Abstract 19: Progressive Metabolic Derangement During Prolonged Resuscitation for Refractory VT/VF Cardiac Arrest and the Relationship to Neurologically Intact Survival With Extracorporeal Cardiopulmonary Resuscitation

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Jason A Bartos ◽  
Claire Carlson ◽  
Ganesh Raveendran ◽  
Ranjit John ◽  
Tom P Aufderheide ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Metabolic Derangement ◽  
Catheterization Laboratory ◽  
Cardiac Catheterization Laboratory ◽  
Substantial Decline ◽  
Lactic Acidemia ◽  
First Time ◽  
Neurologically Intact ◽  
Over Time

Background: Multiple studies have shown declining likelihood of neurologically intact survival with prolonged resuscitation with standard CPR. With standard CPR, survival after VT/VF arrest declines from 35-45% at initiation of CPR to 10-20% survival at 30 min. Objective: The aim of this study was to examine the effects of resuscitation duration on neurologically intact survival in the Minnesota Resuscitation Consortium ECPR protocol. Further, the progressive metabolic derangement of prolonged resuscitation was observed for the first time in this population. Methods: Between December 1, 2015 and May 1, 2018, 115 consecutive adult patients with refractory out-of-hospital VT/VF cardiac arrest requiring ongoing CPR were transported to the cardiac catheterization laboratory where ECLS was initiated and coronary angiography and PCI were performed as needed. Patients achieving an organized cardiac rhythm were admitted for further treatment. Results: Overall, 41% of patients receiving full resuscitative efforts were discharged neurologically intact. Neurologically intact survival declined with increasing duration of CPR with 100% survival in patients placed on ECLS within 30 min. Survival declined to 50% within 50 min and 20% within 70 min. Lactic acid and paCO2 increased over time peaking at 15 mmol/L and 72 mmHg, respectively. pH declined accordingly reaching 6.92 at its nadir. paO2 was stable over time but variable between patients. Conclusions: Likelihood of neurologically intact survival declined with increasing duration of CPR for patients going on to receive ECLS. The metabolic profile worsened during prolonged CPR with increasing lactic acidemia and hypercapnia but survival could be achieved with the hemodynamic support provided by ECLS. Together these findings support the need for rapid transport of patients to teams prepared to place ECLS. Substantial decline in survival begins at 30 min of CPR.

Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)?

2021 ◽  
pp. 088506662110189
Author(s):  
Merry Huang ◽  
Aaron Shoskes ◽  
Migdady Ibrahim ◽  
Moein Amin ◽  
Leen Hasan ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Neurological Outcome ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Survival Outcomes ◽  
Pool Data ◽  
Good Neurological Outcome ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Over Time

Purpose: Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest. Methods: We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data. Results: We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR ( P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) ( P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time. Conclusions: Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.

Abstract 165: Impact of Prehospital Epinephrine for Patients Treated With Extracorporeal Cardiopulmonary Resuscitation After Refractory Out-Of-Hospital Shockable Cardiac Arrest

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Ken Nagao ◽  
Yoshio Tahara ◽  
Hiroshi Nonogi ◽  
Naohiro Yonemoto ◽  
David Gaieski ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Neurological Outcome ◽  
Standard Dose ◽  
Rescue Therapy ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Hospital Arrival ◽  
Curve Estimation ◽  
Favorable Neurological Outcome ◽  
Neurologically Intact

