Cardiopulmonary resuscitation in veno-venous-ECMO patients—A retrospective study on incidence, causes and outcome

PLOS ONE RESEARCH ARTICLE Cardiopulmonary resuscitation in venovenous-ECMO patients—A retrospective study on incidence, causes and outcome Hendrik Booke1,2, Kai Zacharowski ID1, Elisabeth Hannah Adam1, Florian Jürgen Raimann ID1, Frederike Bauer1, Armin Niklas Flinspach ID1* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany, 2 Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany * Abstract Introduction OPEN ACCESS Citation: Booke H, Zacharowski K, Adam EH, Raimann FJ, Bauer F, Flinspach AN (2023) Cardiopulmonary resuscitation in veno-venousECMO patients—A retrospective study on incidence, causes and outcome. PLoS ONE 18(8): e0290083. https://doi.org/10.1371/journal. pone.0290083 Editor: Andrea Ballotta, IRCCS Policlinico S. Donato, ITALY Received: November 16, 2022 Cardiac arrest in a modern intensive care unit (ICU) is associated with poor outcome although optimal resources are present at all times. Data on cardiac arrest (CA) of the increasing cohort of patients with veno-venous-extracorporeal membrane oxygenation (VVECMO) are not available. Due to the highly invasive nature of this procedure, other incidences and causes of cardiac arrest are expected when compared to the ICU population without ECMO. This study focuses on cardiac arrest under VV-ECMO treatment. Methods Retrospective single-center observational study including all VV-ECMO patients from 1st January 2019 until 31st March 2022. Primary focus of this study was number and causes for CA during VV-ECMO treatment. Secondary endpoints were treatment procedure, complications and outcome. Accepted: August 1, 2023 Published: August 11, 2023 Results Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0290083 140 patients were treated with VV-ECMO in the study period. Of those, 23 patients had 29 CA with need for cardiopulmonary resuscitation (CPR) during VV-ECMO treatment. Nearly half of all CA (48%; n = 14) occurred during medical procedures and 21% (n = 6) were device related. Pulseless electric activity (PEA) was the most common rhythm upon CPR initiation (72%). ROSC was achieved in 86%, two CA (6.9%) resulted in extracorporeal CPR. Survival to hospital discharge was 13% following CPR. Copyright: © 2023 Booke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The dataset supporting the conclusions of this article contained potentially highly sensitive patient data, such that Conclusion CA occurs in over 15% of all patients treated with a VV-ECMO. Medical procedures during VV-ECMO are associated with a high risk of CA and should be planned with care. Also, the rate of ROSC was very high, only a small number of patients survived the overall VV-ECMO treatment course. PLOS ONE | https://doi.org/10.1371/journal.pone.0290083 August 11, 2023 1/8 PLOS ONE publication of the original dataset is prohibited by both the jurisdiction and the Ethics Committee under strict local data protection jurisprudence. Data disclosure may be addressed to the corresponding author (ANF) armin.flinspach@kgu. de or the Data Protection Representative upon reasonable request. Funding: The authors received no specific funding for this work. Competing interests: A.N.F. received speaker fees from P.J. Dahlhausen & Co. GmbH, Cologne, Germany, received the Sedana Medical Research Grant 2020 and Thieme Teaching Award 2022. E.H. A. received a research grant of the German Research Foundation (AD 592/1-1) F.J.R received speaker fees from Helios Germany, university hospital Würzburg and Keller Medical GmbH. FJR received financial support by HemoSonics LLC, pharma-consult Petersohn and Boehringer Ingelheim. K.Z. has received honoraria for participation in advisory board meetings for Haemonetics and Vifor and received speaker fees from CSL Behring and GE Healthcare. He is the Principal Investigator of the EU-Horizon 2020 project ENVISION (Intelligent plug-and-play digital tool for real-time surveillance of COVID-19 patients and smart decision-making in Intensive Care Units). F.B. & H.B. declare that there are no conflicts of interest. The other authors declare that there are no conflicts of interest.This does not alter our adherence to PLOS ONE policies on sharing data and materials. CPR in VV-ECMO patients Introduction In hospital cardiac arrest (IHCA) is a common scenario with reports of up to 10 cases per 1000 admissions. Most of these cases happen on intensive care units (ICU) and although optimal resources are available, outcome of IHCA rates from 18 to 20% [1–4]. A special cohort within these patients is the one on extracorporeal membrane oxygenation (ECMO). In recent decades and especially in the past couple of years, ECMO has gained a lot of attention [5]. ECMO can be used in two configurations: veno-arterial configuration (VA-ECMO; substituting or supporting native heart-lung function) as well as veno-venous configuration (VV-ECMO; substituting or supporting native lung function). Recently, the use of the latter has increased due to the high number of patients with solely respiratory failure during the worldwide COVID-19 pandemic. While both configurations mainly use centrifugal pumps to drain blood and reinfuse it to the patient, only VA-ECMO can support the heart whereas VV-ECMO is depended on sufficient native heart function. Subsequently, CA on VV-ECMO has similar consequences as CA in patients not on VV-ECMO i.e. loss of blood flow and peripheral oxygen supply. Due to the high invasive nature of ECMO-treatment and the patients’ high dependence on device function, incidence, causes and outcome of CA might be different in comparison to the general ICU population. Additionally, cardiopulmonary resuscitation (CPR) during ECMO treatment may cause unexpected complications in comparison to other patients. ECMOpatients typically have large cannulas in the area where chest compressions take place. This might further increase the pre-existing risk of bleeding which already sums up to 30% [6]. This study aims to investigate the incidence, causes and outcome of CA on VV-ECMO in a university Hospital. Materials and methods Study design, setting This was a retrospective monocentric study at the University ARDS/ECMO-center in Frankfurt, Germany and was conducted in accordance to the Declaration of Hels (...truncated)