Anna Coppo

Favourable survival of in-hospital compared to out-of-hospital refractory cardiac arrest patients treated with extracorporeal membrane oxygenation: An Italian tertiary care centre experience

OBJECTIVE Extracorporeal membrane oxygenation (ECMO) support has been suggested to improve the survival rate in patients with refractory in- and out-of-hospital cardiac arrest (IHCA and OHCA). The aim of our study is to report our experience with ECMO in these patients. DESIGN Retrospective, single-centre, observational study. PATIENTS From January 2006 to February 2011 we studied 42 patients (31 males) with refractory cardiac arrest. MEASUREMENT AND MAIN RESULTS ECMO implantation was successful in 38 (90%) of the 42 patients. ECMO support was positioned: three times (8%) in the operating room, six (16%) in the cardiac surgery intensive care unit, 21 (55%) in the emergency room, five (13%) in the catheterisation laboratory and three (8%) in the general ward. A total of 14 IHCA (58%) and three OHCA (16%) patients were weaned from ECMO (p<0.05). Eleven IHCA (46%) and one OHCA (5%, p<0.05) patients were discharged from intensive care unit (ICU). Among IHCA patients, 10 were alive at 6 months, nine of whom (38%) with good neurological outcome. Among OHCA patients weaned from ECMO, one was alive at 6 months with good neurological outcome (5%, p<0.05 vs. IHCA). CONCLUSIONS ECMO support should be considered as a resuscitation alternative in selected patients. More specifically, patients with witnessed IHCA benefit more from ECMO treatment compared to those who experience an out-of-hospital cardiac arrest.

New treatment bundles improve survival in out-of-hospital cardiac arrest patients: a historical comparison.

INTRODUCTION Before the introduction of the new international cardiac arrest treatment guidelines in 2005, patients with out-of-hospital cardiac arrest (OHCA) of cardiac origin in Northern Italy had very poor prognosis. Since 2006, a new bundle of care comprising use of automated external defibrillators (AEDs) and therapeutic hypothermia (TH) was started, while extracorporeal CPR program (ECPR) for selected refractory CA and dispatcher-assisted cardio-pulmonary resuscitation (CPR) was started in January 2010. OBJECTIVES We hypothesized that a program of bundled care might improve outcome of OHCA patients. METHODS We analyzed data collected in the OHCA registry of the MB area between September 2007 and August 2011 and compared this with data from 2000 to 2003. RESULTS Between 2007 and 2011, 1128 OHCAs occurred in the MB area, 745 received CPR and 461 of these had a CA of presumed cardiac origin. Of these, 125 (27%) achieved sustained ROSC, 60 (13%) survived to 1 month, of whom 51 (11%) were discharged from hospital with a good neurological outcome (CPC≤2), and 9 with a poor neurological outcome (CPC>2). Compared with data from the 2000 to 2003 periods, survival increased from 5.6% to 13.01% (p<0.0001). In the 2007-2011 group, low-flow time and bystander CPR were independent markers of survival. CONCLUSIONS OHCA survival has improved in our region. An increased bystander CPR rate associated with dispatcher-assisted CPR was the most significant cause of increased survival, but duration of CA remains critical for patient outcome.

Organ donation in cardiac arrest patients treated with extracorporeal CPR: A single centre observational study

AIM OF THE STUDY In a consecutive cohort of cardiac arrest (CA) treated with extracorporeal cardiopulmonary resuscitation (eCPR), we describe the incidence of brain death (BD), the eligibility for organ donation and the short-term follow-up of the transplanted organs. METHODS All refractory in- and out-of-hospital CA admitted to our Cardiac Intensive Care Unit between January 2011 and September 2016 treated with eCPR were enrolled in the study. RESULTS 112 CA patients received eCPR. 82 (73.2%) died in hospital, 25 BD (22.3%) and 57 for other causes (50.9%). At the time of first neurological evaluation after rewarming, variables related to evolution to BD were a lower GCS (3 [3-3] vs. 8 [3-11], p<0.001), a higher level of neuron specific enolase (269.3±49.4 vs. 55.2±37.2ng/ml, p<0.001), a higher presence of EEG indices of poor outcome (84% vs. 15%, p<0.001), absence of brainstem reflexes (p<0.001), absence of bilateral N20 SSEPS waves (66.7% vs. 3.7%, p<0.001). None of BD patients present a normal CT scan (at 2.5±2days), with 85% prevalence of diffuse hypoxic injury and a mean grey/white matter ratio of 1.1±0.1. Rate of donation in BD patients was 56%, with 39 donated organs: 23 kidneys, 12 livers, and 4 lungs. 89.74% of the transplanted organs reached an early good functional recovery. CONCLUSION In refractory CA patients treated with eCPR, the prevalence of BD is high. This population has a high potential for considering organ donation. Donated organs have a good outcome.

