Introduction:
Cardiac arrest is traditionally treated with advanced cardiovascular life support, which includes high-quality CPR (cardiopulmonary resuscitation), the standard dose of epinephrine, rapid defibrillation, and antiarrhythmic medication that facilitates successful defibrillation and increases return of spontaneous circulation and maintains stable hemodynamic state. In some cases of cardiac arrest, prolonged resuscitation efforts are required. This prolonged CPR, along with mechanical CPR by trained personnel, an impedance threshold device, and extracorporeal cardiopulmonary resuscitation.
What Is Extracorporeal Cardiopulmonary Resuscitation?
Extracorporeal cardiopulmonary resuscitation is an emerging concept and therapy used in cardiac arrest and cardiopulmonary resuscitation. Significant improvement in favorable outcomes, survival to discharge, and neurologically intact survival. At the same time, conventional CPR procedures provide about a quarter of normal cardiac output. ECPR provides sufficient perfusion to the vital organs and reduces the duration of low flow status. Maintenance of the targeted temperature and rapid achievement is possible with ECPR due to the availability of heat exchangers. ECRP is also facilitated in coronary interventions and individuals with sustained ventricular fibrillation, as VA-ECMO provides stable systemic perfusion.
What Is ECMO (Extracorporeal Membrane Oxygenation)?
ECMO is extracorporeal membrane oxygenation. In ECMO, the blood is pumped outside the body to a machine that removes the carbon dioxide and sends oxygen-filled blood back to the tissues of the body. ECMO is commonly used in situations where the heart and lungs need help to heal. The ECMO machine is similar to a heart-lung bypass machine and is used in open-heart surgery. This pumps and oxygenates the individual's blood outside the body. Depending on per indication, there are mainly two main setups: veno arterial and veno venous. Veno arterial ECMO provides both hemodynamic and respiratory support. ECMO circuit here is connected parallel with the heart and lungs, while the venovenous ECMO is a circuit connected to a series of lungs and heart. In veno arterial ECMO, blood may bypass both the lungs and heart.
VA- ECMO is a temporary mechanical circulatory support system that enables immediate and complete cardiopulmonary support in cardiac arrest or cardiogenic shock. This consists of a centrifugal pump that is capable of propelling around 8 L/min of blood and arterial return cannulas and venous drainage. The heart continues to beat, but its work is easier as the ECMO machine pumps. The ECMO ensures the body has enough blood flow and temporarily manages the workload of the lungs and heart. ECMO does not treat the condition or cure the disease. It is a help provided to the body temporarily so as to provide oxygenated blood to the tissues. The most common sites used for establishing peripheral ECMO are the femoral vein, femoral artery, and internal jugular vein. In central ECMO aorta and right atrium are the preferred vessels.
What Are the Indications of Extracorporeal Cardiopulmonary Resuscitation?
The indication for CPR is done for the most controversial associated individuals. Major contributors of cofounders to various studies are undertaken to assess the feasibility and appropriateness of ECPR. The patient selection is made based on three-step criteria. This includes:
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An individual’s general health before the arrest. This requires rapid global assessment by a critical care physician.
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Overall goals of therapy are curative.
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Causal pathology of cardiac arrest is thought to be reversible with available surgical and medical intervention.
The guidelines of the extracorporeal cardiopulmonary series indicated are considered for both out-of-hospital cardiac arrest and in-hospital cardiac arrest.
1. Out-Of-Hospital Cardiac Arrest
The individuals are located within an appropriately equipped emergency department which is refractory to ACLS (standard advanced cardiac life support). The following criteria need to be met:
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A paramedic or a bystander witnessed the cardiac arrest.
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Cardiac arrest is likely to be the respiratory cause of primary cardiac arrest.
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Chest compression commenced within 10 mins.
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The patient is aged between 12 -70 years.
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The cardiac arrest duration <60 mins.
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No major comorbidities preclude a return to independent living.
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An individual is profoundly hypothermic due to accidental exposure.
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Significant overdose of a vaso-active drug.
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Cause where there is likely reversible cardiac arrest if artificial circulation is provided.
2. In-Hospital Cardiac Arrest
Individuals with hospital cardiac arrest are refractory to standard ACLS and may be reversible as:
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Individuals in cardiac catheterization undergoing coronary angiography suffer cardiac arrest and do not immediately respond to standard ACLS.
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Individuals with suspected massive pulmonary embolism.
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For individuals with the acute coronary syndrome who do not respond to standard ACLS is reversible with treatment.
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Another cause is the reversibility of the underlying condition if artificial circulation is provided.
What Are the Contraindications of Extracorporeal Cardiopulmonary Resuscitation?
There are no specific contraindications, and many studies and guidelines are adopted in the use of the ECPR:
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Premorbid severe neurological impairment like dementia, stroke, and traumatic brain injury.
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Total arrest time that is greater than 60 mins.
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The shock is secondary to hemorrhage or sepsis.
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Chest compressions within 10 mins of commencement of cardiac arrest.
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Presence of “not for resuscitation” order.
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No realistic reversal of underlying cardiac and respiratory pathology.
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Improperly trained and equipped staff available to initiate extracorporeal cardiopulmonary resuscitation.
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Extended ICU admission for requiring mechanical support.
What Are the Complications of Extracorporeal Cardiopulmonary Resuscitation?
The complications of extracorporeal cardiopulmonary resuscitation in any circumstances are technically difficult and invasive. In addition, the risk associated with the initial process of connecting the individual with an extracorporeal life support device is exacerbated by the emergent nature of ECMO CPR. The recent observational complications are in one-quarter of individuals. The complications include initial application and extracorporeal oxygenation circuit. The complications are:
Conclusion:
Extracorporeal cardiopulmonary resuscitation is a life-saving therapy used in refractory ventricular dysrhythmias. Successful implementation of ECPR from the prehospital arena to the intensive care unit. It is better to understand ECPR for emergency developing multidisciplinary ECPR pathways. Thai functions as bridge therapy, enabling temporary systemic organ perfusion till the cause of cardiac failure can be treated. The major advantage of ECMO is it can maintain the supply of oxygen to the body while keeping the lungs at rest. An oxygenator, the ECMO circuit, relies on a motor to pump blood around.
