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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Major interventions are associated with survival of out of hospital cardiac arrest patients – a population based survey


Background. The overall survival rate of out-of-hospital cardiac arrest (OHCA) in Taiwan or even in the whole of Asia is relatively low. Major interventions, such as target temperature management (TTM), coronary artery angiography, and extracorporeal membrane oxygenation (ECMO), have been associated with better patient outcome. However, studies in Taiwan revealing evidence of the benefits of these interventions are limited.

Methods. A population-based study used an 8-year database to analyze overall survival and risk factors ˝among OHCA patients. All adult non-trauma OHCA patients were identified through diagnostic and procedure codes. Hospital survival and return of spontaneous circulation (ROSC) were primary and secondary outcomes. Logistic regression and Cox regression analyses were conducted.

Results. There was a relationship between major interventions (including TTM, coronary artery angiography, and ECMO) and better hospital survival. Age, income, major interventions, and acute myocardial infarction history were associated with hospital survival. The adjusted hazard ratios (HRs) were 0.406 (95% CI, 0.295 to 0.558), 1.109 (95% CI, 1.027 to 1.197), 1.075 (95% CI, 1.002 to 1.154), 1.097 (95% CI, 1.02 to 1.181) and 0.799(95% CI, 0.677 to 0.942) for patients with major interventions, age≥50, medium low and low income, middle income, and acute myocardial infarction history, respectively.

Conclusion. This population-based study in Taiwan revealed that older age (≥50), medium low and low income were associated with a lower rate of survival. Major interventions, including TTM, coronary angiography, and ECMO, were related to better survival.

Key words: OHCA, ROSC, out-of-hospital cardiac arrest, target temperature management, ECMO

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Percutaneous mechanical support in acute coronary syndromes


Despite advances in interventional cardiology, persistently disappointing outcomes in patients with cardiogenic shock complicating myocardial infarction, together with the lack of evidence the that intra-aortic balloon pump improves outcomes in this patient population have led to a re-evaluation of other types of mechanical circulatory support. The increase in extracorporeal membrane oxygenation (ECMO) prompted by the H1N1 pandemic led to an increase in experience in using this technique in critically ill adult patients, and its use is now expanding in both respiratory and cardiac failure. Despite enthusiasm for the technique, high-quality evidence is lacking for its benefit. Nonetheless, ECMO and other types of percutaneous mechanical circulatory support do provide critical care clinicians with new supportive therapies that may prove to benefit patients, both from the high level of support that can be offered, and also minimising the use of potentially toxic inotropic agents.

Key words: cardiogenic shock, heart failure, mechanical circulatory support, extracorporeal membrane oxygenation, ECMO, myocardial infarction, acute coronary syndromes

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Massive RBC fragmentation masks severe thrombocytopenia in both impedance and optical platelet count measurements – a case report of a neonate on ECMO support


Extracorporeal membranous oxygenation (ECMO) is a life-saving treatment for paediatric patients with cardiac or respiratory failure of diverse aetiology. ECMO support is implemented only when all other available medications and procedures fail to treat the underlying cause of organ failure. The reason for caution is a high risk of complications, including intravascular haemolysis, bleeding or clot formation, inflammation and sepsis. Platelet count is closely monitored in assessment of bleeding risk associated with ECMO support. Platelets are counted as a parameter of the complete blood count and can be measured using impedance or optical technology. We report a case of severe red blood cell (RBC) fragmentation in a neonate on ECMO in whom erroneously normal platelet counts were obtained by all available automated methods for platelet count in an emergency laboratory. Based on those observations we have implemented an additional procedure for recognising interferences of fragmented and microcytic RBCs that cause spuriously normal platelet counts.

Key words: platelet count, ECMO, fragmented RBC, neonates, analytical interference

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Veno-venous two-site cannulation versus veno-venous double lumen ECMO: complications and survival in infants with respiratory failure


Objective. To compare complications and survival between the two-site veno-venous versus the veno-venous double lumen extracorporeal membrane oxygenation (ECMO) in infants with respiratory failure.
Methods. The Extracorporeal Life Support Organization (ELSO, Ann Arbor, Michigan) provided the registry database, collected between 1999-2009 for this research project. During this period, 9086 infants ≤ 7 kg birth weight (BW) were treated with ECMO. From these children, those who were older than 32 days and received veno-venous extracorporeal membrane oxygenation (VV ECMO), were extracted for analysis. From a total of 270 infants who met the inclusion criteria, 236 infants were treated with veno-venous double lumen (VVDL) ECMO and 34 infants received VV two-site ECMO. ELSO records were reviewed for the following information: demographic data, type of ventilation, ventilator days and settings during ECMO, complications during ECMO and survival.
Results. Eighty-seven percent (n=236) of infants were cannulated with VVDL and 13% (n=34) with VV two-site cannulation. Twenty-four hours after ECMO onset, ventilator settings were significantly higher in the VV two-site group. Median ECMO duration was significantly shorter in the VV two-site group (137(90/208) vs. 203(128/336) hours, p=0.01). Total complication rate and survival rates (71% in the VVDL group and 56% in the VV two-site group) were not significantly different.
Conclusion. Both cannulation modes for ECMO are safe for use in infants with respiratory failure. The decision regarding which technique should be used for this group of patients depends mainly on best practice experience of the individual ECMO center and on the technical equipment routinely used by the center.


Key words: ECMO, infants, respiratory failure, complications, survival

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