Cíl: Zážitky blízké smrti (near death experience, NDE) dosud nebyly studovány u pacientů s refrakterní srdeční zástavou léčených extrakorporální kardiopulmonální resuscitací (ECPR). cílem tohoto pilotního projektu bylo zjistit výskyt NDE u pacientů z randomizované studie refrakterních srdečních zástav Prague ohcA a analyzovat rozdíly mezi pacienty resuscitovanými standardní kardiopulmonální resuscitací (KPr) a pacienty resuscitovanými metodou ecPr. Metodika: Analýza NDE pomocí standardizovaného mezinárodně používaného dotazníku pacientů z randomizované studie Prague OHCA s dlouhodobým přežitím. Srovnání výskytu nDe u pacientů po srdeční zástavě léčených standardní KPr a pacientů resuscitovaných metodou ecPr. Výsledky: Dotazník vyplnilo 44 z 60 pacientů, kteří byli dlouhodobě sledováni po studii Prague ohcA (medián věku 57,5 roku, 83 % muži, průměrná délka KPr 37,5 min), z toho 12 pacientů léčených ecPr (průměrná délka srdeční zástavy 54 min). Alespoň jeden příznak NDE prožilo celkem 15/44 pacientů (34,1 %), z toho 10/32 (31,3 %) ve skupině standardní KPr a 5/12 (41,6%) ve skupině ecPr (p = 0,52). Kritéria kompletní nDe (28 a více bodů v dotazníku nDe) splňovalo celkem 9/44 pacientů (20,5 %), z toho 6/32 (18,8 %) ve skupině standardní KPr a 3/12 (25 %) ve skupině ecPr (p = 0,65). Závěr: Výskyt NDE v našem souboru pacientů s refrakterní srdeční zástavou odpovídá výskytu NDE v dosud publikovaných studiích, které analyzovaly pacienty léčené standardní KPr s kratší délkou srdeční zástavy. numericky vyšší počet nDe u pacientů léčených strategií ecPr je hypotézu generující a nedosáhl statistické významnosti. Pro další závěry je nutná analýza větší kohorty pacientů.
Objective: Near-death experiences (NDE) have not yet been studied in patients with refractory cardiac arrest treated with extracorporeal cardiopulmonary resuscitation (ECPR). The aim of this pilot project was to determine the prevalence of NDEs in patients from the randomized Prague OHCA study with refractory cardiac arrest and to analyze differences between patients resuscitated with standard cardiopulmonary resuscitation (CPR) and those resuscitated using the ECPR method. Methods: NDEs were analyzed using a standardized and internationally validated questionnaire among long-term survivors of the randomized Prague OHCA study. The prevalence of NDEs was compared between patients treated with standard CPR and those resuscitated with the ECPR method. Results: The questionnaire was completed by 44 out of 60 patients who were followed up long-term after the Prague OHCA study (median age: 57.5 years, 83% male, average CPR duration: 37.5 minutes), including 12 patients treated with ECPR (average cardiac arrest duration: 54 minutes). At least one symptom of NDE was experienced by 15/44 patients (34.1%), including 10/32 (31.3%) in the standard CPR group and 5/12 (41.6%) in the ECPR group (p = 0.52). Criteria for a complete NDE (score ≥28 on the NDE questionnaire) were met by 9/44 patients (20.5%), including 6/32 (18.8%) in the standard CPR group and 3/12 (25%) in the ECPR group (p = 0.65). Conclusion: The prevalence of NDEs in our cohort of patients with refractory cardiac arrest corresponds to the prevalence reported in previous studies that analyzed patients treated with standard CPR and shorter durations of cardiac arrest. The numerically higher occurrence of NDEs in patients treated with the ECPR strategy is hypothesis-generating but did not reach statistical significance. Further conclusions require analysis in larger patient cohorts.