Effects of extracorporeal cardiopulmonary resuscitation on neurological and cardiac outcome after ischaemic refractory cardiac arrest

Background: Extracorporeal cardiopulmonary resuscitation is increasingly recognised as a rescue therapy for refractory cardiac arrest, nevertheless data are scanty about its effects on neurologic and cardiac outcome. The aim of this study is to compare clinical outcome in patients with cardiac arrest of ischaemic origin (i.e. critical coronary plaque during angiography) and return of spontaneous circulation during conventional cardiopulmonary resuscitation vs refractory cardiac arrest patients needing extracorporeal cardiopulmonary resuscitation. Moreover, we tried to identify predictors of survival after successful cardiopulmonary resuscitation. Methods: We enrolled 148 patients with ischaemic cardiac arrest admitted to our hospital from 2011–2015. We compared clinical characteristics, cardiac arrest features, neurological and echocardiographic data obtained after return of spontaneous circulation (within 24 h, 15 days and six months). Results: Patients in the extracorporeal cardiopulmonary resuscitation group (n=63, 43%) were younger (59±9 vs 63±8 year-old, p=0.02) with lower incidence of atherosclerosis risk factors than those with conventional cardiopulmonary resuscitation. In the extracorporeal cardiopulmonary resuscitation group, left ventricular ejection fraction was lower than conventional cardiopulmonary resuscitation at early echocardiography (19±16% vs 37±11 p<0.01). Survivors in both groups showed similar left ventricular ejection fraction 15 days and 4–6 months after cardiac arrest (46±8% vs 49±10, 47±11% vs 45±13%, p not significant for both), despite a major extent and duration of cardiac ischaemia in extracorporeal cardiopulmonary resuscitation patients. At multivariate analysis, the total cardiac arrest time was the only independent predictor of survival. Conclusions: Extracorporeal cardiopulmonary resuscitation patients are younger and have less comorbidities than conventional cardiopulmonary resuscitation, but they have worse survival and lower early left ventricular ejection fraction. Survivors after extracorporeal cardiopulmonary resuscitation have a neurological outcome and recovery of heart function comparable to subjects with return of spontaneous circulation. Total cardiac arrest time is the only predictor of survival after cardiopulmonary resuscitation in both groups.

Weaning from Extracorporeal Circulatory Support

Extracorporeal membrane oxygenation provides effective circulatory support while waiting for cardiac recovery in patients with potentially reversible heart disease, or for heart transplantation, or for implantation of a ventricular assist device (VAD) in patients with terminal heart disease [1–4].

Efficacy and safety of perampanel oral loading in postanoxic super-refractory status epilepticus: A pilot study

Refractory nonconvulsive status epilepticus (NCSE) occurs in 10%‐30% of patients following resuscitation after cardiac arrest. Both the optimal treatment and prognosis of postanoxic status epilepticus remain uncertain. We analyzed acute electroencephalographic changes, neurological outcome at 3 months, and adverse effects in consecutive postanoxic patients with super‐refractory NCSE treated with add‐on oral loading of perampanel. Eight postanoxic patients with super‐refractory NCSE were treated with perampanel (dose range = 6‐12 mg). All patients had continuous electroencephalographic monitoring showing definite generalized NCSE and favorable multimodal prognostic indicators (presence of brainstem reflexes, presence of bilateral N20 responses, absence of periodic discharges/generalized epileptic periodic discharges). In six patients (75%), status epilepticus resolved within 72 hours after administration of perampanel, without changing the comedication. Neurological outcomes at 3 months were return to normal or minimal disability in four patients (50%). A mild cholestatic liver injury, which required no specific treatment, was observed in five patients (62.5%). Perampanel 6‐12 mg oral loading appeared to be an effective option in selected patients with postanoxic super‐refractory NCSE with good prognostic indicators. In this patient population, our safety data indicate a risk of cholestasis.

