Mechanical chest compressions for cardiac arrest in the cath-lab: when is it enough and who should go to extracorporeal cardio pulmonary resuscitation?
verfasst von:
Bjarne Madsen Hardig, Karl B. Kern, Henrik Wagner
Treating patients in cardiac arrest (CA) with mechanical chest compressions (MCC) during percutaneous coronary intervention (PCI) is now routine in many coronary catheterization laboratories (cath-lab) and more aggressive treatment modalities, including extracorporeal CPR are becoming more common. The cath-lab setting enables monitoring of vital physiological parameters and other clinical factors that can potentially guide the resuscitation effort. This retrospective analysis attempts to identify such factors associated with ROSC and survival.
Methods
In thirty-five patients of which background data, drugs used during the resuscitation and the intervention, PCI result, post ROSC-treatment and physiologic data collected during CPR were compared for prediction of ROSC and survival.
Results
Eighteen (51%) patients obtained ROSC and 9 (26%) patients survived with good neurological outcome. There was no difference between groups in regards of background data. Patients arriving in the cath-lab with ongoing resuscitation efforts had lower ROSC rate (22% vs 53%; p = 0.086) and no survivors (0% vs 50%, p = 0.001). CPR time also differentiated resuscitation outcomes (ROSC: 18 min vs No ROSC: 50 min; p = 0.007 and Survivors: 10 min vs No Survivors: 45 min; p = 0.001). Higher arterial diastolic blood pressure was associated with ROSC: 30 mmHg vs No ROSC: 19 mmHg; p = 0.012).
Conclusion
Aortic diastolic pressure during CPR is the most predictive physiological parameter of resuscitation success. Ongoing CPR upon arrival at the cath-lab and continued MCC beyond 10–20 min in the cath-lab were both predictive of poor outcomes. These factors can potentially guide decisions regarding escalation and termination of resuscitation efforts.
Hinweise
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abkürzungen
ALS
Advanced life support
CA
Cardiac arrest
CPR
Cardio- pulmonary resuscitation
ECPR
Extracorporeal cardio pulmonary resuscitation
MCC
Mechanical chest compressions
PCI
Coronary catheterization laboratories
ROSC
Return of spontaneous circulation
TIMI
Thrombolysis in myocardial infarction
VF
Ventricular fibrillation
VT
Ventricular tachycardia
Background
Increasing interest to treat the underlying cause of cardiac arrest (CA) during resuscitation efforts has evolved since the first extended case series described the use of mechanical chest compressions (MCC) during refractory CA in the coronary catheterization laboratory (cath-lab) 8 years ago [1‐5]. This treatment option has led to further studies treating refractory CA in the cath-lab setting [6]. Treatment with extracorporeal cardio pulmonary resuscitation (ECPR) has further developed this field, but also includes patients who experience CA outside the cath-lab setting, where early experience shows good outcome [4‐7]. Some of these studies has been made as case series [5], ongoing randomized controlled trials (Prague NCT01511666), (Maastricht NCT03101787) (British Columbia NCT02832752) and other organizations have implemented this as a clinical routine [6]. In our early experience we observed that resuscitation in the cath-lab during simultaneous PCI vastly deviated from the normal ALS-algorithm recommended by guidelines. This demanded adjustments to the ALS-algorithms to be suitable for resuscitation efforts during simultaneous PCI, such as delaying further defibrillation attempts until coronary reperfusion is accomplished. These adjustments were recognized by resuscitation guidelines in 2015 [8]. The cath lab setting enables monitoring of physiological parameters and thus a more individual patient tailored treatment can be given [9]. Adequate levels of physiological parameters have previously been correlated with successful return of spontaneous circulation (ROSC) [7‐13]. This retrospective analysis therefore explores multiple factors to identify which might be associated with ROSC and survival to understand which patients will do well with MCC alone and which may need ECPR.
Methods
At the university hospital in Lund Sweden, a tertiary hospital with PCI facilities 24/7, 75 patients suffering CA in the cath-lab have been treated and evaluated in the cath-lab setting from January 1, 2004 to April 9, 2013 where outcome data that has been published [1, 5]. Detailed information regarding important clinical parameters were collected for 35 patients where, eight patients (23%) suffered CA out of hospital and arrived to the cath-lab with ongoing resuscitation efforts and 27 (77%) suffered CA during the intervention (with approval from the local ethical board in Lund (667/2009)). To evaluate the aspects of important confounding factors related to ROSC and survival, patients were divided into four different groups; data from patients that obtained ROSC were compared to data from those not obtaining ROSC and data for survivors were compared to non- survivors. The following data were collected and compared: Background data including concomitant diseases, reason to be admitted to the cath-lab i.e. the diagnosis, culprit lesion, rhythm causing the CA, drugs used during the resuscitation, anticoagulants used during the intervention, PCI-results, post ROSC-treatment and physiologic data collected during CPR. These data were compared for prediction of ROSC and survival differences.
