Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to ...improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.
Fluoroquinolones have been associated with collagen degradation, raising safety concerns related to more serious collagen disorders with use of these antibiotics, including aortic aneurysm and ...dissection.
To examine the relationship between fluoroquinolone therapy and the risk of developing aortic aneurysm and dissection.
We conducted a nested case-control analysis of 1477 case patients and 147 700 matched control cases from Taiwan's National Health Insurance Research Database (NHIRD) from among 1 million individuals longitudinally observed from January 2000 through December 2011. Cases patients were defined as those hospitalized for aortic aneurysm or dissection. One hundred control patients were matched for each case based on age and sex.
Current, past, or any prior-year use of fluoroquinolone. Current use was defined as a filled fluoroquinolone prescription within 60 days of the aortic aneurysm or dissection; past use refers to a filled fluoroquinolone prescription between 61 and 365 days prior to the aortic aneurysm; and any prior-year use refers to having a fluoroquinolone prescription filled for 3 or more days any time during the 1-year period before the aortic aneurysm or dissection.
Risk of developing aortic aneurysm or dissection.
A total of 1477 individuals who experienced aortic aneurysm or dissection were matched to 147 700 controls. After propensity score adjustment, current use of fluoroquinolones was found to be associated with increased risk for aortic aneurysm or dissection (rate ratio RR, 2.43; 95% CI, 1.83-3.22), as was past use, although this risk was attenuated (RR, 1.48; 95% CI, 1.18-1.86). Sensitivity analysis focusing on aortic aneurysm and dissection requiring surgery also demonstrated an increased risk associated with current fluoroquinolone use, but the increase was not statistically significant (propensity score-adjusted RR, 2.15; 95% CI, 0.97-4.60).
Use of fluoroquinolones was associated with an increased risk of aortic aneurysm and dissection. While these were rare events, physicians should be aware of this possible drug safety risk associated with fluoroquinolone therapy.
Background
The major concern in patients who have suffered from cardiac arrest (CA) and undergone successful extracorporeal cardiopulmonary resuscitation (E‐CPR) is poor neurological outcomes. In ...this study, we aimed to introduce a rat model of selective brain perfusion (SBP) during E‐CPR to improve the neurological outcome after CA.
Methods
The rats underwent 7 min of untreated asphyxial CA and then were resuscitated with E‐CPR for 30 min. The right external jugular vein and right femoral artery were separately cannulated to the E‐CPR outflow and inflow. The right common carotid artery was cannulated from the proximal to the distal side for SBP. Subsequently, rats were removed from E‐CPR, wounds were closed, and 90 min of intensive care were provided. Neurological deficit scores were tested after 4 h of recovery when the rats were mechanical ventilation‐free. S100 calcium‐binding protein B (S100B) and glial fibrillary acidic protein (GFAP) were detected through immunohistochemistry (IHC) of brain tissue.
Results
The rats that received SBP while resuscitated by E‐CPR showed markedly better neurological performances after 4‐h recovery than those resuscitated by E‐CPR only. The IHC staining of GFAP and S100B in the hippocampus was low in the rats receiving SBP during E‐CPR, but only GFAP showed significant differences.
Conclusions
We successfully developed a novel and reproducible rat model of SBP while resuscitated by E‐CPR to ameliorate the neurological performances after CA. This achievement might have opportunities for studying how to improve the neurological outcome in the clinical condition.
Extracorporeal cardiopulmonary resuscitation with selective brain perfusion system in a rat model.
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (RCS) is increasingly used in adult patients, but age represents a controversial factor in this setting.
...Data from the Extracorporeal Life Support Organization registry was analyzed to assess in-hospital survival of elderly patients (≥70 years of age) undergoing VA-ECMO for RCS from 1992 to 2015. In-hospital survival and complications for elderly patients were compared with data in younger adults (≥18 to <70 years of age) supported with VA-ECMO during the same time period for similar indications.
The mean age of the patient cohort (n = 5,408) was 53.0 ± 15.7 years (range, 18 to 91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2 ± 4.4 years. In the elderly group, pre-ECMO cardiac procedures were performed in 134 cases (18.9%), and 2.2% received VA-ECMO for postcardiotomy support compared with 0.7% in the younger cohort. The mean duration of VA-ECMO in the elderly group was 101 ± 91 h compared with 138 ± 146 h in the younger group (p < 0.001). Overall, survival to hospital discharge for the entire adult cohort was 41.4% (2,240 of 5,408), with 30.5% (224 of 735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (p < 0.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival.
Based on the acceptable survival to hospital discharge in our study, older age alone should not represent an absolute contraindication when considering VA-ECMO support for RCS.
Purpose
Caseloads of extracorporeal cardiopulmonary resuscitation (ECPR) have increased considerably, and hospital mortality rates remain high and unpredictable. The present study evaluated the ...effects of the interplay between age and prolonged low-flow duration (LFD) on hospital survival rates in elderly patients to identify subgroups that can benefit from ECPR.