Background: The 2015 CoSTR recommended that standard-dose epinephrine (SDE) was reasonable for patients with out-of-hospital cardiac arrest (OHCA) and extracorporeal cardiopulmonary resuscitation (ECPR) was reasonable rescue therapy for selected patients with ongoing cardiac arrest when initial conventional CPR was unsuccessful. We investigated the effect of prehospital SDE for patients who met the criteria of ECPR. Methods: From the All-Japan OHCA Utstein Registry between 2007 and 2015, we included 22,552 patients who met the criteria of ECPR of the SAVE-J study (age between 20 and 75, witnessed shockable OHCA, cardiac arrest on hospital arrival, cardiac etiology, and collapse-to-ECPR interval within 60 minutes). Study patients were divided into two groups according to prehospital SDE or not. Primary endpoint was favorable 30-day neurological outcome after OHCA. Results: Of the 22,552 study patients, 5,659 (25%) received prehospital SDE and 16,893 (75%) did not. The SDE group resulted in lower proportion of favorable 30-day neurological outcome than the no-SDE group (5.6% versus 8.4%, p<0.001) with longer collapse-to-hospital-arrival interval (36.7±9.8 min vs. 29.6±11.3 min, p<0.001). After adjustment for independent predictors of resuscitation, prehospital SDE did not impact on neurological benifit (adjusted OR,1.13; 95%CI,0.98-1.29), but the collapse-to-hospital-arrival interval was associated with neurological benefit (adjusted OR, 0.94; 95% CI, 0.93-0.95). In curve estimation of the SDE group, when collapse-to-hospital-arrival interval was delayed, proportion of the favorable neurological outcome decreased to about 25% at 1 minute and about 0% at 54 minutes (R=0.14). In the 274 patients undergoing ECPR of the SAVE-J study, however, it was about 43% at 1 minute and about 0% at 96 minutes (R=0.17). Conclusions: Prehospital SDE did not improve likelihood of favorable neurological outcome for patients who met the criteria of ECPR (age between 20 and 75, witnessed shockable OHCA, cardiac arrest on hospital arrival, cardiac etiology and collapse-to-ECPR interval within 60 minutes), because SED administration delayed the collapse-to-hospital-arrival interval which was closely related to the neurologically intact survival on ECPR.

Abstract 81: Early Access to Cardiac Catheterization Laboratory for Patients Resuscitated from Cardiac Arrest Due to a Shockable Rhythm: The Minnesota Resuscitation Consortium Twin Cities Unified Protocol Two-Year Report

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Demetris Yannopoulos ◽  
Santiago Garcia ◽  
Brian Mahoney ◽  
Ralph J Frascone ◽  
Greg Helmer ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiac Catheterization ◽  
Real Life ◽  
Inclusion Criteria ◽  
Catheterization Laboratory ◽  
Cardiac Catheterization Laboratory ◽  
Early Access ◽  
Shockable Rhythm ◽  
Surface Ecg ◽  
Gain Access

Background: Cardiac arrest patients that have been successfully resuscitated from shockable rhythms have a high prevalence of thrombotic and/or flow limiting coronary occlusion regardless of the presence of STEMI on the ECG. In 2012, the Minnesota Resuscitation Consortium (MRC) developed an organized approach for all those patients to gain early access to the cardiac catheterization laboratory (CCL). We report the two-year outcomes. Methods: Eleven metropolitan hospitals with 24/7 PCI capabilities agreed to provide early (within 2 hours of arrival to the emergency department) access to the CCL for all patients that were successfully resuscitated from VF/VT arrest regardless of the presence or absence of STEMI on the surface ECG. Inclusion criteria were: witnessed or un-witnessed, age >18 and <70, cardiac arrest of presumed cardiac etiology, comatose or conscious patients. Patients with PEA or asystole, known DNR/DNI, non-cardiac etiology, significant bleeding of any cause, terminal disease were excluded. Patient outcomes were recorded in the state database Cardiac Arrest Registry to Enhance Survival. Results: A total of 370 patients were resuscitated and met the inclusion criteria. Of those, 313 (85%) patients were taken to the CCL per protocol. The mean age was 55.5 years, 77% were men and 79% had witnessed arrest. Only 57 patients (15%) did not gain access to the CCL. Of the 313 patients that had early coronary angiography a total of 47% received primary angioplasty and had at least one vessel disease and 5% received coronary artery bypass. All comatose patients received therapeutic hypothermia and 35% received and implantable cardiac defibrillator. A total of 235/313 (75%) were discharged alive and of those 222/235 (94.5%) were discharged neurologically intact with a CPC of 1. Of the patients that did not gain access to the CCL, 46% (26/57) were discharged alive and of those 73% (19/26) had CPC of 1 [OR: 3.63; 2.03-6.5, p< 0.001]. Conclusions: Over the first two years of implementation, the MRC protocol for early access to the CCL in resuscitated patients from shockable rhythm was associated with 75% survival to hospital discharge and excellent neurological outcomes in a large metropolitan area and real-life clinical practice.

