Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Importance: Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and treatment (invasive strategy) is beneficial in this setting remains uncertain. Objective: To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival. Design, Setting, and Participants: Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021). Interventions: In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132). Main Outcomes and Measures: The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category [CPC] 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours). Results: The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 [17%] women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio [OR], 1.63 [95% CI, 0.93 to 2.85]; difference, 9.5% [95% CI, -1.3% to 20.1%]; P = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 [95% CI, 1.11 to 3.57]; difference, 12.4% [95% CI, 1.9% to 22.7%]; P = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 [95% CI, 0.91 to 2.47]; difference, 9.4% [95% CI, -2.5% to 21%]; P = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively). Conclusions and Relevance: Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference. Trial Registration: ClinicalTrials.gov Identifier: NCT01511666.

Management of accidental hypothermia: an established extracorporeal membrane oxygenation centre experience.

INTRODUCTION: Data on management of severe accidental hypothermia published from an established high-volume extracorporeal membrane oxygenation centre are scarce. METHODS: A total of 28 patients with intravesical temperature lower than 28°C on admission were either treated with veno-arterial extracorporeal membrane oxygenation or rewarmed conservatively. RESULTS: A total of 10 patients rewarmed on veno-arterial extracorporeal membrane oxygenation (age: 37 ± 12.6 years) and 18 conservatively (age: 55.2 ± 11.2 years) were collected over a course of 5 years. The dominant cause was alcohol intoxication with exposure to cold (39%), 12 patients were resuscitated prior to admission. The admission temperature in the extracorporeal membrane oxygenation group (23.8 ± 2.6°C) was lower than in the non-extracorporeal membrane oxygenation group (26.0 ± 1.5°C, p = 0.01). The peripheral percutaneous veno-arterial extracorporeal membrane oxygenation was always cannulated in malignant arrhythmias causing refractory cardiac arrest. The typical extracorporeal membrane oxygenation blood flow was 3-4 L/minute and sweep gas flow 2 L/minute, the median extracorporeal membrane oxygenation duration was 48.3 (28.1-86.7) hours. The median rates of rewarming did not differ (0.41 (0.35-0.7)°C/hour in extracorporeal membrane oxygenation and 0.77 (0.54-0.98)°C/hour in non-extracorporeal membrane oxygenation, p = 0.46) as well as the admission arterial lactate, pH and potassium. Their development was not different between the groups except for higher pH between the third and ninth hour of rewarming in the extracorporeal membrane oxygenation group. The hospital mortality was 10% in the extracorporeal membrane oxygenation group and 11.1% in the non-extracorporeal membrane oxygenation group with the median last Glasgow Coma Scale 15 and Cerebral Performance Score 1. CONCLUSION: Veno-arterial extracorporeal membrane oxygenation for severe hypothermia shows promising outcome data collected in an extracorporeal membrane oxygenation/extracorporeal cardiopulmonary resuscitation centre located in a European urban area. Except for presence of refractory cardiac arrest, the established hypothermia-related prognostic indicators did not differ between patients in need for extracorporeal membrane oxygenation and those rewarmed without extracorporeal membrane oxygenation.

Management of severe pulmonary hemorrhage in a neonate on veno-arterial ECMO by the temporary clamping of the endotracheal tube - a case report.

Severe pulmonary hemorrhage in the newborn is an infrequent, but life-threatening, event. A newborn with persistent pulmonary hypertension and a large persistent ductus arteriosus and open foramen ovale presented with hypoxemia and progressive right heart failure shortly after birth, requiring veno-arterial extracorporeal membrane oxygenation (ECMO) support. Twenty minutes after the initiation of ECMO, the patient developed severe pulmonary hemorrhage refractory to conventional treatment. As a last resort, the endotracheal tube was clamped. After transport to the ECMO center, repeated attempts to open the endotracheal tube resulted in continued blood loss and the endotracheal tube was clamped for a total of 63 hours without any mechanical ventilation. On the third postnatal day, the endotracheal tube was reopened, large amounts of clot were removed by bronchoscopy and mechanical ventilation was resumed followed by improved general condition and favorable outcome.

A rationale for early extracorporeal membrane oxygenation in patients with postinfarction ventricular septal rupture complicated by cardiogenic shock.

AIMS: Ventricular septal rupture (VSR) became a rare mechanical complication of myocardial infarction in the era of percutaneous coronary interventions but is associated with extreme mortality in patients who present with cardiogenic shock (CS). Promising outcomes have been reported with the use of circulatory support allowing haemodynamic stabilization, followed by delayed repair. Therefore, we analysed our experience with an early use of Veno-Arterial Extracorporeal Membrane Oxygenation (V-A ECMO) for postinfarction VSR. METHODS AND RESULTS: We conducted a retrospective search of institutional database for patients presenting with postinfarction VSR from January 2007 to June 2016. Data from 31 consecutive patients (mean age 69.5 ± 9.1 years) who were admitted to hospital were analysed. Seven out of 31 patients with VSR who were in refractory CS received V-A ECMO support preoperatively. ECMO improved end-organ perfusion with decreased lactate levels 24 hours after implantation (7.9 mmol/L vs. 1.6 mmol/L, p = 0.01), normalized arterial pH (7.25 vs. 7.40, p < 0.04), improved mean arterial pressure (64 mmHg vs. 83 mmHg, p < 0.01) and lowered heart rate (115/min vs. 68/min, p < 0.01). Mean duration of ECMO support was 12 days, 5 out of 7 patients underwent surgical repair, 4 were weaned from ECMO, 3 survived 30 days and 2 survived more than 1 year. The most frequent complication (5 patients) and the cause of death (3 patients) was bleeding. CONCLUSIONS: Our experience suggests that early V-A ECMO in patients with VSR and refractory CS might prevent irreversible multiorgan failure by improved end-organ perfusion. Bleeding complications remain an important limitation of this approach.

