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American College of Chest Physicians (ACCP): Annual International Scientific Assembly (CHEST 2014)
Extracorporeal membrane oxygenation doubled survival rate of conventional CPR
AUSTIN, TEX. – Extracorporeal membrane oxygenation delivered during cardiopulmonary resuscitation allowed nearly twice as many patients to survive after discharge when compared against typical CPR-only procedures in a small, retrospective study.
“It’s no secret that conventional CPR is not terrifically successful,” Graham Peigh, a second-year medical student at Jefferson Medical College in Philadelphia, said during the Hot Topics in Pulmonary and Critical Care session at the annual meeting of the American College of Chest Physicians. “Extracorporeal membrane oxygenation [ECMO] gives patients a second chance at life.”
Mr. Peigh and his colleagues retrospectively analyzed 100 ECMO procedures performed on adults at a single teaching hospital during 2010-2013 and found that when ECMO was added to CPR, the survival rate to discharge went from 15% as calculated in a previously reported meta-analysis (J. Gen. Intern. Med. 1998;13:805-16) to 29% (P = .04).
When an arrested patient does not respond to CPR, cannulation through the femoral artery and vein can be combined with compressions to improve chances of survival.
In their analysis of ECMO delivered in an academic hospital setting, Mr. Peigh and his colleagues found that in the 24 cases in which ECMO was added to conventional CPR after the patients failed to respond to CPR alone, the survival rate with full neurologic recovery was 29%.
ECMO support was delivered in a number of scenarios, ranging from acute myocardial infarction to malignant arrhythmia to at least one case each of drug overdose induced cardiac arrest, septic shock, postcardiotomy failure, and acute rejection.
The ECMO support was provided for a mean of 5 days. The mean age for all patients studied was 47 years, and 15 were male. All cases followed a 24-hour hypothermia protocol.
Six of the ECMO-CPR patients died post ECMO of anoxic brain injury, stroke, or sepsis while still in the hospital, but the remaining seven patients (54%) survived after discharge and made full neurologic recoveries. The other 11 died during ECMO-CPR. During ECMO-CPR, 11 patients died of anoxic brain injury, stroke, metabolic acidosis, bowel necrosis, and family withdrawal of life support. Predictors of ECMO death were a pre-ECMO creatinine level of 1.7 mg/dL (P = .02) and the presence of acidosis (P = .04).
The ECMO survivor cohort also had what Mr. Peigh said were “encouraging” organ function results, with kidney and liver function remaining essentially unchanged after discharge.“Two of the patients who died of anoxic brain injuries were able to donate multiple organs for transplant,” Mr. Peigh said.
Previously reported ECMO data have shown there is at least a 20% increase in survival without notable neurologic effect, compared with conventional CPR (Lancet 2008;372:554-61; Crit. Care Med. 2011;39:1-7).
However, since these data were derived from centers where code teams were available at all times to treat a high volume of cardiac arrest patients, Mr. Peigh said the results – although indicative of the procedure’s value – “were not generalizable” to all institutions. But he noted that his and his colleagues’ study showed that even in institutions without a dedicated ECMO-CPR code team, ECMO-CPR resulted in demonstrably better outcomes for patients unresponsive to conventional CPR.
On Twitter @whitneymcknight
AUSTIN, TEX. – Extracorporeal membrane oxygenation delivered during cardiopulmonary resuscitation allowed nearly twice as many patients to survive after discharge when compared against typical CPR-only procedures in a small, retrospective study.
“It’s no secret that conventional CPR is not terrifically successful,” Graham Peigh, a second-year medical student at Jefferson Medical College in Philadelphia, said during the Hot Topics in Pulmonary and Critical Care session at the annual meeting of the American College of Chest Physicians. “Extracorporeal membrane oxygenation [ECMO] gives patients a second chance at life.”
Mr. Peigh and his colleagues retrospectively analyzed 100 ECMO procedures performed on adults at a single teaching hospital during 2010-2013 and found that when ECMO was added to CPR, the survival rate to discharge went from 15% as calculated in a previously reported meta-analysis (J. Gen. Intern. Med. 1998;13:805-16) to 29% (P = .04).
When an arrested patient does not respond to CPR, cannulation through the femoral artery and vein can be combined with compressions to improve chances of survival.
In their analysis of ECMO delivered in an academic hospital setting, Mr. Peigh and his colleagues found that in the 24 cases in which ECMO was added to conventional CPR after the patients failed to respond to CPR alone, the survival rate with full neurologic recovery was 29%.
ECMO support was delivered in a number of scenarios, ranging from acute myocardial infarction to malignant arrhythmia to at least one case each of drug overdose induced cardiac arrest, septic shock, postcardiotomy failure, and acute rejection.