Cardiac Arrest in the Cardiac Catheterization Laboratory: Initial Experience With the Role of Simulation Setup and Training

2020 ◽  
pp. 106286062095080
Author(s):  
Omar Al-Mukhtar ◽  
Irma Bilgrami ◽  
Samer Noaman ◽  
Rebecca Lapsley ◽  
John Ozcan ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiac Catheterization ◽  
Physical Environment ◽  
Improve Patient Care ◽  
Clinical Event ◽  
Catheterization Laboratory ◽  
Cardiac Catheterization Laboratory ◽  
Percutaneous Coronary ◽  
Specialized Equipment ◽  
Multidisciplinary Simulation

With rising complexity of percutaneous coronary interventions being performed, the incidence of cardiac arrest in the cardiac catheterization laboratory (CCL) is likely to increase. The authors undertook a series of multidisciplinary simulation sessions to identify practice deficiencies and propose solutions to improve patient care. Five simulation sessions were held at Western Health CCL to simulate different cardiac arrest scenarios. Participants included cardiologists, intensivists, anesthetists, nurses, and technicians. Post-simulation feedback was analyzed qualitatively. Challenges encountered were grouped into 4 areas: (1) communication and teamwork, (2) equipment, (3) vascular access and drugs, and (4) physical environment and radiation exposure. Proposed solutions included regular simulation training; increasing familiarity with the physical environment, utilization of specialized equipment; and formation of 2 team leaders to improve efficiency. Cardiac arrest in the CCL is a unique clinical event that necessitates specific training to improve technical and nontechnical skills with potential to improve clinical outcomes.

scholarly journals Shortening of low-flow duration over time was associated with improved outcomes of extracorporeal cardiopulmonary resuscitation in in-hospital cardiac arrest

2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Akiko Higashi ◽  
Taka-aki Nakada ◽  
Taro Imaeda ◽  
Ryuzo Abe ◽  
Koichiro Shinozaki ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Cardiac Arrest ◽  
Quality Improvement ◽  
Cardiopulmonary Resuscitation ◽  
Neurological Outcome ◽  
Low Flow ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Neurological Outcomes ◽  
Flow Duration ◽  
Over Time

Abstract Introduction Quality improvement in the administration of extracorporeal cardiopulmonary resuscitation (ECPR) over time and its association with low-flow duration (LFD) and outcomes of cardiac arrest (CA) have been insufficiently investigated. In this study, we hypothesized that quality improvement in efforts to shorten the duration of initiating ECPR had decreased LFD over the last 15 years of experience at an academic tertiary care hospital, which in turn improved the outcomes of in-hospital CA (IHCA). Methods This was a single-center retrospective observational study of ECPR patients between January 2003 and December 2017. A rapid response system (RRS) and an extracorporeal membrane oxygenation (ECMO) program were initiated in 2011 and 2013. First, the association of LFD per minute with the 90-day mortality and neurological outcome was analyzed using multiple logistic regression analysis. Then, the temporal changes in LFD were investigated. Results Of 175 study subjects who received ECPR, 117 had IHCA. In the multivariate logistic regression, IHCA patients with shorter LFD experienced significantly increased 90-day survival and favorable neurological outcomes (LFD per minute, 90-day survival: odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.94–1.00, P = 0.032; 90-day favorable neurological outcome: OR = 0.97, 95% CI = 0.94–1.00, P = 0.049). In the study period, LFD significantly decreased over time (slope − 5.39 [min/3 years], P < 0.0001). Conclusion A shorter LFD was associated with increased 90-day survival and favorable neurological outcomes of IHCA patients who received ECPR. The quality improvement in administering ECPR over time, including the RRS program and the ECMO program, appeared to ameliorate clinical outcomes.

scholarly journals In-Hospital Cardiac Arrest in the Cardiac Catheterization Laboratory: Effective Transition from an ICU- to CCU-Led Resuscitation Team

