Download Expanding the Availability of Extracorporeal

Expanding the Availability of Extracorporeal
Cardiopulmonary Resuscitation
abstract
A healthy 14-year-old presented to an emergency department in
Alaska, complaining of shortness of breath, chest pain, and 72 hours
of malaise and headache. On admission, her blood pressure was 80/
50 mm Hg, and she had cool extremities. Electrocardiography
revealed wide-complex ventricular tachycardia. She underwent synchronized electrical cardioversion. Although she initially converted to
sinus rhythm, she subsequently became pulseless, with electrocardiographic evidence of ventricular tachycardia. Despite cardiopulmonary resuscitation, she failed to achieve a perfusing rhythm.
Cardiovascular surgery consultation was obtained, and she was
placed on partial cardiopulmonary bypass during 2 hours of ongoing
chest compressions. Cardiopulmonary bypass flow was limited by the
small size of her femoral arteries. She remained in refractory ventricular tachycardia. The cardiopulmonary bypass circuit was modified for transportation of the patient via air ambulance 1500 miles to
a tertiary medical center that specializes in pediatric heart failure
and mechanical cardiopulmonary support. Upon arrival at the tertiary
medical center, she underwent carotid artery cannulation to improve
total cardiopulmonary support and percutaneous balloon atrial
septostomy to facilitate left ventricular decompression. Intravenous
immunoglobulin and steroids were administered to treat presumed
acute fulminant viral myocarditis. Extracorporeal life support was
support was successfully discontinued after 14 days, but she experienced a thromboembolic stroke. The patient was discharged on hospital day 65 with moderate generalized left-sided weakness, but she
was able to ambulate with minimal assistance. She subsequently
returned to school and is progressing appropriately with her peers.
Cardiac function has normalized, and she remains in normal sinus
rhythm. Pediatrics 2013;131:e934–e938
e934
McMULLAN
AUTHOR: D. Michael McMullan, MD
Division of Pediatric Cardiac Surgery, Seattle Children’s Hospital,
Seattle, Washington
KEY WORDS
extracorporeal life support, cardiopulmonary resuscitation,
extracorporeal membrane oxygenation, extracorporeal
cardiopulmonary resuscitation
ABBREVIATIONS
CPR—cardiopulmonary resuscitation
ECMO—extracorporeal membrane oxygenation
ECPR—extracorporeal cardiopulmonary resuscitation
www.pediatrics.org/cgi/doi/10.1542/peds.2011-2371
doi:10.1542/peds.2011-2371
Accepted for publication Oct 29, 2012
Address correspondence to D. Michael McMullan, MD, Seattle
Children’s Hospital, 4800 Sand Point Way NE, M/S G-0035, Seattle,
WA 98105-0371. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The author has indicated he has no
financial relationships relevant to this article to disclose.
FUNDING: No external funding.
CASE REPORT
Approximately 1% to 2% of all pediatric
patients who are admitted to a hospital
will require cardiopulmonary resuscitation (CPR) for acute cardiopulmonary
failure.1,2 Despite the publication of
standardized Pediatric Advanced Life
Support consensus recommendations3
and subsequent evidence-based revisions,4 overall survival from in-hospital
cardiac arrest and CPR has remained
,30% for .50 years.5–7 Effective CPR
and early return of spontaneous perfusing cardiac rhythm are associated
with improved survival, whereas survival in patients after .60 minutes of
CPR is rare.8,9
The application of extracorporeal life
support during cardiopulmonary resuscitation (ECPR) has been shown to
improve survival in adults10 and children.11 Recognition of this improved
survival benefit has led to increased
use of ECPR over time, with .2400
cumulative cases reported to the Extracorporeal Life Support Registry in
2011.12 However, the provision of salvage extracorporeal life support is
costly13 and generally requires dedicated hospital resources, which restricts universal availability of this
therapeutic option. Despite these limitations, ECPR may be used on an ad hoc
basis in centers without a dedicated
extracorporeal life support program.