The ECMO support was provided for a mean of 5 days. The mean age for all patients studied was 47 years, and 15 were male. All cases followed a 24-hour hypothermia protocol.
Six of the ECMO-CPR patients died post ECMO of anoxic brain injury, stroke, or sepsis while still in the hospital, but the remaining seven patients (54%) survived after discharge and made full neurologic recoveries. The other 11 died during ECMO-CPR. During ECMO-CPR, 11 patients died of anoxic brain injury, stroke, metabolic acidosis, bowel necrosis, and family withdrawal of life support. Predictors of ECMO death were a pre-ECMO creatinine level of 1.7 mg/dL (P = .02) and the presence of acidosis (P = .04).
The ECMO survivor cohort also had what Mr. Peigh said were “encouraging” organ function results, with kidney and liver function remaining essentially unchanged after discharge.“Two of the patients who died of anoxic brain injuries were able to donate multiple organs for transplant,” Mr. Peigh said.
Previously reported ECMO data have shown there is at least a 20% increase in survival without notable neurologic effect, compared with conventional CPR (Lancet 2008;372:554-61; Crit. Care Med. 2011;39:1-7).
However, since these data were derived from centers where code teams were available at all times to treat a high volume of cardiac arrest patients, Mr. Peigh said the results – although indicative of the procedure’s value – “were not generalizable” to all institutions. But he noted that his and his colleagues’ study showed that even in institutions without a dedicated ECMO-CPR code team, ECMO-CPR resulted in demonstrably better outcomes for patients unresponsive to conventional CPR.
On Twitter @whitneymcknight
AUSTIN, TEX. – Extracorporeal membrane oxygenation delivered during cardiopulmonary resuscitation allowed nearly twice as many patients to survive after discharge when compared against typical CPR-only procedures in a small, retrospective study.
“It’s no secret that conventional CPR is not terrifically successful,” Graham Peigh, a second-year medical student at Jefferson Medical College in Philadelphia, said during the Hot Topics in Pulmonary and Critical Care session at the annual meeting of the American College of Chest Physicians. “Extracorporeal membrane oxygenation [ECMO] gives patients a second chance at life.”
Mr. Peigh and his colleagues retrospectively analyzed 100 ECMO procedures performed on adults at a single teaching hospital during 2010-2013 and found that when ECMO was added to CPR, the survival rate to discharge went from 15% as calculated in a previously reported meta-analysis (J. Gen. Intern. Med. 1998;13:805-16) to 29% (P = .04).
When an arrested patient does not respond to CPR, cannulation through the femoral artery and vein can be combined with compressions to improve chances of survival.
In their analysis of ECMO delivered in an academic hospital setting, Mr. Peigh and his colleagues found that in the 24 cases in which ECMO was added to conventional CPR after the patients failed to respond to CPR alone, the survival rate with full neurologic recovery was 29%.
ECMO support was delivered in a number of scenarios, ranging from acute myocardial infarction to malignant arrhythmia to at least one case each of drug overdose induced cardiac arrest, septic shock, postcardiotomy failure, and acute rejection.
The ECMO support was provided for a mean of 5 days. The mean age for all patients studied was 47 years, and 15 were male. All cases followed a 24-hour hypothermia protocol.
Six of the ECMO-CPR patients died post ECMO of anoxic brain injury, stroke, or sepsis while still in the hospital, but the remaining seven patients (54%) survived after discharge and made full neurologic recoveries. The other 11 died during ECMO-CPR. During ECMO-CPR, 11 patients died of anoxic brain injury, stroke, metabolic acidosis, bowel necrosis, and family withdrawal of life support. Predictors of ECMO death were a pre-ECMO creatinine level of 1.7 mg/dL (P = .02) and the presence of acidosis (P = .04).
The ECMO survivor cohort also had what Mr. Peigh said were “encouraging” organ function results, with kidney and liver function remaining essentially unchanged after discharge.“Two of the patients who died of anoxic brain injuries were able to donate multiple organs for transplant,” Mr. Peigh said.
Previously reported ECMO data have shown there is at least a 20% increase in survival without notable neurologic effect, compared with conventional CPR (Lancet 2008;372:554-61; Crit. Care Med. 2011;39:1-7).
However, since these data were derived from centers where code teams were available at all times to treat a high volume of cardiac arrest patients, Mr. Peigh said the results – although indicative of the procedure’s value – “were not generalizable” to all institutions. But he noted that his and his colleagues’ study showed that even in institutions without a dedicated ECMO-CPR code team, ECMO-CPR resulted in demonstrably better outcomes for patients unresponsive to conventional CPR.
