Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (CPR) restores perfusion and oxygenation in a patient who does not have spontaneous circulation. The evidence with regard to the effect of extracorporeal CPR on survival with a favorable neurologic outcome in refractory out-of-hospital cardiac arrest is inconclusive. METHODS: In this multicenter, randomized, controlled trial conducted in the Netherlands, we assigned patients with an out-of-hospital cardiac arrest to receive extracorporeal CPR or conventional CPR (standard advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, had an initial ventricular arrhythmia, and did not have a return of spontaneous circulation within 15 minutes after CPR had been initiated. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 (range, 1 to 5, with higher scores indicating more severe disability) at 30 days. Analyses were performed on an intention-to-treat basis. RESULTS: Of the 160 patients who underwent randomization, 70 were assigned to receive extracorporeal CPR and 64 to receive conventional CPR; 26 patients who did not meet the inclusion criteria at hospital admission were excluded. At 30 days, 14 patients (20%) in the extracorporeal-CPR group were alive with a favorable neurologic outcome, as compared with 10 patients (16%) in the conventional-CPR group (odds ratio, 1.4; 95% confidence interval, 0.5 to 3.5; P = 0.52). The number of serious adverse events per patient was similar in the two groups. CONCLUSIONS: In patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR and conventional CPR had similar effects on survival with a favorable neurologic outcome. (Funded by the Netherlands Organization for Health Research and Development and Maquet Cardiopulmonary [Getinge]; INCEPTION ClinicalTrials.gov number, NCT03101787.).

Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: Design and rationale of the INCEPTION trial.

Return of spontaneous circulation occurs in less than 10% of patients with cardiac arrest undergoing cardiopulmonary resuscitation (CPR) for more than 15 minutes. Studies suggest that extracorporeal life support during cardiopulmonary resuscitation (ECPR) improves survival rate in these patients. These studies, however, are hampered by their non-randomized, observational design and are mostly single-center. A multicenter, randomized controlled trial is urgently warranted to evaluate the effectiveness of ECPR. HYPOTHESIS: We hypothesize that early initiation of ECPR in refractory out-of-hospital cardiac arrest (OHCA) improves the survival rate with favorable neurological status. STUDY DESIGN: The INCEPTION trial is an investigator-initiated, prospective, multicenter trial that will randomly allocate 110 patients to either continued CPR or ECPR in a 1:1 ratio. Patients eligible for inclusion are adults (≤ 70 years) with witnessed OHCA presenting with an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT), who received bystander basic life support and who fail to achieve sustained return of spontaneous circulation within 15 minutes of cardiopulmonary resuscitation by emergency medical services. The primary endpoint of the study is 30-day survival rate with favorable neurological status, defined as 1 or 2 on the Cerebral Performance Category score. The secondary endpoints include 3, 6 and 12-month survival rate with favorable neurological status and the cost-effectiveness of ECPR compared to CCPR. SUMMARY: The INCEPTION trial aims to determine the clinical benefit for the use of ECPR in patients with refractory OHCA presenting with VF/VT. Additionally, the feasibility and cost-effectiveness of ECPR will be evaluated.

Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: A two center observational study.

BACKGROUND: Cardiac arrest (CA) due to pulmonary embolism (PE) is associated with low survival rates and poor neurological outcomes. We examined whether Extracorporeal Cardiopulmonary Resuscitation (ECPR) improves the outcomes of patients who suffer from CA due to massive PE. METHODS: We retrospectively included 39 CA patients with proven or strongly suspected PE in two hospitals in the Netherlands, in a 'before/after'-design. 20 of these patients were treated with Conventional Cardiopulmonary Resuscitation (CCPR) and 19 patients with ECPR. RESULTS: The main outcomes of this study were ICU survival and favourable neurological outcome, defined as Cerebral Performance Category (CPC) score 1-2. The ICU survival rate in CCPR patients was 5% compared to 26% in ECPR patients (p<0.01). Survival with favourable neurological outcome was present in 0/20 (0%) CCPR patients compared to 4/19 (21%) of the ECPR patients (p<0.05). CONCLUSION: ECPR seems a promising treatment for cardiac arrest patients due to (suspected) massive pulmonary embolism compared to conventional CPR, though outcomes remain poor.

Low Transmission of Airway Pressures to the Abdomen in Mechanically Ventilated Patients With or Without Acute Respiratory Failure and Intra-Abdominal Hypertension.

PURPOSE: Intra-abdominal pressure, measured at end expiration, may depend on ventilator settings and transmission of intrathoracic pressure. We determined the transmission of positive intrathoracic pressure during mechanical ventilation at inspiration and expiration into the abdominal compartment. METHODS AND RESULTS: We included 9 patients after uncomplicated cardiac surgery and 9 with acute respiratory failure. Intravesical pressures were measured thrice (reproducibility of 1.8%) and averaged, at the end of each inspiratory and expiratory hold maneuvers of 5 seconds. Transmission, the change in intra-abdominal over intrathoracic pressures from end inspiration to end expiration, was about 8%. End-expiratory intra-abdominal pressure was lower than "total" intra-abdominal pressure over the entire respiratory cycle by 0.34 cm H2O. It was 0.73 cm H2O higher than "true" intra-abdominal pressure over the entire respiratory cycle, taking transmission into account. The percentage error was 3% for total and 10% for true pressure. Results did not differ among patients with or without acute respiratory failure and decreased respiratory compliance or between those with (≥12 mm Hg, n = 5) or without intra-abdominal hypertension. CONCLUSIONS: Transmitted airway pressure only slightly affects intra-abdominal pressure in mechanically ventilated patients, irrespective of respiratory compliance and baseline intra-abdominal pressure values. End-expiratory measurements referenced against atmospheric pressure may suffice for clinical practice.