjel

doi:10.3389/fmed.2021.641633

Cited by 12 publications

(11 citation statements)

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“…The majority of our hypothermic patients died due to asphyxia-related brain death within the first 3 days. A systematic review and meta-analysis including 464 patients reported a nearly double overall survival rate (37%) compared to our results [33]. This discrepancy could be due to the aetiology of hypothermia, as the mentioned review analysed a mixed population from 23 studies, whereas asphyxia-induced cardiac arrests (after avalanche burial and immersion) dominated in our work.…”

Section: Discussioncontrasting

confidence: 76%

ECMO Predictors of Mortality: A 10-Year Referral Centre Experience

Treml

Breitkopf

Bukumirić

et al. 2022

JCM

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Background: Extracorporeal membrane oxygenation (ECMO) is a specialised life support modality for patients with refractory cardiac or respiratory failure. Multiple studies strived to evaluate the benefits of ECMO support, but its efficacy remains controversial with still inconsistent and sparse information. Methods: This retrospective analysis included patients with ECMO support, admitted between January 2010 and December 2019 at a tertiary university ECMO referral centre in Austria. The primary endpoint of the study was overall all-cause three-month mortality with risk factors and predictors of mortality. Secondary endpoints covered the analysis of demographic and clinical characteristics of patients needing ECMO, including incidence and type of adverse events during support. Results: In total, 358 patients fulfilled inclusion criteria and received ECMO support due to cardiogenic shock (258, 72%), respiratory failure (88, 25%) or hypothermia (12, 3%). In total, 41% (145) of patients died within the first three months, with the median time to death of 9 (1–87) days. The multivariate analysis identified hypothermia (HR 3.8, p < 0.001), the Simplified Acute Physiology Score III (HR 1.0, p < 0.001), ECMO initiation on weekends (HR 1.6, p = 0.016) and haemorrhage during ECMO support (HR 1.7, p = 0.001) as factors with higher risk for mortality. Finally, the most frequent adverse event was haemorrhage (160, 45%) followed by thrombosis. Conclusions: ECMO is an invasive advanced support system with a high risk of complications. Nevertheless, well-selected patients can be successfully rescued from life-threatening conditions by prolonging the therapeutic window to either solve the underlying problem or install a long-term assist device. Hypothermia, disease severity, initiation on weekends and haemorrhage during ECMO support increase the risk for mortality. In the case of decision making in a setting of limited (ICU) resources, the reported risk factors for mortality may be contemplable, especially when judging a possible ECMO support termination.

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Section: Discussioncontrasting

confidence: 76%

ECMO Predictors of Mortality: A 10-Year Referral Centre Experience

Treml

Breitkopf

Bukumirić

et al. 2022

JCM

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“…Extracorporeal cardiopulmonary resuscitation (ECPR) [ 139 ] followed by ECLS rewarming may be associated with higher survival and more favourable neurological outcomes than conventional CPR alone in patients with accidental hypothermia without vital signs [ 121 , 126 ]. Rapid technological progress including the miniaturisation and improved efficacy, safety, and transportability of ECLS devices are expanding the possibilities of ECPR and ECLS rewarming [ 122 , 140 ].…”

Section: Treatmentmentioning

confidence: 99%

“…Avalanche victims have the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high serum potassium were associated with decreased chances of survival [ 121 , 146 ].…”

Section: Treatmentmentioning

confidence: 99%

Accidental Hypothermia: 2021 Update

Paal

Pasquier

Darocha

et al. 2022

IJERPH

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Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.

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“…In fact, ECMO rewarming has been suggested to be superior to other ECLS techniques (Silfvast and Pettila, 2003 ). By using the ECMO technique for rewarming, the survival and neurologic outcome of accidental hypothermia patients with HCA has improved significantly (Debaty et al, 2017 ; Bjertnaes et al, 2021 ).…”

Section: Discussionmentioning

confidence: 99%

Rewarming With Closed Thoracic Lavage Following 3-h CPR at 27°C Failed to Reestablish a Perfusing Rhythm

et al. 2021

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Introduction: Previously, we showed that the cardiopulmonary resuscitation (CPR) for hypothermic cardiac arrest (HCA) maintained cardiac output (CO) and mean arterial pressure (MAP) to the same reduced level during normothermia (38°C) vs. hypothermia (27°C). In addition, at 27°C, the CPR for 3-h provided global O2 delivery (DO2) to support aerobic metabolism. The present study investigated if rewarming with closed thoracic lavage induces a perfusing rhythm after 3-h continuous CPR at 27°C.Materials and Methods: Eight male pigs were anesthetized, and immersion-cooled. At 27°C, HCA was electrically induced, CPR was started and continued for a 3-h period. Thereafter, the animals were rewarmed by combining closed thoracic lavage and continued CPR. Organ blood flow was measured using microspheres.Results: After cooling with spontaneous circulation to 27°C, MAP and CO were initially reduced by 37 and 58% from baseline, respectively. By 15 min after the onset of CPR, MAP, and CO were further reduced by 58 and 77% from baseline, respectively, which remained unchanged throughout the rest of the 3-h period of CPR. During CPR at 27°C, DO2 and O2 extraction rate (VO2) fell to critically low levels, but the simultaneous small increase in lactate and a modest reduction in pH, indicated the presence of maintained aerobic metabolism. During rewarming with closed thoracic lavage, all animals displayed ventricular fibrillation, but only one animal could be electro-converted to restore a short-lived perfusing rhythm. Rewarming ended in circulatory collapse in all the animals at 38°C.Conclusion: The CPR for 3-h at 27°C managed to sustain lower levels of CO and MAP sufficient to support global DO2. Rewarming accidental hypothermia patients following prolonged CPR for HCA with closed thoracic lavage is not an alternative to rewarming by extra-corporeal life support as these patients are often in need of massive cardio-pulmonary support during as well as after rewarming.

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Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis

Cited by 12 publications

References 145 publications

ECMO Predictors of Mortality: A 10-Year Referral Centre Experience

ECMO Predictors of Mortality: A 10-Year Referral Centre Experience

Accidental Hypothermia: 2021 Update

Rewarming With Closed Thoracic Lavage Following 3-h CPR at 27°C Failed to Reestablish a Perfusing Rhythm

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