The need to develop standardized protocols for the timing of extracorporeal membrane oxygenation initiation among adult patients in cardiac arrest: A case study

Abstract

The duration of time between cardiac arrest, cardiopulmonary resuscitation (CPR), and initiation of extracorporeal membrane oxygenation (ECMO) among refractory patients is correlated with mortality. The duration of conventional CPR (CCPR) beyond which ECMO support should not be offered due to poor outcomes is not established. This case study describes a patient with heart failure with recurrent episodes of ventricular tachycardia who had a witnessed cardiac arrest in a coronary care unit. The patient received approximately 45 minutes of CCPR. Venoarterial ECMO was then initiated for extracorporeal CPR (ECPR) support. The total recorded ischemic time between CCPR and ECPR was 60 minutes. Despite aggressive medical therapy, ECMO support was discontinued 48 hours later following absence of electroencephalographic activity and no evidence of cardiac function ultimately leading to the patient's death. This case study illustrates the possibility that prolonged ischemia resulting from duration of CCPR and time to initiate ECPR may contribute to adverse clinical outcomes. Systems of care that might reduce delays in ECMO initiation and improve patient outcomes are discussed including: 1) development of standardized protocols to allow for rapid initiation of ECMO support; 2) systematic evaluation of parameters such as biomarkers that might identify patients at risk for cardiac arrest in settings where ECMO is readily available; and 3) assessment of patient criteria to define subsets of individuals among whom late institution of ECMO, an expensive and labor-intensive mode of circulatory support, might be futile.