BACKGROUND: There are limited data on the causes of death in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to analyse the causes of death among patients who received ECPR following out-of-hospital cardiac arrest (OHCA). METHODS: In this post-hoc analysis of a prospective registry, the causes of death were categorized using a predefined method specifically developed for cardiac arrest patients. Two investigators independently assigned each patient to one of five predefined categories of death, with interrater reliability measured using Fleiss' kappa. RESULTS: From January 2012 to December 2023, a total of 1,219 OHCA patients were admitted to the hospital, of whom 210 underwent ECPR. Among these, 152 (72.3%) patients died during their index hospitalization. The median age of deceased patients was 57 years, with 80.9% being male, and the median time to ECPR initiation was 62 min (IQR: 53-72). Interrater agreement was 0.81. The most common primary cause of death was refractory shock (75/152 patients, 49.3%), followed by neurological injury (69/152 patients, 45.3%), rearrest (7/152 patients, 4.6%), and comorbidities (1/152 patients, 0.6%). CONCLUSIONS: Refractory shock was the leading cause of death among our cohort of ECPR patients, followed closely by neurological complications, while other causes were rare.
- MeSH
- Cardiopulmonary Resuscitation * methods mortality MeSH
- Middle Aged MeSH
- Humans MeSH
- Extracorporeal Membrane Oxygenation * mortality methods MeSH
- Cause of Death MeSH
- Prospective Studies MeSH
- Registries MeSH
- Aged MeSH
- Out-of-Hospital Cardiac Arrest * therapy mortality MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
BACKGROUND: Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. METHODS: These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. RESULTS: We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. CONCLUSIONS: The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.
- MeSH
- Adult MeSH
- Consensus MeSH
- Humans MeSH
- Extracorporeal Membrane Oxygenation * methods standards MeSH
- Monitoring, Physiologic methods MeSH
- Critical Care standards methods MeSH
- Brain Injuries therapy MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Publication type
- Journal Article MeSH
- Practice Guideline MeSH
BACKGROUND: The initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. METHODS: This observational, single-center study assessed the influence of the rhythm at hospital admission on 30-day survival and neurological outcomes at discharge in patients who underwent ECPR for out-of-hospital cardiac arrest (OHCA). RESULTS: Between January 2012 and December 2023, 1,219 OHCA patients were admitted, and 210 received ECPR. Of these, 196 patients were analyzed. The average age was 52.9 years (±13), with 80.6 % male. The median time to ECPR initiation was 61 min (IQR 54-72). Patients with ventricular fibrillation as both the initial and admission rhythm had the highest 30-day survival rate (52 %: 35/67), while those with asystole in both instances had the lowest (6 %: 1/17, log-rank p < 0.00001). After adjusting for age, sex, initial rhythm, resuscitation time, location, bystander, and witnessed status, asystole at admission was linked to higher 30-day mortality (OR 4.03, 95 % CI 1.49-12.38, p = 0.009) and worse neurological outcomes (Cerebral Performance Category 3-5) at discharge (OR 4.61, 95 % CI 1.49-17.62, p = 0.013). CONCLUSIONS: The rhythm at hospital admission affects ECPR outcomes. Patients presenting with and maintaining ventricular fibrillation have a higher chance of favorable neurological survival, whereas those presenting with or converting to asystole have poor outcomes. The rhythm at hospital admission appears to be a valuable criterion for deciding on ECPR initiation.
- MeSH
- Adult MeSH
- Ventricular Fibrillation therapy mortality complications MeSH
- Hospitalization statistics & numerical data MeSH
- Cardiopulmonary Resuscitation * methods statistics & numerical data MeSH
- Middle Aged MeSH
- Humans MeSH
- Extracorporeal Membrane Oxygenation * methods statistics & numerical data MeSH
- Survival Rate trends MeSH
- Patient Admission statistics & numerical data MeSH
- Retrospective Studies MeSH
- Aged MeSH
- Heart Rate physiology MeSH
- Out-of-Hospital Cardiac Arrest * therapy mortality MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Observational Study MeSH
BACKGROUND: Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. METHODS: These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. RESULTS: We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. CONCLUSIONS: The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.