Methods
Adult patients who received ECPR in our institution (2006–2016) were classified into groups 1, 2, and 3 (18–65, 65–75, and > 75 years, respectively). Data regarding ECPR and adverse events during hospitalization were collected prospectively. The primary end point was favorable neurologic outcome (cerebral performance category 1 or 2) at hospital discharge.
Results
In total, 482 patients were divided into groups 1, 2, and 3 (70.5%, 19.3%, and 10.2%, respectively). LFDs were comparable among the groups (40.3, 41.0, and 44.3 min in groups 1, 2, and 3,
P
= 0.781, 0.231, and 0.382, respectively). Favorable neurologic outcome rates were nonsignificantly lower in group 3 than in the other groups (27.6%, 24.7%, and 18.4% for group 1, 2, and 3, respectively). Subgroup analysis revealed that the favorable neurologic outcome rates in group 1 were 36.7%, 25.4%, and 13.0% for LFDs of < 30, 30–60, and > 60 min, respectively (
P
= 0.005); in group 2, they were 32.1%, 21.2%, and 23.1%, respectively (
P
= 0.548); in group 3 they were 25.0%, 20.8%, and 0.0%, respectively (
P
= 0.274).
Conclusion
On emergency consultation for ECPR, age and low-flow duration should be considered together to predict neurologic outcome.
Summary Background Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the ...benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin. Methods We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18–75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov , number NCT00173615. Findings Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0·0001) and a better 1-year survival than those who received conventional CPR (log rank p=0·007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio HR 0·51, 95% CI 0·35–0·74, p<0·0001), 30-day survival (HR 0·47, 95% CI 0·28–0·77, p=0·003), and 1-year survival (HR 0·53, 95% CI 0·33–0·83, p=0·006) favouring extracorporeal CPR over conventional CPR. Interpretation Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin. Funding National Science Council, Taiwan.
Microcirculatory dysfunction develops in both septic and cardiogenic shock patients, and it is associated with poor prognosis in patients with septic shock. Information on the association between ...microcirculatory dysfunction and prognosis in cardiogenic shock patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is limited.
Sublingual microcirculation images were recorded using an incident dark-field video microscope at the following time points: within 12 h (T1), 24 h (T2), 48 h (T3), 72 h (T4), and 96 h (T5) after VA-ECMO placement. If a patient could be weaned off VA-ECMO, sublingual microcirculation images were recorded before and after VA-ECMO removal. Microcirculatory parameters were compared between 28-day nonsurvivors and survivors with VA-ECMO support. In addition, the microcirculation and clinical parameters were assessed as prognostic tests of 28-day mortality, and patients were divided into three subgroups according to microcirculation parameters for survival analysis.
Forty-eight patients were enrolled in this study. At T1, the observed heart rate, mean arterial pressure, inotropic score and lactate level of 28-day nonsurvivors and survivors did not differ significantly, but the perfused small vessel density (PSVD) and proportion of perfused vessels (PPV) were lower in the 28-day nonsurvivors than in the survivors. The PSVD and PPV were slightly superior to lactate levels in predicting 28-day mortality (area under curve of 0.68, 0.70, and 0.62, respectively). The subgroup with the lowest PSVD (< 15 mm/mm
) and PPV (< 64%) values exhibited less favorable survival compared with the other two subgroups.
Early microcirculatory parameters could be used to predict the survival of cardiogenic shock patients with VA-ECMO support.
ClinicalTrials.gov, NCT02393274 . Registered on 19 March 2015.
Background
Pulmonary artery (PA) cannulation is an effective extracorporeal life support (ECLS) management for left ventricular (LV) decompression or right ventricular (RV) support. This case series ...explores the results of PA cannulation during ECLS for acute cardiac failure.
Methods
Patients receiving percutaneous PA cannulation between January 2017 and December 2020 in a single institution were retrospectively reviewed. Patients receiving PA cannulation by a surgical cutdown method were excluded. Based on the hemodynamic needs of the patients, percutaneous PA cannulation was applied with ECLS for LV unloading and/or RV support. The primary endpoint was the successful weaning from circulatory support. The secondary endpoints included 30‐day or in‐hospital mortality, significant periprocedural complications, and successful hospital discharge without major complications.
Results
Fifteen patients (13 men, age range 11.2–70.8 years) presented acute heart failure and were initially managed by conventional ECLS mode. Percutaneous PA cannulation was performed for LV unloading in 13 patients (86.67%) and isolated RV circulatory support in two patients (13.33%). Weaning from circulatory support was achieved in 11 patients (73.33%). No significant periprocedural complication, including bleeding, infection, or vascular event requiring surgical exploration, was reported. The 30‐day or in‐hospital mortality rate was 33.33%. Eight cases (53.33%) were successfully discharged without major complications, including permanent stroke or the need for long‐term hemodialysis.
Conclusions
PA cannulation, especially percutaneously performed, was effective and safe for LV unloading and/or RV support during ECLS. Further investigation is required to confirm the efficacy and safety of our approach and management in a larger patient population.
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