Extracorporeal life support treatment bundle for refractory cardiac arrest

We read with great interest the paper by Johnson et al.1Johnson N.J. Acker M. Hsu C.H. et al.Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.Resuscitation. 2014; (pii:S0300-9572(14)00730-8)https://doi.org/10.1016/j.resuscitation.2014.08.028Abstract Full Text Full Text PDF Scopus (93) Google Scholar describing their 7-year institution's experience with Extracorporeal Life Support (ECLS) for out-of-hospital (OHCA) and emergency department refractory cardiac arrest. In their series of 26 patients, four patients survived to discharge (15%) among whom three patients were neurologically intact at 6 months (11.5%, 3/26). Those promising, these results differ from the more encouraging ones reported in similar papers by Wang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and Fagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar in whom the Authors reported the experience of their own centers for patients who received ECLS for OHCA or in-hospital cardiac arrest (IHCA), respectively. In their series of 230 patients, Wang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar reported survival to discharge of about 33% and a favorable outcome of about 25%. Similarly, Fagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar in a study population of 24 patients, reported a survival rate with good neurolocal outcome at day 28 in the 25% (6/24). The following factors may account for the discrepancies in outcome between the investigation by Johnson et al.1Johnson N.J. Acker M. Hsu C.H. et al.Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.Resuscitation. 2014; (pii:S0300-9572(14)00730-8)https://doi.org/10.1016/j.resuscitation.2014.08.028Abstract Full Text Full Text PDF Scopus (93) Google Scholar and those by Wang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and Fagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar (Table 1): (a) stricter selection criteria adopted by Wang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and Fagnoul et al.,3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar especially in respect to age, initial rhythm and no-flow/low flow times; (b) ECLS team expertise which can be inferred by shorter times from cardiac arrest and ECLS initiation; (c) ECLS treatment bundle including the treatment of reversible cause (most frequently by cardiac reperfusion) and neurological protection by means of therapeutic hypothermia. While Johnson et al.1Johnson N.J. Acker M. Hsu C.H. et al.Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.Resuscitation. 2014; (pii:S0300-9572(14)00730-8)https://doi.org/10.1016/j.resuscitation.2014.08.028Abstract Full Text Full Text PDF Scopus (93) Google Scholar did not mention the treatments/therapeutic approaches implemented in their patients during ECLS support, all patients enrolled by Fagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar underwent hypothermia during ECLS support (intra-arrest cooling was performed in 17 patients) and normoxemia (PaO2 was maintained between 60 and 150 mmHg) in order to avoid an increased production of reactive oxygen species. In the series by Wang et al.,3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar cardiac reperfusion was performed in almost half of the population.Table 1Selection criteria, times and ECLS treatment bundle.Selection criteriaAgeInitial rhythmTimesWitnessed cardiac arrestJohnson et al.1Johnson N.J. Acker M. Hsu C.H. et al.Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.Resuscitation. 2014; (pii:S0300-9572(14)00730-8)https://doi.org/10.1016/j.resuscitation.2014.08.028Abstract Full Text Full Text PDF Scopus (93) Google Scholar18–70 yearsVentricular fibrillation or ventricular tachy-cardia as initial rhythm or obvious cardiac or other reversible etiology with non-shockable rhythmCollapse to EMS arrive < 15 minWitnessed cardiac arrestWang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar16–80 years–CPR for longer than 10 min without ROSCWitnessed cardiac arrestFagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar<65 years–Absence of ROSC after 10 min of Advance Life SupportWitnessed cardiac arrestECLS team expertiseTime from cardiac arrest to ECLS initiationJohnson et al.1Johnson N.J. Acker M. Hsu C.H. et al.Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.Resuscitation. 2014; (pii:S0300-9572(14)00730-8)https://doi.org/10.1016/j.resuscitation.2014.08.028Abstract Full Text Full Text PDF Scopus (93) Google Scholar77 ± 51 minWang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google ScholarOHCA: 67 ± 30 minIHCA: 44 ± 25 minFagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar58 min [45–70] minECLS treatment bundleIABPHypothermiaCardiac reperfusionNormoxemiaJohnson et al.1Johnson N.J. Acker M. Hsu C.H. et al.Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.Resuscitation. 2014; (pii:S0300-9572(14)00730-8)https://doi.org/10.1016/j.resuscitation.2014.08.028Abstract Full Text Full Text PDF Scopus (93) Google Scholar1 patientsNot mentionedNot mentionedNot mentionedWang et al.2Wang C.H. Chou N.K. Becker L.B. et al.Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.Resuscitation. 2014; 85: 1219-1224https://doi.org/10.1016/j.resuscitation.2014.06.022Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar61 patients46 patients (46/230, 20%)114/230, 49.5% not mentionedNot mentionedFagnoul et al.3Fagnoul D. Taccone F.S. Belhaj A. et al.Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.Resuscitation. 2013; 84: 1519-1524https://doi.org/10.1016/j.resuscitation.2013.06.016Abstract Full Text Full Text PDF PubMed Scopus (74) Google ScholarAll Intra arrest cooling in 7 ptsTemperature on ECMO: 32 °C7 patients submitted to PCIAll patientsEMS: emergency medical system; CPR: cardiopulmonary resuscitation; ROSC: return of spontaneous circulation; OHCA: out of hospital cardiac arrest; IHCA: in-hospital cardiac arrest; IABP: intra-aortic balloon pump; PCI: percutaneous coronary intervention. Open table in a new tab EMS: emergency medical system; CPR: cardiopulmonary resuscitation; ROSC: return of spontaneous circulation; OHCA: out of hospital cardiac arrest; IHCA: in-hospital cardiac arrest; IABP: intra-aortic balloon pump; PCI: percutaneous coronary intervention. The clinical relevance of the ECLS treatment bundle seems to be confirmed also by the results of the Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial) trial4Stub D. Bernard S. Pellegrino V. et al.Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).Resuscitation. 2014; (pii:S0300-9572(14)00751-5)https://doi.org/10.1016/j.resuscitation.2014.09.010Abstract Full Text Full Text PDF Scopus (380) Google Scholar in whom survival to hospital discharge with full neurological recovery occurred in 14/26 (54%) patients and in particular, in the 60% of IHCA patients and in the 45% of OHCA patients. The available evidence coming from the recent investigations strongly suggests that ECLS support, especially when included in a well defined treatment bundle, is associated with favorable outcome in selected patients with refractory cardiac arrest. Therefore there is the clinical need for shared protocols in order to reduce differences related to the center experience and mostly to increase availability of ECLS as part of a multi-faceted approach for these patients. None declared.