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Extracorporeal cardiopulmonary resuscitation in refractory intra‐operative cardiac arrest: a reply

Last post 12 Nov 2018, 10:26 PM by Stretch Ben. 0 replies.
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  •  12 Nov 2018, 10:26 PM 2688

    Extracorporeal cardiopulmonary resuscitation in refractory intra‐operative cardiac arrest: a reply

    Min’s retrospective analysis of Extra-corporeal Cardiopulmonary Resuscitation (ECPR) in refractory intra-operative cardiac arrest raises some interesting discussion points, particularly on the use of ECPR in hypovolaemic cardiac arrest [1]. However, it is impossible to draw conclusions in a small single centre study with such an heterogenous group of patients. Although all patients suffered intra-operative cardiac arrest, there are three important aetiological subgroups which must be analysed separately.

    Firstly, 5/23 patients had a presumed cardiac cause of arrest, which is already internationally recognised by the Resuscitation Council [2], American Heart Association [3] and Extracorpeal Life Support Organisation [4] as an indication for ECPR. As expected, this group had the best outcomes of 2/5 neurologically intact at discharge. It will be interesting to know more about the underlying cardiac pathology and whether ECPR was a bridge to further treatment such as percutaneous coronary intervention.

    Secondly, there are 3 patients who were placed on VV-ECMO for severe acute respiratory failure. A logical conclusion would be that VV ECMO is being used to treat hypoxia as a reversible cause of cardiac arrest. Although the authors describe this as ECPR, this is up for debate as this technique will not improve end organ perfusion and oxygen delivery without return of spontaenous circulation. I would invite the authors to comment on the advantages of VV ECMO over VA ECMO in patients in patients who remain in cardiac arrest secondary to respiratory failure.

    The third group includes 13 patients in refractory cardiac arrest secondary to massive haemorrhage. In this group, there were 3 patients with a meaningful survival despite prolonged cardiac arrest - better outcomes than the author’s predicted 10% survival with conventional management. Min et al. suggest that there may be role for ECPR in refractory hypovolaemic cardiac arrest - restoring end organ perfusion as a bridge to return of spontaneous circulation. Was haemostasis achieved in these cases? If not, was bleeding worsened by the use of intravenous heparin?

    Massive haemorrhage is not only the number one risk factor for intra-operative cardiac arrest, but also the most common preventable cause of death in major trauma [5]. Trauma patients in hypovolaemic cardiac arrest rarely survive - a retrospective study of 909 patients in cardiac arrest after trauma found only one survivor when the cause was exsanguination [5]. Can these results be extrapolated to include other causes of massive haemorrhage? The authors suggests a variety of reasons why a patient may remain in cardiac arrest despite control of bleeding and fluid resuscitation - hypothermia; electrolyte imbalance; severe acidosis; myocardial stunning; right ventricular failure and pulmonary oedema. Can ECPR provide adequate organ perfusion as a bridge to return of spontaenous circulation in these patients? What selection criteria will allow us to predict which patients can benefit from this technique?


    Benjamin Stretch

    Anaesthesia trainee, Barts and the London School of Anaesthesia



    [1] Min JJ, Tay CK, Ryu DK et al. Extracorporeal cardiopulmonary resuscitation in refractory intra-operative cardiac arrest: an observational study of 12-year outcomes in a single tertiary hospital. Anaesthesia 2018; 73: 1515–23.

    [2] Resus guidelines - Adult Advanced Life Support - https://www.resus.org.uk/resuscitation-guidelines/adult-advanced-life-support/#techniques

    [3] Goldberger Z.D., Chan P.S., Berg R.A et al. American Heart Association get with the guidelines – resuscitation I. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012; 380: pp. 1473-1481

    [4] ELSO ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.4 August 2017 Ann Arbor, MI, USA 

    [5] Curry NHopewell SDorée C et al. The acute management of trauma hemorrhage: a systematic review of randomized controlled trials. Critical Care 2011

    [6] Lockey D, Crewdson K and Davies G. Traumatic Cardiac Arrest: Who Are the surivors? Annals of Emergency Medicine 2006.


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