extracorporeal cardiopulmonary resuscitation in a hybrid resuscitation room

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American Journal of Emergency Medicine

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To the Editor,

extracorporeal cardiopulmonary resuscitation is a technique involving venoarterial extracorporeal circulation and membrane oxy- genation, and it has the potential to improve the prognoses of cardiopul- monary arrest by allowing physicians some time for treating Reversible causes of arrests [1]. However, it can cause various complications. The risk of complications with percutaneous cannulation, which is prefera- ble in terms of speed, is relatively high. To reduce complications, cannu- lation under fluoroscopy is recommended [2]; however, Transfer of patients to the angio-suite requires additional time. This dilemma has been resolved with the recent advent of “hybrid resuscitation rooms,” which are equipped with fluoroscopy and computed tomography [3]. Although hybrid resuscitation rooms are effective in improving the out- comes of severe trauma [4], their effectiveness in improving the man- agement of other conditions remains unclear. In this study, we examined whether the introduction of fluoroscopy-equipped hybrid re- suscitation rooms has reduced the time from hospital arrival to ECPR initiation and the complication rate.

In this retrospective, observational study, we analyzed data ex- tracted from medical records in an emergency critical care center in Tokyo, Japan. This study was approved and informed consent from the patients was waived by the Institutional Review Board of Teikyo University.

The center is an advanced tertiary care facility providing specializED treatments to critically ill and injured patients. Its hybrid resuscitation room, equipped with fluoroscopy and computed tomography, was in- troduced in July 2017. In conventional resuscitation rooms, ECPR is per- formed through ultrasound-guided femoral vessel puncture and

resuscitation room) and hybrid group (23 patients in the hybrid resus- citation room). Even after introduction of the hybrid resuscitation room, five cases received ECPR in the conventional resuscitation rooms be- cause the former was occupied.

The primary endpoint was the door-to-pump time, defined as the time from hospital arrival to ECPR initiation. The secondary endpoint was the incidence of cannulation-associated complications, including Vascular injury, Retroperitoneal hematoma, and misinsertion or abnor- mal placement of the cannula. The first author manually extracted these data from computerized medical records.

Continuous and categorical variables are presented as median (in- terquartile range) and number and percentage, respectively. Between- group comparisons were performed using rank-biserial correlation for continuous variables with non-normal distribution and Cramer’s V for categorical variables as effect sizes; Mann-Whitney U and chi-square tests were used for the endpoints. Effect sizes with values >=0.2 were considered substantially significant [5], and p b 0.05 was considered sta- tistically significant. All analyses were performed using IBM SPSS Statis- tics, version 24.

Baseline characteristics except the initial rhythm were similar be- tween groups (Table 1). The door-to-pump time was significantly shorter in the hybrid group than in the non-hybrid group (median: 26 min vs. 35 min; p b 0.01). The complication rate was lower in the hy- brid group than in the non-hybrid group, although the difference was not statistically significant (0% vs. 17%; p = 0.10).

The results of this study suggest that resuscitation rooms equipped

with fluoroscopy can reduce the door-to-pump time for ECPR in cases where the time is relatively long, contradicting previous findings in Japan that indicated no effects of fluoroscopy in reducing the door-to- pump time [2]. This inconsistency may be attributed to differences in

Table 1

Baseline characteristics and outcomes of patients with out-of-hospital cardiac arrest who underwent ECPR.

positioning of the guidewire and cannula using a portable X-ray device.

rhythm is not asystole, no return of spontaneous circulation at the time of hospital arrival, and time from collapse to hospital arrival and ECPR initiation is b45 min and b60 min, respectively. Exclusion criteria were as follows: b15 or N70 years of age, trauma, suspected intracranial dis- ease, and hemorrhagic disease.

In total, 59 participants were included and divided into a non-hybrid group (36 patients who underwent ECPR in the conventional

(24-34)

Complication, n (%) 0 (0) 6 (16.7)^b 0.27

ECPR, extracorporeal cardiopulmonary resuscitation; IQR, interquartile range; CPR, cardio- pulmonary resuscitation.

^a Cramer’s V for categorical data and rank-biserial correlation for continuous data.

^b Complications included retroperitoneal hematoma (n = 1), misinsertion of cannula (n = 4), and conversion to a surgical approach (n = 1).

https://doi.org/10.1016/j.ajem.2020.04.067

0735-6757/(C) 2020

the baseline time, which was 35 min in the present study as opposed to 17 min in the previous study, where there was no scope for further re- duction. Hybrid resuscitation rooms may reduce institutional variations. The low complication rate in the hybrid group in our study is consis- tent with that in the previous study in Japan [2], although the between- group difference in our study could not reach statistical significance be- cause of insufficient power resulting from the small sample size of this study. Larger-scale studies including various facilities are needed to in-

vestigate the impact of hybrid resuscitation rooms.

Acknowledgment

Contribution

RN conceived the study design and obtained the data. All authors contributed to the analysis and interpretation of the results. RN and SN drafted the manuscript. All authors contributed to revising the man- uscript and approved the final manuscript.

Presentation

This study was presented at the 47th Annual Meeting of the Japanese Association for Acute Medicine held in Tokyo, 2 to 4 October 2019.

Funding support

No funding support.

Data access

The first author had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Declaration of competing interest

None declared.

Ethical consideration

This study was approved by the ethics committee of Teikyo University School of Medicine.

References

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   Ryuichi Nishi

   Department of Emergency Medicine, Teikyo University School of Medicine,

   Tokyo, Japan

   Shinji Nakahara

   Department of Emergency Medicine, Teikyo University School of Medicine,

   Tokyo, Japan Graduate School of Health Innovation, Kanagawa University of Human

   Services, Kawasaki, Japan Corresponding author at: Graduate School of Health Innovation, Kanagawa University of Human Services, 3-25-10 Tonomachi, Kawasaki-ku, Kawasaki, Kanagawa 210-0821, Japan.

   E-mail address: [email protected]

   Yasufumi Miyake Tetsuya Sakamoto

   Department of Emergency Medicine, Teikyo University School of Medicine,

   Tokyo, Japan

   8 April 2020