Case Report

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American Journal of Emergency Medicine

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Prolonged cardiac arrest: successful resuscitation with extracorporeal membrane oxygenation?,??

Abstract

Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation (CPR), but prolonged CPR may develop multiple organ failure, and neurologic death is a major complication. We present a case of a 35-year-old woman with fulminant myocarditis secondary to H1N1 influenza A infection, in which cardiac arrest was refractory to prolonged conventional CPR. Extracorporeal membrane oxygenation was initiated 250 minutes after prolonged CPR. Extracorporeal membrane oxygenation provided cardiopulmonary life support for prolonged CPR, achieving a sustained return of spontaneous circulation, which allowed further treatment and made a good recovery with intact cerebral performance.

A 35-year-old woman visited her referring hospital with complaints of fever and dyspnea since 1 day. She then developed foamy-pink sputum and sudden cardiac arrest and was administered 4 periods of cardiopul- monary resuscitation (CPR). After approximately 95 minutes of CPR, return of spontaneous circulation (ROSC) was achieved. At this time, her blood pressure was 66/34 mm Hg, and her heart rate was 134 beats per minute. A chest radiograph showed massive pulmonary edema. Her cardiac enzyme levels were elevated, and echocardiography demonstrat- ed severe diffuse hypokinesia of the left ventricle with a left ventricular ejection fraction (LVEF) of 15% (Table). Cardiac arrest occurred repeatedly during echocardiography, and sustained ROSC was not achieved. Repeated CPR was necessary, and its duration was approximately 100 minutes. Although ROSC was achieved again, it lasted for less than 20 minutes, which did not allow adequate time for transfer to our hospital. Therefore, advanced cardiovascular life support was provided in an ambulance (25 km from the referring hospital). During transfer to our emergency department (ED), resuscitation was continued without interruption. On arrival, she had cardiac arrest with refractory ventricular fibrillation and was pulseless without defibrillation or chest compressions. We decided to use extracorporeal membrane oxygen- ation (ECMO) for cardiopulmonary life support in our ED. Venoarterial ECMO catheters were inserted into her right femoral vessels for resuscitation. The pump flow was set to 2.5 L/min, with a fraction of inspired oxygen of 1.0. Sustained ROSC was dramatically achieved. Prompt percutaneous coronary intervention was performed for presumed acute myocardial infarction. A coronary angiogram showed Normal coronary arteries. Initial investigations indicated a positive H1N1 influenza A infection, and fulminant myocarditis was clinically diagnosed. Myocardial biopsy was not obtained due to the patient’s clinical instability, and an antiviral drug (oseltamivir, 75 mg twice

? Disclosure: The authors did not have conflict of interest to disclose.

?? The authors did not receive any fund for this article.

daily for 10 days) was administered. After the postresuscitation treatment, serial echocardiography revealed gradual recovery of heart contractility (LVEF increased from 15% to 55% in 4 days). Extracorporeal membrane oxygenation was successfully weaned off on day 4. She later developed multiple complications, including pneumonia, Pulmonary hemorrhage, respiratory failure, metabolic acidosis, acute renal failure, thrombocytopenia, gastrointestinal bleeding, bacteremia, transverse colon perforation, and Abdominal abscess formation, and required Prolonged hospitalization, with surgical intervention, antibiotic therapy, hemodialysis, and mechanical ventilatory support. After this aggressive treatment, her clinical condition and laboratory data improved (Table), and she was discharged on day 121, without serious sequelae or neurologic deficits.

In patients with cardiac arrest, the survival rate decreases as the duration of cardiac arrest increases, and thus far, no patient who has required CPR for more than 60 minutes has survived to hospital discharge [1]. Extracorporeal membrane oxygenation support as an adjunct to Cardiac resuscitation can extend the CPR duration to 60 minutes, with a 0.3 Probability of survival and a low incidence of major neurologic deficits [2,3]. However, the upper limit of CPR duration remains unknown. Prolonged CPR is associated with multiple organ failure and neurologic deficits, with brain death being a major complication of prolonged cardiac arrest [4,5]. In our patient, prolonged cardiac arrest with ventricular fibrillation was secondary to an H1N1 influenza A infection, and this critical complication was refractory to conventional CPR. Extracorporeal membrane oxygena- tion was initiated 250 minutes after prolonged CPR. Although she developed multiple complications after prolonged CPR, she complete- ly recovered and did not need further hemodialysis. Extracorporeal membrane oxygenation was successfully used to provide cardiopul- monary life support for our patient with prolonged cardiac arrest, and it resulted in a sustained ROSC, which allowed us to administer further treatment after resuscitation. She eventually made a good recovery with intact cerebral performance. The factors that contributed to her recovery included high-quality CPR and aggressive postresuscitation treatment and, most importantly, timely ECMO support.

Chun-Wen Chiu MD Department of Emergency Medicine Changhua Christian Hospital

Changhua, Taiwan

Hsu-Heng Yen MD Department of Internal Medicine Changhua Christian Hospital

Changhua, Taiwan

0735-6757/$ - see front matter. Crown Copyright (C) 2013 Published by

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Abbreviations: ABG, arterial blood gas; CPK-MB, Creatine phosphokinase-MB; BUN, blood urea nitrogen.

Chun-Chieh Chiu MD Department of Emergency Medicine Changhua Christian Hospital

Changhua, Taiwan

Ying-Cheng Chen MD Department of Cardiovascular Surgery Changhua Christian Hospital

Changhua, Taiwan

Fu-Yuan Siao MD Department of Emergency Medicine Changhua Christian Hospital

Changhua, Taiwan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.06.040

References

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