This report describes the case of
a child who received ECPR in a hospital
that does not provide extracorporeal
membrane oxygenation (ECMO) services
and the subsequent transportation of
the child to a center that specializes in
extracorporeal life support.
PATIENT PRESENTATION
In October 2010, a previously healthy 14year-old girl (57 kg, 163 cm in height)
presented to the emergency department of a hospital in Alaska, complaining of shortness of breath and
chest pain. She described malaise,
dizziness, anorexia, and headache
PEDIATRICS Volume 131, Number 3, March 2013
during the preceding 72 hours and
denied recreational drug use. On admission, her blood pressure was 80/50
mm Hg, and she had cool extremities.
Electrocardiography revealed widecomplex ventricular tachycardia with
a heart rate of 130 beats per minute.
She underwent sedated, biphasic synchronized electrical cardioversion with
150 J. Although she initially converted
to sinus rhythm for 90 seconds, she
subsequently became pulseless, with
electrocardiographic evidence of ventricular tachycardia. CPR was initiated.
Nonperfusing, wide-complex ventricular tachycardia was refractory to additional multiple additional attempts at
electrical cardioversion (200 J) and
administration of sodium bicarbonate,
calcium chloride, lidocaine, amiodarone, and milrinone. During resuscitation efforts, femoral venous and
arterial catheters were inserted. The
adequacy of CPR was ascertained by
the presence of palpable femoral pulses and pulsatile arterial catheter
tracings during chest compressions.
CPR was briefly (,1 minute) discontinued intermittently to perform
transthoracic echocardiographic imaging. The patient had no spontaneous
circulation during these periods.
Echocardiography revealed left ventricular dilation with severely depressed systolic function. The patient
developed significant acidemia (arterial blood pH = 7.1).
Cardiovascular surgery consultation
was obtained for urgent mechanical
cardiopulmonary support. The patient
was taken to the operating room where
she was noted to have hemorrhagic
pulmonary edema. Partial cardiopulmonary bypass was initiated using
right femoral artery (14F catheter) and
vein (22F catheter) cannulation during
ongoing chest compressions. Cardiopulmonary bypass flow was limited (20
mL/kg per minute) by the small size of
the femoral artery, which prevented
insertion of a larger cannula. The total
duration of CPR had been 2 hours when
cardiopulmonary bypass was initiated.
Although arterial pH improved from
7.07 to 7.31 during 1 hour of femoralfemoral bypass, the patient remained
in refractory ventricular tachycardia
and required epinephrine infusion to
maintain systolic blood pressure near
100 mm Hg. The cardiopulmonary
bypass circuit, which consisted of a
Medtronic BP80 centrifugal pump, an
Affinity NT oxygenator, and a BioConsole 560 Speed Controller System
(Medtronic, Minneapolis, MN), was configured to enable cardiopulmonary bypass support of the patient during
transportation via air ambulance 1500
miles to Seattle Children’s Hospital,
a center that specializes in pediatric
heart failure and mechanical cardiopulmonary support. Continuous epinephrine infusion with additional
intermittent boluses, packed red blood
cells, and sodium bicarbonate were
administered during transportation to
maintain adequate blood pressure.
Upon the patient’s arrival at Seattle
Children’s Hospital, she had widecomplex tachycardia (140 beats per
minute), hypotension, anuria, and bloody
pulmonary edema. Left ventricular systolic dysfunction and dilation were
noted by transthoracic echocardiography. Additional attempts at electrical
cardioversion were unsuccessful. The
patient was taken to the operating room
and underwent exchange of the 14F
femoral artery catheter for a 19F right
common carotid catheter and insertion
of an additional 23F right internal jugular catheter to improve total cardiopulmonary support. She was then
transferred to the cardiac catheterization suite, where she underwent percutaneous balloon atrial septostomy
and placement of a stent across the
foramen ovale to facilitate left ventricular decompression. Although an
endomyocardial biopsy may have proven
e935
beneficial in this patient’s clinical management, a biopsy was not performed at
that time. Continuous intravenous
amiodarone infusion was initiated. The
patient was cooled to 34°C and subjected
to pharmacologic muscle relaxation for
72 hours to reduce oxygen demand. Renal function briefly improved after
achieving improved ECMO support, consistent with the presence of acute tubular necrosis related to prolonged
resuscitation and limited ECMO perfusion. However, she subsequently experienced increasing serum creatinine
levels and complete anuria, necessitating the addition of continuous renal replacement therapy to the ECMO circuit.
