Emergency Cardiopulmonary Bypass: A Promising Rescue Strategy for Refractory Cardiac Arrest
Section snippets
Background of Cardiac Arrest and Post Cardiac Arrest Syndrome
There is no universal reporting system for cardiopulmonary arrests in the United States. However, it has been estimated that approximately 350,000 arrests occur each year, with 50% happening out-of-hospital and the other half to patients in a hospital setting.1 Less than 40% of these patients have return of spontaneous circulation (ROSC), and mortality for those with ROSC exceeds 60%.2 The 2010 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) emphasize
Definition of Terms/Concepts/Types of Extracorporeal Circulation
A number of different options for extracorporeal circulation exist including extracorporeal membrane oxygenation (ECMO), ECPB, continuous venovenous hemofiltration (CVVH), hemodialysis, and plasmapheresis. These modalities vary depending on their primary function: circulation, gas exchange, or filtration of electrolytes and other metabolically active substances. For this review the authors focus almost exclusively on ECPB, which can provide adequate circulation and gas exchange to replace
Brief History of Emergency Cardiopulmonary Bypass
ECPB grew out of the initial use of cardiopulmonary bypass for surgical repair of cardiac defects. After conceptual and developmental advances in the early part of the 20th century, the first clinical applications of extracorporeal circulation were undertaken in the 1950s.7 As early as 1937, Gibbon8 proposed the idea of using cardiopulmonary bypass (CPB) to treat massive pulmonary embolism. The first known CPB-assisted operation was performed by Dr Clarence Dennis at the University of Wisconsin
Rationale for ECPB in CPR
The rationale for studying ECPB in CPR settings includes the following:
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A growing literature to support its effectiveness.
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In expert hands, can be rapidly initiated to maintain circulation.
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Bridge until effective native cardiac output is restored.
Experimental Evidence Supporting Implementation of Emergency Cardiopulmonary Bypass
Animal models in species such as rats, dogs, and swine have been fundamental to the development of CPB and ECMO.12 In contrast to a vast literature on CPB, only a small number of studies have been published on the use of extracorporeal circulation technology as a resuscitative measure after cardiac arrest.
Initial Clinical Trials
ECPB is a new concept, with the bulk of human literature reported only during the last 12 years. There are some earlier studies investigating ECPB that are available only in Japanese-language literature. Preliminary English-language studies on treating a heterogeneous patient populations including cardiac arrest, refractory shock, and complicated myocardial infarction began to appear as early as 1976; however, the majority of reports on the human use of ECPB begin in 1999.60, 61, 62 The first
Summary
ECPB is a relatively new, advanced resuscitation method that is growing in technical sophistication, shows promising experimental data, and is expanding in clinical practice. Experimental data and clinical studies suggest its ability to be highly effective at producing ROSC for refractory cardiac arrest. Currently however, the majority of patients who achieve ROSC with ECPB do not survive long-term with good neurologic function. Despite this limitation, survival rates may be far better than
The Future
The future of ECPB will depend on new data gathered in the next decade. There are significant opportunities and methodologies that may be further optimized to improve survival using ECPB. The collective data on ECPB suggest that it may be the best hope available for survival in patients with refractory cardiac arrest.
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Cited by (16)
Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury
2018, ChestCitation Excerpt :Culture data can subsequently be used to narrow or stop antimicrobial agents. There is growing interest in the use of extracorporeal life support (ECLS) for hemodynamic support in post-cardiac arrest patients.92-95 Added advantages of ECLS may include the ability to closely titrate arterial oxygen and CO2 tensions by modulating the blood and sweep gas flow rates, respectively, through the ECLS pump.
The association between hemoglobin concentration and neurologic outcome after cardiac arrest
2016, Journal of Critical CareExtracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes
2016, ResuscitationCitation Excerpt :Although this review focuses on refractory OHCA of cardiac origin, the results are comparable to previous adult ECPR reports that include various mixes of in/out of hospital cardiac arrest and cardiogenic shock.32 Previously reported survival rates to hospital discharge range from 29 to 47%, including the large Extracorporeal Life Support Organization (ELSO) registry report of 4200 ECPR patients.6,33,34 Given that this review is based largely on existing case reports, case series or small observational studies, heterogeneity was evidenced in both populations and interventions.
Developing dual hemofiltration plus cardiopulmonary bypass in rodents
2015, Journal of Surgical ResearchCitation Excerpt :ECPB, a system that pumps the oxygenated blood through a whole body, is thought to rescue a CA patient [1–3]. This system allows an extended window of time to determine the cause of CA and takes the necessary steps to restore adequate organ functions of patients [4]. CVVHF is a therapy for blood purification using a pump to pass the blood over a filter.
Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest
2014, ResuscitationCitation Excerpt :Extracorporeal life support (ECLS) has been used in cardiac surgery since the 1950s and has subsequently been applied to patients outside of the operating room with cardiopulmonary failure. A number of ECLS case series have demonstrated successful treatment of refractory respiratory failure, poisoning, cardiac arrest, and cardiogenic shock 1–7. Japanese case reports of application of ECLS to patients with refractory cardiac arrest have appeared in journals since the mid-1980s.
A bridge to life: ECPR who, when, where and why?
2014, Resuscitation
The authors have nothing to disclose.