Jayne Sheldrake

Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).

INTRODUCTION Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia. METHODS The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24h in the intensive care unit. RESULTS There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients. CONCLUSIONS A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.

Predicting Survival after Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score

RATIONALE Increasing use of extracorporeal membrane oxygenation (ECMO) for acute respiratory failure may increase resource requirements and hospital costs. Better prediction of survival in these patients may improve resource use, allow risk-adjusted comparison of center-specific outcomes, and help clinicians to target patients most likely to benefit from ECMO. OBJECTIVES To create a model for predicting hospital survival at initiation of ECMO for respiratory failure. METHODS Adult patients with severe acute respiratory failure treated by ECMO from 2000 to 2012 were extracted from the Extracorporeal Life Support Organization (ELSO) international registry. Multivariable logistic regression was used to create the Respiratory ECMO Survival Prediction (RESP) score using bootstrapping methodology with internal and external validation. MEASUREMENTS AND MAIN RESULTS Of the 2,355 patients included in the study, 1,338 patients (57%) were discharged alive from hospital. The RESP score was developed using pre-ECMO variables independently associated with hospital survival on logistic regression, which included age, immunocompromised status, duration of mechanical ventilation before ECMO, diagnosis, central nervous system dysfunction, acute associated nonpulmonary infection, neuromuscular blockade agents or nitric oxide use, bicarbonate infusion, cardiac arrest, PaCO2, and peak inspiratory pressure. The receiver operating characteristics curve analysis of the RESP score was c = 0.74 (95% confidence interval, 0.72-0.76). External validation, performed on 140 patients, exhibited excellent discrimination (c = 0.92; 95% confidence interval, 0.89-0.97). CONCLUSIONS The RESP score is a relevant and validated tool to predict survival for patients receiving ECMO for respiratory failure.

Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score

RATIONALE Extracorporeal membrane oxygenation (ECMO) may provide mechanical pulmonary and circulatory support for patients with cardiogenic shock refractory to conventional medical therapy. Prediction of survival in these patients may assist in management of these patients and comparison of results from different centers. AIMS To identify pre-ECMO factors which predict survival from refractory cardiogenic shock requiring ECMO and create the survival after veno-arterial-ECMO (SAVE)-score. METHODS AND RESULTS Patients with refractory cardiogenic shock treated with veno-arterial ECMO between January 2003 and December 2013 were extracted from the international Extracorporeal Life Support Organization registry. Multivariable logistic regression was performed using bootstrapping methodology with internal and external validation to identify factors independently associated with in-hospital survival. Of 3846 patients with cardiogenic shock treated with ECMO, 1601 (42%) patients were alive at hospital discharge. Chronic renal failure, longer duration of ventilation prior to ECMO initiation, pre-ECMO organ failures, pre-ECMO cardiac arrest, congenital heart disease, lower pulse pressure, and lower serum bicarbonate (HCO3) were risk factors associated with mortality. Younger age, lower weight, acute myocarditis, heart transplant, refractory ventricular tachycardia or fibrillation, higher diastolic blood pressure, and lower peak inspiratory pressure were protective. The SAVE-score (area under the receiver operating characteristics [ROC] curve [AUROC] 0.68 [95%CI 0.64-0.71]) was created. External validation of the SAVE-score in an Australian population of 161 patients showed excellent discrimination with AUROC = 0.90 (95%CI 0.85-0.95). CONCLUSIONS The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory cardiogenic shock (www.save-score.com).

A qualitative exploration of acute care and psychological distress experiences of ECMO survivors

OBJECTIVES To explore the acute care experience of extracorporeal membrane oxygenation (ECMO) patients. BACKGROUND ECMO is used in life-threatening scenarios of acute lung or heart failure. The patients experience with ECMO treatment and the psychological distress are unknown. METHODS Qualitative analysis of semi-structured interviews with ECMO survivors 12 months after discharge were conducted and thematically analyzed. RESULTS Ten participants treated with ECMO for life-threatening acute heart or lung failure were interviewed. Six themes that captured the ICU experience of ECMO patients were identified including; dealing with crisis, critical care, memory, role of significant others and existence today and tomorrow. Deconditioning was the most frequently reported experience. Patchy factual memories contrasted with detailed delirious memories and paranoid ideations. CONCLUSION Patients treated with ECMO experienced deconditioning, perceived threats of serious injury or death and delusional episodes with recalls of psychological distress.