- MeSH
- Delphi Technique MeSH
- Adult MeSH
- Consensus * MeSH
- Humans MeSH
- Extracorporeal Membrane Oxygenation * methods standards MeSH
- Monitoring, Physiologic methods standards MeSH
- Brain Injuries therapy physiopathology MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Publication type
- Journal Article MeSH
- Review MeSH
BACKGROUND: We aimed to estimate the effect of extracorporeal cardiopulmonary resuscitation (ECPR) on neurological outcome and mortality, when compared to conventional cardiopulmonary resuscitation (CCPR), using an individual patient data meta-analysis (IPDMA). METHODS: A systematic literature search was performed up to the 20th of October 2022 in the PubMed, EMBASE and CENTRAL databases. For observational studies with unmatched populations, a propensity score including age, location of arrest and initial rhythm was used to match ECPR and CCPR patients in a 1:1 ratio. The primary and secondary outcomes were unfavorable neurological outcome (Cerebral Performance Category of 3-5) and mortality, respectively, which were both collected at different time-points. RESULTS: Data from 17 studies, including 2064 matched cardiac arrest (CA) patients (1031 ECPR and 1033 CCPR cases) were included. In comparison to CCPR, ECPR was associated with a decreased odds of unfavorable neurological outcome (847, 82.2% vs. 897, 86.8% - OR 0.68 [95%CI 0.53-0.87]; p = 0.002) and death (803, 77.9% vs. 860, 83.3% - OR 0.68 [95%CI 0.54-0.86]; p = 0.001). These results were consistent across most of the prespecified subgroups. Moreover, the odds of both unfavorable neurological outcome and mortality were significantly influenced by initial rhythm, cause of arrest and combinations of lactate levels on admission and duration of resuscitation. CONCLUSIONS: This IPDMA showed that ECPR was associated with significantly lower rates of unfavorable neurological outcome and mortality in refractory CA. The overall effect could be influenced by CA characteristics and the severity of the initial injury.
BACKGROUND: It is unclear how invasive resuscitative protocols may impact the time-dependent prognosis of out-of-hospital cardiac arrest (OHCA) resuscitations, or the relationship between intra-arrest transport and outcomes. METHODS: We performed a secondary analysis of the Prague OHCA Study, which randomized refractory OHCAs to "invasive" (intra-arrest transport for possible ECPR initiation) vs. "standard" resuscitation strategies (predominantly performed on-scene). Between groups, we compared outcomes of the initial resuscitation and 180- and 30-day favourable neurological outcomes (CPC 1-2), and within categories based on resuscitation duration (collapse-to-ROSC/ECPR interval). We plotted the dynamic probability of favourable outcomes with increasing durations of unsuccessful resuscitation. RESULTS: Among invasive and standard groups, respectively: 34/124 (27%) vs. 58/132 (44%) had sustained ROSC (difference -17%, 95%CI -5.0, -28); 38/124 (31%) vs. 24/132 (18%) had 30-day favourable neurological outcomes (difference 12%; 95%CI 2.0, 23); and 39/124 (31%) vs. 29/132 (22%) had 180-day favourable neurological outcomes (difference 9.5%; 95%CI -1.3, 20). For favourable outcome cases: standard group resuscitation durations were right-skewed within the first 60 min; for the invasive group the distribution was bimodal, extending to 77 min. For invasive- and standard-treated cases, the probability of favourable outcomes among those in refractory arrest at 30 min was 28% and 7.6%, respectively; declining to 0% at 77 and 60 min. CONCLUSION: In comparison to standard resuscitation, invasive strategy cases had fewer achieve sustained ROSC, however improved overall 30-day favourable neurological outcomes. While standard resuscitation yield was limited to < 60 min, invasive protocols offer a second extended window of potential successful resuscitation.
- MeSH
- Time Factors MeSH
- Cardiopulmonary Resuscitation * methods MeSH
- Middle Aged MeSH
- Humans MeSH
- Aged MeSH
- Emergency Medical Services methods MeSH
- Out-of-Hospital Cardiac Arrest * therapy mortality MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Randomized Controlled Trial MeSH
- MeSH
- Bayes Theorem MeSH
- Cardiopulmonary Resuscitation * MeSH
- Humans MeSH
- Heart Arrest * therapy MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Randomized Controlled Trial MeSH
