Abstract
Aim
Describe the lung injury patterns among patients presenting with refractory ventricular
tachycardia/ventricular fibrillation out-of-hospital cardiac arrest (VT/VF OHCA) supported
with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) facilitated resuscitation.
Methods
In this retrospective single-center cohort study including VT/VF OHCA patients supported
with VA ECMO, we compared OHCA characteristics, post-arrest computed tomography (CT)
scans, ventilator parameters, and other lung-related pathology between survivors,
patients who developed brain death, and those with other causes of death.
Results
Among 138 patients, 48/138 (34.8%) survived, 31/138 (22.4%) developed brain death,
and 59/138 (42.7%) died of other causes. Successful extubation was achieved in 39/138
(28%) with a median time to extubation of 8.0 days (6.0, 11.0) in those who survived.
Tracheostomy was required in 15/48 (31.3%) survivors. Chest CT obtained on all patients
showed lung injury in at least one lung area in 124/135 (91.8%) patients, predominantly
in the dependent posterior areas. There was no association between the number of affected
areas and survival. Lung compliance was low on admission [26 (19,33) ml/cmH20], improved throughout hospitalization (p = 0.03), and recovered faster in survivors
compared to those who died (p < 0.001). VA-ECMO allowed the use of lung-protective
ventilation while maintaining normalized PaO2 and PaCO2. Patients treated with V-A ECMO and either IABP or Impella had lower pulmonary compliance
and more affected areas on their CT compared to those treated with V-A ECMO alone.
Conclusions
Lung injury is common among patients with refractory VT/VF OHCA requiring V-A ECMO,
but imaging severity is not associated with survival. Reductions in lung compliance
accompany post-arrest lung injury while compliance recovery is associated with survival.
Keywords
Abbreviations:
OHCA (Out-of Hospital Cardiac Arrest), CPR (Cardiopulmonary resuscitation), LV (Left Ventricle), V-A ECMO (Veno-arterial Extracorporeal Membrane Oxygenator), ECPR (Extracorporeal cardiopulmonary resuscitation), ROSC (Return of Spontaneous Circulation), VT/VF (ventricular tachycardia or ventricular fibrillation), CAD (Coronary artery disease), PCI (percutaneous coronary intervention), IABP (intra-aortic balloon pump), PEEP (Positive end expiratory pressure), CT (Computed tomography)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to ResuscitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The Minnesota mobile extracorporeal cardiopulmonary resuscitation consortium for treatment of out-of-hospital refractory ventricular fibrillation: Program description, performance, and outcomes.EClinicalMedicine. 2020; 29–30: 100632https://doi.org/10.1016/j.eclinm.2020.100632
- Chest compression fraction: A time dependent variable of survival in shockable out-of-hospital cardiac arrest.Resuscitation. 2015; 97: 129-135https://doi.org/10.1016/j.resuscitation.2015.07.003
- Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest.The New England Journal of Medicine. 2011; 365: 787-797https://doi.org/10.1056/NEJMoa1010076
- Heart disease and stroke statistics-2020 update: A report from the American heart association.Circulation. 2020; 141: e139-e596https://doi.org/10.1161/CIR.0000000000000757
- The evolving role of the cardiac catheterization laboratory in the management of patients with out-of-hospital cardiac arrest: A scientific statement from the American heart association.Circulation. 2019; 139: e530-e552https://doi.org/10.1161/CIR.0000000000000630
- Improved survival with extracorporeal cardiopulmonary resuscitation despite progressive metabolic derangement associated with prolonged resuscitation.Circulation. 2020; 141: 877-886https://doi.org/10.1161/CIRCULATIONAHA.119.042173
- Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).Resuscitation. 2015; 86: 88-94https://doi.org/10.1016/j.resuscitation.2014.09.010
- Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.Lancet. 2020; 396: 1807-1816https://doi.org/10.1016/S0140-6736(20)32338-2
- Surviving refractory out-of-hospital ventricular fibrillation cardiac arrest: Critical care and extracorporeal membrane oxygenation management.Resuscitation. 2018; 132: 47-55https://doi.org/10.1016/j.resuscitation.2018.08.030
- Acute respiratory failure and inflammatory response after out-of-hospital cardiac arrest: results of the Post-Cardiac Arrest Syndrome (PCAS) pilot study.European Heart Journal Acute Cardiovascular Care. 2020; 9: S110-S121https://doi.org/10.1177/2048872619895126
- The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes.Resuscitation. 2019; 135: 37-44https://doi.org/10.1016/j.resuscitation.2019.01.009
- Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council.Circulation. 2008; 118: 2452-2483https://doi.org/10.1161/CIRCULATIONAHA.108.190652
- Multiple organ dysfunction after return of spontaneous circulation in postcardiac arrest syndrome.Critical Care Medicine. 2013; 41: 1492-1501https://doi.org/10.1097/CCM.0b013e31828a39e9