Refractory cardiogenic shock due to extensive anterior STEMI with covered left ventricular free wall rupture treated with awake VA-ECMO and LVAD as a double bridge to heart transplantation - collaboration of three cardiac centres.

AIM: To highlight an optimal collaborative strategy of three different levels of specialized care cardiac centres. BACKGROUND: Refractory cardiogenic shock is a life-threatening condition. A myocardial recovery is not achieved in many cases despite all efforts and subsequently the heart transplantation remains an ultimate option. Thereby, the use of extracorporeal membrane oxygenation (ECMO) followed by a ventricular assist device in staged bridging provides an attractive approach. CASE REPORT: We report on an optimal cooperation of PCI (percutaneous coronary intervention) centre with ELSO (extracorporeal life support organization) centre and transplant centre in a patient suffering from refractory cardiogenic shock due to acute myocardial infarction (RCSMI) complicated by left ventricle free wall rupture with pericardial tamponade. CONCLUSION: The interhospital collaboration can be essential in the context of patients with RCSMI. The use of ECMO enables safe interhospital transport and gains time for further diagnostic and therapeutic steps in such critically ill patients.

The effect of adjusting tracheal tube cuff pressure during deep hypothermic circulatory arrest: a randomised trial.

BACKGROUND: Regular endotracheal tube cuff monitoring may prevent silent aspiration. OBJECTIVES: We hypothesised that active management of the cuff of the tracheal tube during deep hypothermic cardiac arrest would reduce silent subglottic aspiration. We also determined to study its effect on postoperative mechanical ventilation and the incidence of postoperative positive tracheal cultures. DESIGN: A randomised clinical trial. SETTING: The study was conducted in a University Teaching Hospital from September 2008 to November 2009. PATIENTS: Twenty-four patients undergoing elective pulmonary endarterectomy were included in the study. INTERVENTION: After induction of general anaesthesia and tracheal intubation, the cuff of the tracheal tube was inflated to 25 cmH2O. Following this, 1 ml of methylene blue dye diluted in 2 ml of physiological saline was injected into the hypopharynx. Patients were randomly assigned to active cuff management during cooling and warming (where cuff pressure was monitored and the cuff was reinflated if it dropped below 20 cmH2O, or deflated if pressure exceeded 30 cmH2O) or passive monitoring (where cuff pressure was monitored but volume was not altered). Before weaning from cardiopulmonary bypass, fibreoptic bronchoscopy was performed. Silent aspiration was then diagnosed if blue dye was seen in the trachea below the cuff of the tube. MAIN OUTCOME MEASURES: The primary aim of this study was to determine the incidence of silent aspiration. Secondary outcomes included duration of postoperative mechanical ventilation of the lungs and incidence of positive culture of tracheal aspirate. RESULTS: Active cuff management patients were younger than controls (51.2 ±â€Š11.6 vs. 63.2 ±â€Š9 years, P = 0.028), but otherwise the two groups were similar. The primary endpoint was reached because we showed that silent aspiration was significantly less frequent in the study group (0/12 vs. 8/12 patients, P = 0.001). Significantly lower intracuff pressures were measured in the control group patients at several timepoints during cooling, just before hypothermic arrest and at all timepoints during rewarming. CONCLUSION: We recommend that the cuff of the tracheal tube should be checked regularly during surgery under deep hypothermia, and the cuff pressure adjusted as required.