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Rajat Sharma ◽  
Hilary Bews ◽  
Hardeep Mahal ◽  
Chantal Y. Asselin ◽  
Megan O’Brien ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiac Catheterization ◽  
Tertiary Care ◽  
Pulseless Electrical Activity ◽  
Hospital Length Of Stay ◽  
Health Concern ◽  
Catheterization Laboratory ◽  
Cardiac Catheterization Laboratory ◽  
Coronary Syndrome ◽  
Code Blue

Objectives. (1) To examine the incidence and outcomes of in-hospital cardiac arrests (IHCAs) in a large unselected patient population who underwent coronary angiography at a single tertiary academic center and (2) to evaluate a transitional change in which the cardiologist is positioned as the cardiopulmonary resuscitation (CPR) leader in the cardiac catheterization laboratory (CCL) at our local tertiary care institution. Background. IHCA is a major public health concern with increased patient morbidity and mortality. A proportion of all IHCAs occurs in the CCL. Although in-hospital resuscitation teams are often led by an Intensive Care Unit- (ICU-) trained physician and house staff, little is known on the role of a cardiologist in this setting. Methods. Between 2012 and 2016, a single-center retrospective cohort study was performed examining 63 adult patients (70 ± 10 years, 60% males) who suffered from a cardiac arrest in the CCL. The ICU-led IHCAs included 19 patients, and the Coronary Care Unit- (CCU-) led IHCAs included 44 patients. Results. Acute coronary syndrome accounted for more than 50% of cardiac arrests in the CCL. Pulseless electrical activity was the most common rhythm requiring chest compression, and cardiogenic shock most frequently initiated a code blue response. No significant differences were observed between the ICU-led and CCU-led cardiac arrests in terms of hospital length of stay and 1-year survival rate. Conclusion. In the evolving field of Critical Care Cardiology, the transition from an ICU-led to a CCU-lead code blue team in the CCL setting may lead to similar short-term and long-term outcomes.

Abstract 10476: Patient Characteristics and Survival Outcomes of Cardiac Arrest in the Cardiac Catheterization Laboratory: Insights from Get with the Guidelines-Resuscitation Registry

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Ahmed Elkaryoni ◽  
John J Lopez ◽  
Paul S Chan
Keyword(s):  
Cardiac Arrest ◽  
Cardiac Catheterization ◽  
Odds Ratio ◽  
American Heart ◽  
Patient Characteristics ◽  
Lower Survival Rate ◽  
Catheterization Laboratory ◽  
Cardiac Catheterization Laboratory ◽  
Get With The Guidelines ◽  
Hospital Cardiac Arrest

Background: The characteristics and outcomes of in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. We compared the characteristics and outcomes of patients with an IHCA in the CCL versus those in the operating room (OR) and the intensive care unit (ICU). Methods: Within the American Heart Association’s Get With the Guidelines-Resuscitation® registry, we identified patients 18 years of age or older with an IHCA in the CCL, OR, or ICU between 2000 and 2019. We compared rates of survival to discharge for patients in the CCL, OR, and ICU. Additionally, we examined predictors of survival to discharge for patients with IHCA in the CCL. Results: There were 6866, 5181, and 181,832 patients with an IHCA in the CCL, OR, and ICU, respectively. Patients with IHCAs in the CCL were more likely to have a shockable cardiac arrest rhythm as compared with those in the OR and ICU. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, as compared with 30,833 (16.9%) from the ICU and 2096 (40.5%) from the OR. After adjustment for 27 patient and cardiac arrest factors, patients with IHCA in CCL were more likely to survive to discharge as compared with those with IHCA from the ICU (odds ratio, 1.37 [95% CI: 1.29-1.46], p<0.001). In contrast, they were less likely to survive to discharge as compared with those with IHCA in the OR (odds ratio, 0.81 [95% CI: 0.69-0.94], p=0.006). Predictors of survival to discharge in patients with IHCA in the CCL included white race, pulseless ventricular tachycardia/fibrillation, and IHCA during normal hours and on weekdays, while having myocardial infarction during this or prior hospitalization was associated with less survival to discharge. (Table). Conclusion: IHCA in the CCL is not uncommon and has a lower survival rate as compared with IHCA in other procedural areas such as the OR. The reasons for this difference deserve further study given that response to IHCAs in both settings should be similar.

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