Continuous renal replacement therapy
was discontinued with a return of intrinsic renal function after 10 days of
ECMO support.
The patient’s history, presentation,
and echocardiographic findings were
consistent with the diagnosis of acute
fulminant myocarditis. Serum viral titers, which were obtained because of
the presumed diagnosis of viral myocarditis, were negative. Intravenous
immunoglobulin and steroids were administered. Although the patient converted to sinus rhythm within 48 hours
of ECMO, she required intravenous lidocaine infusion and electrical cardioversion for intermittent return of
ventricular tachycardia. Serial transthoracic echocardiographic evaluations revealed improved ventricular
function. She began to follow commands on the 11th day of mechanical
cardiopulmonary support. ECMO was
discontinued after 14 days and cannulae were removed. Reconstruction of
the right common carotid artery and
internal jugular vein was performed.
The following day, the patient was
noted to exhibit left-sided weakness.
The results of computed tomographic
cerebral angiography were consistent
with focal embolic occlusion of the
right middle cerebral artery, without
e936
McMULLAN
evidence of hemorrhagic sequelae.
Subsequent MRI confirmed an acute
focal infarct but did not indicate diffuse
hypoxic ischemic brain injury. Mechanical ventilation was discontinued,
and the patient was extubated 4 days
after discontinuation of ECMO. She was
transitioned to oral amiodarone, carvedilol, warfarin, and tapered prednisone.
The patient was discharged on hospital
day 65. At the time of discharge she
exhibited moderate generalized leftsided weakness but was able to ambulate with minimal assistance. She has
returned to school where she participates in competitive sports and continues to be an “A” student. She has no
discernable physical or intellectual
sequelae of cerebral infarct. Cardiac
function has normalized, and she
remains in normal sinus rhythm.
DISCUSSION
This case highlights the importance of
appropriately performed CPR and the
improved survival associated with the
use of ECPR. Although overall survival in
patients requiring CPR for acute cardiopulmonary failure has remained
,30% for more than half a century,5,6,14
survival of individual patients appears
to correlate with early initiation of CPR
and the quality of CPR being performed.15 Myocardial, cerebral, and
peripheral oxygen delivery during CPR
is dependent on external compressive
forces that squeeze the heart between
the sternum and spine to forcibly eject
blood into the pulmonary and systemic
circulations. The appropriate timing
and force of compressions are critical
to achieve optimal systemic perfusion
and oxygen delivery. It has been shown
that systemic blood pressure and endtidal carbon dioxide, an indicator of
pulmonary perfusion, directly correlate with the compressive force applied
during CPR, with compressive forces
.16.7 pounds per square inch pro-
ducing the greatest changes in these
indexes in adults.16 However, the quality of CPR chest compressions decreases quickly, with only 18% of chest
compressions being performed correctly after 3 minutes of CPR by a single
provider.17 This may be an important
contributing factor in the observation
that 30-day survival decreases by 5%
with each elapsed minute of CPR.1 The
recently updated 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care recommend that
the task of chest compressions should
rotate every 2 minutes when multiple
rescuers are available.18
When compared with CPR alone, the use
of ECMO as an adjunct to CPR has been
shown to significantly improve survival
in children19 and adults.20 By using a
propensity-score–based analysis, Chen
et al8 observed that adult patients who
received ECPR were twice as likely to
survive than patients who received
conventional CPR alone when ECMO
was initiated #30 minutes of arrest.
