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Ann Thorac Surg 2005;79:183-184
© 2005 The Society of Thoracic Surgeons
Pediatric and Congenital Heart Surgery/M41, The Children's Hospital, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
Massetti and colleagues report the use of extracorporeal life support (ECLS) for the treatment of adults who suffer cardiac arrest refractory to conventional medical therapy. ECLS had to be discontinued within 24 hours due to brain death or multiorgan failure in the majority of patients (55%) while only 8 patients (20%) survived to hospital discharge. These results are substantially worse than reports of survival rates exceeding 50% when ECLS is used as a resuscitation tool for children [1, 2]. The extended duration of conventional resuscitation in the present study (105 minutes vs 12 to 55 minutes in pediatric studies) emphasizes the need for a systematic approach to emergency ECLS that addresses the following issues: organization of a "rapid resuscitation" ECLS team; development of a modified ECLS circuit suitable for rapid deployment; and provision of an expedited cannulation process. Creation of a rapid resuscitation team with a permanent contact list for immediate notification, although not specifically detailed in the present report, is the simplest and perhaps most important component in reducing resuscitation times. Regarding the rapid resuscitation circuit, the hollow-fiber oxygenator/centrifugal pump system described in this report is portable, quick to prime, and has become the mainstay for emergency ECLS systems. Expedited cannulation begins with an early decision to initiate emergency ECLS (within 10 minutes of refractory cardiac arrest in successful pediatric reports), whereas the 45 minutes quoted in this study is an unacceptable delay. In addition, transthoracic cannulation is the most expeditious route in postcardiotomy patients and could have decreased response times in the 10% of patients who had undergone cardiac surgery in this series.
Other management issues are raised by the present report: adjunctive neurological protection is achieved by packing ice around the patient's head during resuscitation and avoiding temperature elevations during the first 48 to 72 hours postarrest. The need for norepinephrine infusions suggests that flow rates may have been inadequate because it is unusual for patients on ECLS to require high-dose inotropic agents. Higher flow rates can easily be provided with the improved venous drainage from an additional jugular venous cannula. This also provides more complete cardiac decompression, which may avoid significant pulmonary congestion and the need for balloon atrial septostomy. Finally, clinical factors are often more important for weaning than normalization of ventricular function by echocardiography. This is especially true for myocarditis patients who often continue to exhibit impaired ventricular function on echocardiography yet who may be clinically ready for discontinuation of ECLS [3].
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