Anzeige
Statistics
Background parameters, resuscitation related parameters, PCI treatment variables and post ROSC treatment variables were presented as percentages for categorical data, while mean and standard deviation were used for continuous data, as appropriate. P-values for differences between the two groups was calculated using Fisher’s exact test for categorical data and using Mann-Whitney U test for numerical parameters. A P-value of < 0.01 was considered to indicate a significant difference as no other adjustment for multiple comparison was made.
Results
Eighteen (51%) of the patients gained ROSC and 9 (26%) patients survived with good neurological outcome. There was no difference between those that obtained ROSC and those that did not nor when comparing data from survivors and non-survivors in regards of background data including concomitant diseases, reason for admission to the cath-lab i.e. cardiac diagnosis, culprit lesion, rhythm causing the arrest (Table 1). Both ROSC patients and surviving patients had VF/VT (N = 7 (20%)), asystole (N = 4 (11%)), bradycardia (N = 7 (20%)) and pulseless electric activity (N = 17 (49%)) as the initiating rhythm for CA (Fig. 1). Fewer ROSC patients and surviving patients received epinephrine and the amount given was lower (Table 1). The CPR time was shorter for those that gained ROSC and survivors (Table 1). Those that arrived at the cath-lab with ongoing CPR had lower chance of obtaining ROSC (22% compared to 53% if the CA occurred in the cath-lab, not significant P = 0.086). None of the patients survived when resuscitation was ongoing when they were admitted to the cath-lab (Table 1). There was a significant higher median arterial early diastolic blood pressure among those that obtained ROSC compared to non-ROSC patients (30 (22–40) mmHg vs 19 (14–28) mmHg, P = 0.012), but only a trend to higher end diastolic and mean arterial pressures (Table 1), these numerical higher values were also seen among surviving patients however these were not significant (Table 1).
Table 1
Shows comparison of the data for patients that gained ROSC vs Non-ROSC patients as well for survivor’s vs Non-survivors
All
ROSC
NO ROSC
P-value
Survivors
Non- survivors
P-value
(N = 35)
(N = 18 (51%))
(N = 17 (49%))
(N = 9 (26%))
(N = 26 (74%))
Background data (N (%) or Median (25th - 75th quartile))
Gender (Females)
6 (17%)
3 (17%)
3 (17%)
> 0.99
1 (3%)
5 (19%)
> 0.99
Age (years)
72 (61–78)
71 (57–75)
76 (62–78)
0.306
74 (55–80)
71 (63–78)
0.806
AMI
10 (29%)
6 (33%)
4 (24%)
0.711
5 (56%)
5 (19%)
0.081
Angina pectoris
3 (9%)
3 (17%)
0 (0%)
0.229
0 (0%)
3 (12%)
0.553
Hypertension
18 (51%)
11 (61%)
7 (41%)
0.318
8 (89%)
10 (39%)
0.018
Diabetes
7 (20%)
3 (17%)
4 (24%)
0.691
3 (33%)
4 (15%)
0.340
Treated hypercholesterolemia
6 (17%)
3 (17%)
3 (18%)
> 0.99
2 (22%)
4 (15%)
0.635
Stroke
5 (14%)
4 (22%)
1 (6%)
0.338
1 (11%)
5 (19%)
> 0.99
Heart failure
3 (9%)
1 (6%)
2 (12%)
0.603
1 (11%)
2 (8%)
> 0.99
Asthma
2 (6%)
0 (0%)
2 (12%)
0.229
0 (0%)
2 (8%)
> 0.99
Renal disease
2 (6%)
1 (6%)
1 (6%)
> 0.99
0 (0%)
2 (8%)
> 0.99
Valvular disease
2 (6%)
0 (0%)
2 (11%)
0.299
0 (0%)
2 (8%)
> 0.99
Cancer
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
Smoker
7 (20%)
4 (22%)
3 (18%)
> 0.99
2 (22%)
5 (19%)
> 0.99
X-Smoker
9 (26%)
5 (28%)
4 (24%)
> 0.99
4 (44%)
5 (19%)
0.192
Reason to be admitted to the Cath-lab (N (%))
Planned Angiography
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
Planned PCI
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
N-STEMI
4 (11%)
3 (17%)
1 (6%)
0.603
2 (22%)
2 (8%)
0.268
STEMI (all)
26 (74%)
10 (56%)
16 (94%)
0.018
5 (55%)
21 (81%)
0.192
Inferior STEMI
9 (26%)
3 (17%)
6 (35%)
0.264
2 (22%)
7 (27%)
> 0.99
Anterior STEMI
16 (46%)
6 (33%)
10 (59%)
0.181
3 (33%)
13 (50%)
0.460
Lateral STEMI
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
LBBB
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
Acute stent occlusion.
