key: cord-0029744-yxtj6h5h
authors: Magnet, Ingrid; Poppe, Michael
title: Extrakorporale Reanimation – Kriterien, Bedingungen, Outcome: Ein Reality-Check
date: 2022-04-11
journal: Med Klin Intensivmed Notfmed
DOI: 10.1007/s00063-022-00913-9
sha: 46646f9b4ba462f5c15df8f3174932455f2ea915
doc_id: 29744
cord_uid: yxtj6h5h

In select patients, in whom conventional cardiopulmonary resuscitation (cCPR) fails to re-establish circulation, the 2021 European Resuscitation Council guidelines suggest considering extracorporeal resuscitation (eCPR) as a rescue therapy in settings in which it can be implemented. eCPR is becoming established during refractory cardiac arrest as a bridge-to-therapy for diagnosis and treatment of reversible causes of cardiac arrest, such as myocardial infarction, pulmonary embolism, accidental hypothermia, overdose with cardiotoxic substances, and acute hypoxia. Patient selection criteria comprise prognostic characteristics of cardiac arrest such as witnessed status, resuscitation efforts within 5 min, shockable initial rhythm, and characteristics of effective cCPR such as signs of life during resuscitation, persistent ventricular fibrillation, intermittent episodes of spontaneous circulation or end-tidal CO(2) levels constantly > 10 mm Hg, patient age and health status. The timeframe from cardiac arrest to eCPR is a major contributor for neurologically favourable survival and should not exceed 60 min according to current guidelines. This may be achieved with an efficient “load & go” strategy, including early patient selection and rapid transport with ongoing mechanical cCPR to the eCPR centre, or with a prehospital eCPR strategy. Two randomized controlled eCPR trials demonstrated survival rates of 43% and 31.5% in patients with refractory ventricular fibrillation and cardiac-origin cardiac arrest, respectively. Whether these results are generalizable outside such highly specialized centres, and which prehospital and in-hospital strategy is best for which patients, remains to be determined in future studies.

In einer Metaanalyse zu eCPR ohne cCPR-Kontrollgruppe bei Kreislaufstillstand durch Lungenembolie überlebten 65 % (64 von 99) der Patienten, 88 % davon mit neurologisch gutem Überleben, wobei in der Literatur eine Mortalität von bis zu 90 % angegeben wird [16] . Eine Registerstudie zu Lungenembolie und Kreislaufstillstand zeigte einen Überlebensvorteil für den sehr kleinen Anteil der Patienten mit eCPR und Thrombolyse, eCPR und Thrombektomie, aber auch eCPR allein ohne Reperfusionstrategie gegenüber der Behandlung mit Thrombolyse allein [17] . Eine ELSO-Registerstudie der Jahre 1997-2017 fand in 42 schwangeren Patienten mit eCPR eine Überlebensrate von 55 % [18] . Die eCPR-Ursachen umfassten peri-und postpartale Kardiomyopathie sowie Lungenembolie inklusive Fruchtwasserembolie.

In rezenten Metaanalysen von Patienten mit akzidentieller Hypothermie und eCPR lag das Überleben bei 73 % (153 von 210 Patienten) für beobachteten und 27 % (60 von 221 Patienten) für nichtbeobachteten Kreislaufstillstand mit jeweils neurologisch gutem Überleben von 89 % respektive 83 % [19, 20] . Hypotherme Patienten mit hämodynamischer Instabilität sollten daher a priori an Zentren mit Möglichkeit zur eCPR transferiert werden. Für die Indikationsstellung zur eCPR können Prädiktoren wie z. B. der HOPE-Score herangezogen werden [21] . Der EKG-Erstrhythmus fließt in dieses Prognosetool nicht ein. So fand sich bei 48 % (28 von 60) der Überleber eines unbeobachteten hypothermieassoziierten Kreislaufstillstands eine Asystolie als Erstrhythmus, 79 % davon zeigten neurologisch gutes Überleben [20] .