Safe ECMO femoral decannulation by placement of inferior vena cava filter via internal jugular vein.

Veno-arterial extracorporeal membrane oxygenation (ECMO) is a lifesaving treatment in patients with cardiogenic shock or cardiac arrest caused by massive pulmonary embolism. In these patients, positioning an inferior vena cava filter is often advisable, especially if deep venous thrombosis is not resolved at the time of the ECMO suspension. Moreover, in ECMO patients, a high incidence of deep venous thrombosis at the site of venous cannulation has been reported, and massive pulmonary embolism following ECMO decannulation has been described. Nonetheless, an inferior vena cava filter cannot be positioned as long as an ECMO cannula is inside the inferior vena cava. Thus, we developed a strategy to allow placement of an inferior vena cava filter through the internal jugular concurrently with the removal of the femoral venous ECMO cannula. In two women supported by veno-arterial ECMO for cardiac arrest secondary to pulmonary embolism, this novel approach allowed for safe ECMO decannulation.

Absence and reappearance of N20 response after thiopental withdrawal in postanoxic comaAuthors Respond

I read with interest the case report by Coppo et al.1 After coma was induced in the patient by high-dose barbiturate (thiopental) administration to combat refractory nonconvulsive status epilepticus, median nerve somatosensory evoked potential (SSEP) N20 responses elicited from the primary somatosensory cortex were bilaterally absent but responses from brainstem-cervical components were present. Continuous EEG recording at that time showed an isoelectric pattern. N20 responses reappeared after the barbiturate was …

Absence and reappearance of N20 response after thiopental withdrawal in postanoxic coma

A 42-year-old woman with witnessed out-of-hospital cardiac arrest (CA) reached the emergency department after 38 minutes of cardiopulmonary resuscitation. Since the return of spontaneous circulation did not occur, extracorporeal membrane oxygenation (ECMO) was applied. The ECMO circuit was connected to a heat exchanger to induce therapeutic hypothermia (34°C). Continuous EEG monitoring with a simplified 4-channel montage (EEG Infinity POD, Drager, Lubeck, Germany) was started. After 24 hours of hypothermia, the patient was gradually rewarmed, according to the local protocol. At the withdrawal of sedation, she remained comatose, and standard reduced-montage (8-channel) EEG showed nonconvulsive status epilepticus (NCSE, figure e-1 at [Neurology.org/cp][1]), which was initially treated with propofol and valproate infusion (20 mg/kg followed by 1 mg/kg/hr). She was weaned from ECMO 48 hours after CA. She remained in a coma, all brainstem reflexes were present, neuron-specific enolase was 21 ng/mL, and brain CT scan was normal, with no evidence of traumatic brain injury or other brain lesions. Standard EEG was repeated and showed refractory NCSE. Levetiracetam was added (2,000 mg bolus followed by 2,000 mg/24 hours), and propofol-induced coma was initiated to obtain a burst-suppression pattern for 24 hours, guided by EEG monitor. Propofol was gradually stopped 72 hours after CA, and EEG still showed refractory NCSE. High-dose barbiturate coma was induced (thiopental 10 mg/kg/hr). At this time point, EEG was isoelectric and the patient was hemodynamically stable. Median nerve somatosensory evoked potentials (SSEP, see figure 1 for technical details) were recorded 72 hours after CA, and N20 cortical responses were bilaterally absent, while potentials at Erb point (N9), cervical spine (N13), and lower brainstem (P14) were present (figure 1A). Barbiturate coma was maintained for 24 hours. After barbiturate withdrawal, EEG showed diffuse slow wave activity with superimposed irregular beta activity. SSEP recording was repeated 10 days after the first recording (9 days after thiopental withdrawal) and showed bilateral reappearance of the N20 response (figure 1B). The patient showed a gradual improvement in both consciousness and neurologic examination and was discharged from the intensive care unit 4 weeks after CA. At 3-month follow-up she was independent in activities of daily living (Cerebral Performance Category 2). [1]: http://cp.neurology.org/lookup/doi/10.1212/CPJ.0000000000000135