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
Tamponade
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
Heart failure
1 (3%)
1 (6%)
0 (0%)
> 0.99
1 (11%)
0 (0%)
> 0.99
Culprit lesion (N (%))
1 vessel
26 (74%)
12 (67%)
14 (82%)
0.433
5 (55%)
22 (85%)
0.162
2 vessels
7 (20%)
4 (22%)
3 (18%)
> 0.99
4 (44%)
3 (12%)
0.055
Left Main
12 (34%)
5 (28%)
7 (41%)
0.489
3 (33%)
9 (35%)
> 0.99
LAD
12 (34%)
6 (33%)
6 (35%)
> 0.99
3 (33%)
9 (35%)
> 0.99
M
2 (6%)
2 (11%)
0 (0%)
0.489
2 (22%)
0 (0%)
0.061
CX
4 (11%)
2 (11%)
2 (12%)
> 0.99
1 (11%)
3 (12%)
> 0.99
RCA
7 (6%)
1 (0%)
6 (12%)
0.229
1 (0%)
6 (8%)
> 0.99
Post lateral
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
LIMA
2 (6%)
1 (6%)
1 (6%)
> 0.99
1 (11%)
1 (4%)
0.454
Rhythm causing the arrest (N (%))
VF/VT
7 (20%)
4 (11%)
3 (9%)
> 0.99
2 (6%)
5 (14%)
> 0.99
PEA
17 (49%)
8 (23%)
9 (26%)
0.505
3 (9%)
14 (40%)
0.460
Asystole
4 (11%)
3 (9%)
1 (3%)
0.603
2 (6%)
2 (6%)
0.268
Bradycardia
7 (20%)
3 (9%)
4 (11%)
0.691
2 (6%)
5 (14%)
0.268
Drugs used during resuscitation efforts (N (%) or Median (25th - 75th quartile))
Epinephrine injection (1 mg)
23 (66%)
9 (50%)
14 (82%)
0.075
2 (22%)
21 (81%)
0.003
Dose of Epinephrine
1 (0–3)
0 (0–1)
2 (2–5)
0.004
0 (0–0.5)
2 (1–4)
0.008
Nor-Adrenaline
24 (69%)
11 (61%)
13 (76%)
0.471
4 (11%)
20 (77%)
0.103
Atropine
11 (31%)
2 (11%)
9 (53%)
0.012
3 (33%)
8 (31%)
> 0.99
Amiodarone
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
Dobutamine
11 (31%)
6 (33%)
5 (29%)
> 0.99
0 (0%)
11 (42%)
0.033
Levosimendan
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
Isoprenaline
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
Buffer
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
Adenosine
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
Anti-coagulants during PCI (N (%))
Bivalirudin
19 (54%)
9 (50%)
10 (59%)
0.738
5 (55%)
14 (54%)
> 0.99
Klopidogrel
18 (51%)
10 (56%)
8 (47%)
0.740
5 (55%)
13 (50%)
> 0.99
Prasugrel
2 (6%)
2 (11%)
0 (0%)
0.489
2 (22%)
0 (0%)
0.061
Heparin
29 (83%)
15 (83%)
14 (82%)
> 0.99
8 (89%)
21 (81%)
> 0.99
Abciximab
3 (9%)
2 (11%)
1 (6%)
> 0.99
1 (11%)
2 (8%)
> 0.99
ASA
21 (60%)
11 (61%)
10 (56%)
0.733
6 (67%)
15 (58%)
0.712
Eptifibatide
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
Fondaparinux
1 (3%)
1 (6%)
0 (0%)
> 0.99
0 (0%)
1 (4%)
> 0.99
Ticagrelor
4 (11%)
1 (6%)
3 (18%)
0.338
0 (0%)
4 (15%)
0.553
Warfarin
3 (9%)
2 (11%)
1 (6%)
0.658
1 (11%)
2 (8%)
> 0.99
PCI results (TIMI flow) (N (%))
3
27 (77%)
14 (78%)
13 (72%)
> 0.99
7 (78%)
20 (77%)
> 0.99
2
1 (3%)
0 (0%)
1 (6%)
0.486
0 (0%)
1 (4%)
> 0.99
0
4 (11%)
1 (6%)
3 (17%)
0.338
1 (11%)
0 (0%)
> 0.99
CPR data (N (%))Median (25th - 75th quartile)
CPR prior to arrival
13 (37%)
4 (22%)
9 (53%)
0.086
0 (0%)
13 (50%)
0.001
CPR during angiography
13 (37%)
5 (28%)
8 (47%)
0.305
3 (33%)
10 (38%)
> 0.99
CPR during PCI
26 (74%)
12 (67%)
14 (78%)
0.443
5 (55%)
21 (81%)
0.192
CPR time in the cath-lab
35 (12–52)
18 (10–41)
50 (33–60)
0.007
10 (8–25)
45 (30–60)
0.001
Post ROSC treatments (N (%) Median (25th - 75th quartile))
Cooling
6 (17%)
6 (33%)
0 (0%)
0.019
1 (11%)
5 (19%)
> 0.99
Heartmate
1 (3%)
1 (6%)
0 (0%)
> 0.99
1 (11%)
0 (0%)
> 0.99
CABG
3 (9%)
3 (17%)
0 (0%)
0.229
1 (11%)
2 (8%)
> 0.99
Pacing
2 (6%)
0 (0%)
2 (12%)
0.229
0 (0%)
2 (8%)
> 0.99
IABP
12 (34%)
9 (50%)
3 (17%)
0.075