- Post cardiac arrest syndrome: a review of therapeutic strategies.Circulation. 2011; 123: 1428-1435https://doi.org/10.1161/CIRCULATIONAHA.110.988725
- High plasma levels of pro-inflammatory factors interleukin-17 and interleukin-23 are associated with poor outcome of cardiac-arrest patients: a single center experience.BMC Cardiovascular Disorders. 2020; 20: 170https://doi.org/10.1186/s12872-020-01451-y
- Acute lung injury after mechanical circulatory support implantation in patients on extracorporeal life support: an unrecognized problem.European Journal of Cardio-Thoracic Surgery. 2013; 44: 544-549https://doi.org/10.1093/ejcts/ezt125
- Parenchymal lung injuries related to standard cardiopulmonary resuscitation.The American Journal of Emergency Medicine. 2017; 35: 117-121https://doi.org/10.1016/j.ajem.2016.10.036
- Ventilator management and respiratory care after cardiac arrest: oxygenation, ventilation, infection, and injury.Chest. 2018; 153: 1466-1477https://doi.org/10.1016/j.chest.2017.11.012
- The incidence and significance of emesis associated with out-of-hospital cardiac arrest.Resuscitation. 2007; 74: 427-431https://doi.org/10.1016/j.resuscitation.2007.01.038
- Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest.Resuscitation. 2007; 73: 29-39https://doi.org/10.1016/j.resuscitation.2006.08.016
- Minnesota resuscitation consortium's advanced perfusion and reperfusion cardiac life support strategy for out-of-hospital refractory ventricular fibrillation.Journal of the American Heart Association. 2016; 5https://doi.org/10.1161/JAHA.116.003732
- Outcomes associated with delayed enteral feeding after cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation and targeted temperature management.Resuscitation. 2021; 164: 20-26https://doi.org/10.1016/j.resuscitation.2021.04.029
- The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.Intensive Care Medicine. 1996; 22: 707-710https://doi.org/10.1007/BF01709751
- APACHE II: a severity of disease classification system.Critical Care Medicine. 1985; 13: 818-829
- Regional distribution of gas and tissue in acute respiratory distress syndrome. III. Consequences for the effects of positive end-expiratory pressure. CT Scan ARDS Study Group. Adult Respiratory Distress Syndrome.Intensive Care Medicine. 2000; 26: 1215-1227https://doi.org/10.1007/s001340051340
- Detection of fibroproliferation by chest high-resolution CT scan in resolving ARDS.Chest. Nov 2014; 146: 1196-1204https://doi.org/10.1378/chest.13-2708
Marino PL. The ICU Book. 4th ed. 2014.
- Early-onset pneumonia after cardiac arrest: characteristics, risk factors and influence on prognosis.American Journal of Respiratory and Critical Care Medicine. 2011; 184: 1048-1054https://doi.org/10.1164/rccm.201102-0331OC
- Differential hypoxemia during venoarterial extracorporeal membrane oxygenation.Perfusion. 2019; 34: 22https://doi.org/10.1177/0267659119830513
- Regional distribution of gas and tissue in acute respiratory distress syndrome. I. Consequences for lung morphology. CT Scan ARDS Study Group.Intensive Care Medicine. 2000; 26: 857-869https://doi.org/10.1007/s001340051274
- The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest.Resuscitation. 2022; 174: 53-61https://doi.org/10.1016/j.resuscitation.2022.03.016
- Pulmonary edema following generalized tonic clonic seizures is directly associated with seizure duration.Seizure. 2015; 27: 19-24https://doi.org/10.1016/j.seizure.2015.02.023
- Postictal pulmonary oedema: a review of the literature.Revista de Neurologia. 2019; 68 (Edema pulmonar postictal: revision de la bibliografia): 339-345https://doi.org/10.33588/rn.6808.2018356
- Neurogenic pulmonary edema in head injuries: analysis of 5 cases.Chinese Journal of Traumatology. 2005; 8 (172-4, 178)
- Extracorporeal membrane oxygenation for acute life-threatening neurogenic pulmonary edema following rupture of an intracranial aneurysm.Journal of Korean Medical Science. 2013; 28: 962-964https://doi.org/10.3346/jkms.2013.28.6.962
- Left ventricle unloading by percutaneous pigtail during extracorporeal membrane oxygenation.Interactive Cardiovascular and Thoracic Surgery. 2011; 13: 293-295https://doi.org/10.1510/icvts.2011.269795
- Concomitant implantation of Impella((R)) on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock.European Journal of Heart Failure. 2017; 19: 404-412https://doi.org/10.1002/ejhf.668
- Incidence and implications of left ventricular distention during venoarterial extracorporeal membrane oxygenation support.ASAIO Journal. 2017; 63: 257-265https://doi.org/10.1097/MAT.0000000000000553
- Echocardiographic evaluation of cardiac recovery after refractory out-of-hospital cardiac arrest.Resuscitation. 2020; 154: 38-46https://doi.org/10.1016/j.resuscitation.2020.06.037
Article info
Publication history
Published online: November 25, 2022
Accepted:
November 21,
2022
Received in revised form:
November 19,
2022
Received:
August 25,
2022
Identification
Copyright
Published by Elsevier B.V.