Percutaneous cannulation in predominantly venoarterial extracorporeal membrane oxygenation by intensivists

Critical Care Medicine www.ccmjournal.org e595 The authors reply: The letter by Burrell et al (1) describing the percutaneous cannulation experience by intensivists at Alfred Hospital provides important information for intensivists involved in extracorporeal life support (ECLS) programs and nicely complements our reported experience (2). Our ECLS program has historically provided predominantly respiratory support, and our cardiac support experience is more limited. Our ECLS experience consists mostly of venovenous cannulation with a smaller venoarterial cohort. Burrell et al (1) describe their cannulation experience, which includes a large venoarterial cohort. Aspects of the Alfred Hospital experience deserve mention. The first is their success with arterial cannulation with a low complication rate. Arterial cannulation entails more inherent risk than venous because arterial injury can lead to substantial more morbidity than venous injury. The 8% arterial complication rate reported, although higher than their venous rate (2%), is not unexpected and would not be considered excessive. Some of their complications required surgical management, so the availability of surgical services would seem advisable. Another aspect is the larger number of intensivists (16) available to perform cannulations. Although this would seem to dilute the experience of each intensivist, the approach of having more than one intensivist cannulating a given patient (as we do) increases the exposure to the procedure and helps maintain cannulation skills. secured. A second patient’s internal jugular venous access cannula was accidentally dislodged and removed but was resecured without major consequence. Overall average ECMO duration was 4 ± 4 days for VA ECMO and 14 ± 4 days for VV ECMO. Survival to hospital discharge was 73 of 122 (60%) for VA ECMO (including extracorporeal CPR) and 32 of 45 (71%) for VV ECMO. In total, seven of 167 patients (4%) had hemorrhagic or ischemic stroke, and there was one blood stream infection, and one confirmed cannula related infection. In conclusion, intensivist-led cannulation is also possible for a predominantly VA ECMO service and is associated with an acceptable complication rate. The authors have disclosed that they do not have any potential conflicts of interest.

Experience and needs of family members of patients treated with extracorporeal membrane oxygenation

AIMS AND OBJECTIVES To explore the experiences of family members of patients treated with extracorporeal membrane oxygenation. BACKGROUND Sudden onset of an unexpected and severe illness is associated with an increased stress experience of family members. Only one study to date has explored the experience of family members of patients who are at high risk of dying and treated with extracorporeal membrane oxygenation. DESIGN A qualitative descriptive research design was used. METHODS A total of 10 family members of patients treated with extracorporeal membrane oxygenation were recruited through a convenient sampling approach. Data were collected using open-ended semi-structured interviews. A six-step process was applied to analyse the data thematically. Four criteria were employed to evaluate methodological rigour. RESULTS Family members of extracorporeal membrane oxygenation patients experienced psychological distress and strain during and after admission. Five main themes (Going Downhill, Intensive Care Unit Stress and Stressors, Carousel of Roles, Today and Advice) were identified. These themes were explored from the four roles of the Carousel of Roles theme (decision-maker, carer, manager and recorder) that participants experienced. CONCLUSION Nurses and other staff involved in the care of extracorporeal membrane oxygenation patients must pay attention to individual needs of the family and activate all available support systems to help them cope with stress and strain. RELEVANCE TO CLINICAL PRACTICE An information and recommendation guide for families and staff caring for extracorporeal membrane oxygenation patients was developed and needs to be applied cautiously to the individual clinical setting.

Recovery, Risks, and Adverse Health Outcomes in Year 1 After Extracorporeal Membrane Oxygenation

Background Cross‐sectional studies suggest that patients treated with extracorporeal membrane oxygenation (ECMO) have adverse health outcomes and high risk for mental health problems after discharge. Objectives To describe the recovery of discharged patients during the first year after ECMO. Methods In a prospective cohort study, data were collected 3, 6, and 12 months after discontinuation of ECMO and discharge. Postal surveys included the 36‐Item Short Form Health Survey, the EuroQol‐5‐Dimensions‐5‐Levels health questionnaire, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale‐Revised. Telephone interviews were used to track adverse physical outcomes. The Telephone Interview for Cognitive Status questionnaire was administered at the end of each call. Results Patients in the study experienced more physical than mental adverse health outcomes, and the risk for mental problems was 2 or 3 times the rate expected. Adverse physical outcomes were common. One‐quarter of patients remained significantly restricted; some had severe neurological impairments of the lower extremities. On cognitive tests, about half scored inconclusive or mildly impaired. Patients were often admitted to the hospital. Conclusions Physical health was more severely impaired than was mental health, and both types improved over time. The EuroQol‐5‐Dimensions‐5‐Levels instrument was useful for detecting neurological problems of the lower extremities early and may qualify as a core outcome measure for patients treated with ECMO.