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Reply to Letter: “Extracoporeal life support treatment bundle for refractory cardiac arrest”
Resuscitation 87 (2015) e7
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Reply to Letter: “Extracoporeal life support treatment bundle for refractory cardiac arrest”
their practices, successes, and challenges so that we may all benefit.
Sir,
Conflict of interest statement
We thank Dr. Lazzeri and colleagues for their interest in our recent article. We also believe that it adds to a growing body of observational data demonstrating that extracorporeal life support (ECLS) shows promise as a rescue strategy for cardiac arrest. We agree wholeheartedly that ECLS is a treatment not to be implemented in isolation. Ideally, it should be one component of a comprehensive bundle of intra-arrest and post-arrest care that includes multiple interventions: immediate cardiopulmonary resuscitation (CPR) and defibrillation, rapid transport with highquality CPR in-progress, early initiation of ECLS by experienced providers, targeted temperature management, cutting-edge critical care, and definitive therapy aimed at reversing the underlying cause of the arrest, which often includes percutaneous coronary intervention. These interventions were implemented variably in our case series due to provider preference, largely because intraarrest cooling and percutaneous coronary intervention have not been definitively shown to confer a survival benefit in this population. Recent studies report neurologically intact survival among patients with out-of-hospital cardiac arrest treated with ECLS ranging from 12 to 45%.1–7 It is important to note that studies by Wang et al.,1 Fagnoul et al.,2 and the CHEER trial3 included only 31, 25, and 11 out-of-hospital cardiac arrest (OHCA) patients respectively. Our study included only 26 patients. It is difficult to say that outcomes in our study differed significantly from other recent studies when those differences may be attributable to fewer than five neurologically intact survivors. Additionally, the CHEER trial reported a 45% survival among the 11 patients who suffered OHCA, but 2 out of the 5 survivors did not actually receive ECLS (one due to failed cannulation and the other who achieved return of spontaneous circulation before ECLS was initiated). Thus, the per-protocol survival was 3/11 or 27%. As Lazzeri et al. suggest, some variation in survival may be attributable to patient selection, ECLS experience and volume, and adjunctive therapies, but may also stem from variability in prehospital care and prognostication practices. Interestingly, the vast majority of survivors in the studies discussed by Lazzeri et al. were neurologically intact. This differs from other recent studies, such as the SAVE-J trial, which reported that, among patients who received ECLS, 68% survived for 24 h, but only 12.4% were neurologically intact at 6 months.7 Clearly, larger, controlled studies are needed, but they are challenging to perform. What is clear from the current data is that ECLS is feasible for out-of-hospital cardiac arrest and shows great potential in multiple settings. We believe that ECLS for cardiac arrest represents the frontier of resuscitation, and encourage other groups to share
http://dx.doi.org/10.1016/j.resuscitation.2014.11.020 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
The authors report no conflict of interest to disclose. References 1. Johnson NJ, Acker M, Hsu CH, et al. Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. Resuscitation 2014. 2. Wang CH, Chou NK, Becker LB, et al. Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest. Resuscitation 2014;85:1219–24. 3. Fagnoul D, Taccone FS, Belhaj A, et al. Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest. Resuscitation 2013;84:1519–24. 4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2014. 5. Bellezzo JM, Shinar Z, Davis DP, et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitation. Resuscitation 2012;83:966–70. 6. Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med 2013;41:1186–96. 7. Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation 2014;85:762–8.
Nicholas Johnson ∗,1 Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, United States Cindy Hsu 1 R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States David F. Gaieski 1 Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, United States ∗ Corresponding
author at: Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, University of Washington Box 356522 Seattle, WA 98195–6522 E-mail address: [email protected] (N. Johnson) 1
Formerly of University of Pennsylvania, United States. 22 November 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Reply to Letter: “Extracoporeal life support treatment bundle for refractory cardiac arrest”
their practices, successes, and challenges so that we may all benefit.
Sir,
Conflict of interest statement
We thank Dr. Lazzeri and colleagues for their interest in our recent article. We also believe that it adds to a growing body of observational data demonstrating that extracorporeal life support (ECLS) shows promise as a rescue strategy for cardiac arrest. We agree wholeheartedly that ECLS is a treatment not to be implemented in isolation. Ideally, it should be one component of a comprehensive bundle of intra-arrest and post-arrest care that includes multiple interventions: immediate cardiopulmonary resuscitation (CPR) and defibrillation, rapid transport with highquality CPR in-progress, early initiation of ECLS by experienced providers, targeted temperature management, cutting-edge critical care, and definitive therapy aimed at reversing the underlying cause of the arrest, which often includes percutaneous coronary intervention. These interventions were implemented variably in our case series due to provider preference, largely because intraarrest cooling and percutaneous coronary intervention have not been definitively shown to confer a survival benefit in this population. Recent studies report neurologically intact survival among patients with out-of-hospital cardiac arrest treated with ECLS ranging from 12 to 45%.1–7 It is important to note that studies by Wang et al.,1 Fagnoul et al.,2 and the CHEER trial3 included only 31, 25, and 11 out-of-hospital cardiac arrest (OHCA) patients respectively. Our study included only 26 patients. It is difficult to say that outcomes in our study differed significantly from other recent studies when those differences may be attributable to fewer than five neurologically intact survivors. Additionally, the CHEER trial reported a 45% survival among the 11 patients who suffered OHCA, but 2 out of the 5 survivors did not actually receive ECLS (one due to failed cannulation and the other who achieved return of spontaneous circulation before ECLS was initiated). Thus, the per-protocol survival was 3/11 or 27%. As Lazzeri et al. suggest, some variation in survival may be attributable to patient selection, ECLS experience and volume, and adjunctive therapies, but may also stem from variability in prehospital care and prognostication practices. Interestingly, the vast majority of survivors in the studies discussed by Lazzeri et al. were neurologically intact. This differs from other recent studies, such as the SAVE-J trial, which reported that, among patients who received ECLS, 68% survived for 24 h, but only 12.4% were neurologically intact at 6 months.7 Clearly, larger, controlled studies are needed, but they are challenging to perform. What is clear from the current data is that ECLS is feasible for out-of-hospital cardiac arrest and shows great potential in multiple settings. We believe that ECLS for cardiac arrest represents the frontier of resuscitation, and encourage other groups to share
http://dx.doi.org/10.1016/j.resuscitation.2014.11.020 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
The authors report no conflict of interest to disclose. References 1. Johnson NJ, Acker M, Hsu CH, et al. Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. Resuscitation 2014. 2. Wang CH, Chou NK, Becker LB, et al. Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – a comparison with that for extracorporeal rescue for in-hospital cardiac arrest. Resuscitation 2014;85:1219–24. 3. Fagnoul D, Taccone FS, Belhaj A, et al. Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest. Resuscitation 2013;84:1519–24. 4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2014. 5. Bellezzo JM, Shinar Z, Davis DP, et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitation. Resuscitation 2012;83:966–70. 6. Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med 2013;41:1186–96. 7. Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation 2014;85:762–8.
Nicholas Johnson ∗,1 Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, United States Cindy Hsu 1 R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States David F. Gaieski 1 Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, United States ∗ Corresponding
author at: Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, University of Washington Box 356522 Seattle, WA 98195–6522 E-mail address: [email protected] (N. Johnson) 1
Formerly of University of Pennsylvania, United States. 22 November 2014