Coronary versus carotid blood flow and coronary perfusion pressure in a pig model of prolonged cardiac arrest treated by different modes of venoarterial ECMO and intraaortic balloon counterpulsation.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is increasingly used in cardiac arrest (CA). Adequacy of carotid and coronary blood flows (CaBF, CoBF) and coronary perfusion pressure (CoPP) in ECMO treated CA is not well established. This study compares femoro-femoral (FF) to femoro-subclavian (FS) ECMO and intraaortic balloon counterpulsation (IABP) contribution based on CaBF, CoBF, CoPP, myocardial and brain oxygenation in experimental CA managed by ECMO. METHODS: In 11 female pigs (50.3 ± 3.4 kg), CA was randomly treated by FF versus FS ECMO ± IABP. Animals under general anesthesia had undergone 15 minutes of ventricular fibrillation (VF) with ECMO flow of 5 to 10 mL/kg/min simulating low-flow CA followed by continued VF with ECMO flow of 100 mL/kg/min. CaBF and CoBF were measured by a Doppler flow wire, cerebral and peripheral oxygenation by near infrared spectroscopy. CoPP, myocardial oxygen metabolism and resuscitability were determined. RESULTS: CaBF reached values > 80% of baseline in all regimens. CoBF > 80% was reached only by the FF ECMO, 90.0% (66.1, 98.6). Addition of IABP to FF ECMO decreased CoBF to 60.7% (55.1, 86.2) of baseline, P = 0.004. FS ECMO produced 70.0% (49.1, 113.2) of baseline CoBF, significantly lower than FF, P = 0.039. Addition of IABP to FS did not change the CoBF; however, it provided significantly higher flow, 76.7% (71.9, 111.2) of baseline, compared to FF + IABP, P = 0.026. Both brain and peripheral regional oxygen saturations decreased after induction of CA to 23% (15.0, 32.3) and 34% (23.5, 34.0), respectively, and normalized after ECMO institution. For brain saturations, all regimens reached values exceeding 80% of baseline, none of the comparisons between respective treatment approaches differed significantly. After a decline to 15 mmHg (9.5, 20.8) during CA, CoPP gradually rose with time to 68 mmHg (43.3, 84.0), P = 0 .003, with best recovery on FF ECMO. Resuscitability of the animals was high, both 5 and 60 minutes return of spontaneous circulation occured in eight animals (73%). CONCLUSIONS: In a pig model of CA, both FF and FS ECMO assure adequate brain perfusion and oxygenation. FF ECMO offers better CoBF than FS ECMO. Addition of IABP to FF ECMO worsens CoBF. FF ECMO, more than FS ECMO, increases CoPP over time.

Predictors of infection after pulmonary endarterectomy for chronic thrombo-embolic pulmonary hypertension.

OBJECTIVE: Pulmonary endarterectomy (PEA) is an effective and potentially curative treatment for chronic thrombo-embolic pulmonary hypertension (CTEPH). The postoperative course after PEA is accompanied by a number of complications, which contribute to the high rate of early postoperative mortality. Markers allowing the early detection of infectious complication during the postoperative period may be of major clinical importance. The aim of the prospective study was to analyse a predictive value of five inflammatory markers to recognise inflammatory complications accompanying PEA before the first clinical signs of infection. METHODS: Eighty-two patients with CTEPH, who underwent PEA using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), were included into the study. Procalcitonin (PCT), tumour necrosis factor-α, interleukin (IL)-6, IL-8 and C-reactive protein arterial concentrations were measured before sternotomy and repeatedly up to 72h after the end of surgery. Haemodynamic parameters, infectious and non-infectious complications were recorded. RESULTS: Postoperative course was uncomplicated in 59/82 patients (group 1). Fourteen out of 82 patients (group 2) developed an infection in the first 3 days after surgery (bronchopneumonia, n = 9; bacterial sepsis, n = 5). Nine out of 82 patients (group 3) developed non-infectious complications in the same period. PCT and IL-6 were the only significant independent predictors of infection in days 1-3 after PEA. The area under receiver operating characteristic (ROC) curve calculated for PCT to predict postoperative infection was 0.83 (95% confidence interval (CI): 0.74-0.92) compared with 0.74 (95% CI: 0.68-0.81) for IL-6. With the cut-off 2.3 ng ml(-1), the test characteristics of PCT were as follows: sensitivity, 86%; specificity, 83%; negative predictive value, 92%; and positive predictive value, 84%. CONCLUSIONS: The increase in PCT and IL-6 may allow patients at increased risk of infection after PEA to be identified, allowing earlier institution of antibiotic treatment. These changes that occur before infection can be detected clinically. This finding may make the daily monitoring of PCT post-PEA useful.

Veno-arterial ECMO in severe acute right ventricular failure with pulmonary obstructive hemodynamic pattern.

Extracorporeal membrane oxygenation (ECMO) is an effective rescue method for severe respiratory and cardiac failure. Right ventricular (RV) failure with cardiogenic shock is a critical condition with generally poor prognosis unless aggressive therapeutical measures are undertaken. Authors report on their initial experience with ECMO support in severe RV failure with cardiogenic shock caused by an obstructive hemodynamic pattern. Four patients with cardiogenic shock due to severe RV failure related to pulmonary arterial hypertension (2 patients), congenital heart disease with Eisenmenger physiology (1 subject) and massive pulmonary embolism (1 patient) were supported with emergency veno-arterial ECMO. ECMO circuit was instituted using peripheral cannulation in all subjects. Immediate hemodynamic and ventilatory improvement was observed in all patients. The mean support duration was 11 days (range 5-16 days), 2 (50%) patients were successfully weaned off ECMO and survived to hospital discharge. The other 2 patients were considered by mutual consensus to have irreversible organ damage, the ECMO support was withdrawn and the patients died. Bleeding complications were the main complications observed. As per initial experience, veno-arterial ECMO allows bypassing of the pulmonary bed, therefore, relieves the RV pressure overload and does not cause further elevation of the pulmonary pressures in contrary to RV assist devices. This aggressive management approach requires further clinical evaluation in order to establish its definite role in critical RV failure.