4 (44%)
8 (31%)
0.685
Heart transplantation
1 (3%)
1 (6%)
0 (0%)
> 0.99
1 (11%)
0 (0%)
> 0.99
Physiologic parameters during CA (Median (25th - 75th quartile))
Arterial Systolic (mmHg)
85 (71–103)
85 (80–96)
84 (48–103)a
0.593
86 (77–98)
84 (70–103)h
0.494
Arterial Early Diastolic (mmHg)
24 (18–35)
30 (22–40)
19 (14–28)b
0.012
34 (23–40)
20 (14–30)i
0.050
Arterial End Diastolic (mmHg)
30 (21–44)
40 (24–46)
26 (18–29)c
0.071
41 (30–43)
27 (19–44)j
0.121
Arterial Mean (mmHg)
51 (41–58)
53 (48–59)
45 (32–58)d
0.074
54 (50–58)
46 (37–58)k
0.270
SpO2 (mmHg)
81 (74–86)
81 (73–82)
83 (74–89)e
0.599
77 (76–81)
82 (74–87)l
0.549
ETCO2 (mmHg)
21 (13–23)
21 (16–26)
21 (8–23)f
0.415
21 (15–26)
21 (13–23)m
0.653
LSCOt (%)
50 (44–56)
44 (44–44)
53 (45–57)g
NA
NA
48 (44–56)n
NA
RScot (%)
55 (49–58)
38 (38–38)
58 (55–59) g
NA
NA
52 (49–58) n
NA
AScot (%)
54 (48–57)
41 (41–41)
56 (54–57) g
NA
NA
51 (48–57) n
NA
AMI acute myocardial infarction, PCI percutaneous coronary intervention, N-STEMI non ST-elevation myocardial infarction, STEMI ST-elevation myocardial infarction, LBBB left bundle branch block, LAD left anterior descendent artery, M marginal branch, Cx circumflex artery, RCA right coronary artery, LIMA left internal mammary artery, VF ventricular fibrillation, VT ventricular tachycardia, PEA pulseless electrical activity, SR sinus rhythm, ASA acetyl salicylic acid, CPR cardio-pulmonary resuscitation, CABG coronary artery by-pass grafting, IABP intra aortic balloon counter pulsation,, SpO2 Index finger saturation, ETCO2 end tidal carbon dioxide, LSctO2 left cerebral tissue oximetry, RSctO2 left cerebral tissue oximetry, ASctO2 Average of left and right cerebral tissue oximetry and NA Not Applicable
a(ROSC N = 18 and No ROSC N = 16), b (ROSC N = 18 and No ROSC N = 15), c(ROSC N = 18 and No ROSC N = 15), d (ROSC N = 14 and No ROSC N = 8), e (ROSC N = 18 and No ROSC N = 15), f (ROSC N = 7 and No ROSC N = 11), g (ROSC N = 1 and No ROSC N = 5), h (Survivors N = 9 and Dead N = 25), i (Survivors N = 7 and Dead N = 24), j (Survivors N = 7 and Dead N = 15), k (Survivors N = 8 and Dead N = 22), l (Survivors N = 7 and Dead N = 15), m (Survivors N = 4 and Dead N = 15) and n (Survivors N = 0 and Dead N = 6)
×
Discussion
This analysis, although admittedly limited by the small number of patients, shows that it is possible to collect and monitor several important parameters that might be predictors of ROSC and survival during treatment of refractory CA patients in the cath-lab setting. The collected data generated a large amount of information from each patient in aspects of background data, concomitant diseases, cause of the CA, circulatory state, rhythm at the event of CA, type of chest compressions, drugs given during advanced life support (ALS), physiologic parameters during ALS, culprit vessel, PCI-outcome, ROSC and survival. From these data several useful parameters emerged, namely if the patient arrived at the cath-lab with ongoing CPR and the length of time MCC were required in the cath-lab to establish ROSC. Both these clinical factors were associated with ultimately poor outcomes. No patient survived who arrived at the cath-lab with ongoing CPR, while the median time of MCC in the cath-lab for those who did survive was 10 min versus 45 min for those patients not surviving.
