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Patient Selection and Therapeutic Strategy for Emergency Percutaneous Cardiopulmonary System in Cardiopulmonary Arrest Patients

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Patient Selection and Therapeutic Strategy for Emergency Percutaneous Cardiopulmonary System in Cardiopulmonary Arrest Patients ORIGINAL ARTICLE Critical Care Circ J 2009; 73: 1416 – 1422 Patient Selection and Therapeutic Strategy for Emergency Percutaneous Cardiopulmonary System in Cardiopulmonary Arrest Patients Naoyoshi Aoyama, MD; Hiroshi Imai, MD; Ken Kono, MD; Shintaro Kato, MD; Naoto Fukuda, MD; Toshiro Kurosawa, MD; Kazui Soma, MD; Tohru Izumi, MD Background: To clarify the appropriate application and therapeutic strategy for the percutaneous cardiopulmo- nary system (PCPS) in patients in cardiopulmonary arrest (CPA), the effects of the duration of cardiopulmonary resuscitation (CPR), diagnosis of underlying diseases, subsequent intervention and complications were retro- spectively investigated for the correlation between discharge or death of patients. The patients were treated under an identical therapeutic PCPS protocol. Methods and Results: The 69 CPA patients [55 males (78.6%), 14 females; age, 55.0±15.3 years; age range 15–79 years, 50 in-hospital CPA (I-CPA) and 19 out-of-hospital CPA (O-CPA) patients] were treated with emergency PCPS. The mean duration of CPR was 43.6±37.4 min. Of 18 discharged patients (26.1%), 14 had I- CPA and 4 had O-CPA. Significant factors in the discharge of patients were confirmed diagnosis, subsequent treatment and prevention of complications associated with PCPS. Conclusions: Appropriate patient selection for PCPS in cases of O-CPA is likely to give a similar survival rate as for I-CPA. Patient selection and reversibility of the underlying disease and clinical state after starting PCPS affect the prognosis. Aggressive diagnosis and therapy for the underlying disease and prevention of complica- tions associated with PCPS are essential factors in successful discharge of patients. Patients with an unknown etiology are not expected to fully recover, despite PCPS. (Circ J 2009; 73: 1416 – 1422) Key Words: Cardiopulmonary bypass; Cardiopulmonary resuscitation; Extracorporeal circulation; Heart-assist device; Prognosis ncreasing numbers of reports have described patients CPA before PCPS;1,3–8,10,14–17,19 however, the appropriate in cardiopulmonary arrest (CPA) or cardiopulmonary indication, management and therapeutic strategy for using I crisis being saved by mechanical cardiopulmonary PCPS for CPA patients are controversial and have not been support, such as intra-aortic balloon pumping (IABP), per- fully characterized. Furthermore, few reports have described cutaneous cardiopulmonary system (PCPS) or ventricular the management details of PCPS. assist device (VAD).1–21 PCPS should be considered for in- To evaluate and discuss these issues, the effects of in- patients suffering cardiac arrest when the duration of CPA hospital CPA (I-CPA) or out-of-hospital CPA (O-CPA), is brief and the condition leading to the cardiac arrest is diagnosis of underlying disease and course of treatment were reversible (eg, hypothermia or drug intoxication) or amena- compared among discharge, surviving more than 1 month, ble to heart transplantation or revascularization as per the weaning from PCPS and patients who died. The patients American Heart Association (AHA) Guidelines 2005.22 were treated under an identical therapeutic PCPS protocol. However, the indications for PCPS have been expanding because the support is either therapeutic in itself or useful for supporting the patient until appropriate palliative or cor- Methods rective interventions can be carried out.18 Patients Patients suffering an unwitnessed arrest, in the terminal In-hospital patients who developed CPA suddenly and stage of malignancy or with cerebral hemorrhage and O-CPA patients who were transported to the emergency lacking treatment options are contraindicated for PCPS.6,19 center between August 1993 and April 2000 were enrolled. Survival rates strongly depend on appropriate patient selec- Patients with CPA, excluding external injuries and cerebro- tion, including age, diagnosis of underlying disease, sub- vascular disease, for whom bystanders initiated CPR, with sequent treatment, underlying condition and duration of an absence of preexisting severe neurological deficits and for whom advanced cardiac life support techniques did not (Received December 2, 2008; revised manuscript received March 13, quickly restore spontaneous circulation and who did not 2009; accepted March 16, 2009; released online June 11, 2009) recover despite maximal medical therapy, including drugs, Departments of Cardio-angiology and Emergency and Critical Care temporary pacemaker and IABP, were treated with PCPS. Medicine, Kitasato University School of Medicine, Sagamihara, Japan Patients younger than 15 years of age or