Robuste Selektionskriterien sollen jene Patienten mit dem größten Nutzen und der größten Überlebenswahrscheinlichkeit durch eCPR finden. Die . Tab. 2 zeigt häufige Einschlusskriterien in eCPR-Studien, deren prospektive Evaluierung steht allerdings noch aus. Der Anteil der potenziellen eCPR-Patienten im HKS-Gesamtkollektiv wird zwischen 6 und 11 % angegeben [8, 22] . Durch die Seltenheit wird der frühzeitigen und akkuraten Identifikation dieser Patienten auf allen Ebenen der Versorgung, beginnend bei In select patients, in whom conventional cardiopulmonary resuscitation (cCPR) fails to re-establish circulation, the 2021 European Resuscitation Council guidelines suggest considering extracorporeal resuscitation (eCPR) as a rescue therapy in settings in which it can be implemented. eCPR is becoming established during refractory cardiac arrest as a bridge-to-therapy for diagnosis and treatment of reversible causes of cardiac arrest, such as myocardial infarction, pulmonary embolism, accidental hypothermia, overdose with cardiotoxic substances, and acute hypoxia. Patient selection criteria comprise prognostic characteristics of cardiac arrest such as witnessed status, resuscitation efforts within 5 min, shockable initial rhythm, and characteristics of effective cCPR such as signs of life during resuscitation, persistent ventricular fibrillation, intermittent episodes of spontaneous circulation or end-tidal CO2 levels constantly > 10 mm Hg, patient age and health status. The timeframe from cardiac arrest to eCPR is a major contributor for neurologically favourable survival and should not exceed 60 min according to current guidelines. This may be achieved with an efficient "load & go" strategy, including early patient selection and rapid transport with ongoing mechanical cCPR to the eCPR centre, or with a prehospital eCPR strategy. Two randomized controlled eCPR trials demonstrated survival rates of 43% and 31.5% in patients with refractory ventricular fibrillation and cardiac-origin cardiac arrest, respectively. Whether these results are generalizable outside such highly specialized centres, and which prehospital and in-hospital strategy is best for which patients, remains to be determined in future studies.

Extracorporeal membrane oxygenation · Cardiac arrest · Cardiopulmonary resuscitation · Pulmonary embolism · Ventricular fibrillation

assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest: a randomized clinical trial

Extracorporeal cardiopulmonary resuscitation for refractoryin-hospitalcardiacarrest:aretrospective cohortstudy

Cardiopulmonary resuscitation with assisted extracorporeal lifesupport versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

A pre-hospital extracorporeal cardio pulmonary resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis

Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study

How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis

Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized and propensity score-matched studies

Venoarterial extracorporeal membrane oxygenation in massive pulmonary embolism-related cardiac arrest: a systematic review

Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism

Extracorporeal membrane oxygenation in pregnancy: an analysis of the extracorporeal life support organization registry

Clinical characteristics and outcomes of witnessed hypothermic cardiac arrest: A systematic review on rescue collapse

Outcomesofpatients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: a systematic review

Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: an external validation of the HOPEscore

Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates

Characteristics and outcome after out-of-hospital cardiac arrest with the emphasis on workplaces: an observational study from the Swedish Registry of Cardiopulmonary Resuscitation

Prognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest

Does cerebral near-infrared spectroscopy (NIRS) help to predict futile cannulation in extracorporeal cardiopulmonary resuscitation (ECPR)?

Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry

eCPR bei prähospitalem therapierefraktärem Herz-Kreislauf-Stillstand

Resuscitation using ECPR during in-hospital cardiac arrest (RESCUE-IHCA) mortality prediction score and external validation

Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest (EROCA): results of a randomized feasibility trial of expedited out-of-hospital transport

The Minnesota mobile extracorporeal cardiopulmonary resuscitation consortium for treatment of out-of-hospital refractory ventricular fibrillation: Program description, performance, and outcomes