Outcomes of Venoarterial Extracorporeal Membrane Oxygenation for Cardiac Arrest in Adult Patients in the United States.

Background Factors associated with poor prognosis following receipt of extracorporeal membrane oxygenation (ECMO) in adults with cardiac arrest remain unclear. We aimed to identify predictors of mortality in adults with cardiac arrest receiving ECMO in a nationally representative sample. Methods and Results The US Healthcare Cost and Utilization Project's National Inpatient Sample was used to identify 782 adults hospitalized with cardiac arrest who received ECMO between 2006 and 2014. The primary outcome of interest was all-cause in-hospital mortality. Factors associated with mortality were analyzed using multivariable logistic regression. The overall in-hospital mortality rate was 60.4% (n=472). Patients who died were older and more often men, of non-White race, and with lower household income than those surviving to discharge. In the risk-adjusted analysis, independent predictors of mortality included older age, male sex, lower annual income, absence of ventricular arrhythmia, absence of percutaneous coronary intervention, and presence of therapeutic hypothermia. Conclusions Demographic and therapeutic factors are independently associated with mortality in patients with cardiac arrest receiving ECMO. Identification of which patients with cardiac arrest may receive the utmost benefit from ECMO may aid with decision-making regarding its implementation. Larger-scale studies are warranted to assess the appropriate candidates for ECMO in cardiac arrest.

Point-of-care Ultrasound-guided Central Venous Catheter Confirmation in Ultrasound Nonexperts.

OBJECTIVE: Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts. METHODS: We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts. RESULTS: Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients. CONCLUSION: Thirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.