ABSTRACT
Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Service, Hospital/organization & administration , Extracorporeal Membrane Oxygenation , Out-of-Hospital Cardiac Arrest/therapy , Program Development , Cardiopulmonary Resuscitation/methods , Extracorporeal Membrane Oxygenation/methods , Humans , Interdisciplinary Communication , Life Support Systems , Out-of-Hospital Cardiac Arrest/mortality , Program Evaluation , Survival Rate , United StatesABSTRACT
PURPOSE: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS: Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.
