Elsevier

Critical Care Clinics

Volume 28, Issue 2, April 2012, Pages 211-229
Critical Care Clinics

Emergency Cardiopulmonary Bypass: A Promising Rescue Strategy for Refractory Cardiac Arrest

https://doi.org/10.1016/j.ccc.2011.12.002Get rights and content

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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:

  • A growing literature to support its effectiveness.

  • In expert hands, can be rapidly initiated to maintain circulation.

  • 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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References (71)

  • W. Behringer et al.

    Fructose-1,6-bisphosphate and MK-801 by aortic arch flush for cerebral preservation during exsanguination cardiac arrest of 20 min in dogsAn exploratory study

    Resuscitation

    (2001)
  • M. Onoe et al.

    The effect of pulsatile perfusion on cerebral blood flow during profound hypothermia with total circulatory arrest

    J Thorac Cardiovasc Surg

    (1994)
  • L.M. Katz et al.

    Low-dose Carbicarb improves cerebral outcome after asphyxial cardiac arrest in rats

    Ann Emerg Med

    (2002)
  • J.H. Levy et al.

    Inflammatory response to cardiopulmonary bypass

    Ann Thorac Surg

    (2003)
  • C.S. Rinder et al.

    Cardiopulmonary bypass induces leukocyte-platelet adhesion

    Blood

    (1992)
  • B.S. Allen et al.

    Conditioned blood reperfusion markedly enhances neurologic recovery after prolonged cerebral ischemia

    J Thorac Cardiovasc Surg

    (2003)
  • B.S. Allen et al.

    Deep hypothermic circulatory arrest and global reperfusion injury: avoidance by making a pump prime reperfusate a new concept

    J Thorac Cardiovasc Surg

    (2003)
  • A. Yoshitake et al.

    Does veno-arterial bypass without an artificial lung improve the outcome in dogs undergoing cardiac arrest?

    Resuscitation

    (2002)
  • J. Engdahl et al.

    The epidemiology of out-of-hospital ‘sudden’ cardiac arrest

    Resuscitation

    (2002)
  • L. Wang et al.

    Inhalational anesthetics as preconditioning agents in ischemic brain

    Curr Opin Pharmacol

    (2008)
  • K. Ichinose et al.

    The effects of pre-arrest heparin administration dose for cardiac arrest model using extracorporeal lung and a heart assist (ECLHA) in dogs

    Resuscitation

    (2006)
  • K. Mattox et al.

    Resuscitation of the moribund patient using portable cardiopulmonary bypass

    Ann Thorac Surg

    (1976)
  • R. Hartz et al.

    Clinical experience with portable cardiopulmonary bypass in cardiac arrest patients

    Ann Thorac Surg

    (1990)
  • G.B. Martin et al.

    Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest

    Chest

    (1998)
  • C. Athanasuleas et al.

    Sudden cardiac death: directing the scope of resuscitation towards the heart and brain

    Resuscitation

    (2006)
  • K. Sung et al.

    Improved survival after cardiac arrest using emergent autopriming percutaneous cardiopulmonary support

    Ann Thorac Surg

    (2006)
  • Y. Chen et al.

    Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

    Lancet

    (2008)
  • G. Nichol et al.

    Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states

    Resuscitation

    (2006)
  • A.H. Travers et al.

    CPR Overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

    Circulation

    (2010)
  • M.L. Weisfeldt et al.

    Resuscitation after cardiac arrest: a 3-phase time-sensitive model [comment]

    JAMA

    (2002)
  • R. Cummins et al.

    Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation

    Am J Emerg Med

    (1985)
  • R. Pionkowski et al.

    Resuscitation time in ventricular fibrillation a prognostic indicator

    Ann Emerg Med

    (1984)
  • J. Gibbon

    Artificial maintenance of circulation during experimental occlusion of the pulmonary artery

    Arch Surg

    (1937)
  • D. Follette et al.

    Reduction of postischemic myocardial damage by maintaining arrest during initial reperfusion

    Surg Forum

    (1977)
  • D. Follette et al.

    Reducing reperfusion injury with hypocalcemic, hyperkalemic, alkalotic blood during reoxygenation

    Surg Forum

    (1978)
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