patients with con- Mailing address: Naoyoshi Aoyama, MD, Departments of Cardio- angiology, Kitasato University School of Medicine, 1-15-1 Kitasato, tinuous CPA after heart surgery were excluded. PCPS was Sagamihara 228-8555, Japan. E-mail: [email protected] performed with familial consent. All rights are reserved to the Japanese Circulation Society. For permis- sions, please e-mail: [email protected] Circulation Journal Vol.73, August 2009 Therapeutic Strategy for CPA Using PCPS 1417 O-CPA I-CPA Advanced cardiac life support (ACLS) Unsuccessful Patient selection ・Bystanders initiate CPR. ・Absence of preexisting severe neurological deficit. ・Definitive diagnosis of underlying disease during PCPS. ・Possibility of specific treatment for the underlying disease. ・No contraindication to PCPS. Initiation of PCPS ・IABP: combine with PCPS as much as possible without contraindications. ・Activated clotting time (ACT): adjustment to 200–300 s (heparin binding PCPS: 150–200 s). ・Hemodynamic monitor: Swan-Ganz catheter, end-tidal carbon dioxide partial pressure (ETCO2), intra-arterial monitor. ・Sadation: Vecuronimu bromide, Midazolam. ・Prevention of circulatory disturbances of the legs: bypassing dorsalis pedis or posterior tibial arteries and arterial cannula of PCPS. ・Initial flow rate: 3.0–3.5 L/min. ・Subsequent PCPS flow rate: the lowest flow rate without peripheral circulatory failure by referring to the indicators of peripheral circulation. Indicators of peripheral circulation Indicators of cardiac function ・Arterial blood gas analysis: pH, BE ・Echocardiography: wall motion, ejection fraction (EF), ・Swan-Ganz catheter: SVO2 ・Lactic acid fractional shortening (%FS), ejection time ・Total bilirubin ・ Arterial ketone body ratio ・End-tidal carbon dioxide partial pressure (ETCO2) ・Blood biochemistry: organ function ・Urinary output ・Swan-Ganz catheter: cardiac index (CI) ・The lowest flow rate without peripheral circulatory failure was continuously adjusted in accordance with the cardiac function by referring to certain indicators of cardiac function. Prevention of complications associated with PCPS ・Circulatory disturbances of the legs: previous insertion of sheaths to femoral artery and vein, bypassing the dorsalis pedis artery or posterior tibial artery and the arterial cannula of PCPS, relaxation incision, lower limb amputation. ・Bleeding: hemostasis, ACT control (150–200 s using nafamostat mesilate), maintain hemoglobin level > 10 g/dl and platelet level > 5.0 × 104 /μl with blood transfusion. ・Hemolysis: initiation of haptoglobin, prevention of poor venous drainage. ・Infection: identify source of infection, initiation of antibiotics, care for the development of sepsis and disseminated intravascular coagulation (DIC). ・Hyperkalemia: investigation of cause, elimination causative factors, continuous hemofiltration (CHF). ・Poor venous drainage: change position of venous cannula, maintain pulmonary artery pressure 20–30/10–15 mmHg with fluid administration. ・Peripheral circulatory failure or multiple organ failure (MOF): increase of the support flow rate, combination of CHF, nafamostat mesilate, ulinastatin. Standard of weaning from PCPS Weaning from PCPS: Flow rate has been 1.0 L/min and patient has satisfied the following conditions. Indicators of peripheral circulation Indicators of cardiac function ・ ・ Arterial blood gas analysis: no metabolic acidosis Echocardiography: wall motion, EF, %FS: improvement Figure 1. Therapeutic percutaneous car- ・Swan-Ganz catheter: SVO2 > 60% ejection time > 200 ms ・Lactic acid: normal ・End-tidal carbon dioxide partial pressure (ETCO2) ≒ PaCO2 diopulmonary system (PCPS) protocol for ・Total bilirubin without hemolysis: 3.0 mg/dl ・ Swan-Ganz catheter: cardiac index (CI) > 2.0 L · min–1 · m–2 cardiopulmonary arrest patients. CPA, car- ・Arterial ketone body ratio: normal diopulmonary arrest; CPR, cardiopulmonary ・Blood biochemistry: recovery from organ dysfunction resuscitation; I-CPA, in-hospital CPA; ・Urinary output without CHF: urinary output > 50 ml/h O-CPA, out-of-hospital CPA. Study Protocol oxygenator and Terumo EBS centrifugal pump, has been A retrospective cohort study was conducted on CPA used since January 1999. A 15Fr arterial cannula and a 21Fr patients who underwent PCPS. The collected data, which venous cannula (Bio-Medicus and Terumo Inc, respec- included age, gender, effects of I-CPA or O-CPA, under- tively) were inserted percutaneously into femoral vessels lying disease, duration from shock or CPA to starting PCPS, using the Seldinger technique. duration until O-CPA patients arrived at hospital, location of Patients underwent the standard therapeutic PCPS pro- CPR, total operating time for PCPS, subsequent treatment, tocol (Figure 1). IABP was combined with PCPS as often and complications associated with PCPS, were investigated as possible without contraindication. To prevent circulatory for the correlation between discharge
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