On Twitter @whitneymcknight
AT CHEST 2014
Key clinical point: ECMO during CPR can improve clinical outcomes for patients in cardiac arrest.
Major finding: The discharge to survival rate for patients given ECMO was 54% with full neurologic recovery.
Data source: A retrospective analysis of 24 ECMO-CPR procedures performed at a single site during 2010-2013.
Disclosures: Mr. Peigh said he had no relevant disclosures.
Lungs donated after cardiac arrest, brain death yield similar survival rates
AUSTIN, TEX. – The risk of death at 1 year after lung transplantation with organs donated either after cardiac arrest or after brain death was virtually the same, an analysis of the literature has shown.
“Donation after cardiac death appears to be a safe and effective method to expand the donor pool,” said Dr. Dustin Krutsinger of the University of Iowa, Iowa City, who presented the findings during the Hot Topics in Pulmonary Critical Care session at the annual meeting of the American College of Chest Physicians.
Over the years, the demand for organ donations for lung transplant candidates has steadily increased while the number of available organs has remained static. This is due, in part, to physicians being concerned about injury to the organs during the ischemic period, as well as what can often be as much as an hour before organ procurement after withdrawal of life support. However, Dr. Krutsinger said the similarities between the two cohorts could result from the fact that before procurement, systemic circulation allows the lungs to oxygenate by perfusion, and so there is less impact during the ischemic period.
“There is also a thought that the ischemic period might actually protect the lungs and the liver from reperfusion injury. And we’re avoiding brain death, which is not a completely benign state,” he told the audience.
After conducting an extensive review of the literature for 1-year survival rates post lung transplantation, the investigators found 519 unique citations, including 58 citations selected for full text review, 10 observational cohort studies for systematic review, and another 5 such studies for meta-analysis.
Dr. Krutsinger and his colleagues found no significant difference in 1-year survival rates between the donation after cardiac death and the donation after brain death cohorts (P = .658). In a pooled analysis of the five studies, no significant difference in risk of death was found at 1 year after either transplantation procedure (relative risk, 0.66; 95% confidence interval, 0.38-1.15; P = .15). Although he thought the findings were limited by shortcomings in the data, such as the fact that the study was a retrospective analysis of unmatched cohorts and that the follow-up period was short, Dr. Krutsinger said in an interview that he thought the data were compelling enough for institutions to begin rethinking organ procurement and transplantation protocols. In addition to his own study, he cited a 2013 study which he said indicated that if lungs donated after cardiac arrest were included, the pool of available organs would increase by as much as 50% (Ann. Am. Thorac. Soc. 2013;10:73-80).
But challenges remain.
“There are some things you can do to the potential donors that are questionable ethicswise, such as administering heparin premortem, which would be beneficial to the actual recipients. But, up until they are pronounced dead, they are still a patient. You don’t really have that complication with a donation after brain death, since once brain death is determined, the person is officially dead. Things you then do to them to benefit the eventual recipients aren’t being done to a ‘patient.’ ”
Still, Dr. Krutsinger said that if organs procured after cardiac arrest were to become more common than after brain death, he would be “disappointed” since the data showed “the outcomes are similar, not inferior.”
Dr. Krutsinger said he had no relevant disclosures.
On Twitter @whitneymcknight
AUSTIN, TEX. – The risk of death at 1 year after lung transplantation with organs donated either after cardiac arrest or after brain death was virtually the same, an analysis of the literature has shown.
“Donation after cardiac death appears to be a safe and effective method to expand the donor pool,” said Dr. Dustin Krutsinger of the University of Iowa, Iowa City, who presented the findings during the Hot Topics in Pulmonary Critical Care session at the annual meeting of the American College of Chest Physicians.
Over the years, the demand for organ donations for lung transplant candidates has steadily increased while the number of available organs has remained static. This is due, in part, to physicians being concerned about injury to the organs during the ischemic period, as well as what can often be as much as an hour before organ procurement after withdrawal of life support. However, Dr. Krutsinger said the similarities between the two cohorts could result from the fact that before procurement, systemic circulation allows the lungs to oxygenate by perfusion, and so there is less impact during the ischemic period.
“There is also a thought that the ischemic period might actually protect the lungs and the liver from reperfusion injury. And we’re avoiding brain death, which is not a completely benign state,” he told the audience.
After conducting an extensive review of the literature for 1-year survival rates post lung transplantation, the investigators found 519 unique citations, including 58 citations selected for full text review, 10 observational cohort studies for systematic review, and another 5 such studies for meta-analysis.