Furthermore, the observed survival
benefit of ECPR increased with longer
duration of chest compressions. Although survival after 60 minutes of CPR
is generally ,1%, ∼18% of the patients
in their study who were placed on
ECMO after 60 minutes of CPR survived
to hospital discharge in their study. In
contrast, a recent retrospective, singlecenter study in pediatric patients
reported no survivors when ECPR was
initiated after $50 minutes of CPR.9 It
is unlikely that a randomized controlled trial of ECPR versus conventional CPR will ever be performed.
However, the available data supporting
a true survival benefit of ECPR are
compelling enough that the American
Heart Association Pediatric Advanced
Life Support guidelines state that
ECPR may be considered for children
with a potentially reversible cause of
cardiac arrest that is refractory to
CASE REPORT
standard resuscitation attempts, because long-term survival is possible
even after .50 minutes of standard
CPR.4 As of October 2012, 88 centers in
the United States have reported the use
of ECPR to the Extracorporeal Life Support Organization, with overall survival
rates ranging from 27% in adults10 to
39% to 41% in pediatric patients.12,21
ECMO and ECPR are costly therapeutic
interventions. However, the results
of several cost-effectiveness analyses
suggest that increased ECMO-related
hospital costs are justified on a costutility basis.13,22 The estimated costutility for salvage ECMO ranges from
$20 88023 to $24 38613 per qualityadjusted life-year saved, which is
less than half the cost of pediatric
heart transplantation ($49 679 per
quality-adjusted life-year saved).24 The
cost-utility for ECPR and the effects of
center volume and/or center centralization on cost-utility are unknown.
Although no studies have critically
examined the actual institutional
costs of maintaining a dedicated ECMO
program, ECMO equipment and personnel costs are not insignificant.
Many low-volume centers may find the
cost of developing and maintaining
ECMO and ECPR programs to be prohibitively expensive. However, maintaining an in-house rapid-response
ECPR team and preprimed ECMO
equipment is not necessary to perform
ECPR.25 Most centers that perform cardiac surgery possess the basic equipment that is necessary to perform ECPR
on an ad hoc basis. As described in this
report, a standard cardiopulmonary
bypass circuit may be modified for use
as an ECPR circuit and then used to
support a patient during transportation
to a center that specializes in heart
failure and extracorporeal life support.
The risks and challenges of applying
ECMO, a highly complex therapy, in an
unusual setting must be weighed
against the potential survival benefit of
ECPR. Standard inclusion and exclusion
criteria for ECPR have not been established. Although it seems intuitive that
ECPR survival should be greatest in
otherwise healthy patients with few
comorbid conditions who experience
a witnessed cardiac arrest with immediate and adequate CPR, the decision to
initiate ECPR is ultimately based on the
availability of resources and clinical
judgment of care providers. Studies that
provide information related to optimal
patient selection, survival, and complications of ECPR in low-volume centers
would be welcome additions to the literature.
The transportation of ECMO patients by
ground and air ambulance has been
performed by a number of centers in
the North America, Europe, Asia, and
Australia.26,27 In most cases, a specialized ECMO center sends a team to the
requesting hospital to place the patient
on ECMO and then the patient is
transported to the specialized center.
Although the safety and effectiveness
of this approach have been demonstrated, the interval of time between
initial request and initiation of ECMO
support is typically several hours.27
Consequently, such a process is not
applicable in situations in which a patient has experienced cardiac arrest
and is receiving chest compressions.
However, establishing some form of
extracorporeal life support after cardiac arrest can stabilize patients so
that arrangements can be made for
transportation to a center that specializes in extracorporeal life support,
as this case clearly illustrates.
In summary, survival after cardiac arrest is dependent on several factors, not
the least of which are the resuscitation
team’s determination and willingness
to explore every therapeutic strategy.
The heroic efforts of this child’s initial
care providers enabled her to be rescued by using ECPR, even without
a dedicated ECMO/ECPR program, and
transported to a specialized center.
This case highlights the notion that the
survival benefits of ECPR may be applicable to patients across a broader
spectrum of medical centers.
“Never give up, for that is just the place
and time that the tide will turn.”
—Harriet Beecher Stowe
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