Review
Extracorporeal life support for refractory out-of-hospital cardiac arrest in adults

https://doi.org/10.1016/j.tacc.2016.06.001Get rights and content

Highlights

  • The role of ECLS for out-of-hospital cardiac arrest is discussed.

  • Techniques, management and strategies are examined.

  • Good quality bystander CPR and ECLS timing are crucial for successful ECLS.

  • Evidence-based inclusion criteria are highly desirable in the future.

Abstract

Survival with good neurological outcome after refractory out-of-hospital cardiac arrest is still low. During the last years, many national guidelines have tried to provide the best evidence-based practice and education to manage this medical challenge. Positive effects of extracorporeal life support for refractory in-hospital cardiac arrest have been found. On the other hand, the role of ECMO for refractory out-of-hospital cardiac arrest in adults is not well clarified, and results are more conflicting.

In this narrative review, we analyse recent updates of the scientific literature on ECMO and ECLS in adults, exploring the strategies and management of this promising and complex procedure.

Introduction

Out-of-hospital cardiac arrest (OHCA) is one of the major causes of death and neurological impairment [1]. In Europe, every year, 38 out of 100.000 persons are treated by emergency medical services (EMS) for OHCA. Survival to hospital discharge is still low, and ranges between 3.6% and 30.7% [2]. The key factor for a favourable outcome in OHCA patients is minimizing the duration of no or significantly reduced blood flow (e.g., no-flow time) to the organs, that is related to timing, quality, and duration of cardiopulmonary resuscitation (CPR) [3], [4], [5], [6].

Good quality CPR allows the transition from a no-flow phase (pre-CPR) to a (low-)flow phase (during CPR) depending on the quality of CPR and in order to maintain a minimum cerebral blood perfusion [4], [7]. This can be achieved either by an increase of bystander CPR rates [4], [8], [9], or by artificial methods to enhance blood flow, such as mechanical CPR devices (e.g., LUCAS [10] or AutoPulse© [11] etc.).

In this perspective, the role of extracorporeal membrane oxygenation (ECMO) has gained more and more importance during the last years, and, although with some limitations, it is now present in national guidelines [3], [8], [12]. Since the first experience of resuscitation with a cardiopulmonary portable bypass system on 39 moribund patients in the year 1969 [13], the use of extracorporeal life support (ECLS) has been associated with an improvement in outcome of in-hospital refractory cardiac arrest [14], [15], [16], while data for OHCA are less convincing [17], [18], [19], [20].

This review aims to explore and discuss the open questions about the strategy (inclusion criteria, best timing, technique), the quality of resuscitation (in terms of mortality and/or neurological sequelae), the complications and the further use of ECLS for refractory OHCA adult patients through the analysis of the literature of the last five years.

Section snippets

Methods

Research of published data about the use of ECLS for OHCA was made in the MEDLINE database (http://www.pubmed.org). In order to identify relevant articles, we used all combinations of the terms “ECLS” or “ECMO” or “ECPR” or “extracorporeal life support” or “extracorporeal resuscitation” and “out-of-hospital cardiac arrest” or “OHCA” or “pre-hospital cardiac arrest” (Table 1).

Analysis was limited to January 1st, 2010, until May 31st, 2015, to identify only recent publications. We included all

Discussion

A first attempt of ECLS at the patient's bedside with a portable cardiopulmonary bypass was made in the USA and dates back on the early 1970s [13]. During the past years other experiences followed [21], [22], [23], [24] and showed low rate of survival for cardiogenic shock due to cardiac arrest.

Following these first experiences, significant improvements were made in the ECLS treatment for in-hospital cardiac arrest [14], [15], [16], [22], [23], intoxication [25], and hypothermia [26], [27], but

Conclusion

Despite the improvement in medical knowledge and technology, treatment of OHCA remains a difficult challenge, with still low probability to survive with good neurological functions. ECLS could play an important role to restore sufficient blood flow for organ perfusion. Continuous education and training in Basic Life Support (BLS) are essential to increase the rate of bystander CPR. New strategies for ECLS, particularly for out-of-hospital setting, could be taken into account to reduce low-flow

Conflicts of interest

None.

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