Predictive parameters have been previously reported for cardiac arrest. These include co-morbid conditions (concomitant diseases, culprit vessel, circulatory state) that are known to affect outcome for STEMI and following PCI [14, 15] and the cause of the CA in these specific cases are often known (coronary artery occlusion) but also, parameters important for assessing CPR-quality [7, 14‐16], parameters important for the assessment of blood pressure and perfusion that might be useful to predict ROSC and survival [10‐13, 17, 18], factors as rhythm at the time of the CA [18], use of vasoactive drugs [19‐22], duration of ALS, TIMI-flow and post-ROSC treatment [23], are also known factors that can affect outcome after CA and feasible to collect.
Anzeige
In this limited series of cath-lab cardiac arrest, initial rhythm did not predict outcome. One parameter reported in series of ECPR patients that was not included in our database is arterial lactate levels, which has appeared to be markedly different between survivors and non-survivors [21].
The median cath-lab CPR time among the non-surviving patients (45 min (30–60) in this series, is in the same range as that seen as unfavourable in some ECPR cohort reports. Lamhaut and collaborators showed a significant increase in survival when the decision point for ECPR was set at 20 min of ALS, from the prior 30 min [24]. This finding of a finite time limit of MCC in the cath-lab of 10 to 20 min to achieve good outcomes suggests that if such a time is approaching the decision for escalating therapy to ECPR must be made before it is too late. Prolonging the period of MCC support too long can impair the chances for a good outcome [1].
In the present case series, patients with both shockable and non-shockable rhythms achieved long-term survival with MCC (Fig. 1), whilst most studies using extracorporeal cardio pulmonary resuscitation have been restricted to patients in refractory VF/VT since these CA are assumed to be of a cardiac origin. However, our data shows that this assumption might not be correct and some patients with non-shockable rhythms may also respond to MCC while the cause of their cardiac arrest is treated in the cath lab.
Limitation
The major limitation is the small number of patients in this case series. Further study with additional patients could better define other important factors regarding the usefulness of MCC in the cath-lab and which patients should go on to ECPR. Another way to overcome this limitation, we suggest collaboration with other cath-labs implementing similar treatment algorithms and monitoring to be able to collect a sufficient number of patients for these rare cases.
Conclusion
When a cardiac arrest occurring in the cath-lab aortic pressure should be monitored during the resuscitation efforts striving for at least 30 mmHg in diastolic values. If this cannot be achieved escalation of therapy to ECPR should be considered. This decision should be made within the first 10–20 min of resuscitation efforts in the cath-lab, as longer periods are associated with a decrease in survival. Finally, cardiac arrest occurring before and still requiring resuscitation efforts upon arrival at the cath-lab should be considered for ECPR as continuing chest compressions alone resulted in poor outcome.
Ethics approval and consent to participate
This study has been performed under the approval from the Swedish Ethical Review Authority at Lund University (approval number: 667/2009). Both verbal and written information and consent were given and taken from the surviving patients. If the patient did not survive the event, verbal and written information and consent were given and taken from the closest relative. Written consent to use the data was thus given from all patients in this study.
Consent for publication
The approval from the Swedish Ethical Review Authority at Lund University (approval number: 667/2009), included a consent for publication and each patient or relative has approved this in their signed written consent.
Competing interests
Bjarne Madsen Hardig was earlier employed by Physio-Control/Lund, a part of Stryker, the manufacturer producing the LUCAS chest compression device. Karl B Kern is a compensated member of the Science Advisory Board for Physio-Control, now a part of Stryker, and has received investigator-initiated grant funding from Physio-Control. Henrik Wagner has received lecture fees from Jolife AB Sweden.
Anzeige
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mechanical chest compressions for cardiac arrest in the cath-lab: when is it enough and who should go to extracorporeal cardio pulmonary resuscitation?