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Canadian Journal of Cardiology

Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: The State of the Evidence and Framework for Application

Published:September 08, 2017DOI:https://doi.org/10.1016/j.cjca.2017.08.015

      Abstract

      Out-of-hospital cardiac arrest (OHCA) affects 134 per 100,000 citizens annually. Extracorporeal cardiopulmonary resuscitation (ECPR), providing mechanical circulatory support, may improve the likelihood of survival among those with refractory OHCA. Compared with in-hospital ECPR candidates, those in the out-of-hospital setting tend to be sudden unexpected arrests in younger and healthier patients. The aims of this review were to summarize, and identify the limitations of, the evidence evaluating ECPR for OHCA, and to provide an approach for ECPR program application. Although there are many descriptions of ECPR-treated cohorts, we identified a paucity of robust data showing ECPR effectiveness compared with conventional resuscitation. However, it is highly likely that ECPR, provided after a prolonged attempt with conventional resuscitation, does benefit select patient populations compared with conventional resuscitation alone. Although reliable data showing the optimal patient selection criteria for ECPR are lacking, most implementations sought young previously healthy patients with rapid high-quality cardiopulmonary resuscitation. Carefully planned development of ECPR programs, in high-performing emergency medical systems at experienced extracorporeal membrane oxygenation centres, may be reasonable as part of systematic efforts to determine ECPR effectiveness and globally improve care. Protocol evaluation requires regional-level assessment, examining the incremental benefit of survival compared with standard care, while accounting for resource utilization.

      Résumé

      L’arrêt cardiaque hors de l’hôpital (ACHH) touche 134 citoyens sur 100 00 par année. La réanimation cardiorespiratoire extracorporelle (RCR-E), qui offre une assistance circulatoire mécanique, pourrait permettre d’améliorer la survie chez ceux qui ont un ACHH réfractaire. Comparativement à la RCR-E à l’hôpital, la RCR-E hors de l’hôpital entraîne généralement des morts subites inopinées chez des patients plus jeunes et en meilleure santé. Les objectifs de la présente revue étaient de résumer et de déterminer les limites des données probantes qui évaluent la RCR-E lors d'ACHH, et de proposer une approche pour l’application du programme de RCR-E. Bien qu’il existe de nombreuses descriptions de cohortes traitées par RCR-E, nous trouvons peu de données fiables qui montrent l’efficacité de la RCR-E par rapport à celle de la réanimation classique. Toutefois, il est fort probable que la RCR-E offerte après une tentative prolongée de réanimation classique constitue un avantage pour certaines populations de patients par rapport à la réanimation classique seule. Bien qu’il manque de données fiables montrant les critères optimaux de sélection des patients admis à la RCR-E, la plupart de ces réanimations étaient pratiquées sur de jeunes patients auparavant en bonne santé qui avaient subi une réanimation cardiorespiratoire immédiate de haute qualité. L’élaboration de programmes de RCR-E minutieusement planifiée, dans des systèmes de soins d’urgence de haute performance de centres expérimentés dans l’oxygénation par membrane extracorporelle (ECMO, de l’anglais extracorporeal membrane oxygenation), serait raisonnable dans le cadre des efforts systématiques pour déterminer l’efficacité de la RCR-E et améliorer les soins à l’échelle mondiale. L’évaluation du protocole exige une évaluation à l’échelle régionale, qui examine les avantages supplémentaires de la survie par rapport aux soins courants en tenant compte de l’utilisation des ressources.
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