Dr. Krutsinger and his colleagues found no significant difference in 1-year survival rates between the donation after cardiac death and the donation after brain death cohorts (P = .658). In a pooled analysis of the five studies, no significant difference in risk of death was found at 1 year after either transplantation procedure (relative risk, 0.66; 95% confidence interval, 0.38-1.15; P = .15). Although he thought the findings were limited by shortcomings in the data, such as the fact that the study was a retrospective analysis of unmatched cohorts and that the follow-up period was short, Dr. Krutsinger said in an interview that he thought the data were compelling enough for institutions to begin rethinking organ procurement and transplantation protocols. In addition to his own study, he cited a 2013 study which he said indicated that if lungs donated after cardiac arrest were included, the pool of available organs would increase by as much as 50% (Ann. Am. Thorac. Soc. 2013;10:73-80).
But challenges remain.
“There are some things you can do to the potential donors that are questionable ethicswise, such as administering heparin premortem, which would be beneficial to the actual recipients. But, up until they are pronounced dead, they are still a patient. You don’t really have that complication with a donation after brain death, since once brain death is determined, the person is officially dead. Things you then do to them to benefit the eventual recipients aren’t being done to a ‘patient.’ ”
Still, Dr. Krutsinger said that if organs procured after cardiac arrest were to become more common than after brain death, he would be “disappointed” since the data showed “the outcomes are similar, not inferior.”
Dr. Krutsinger said he had no relevant disclosures.
On Twitter @whitneymcknight
AUSTIN, TEX. – The risk of death at 1 year after lung transplantation with organs donated either after cardiac arrest or after brain death was virtually the same, an analysis of the literature has shown.
“Donation after cardiac death appears to be a safe and effective method to expand the donor pool,” said Dr. Dustin Krutsinger of the University of Iowa, Iowa City, who presented the findings during the Hot Topics in Pulmonary Critical Care session at the annual meeting of the American College of Chest Physicians.
Over the years, the demand for organ donations for lung transplant candidates has steadily increased while the number of available organs has remained static. This is due, in part, to physicians being concerned about injury to the organs during the ischemic period, as well as what can often be as much as an hour before organ procurement after withdrawal of life support. However, Dr. Krutsinger said the similarities between the two cohorts could result from the fact that before procurement, systemic circulation allows the lungs to oxygenate by perfusion, and so there is less impact during the ischemic period.
“There is also a thought that the ischemic period might actually protect the lungs and the liver from reperfusion injury. And we’re avoiding brain death, which is not a completely benign state,” he told the audience.
After conducting an extensive review of the literature for 1-year survival rates post lung transplantation, the investigators found 519 unique citations, including 58 citations selected for full text review, 10 observational cohort studies for systematic review, and another 5 such studies for meta-analysis.
Dr. Krutsinger and his colleagues found no significant difference in 1-year survival rates between the donation after cardiac death and the donation after brain death cohorts (P = .658). In a pooled analysis of the five studies, no significant difference in risk of death was found at 1 year after either transplantation procedure (relative risk, 0.66; 95% confidence interval, 0.38-1.15; P = .15). Although he thought the findings were limited by shortcomings in the data, such as the fact that the study was a retrospective analysis of unmatched cohorts and that the follow-up period was short, Dr. Krutsinger said in an interview that he thought the data were compelling enough for institutions to begin rethinking organ procurement and transplantation protocols. In addition to his own study, he cited a 2013 study which he said indicated that if lungs donated after cardiac arrest were included, the pool of available organs would increase by as much as 50% (Ann. Am. Thorac. Soc. 2013;10:73-80).
But challenges remain.
“There are some things you can do to the potential donors that are questionable ethicswise, such as administering heparin premortem, which would be beneficial to the actual recipients. But, up until they are pronounced dead, they are still a patient. You don’t really have that complication with a donation after brain death, since once brain death is determined, the person is officially dead. Things you then do to them to benefit the eventual recipients aren’t being done to a ‘patient.’ ”
Still, Dr. Krutsinger said that if organs procured after cardiac arrest were to become more common than after brain death, he would be “disappointed” since the data showed “the outcomes are similar, not inferior.”
Dr. Krutsinger said he had no relevant disclosures.
On Twitter @whitneymcknight
AT CHEST 2014
Key clinical point: Expansion of organ donation programs to include organs donated after cardiac death could help meet a growing demand for donated lungs.
Major finding: No significant difference was seen in lung transplantation 1-year survival rates between donation after cardiac arrest and donation after brain death.
Data source: A systematic review of 10 observational cohort studies and a meta-analysis of 5 studies, chosen from more than 500 citations that included 1-year survival data for lung transplantation occuring after either cardiac arrest or brain death.
Disclosures: Dr. Krutsinger said he had no relevant disclosures.
