G Model
ARTICLE IN PRESS
RESUS 5986 1
Resuscitation xxx (2014) xxx.e1
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
1
Letter to the Editor
2
A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? 3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Sir, For refractory cardiac arrest, defined by the absence of return of spontaneous circulation (ROSC) after 30 min of cardiopulmonary resuscitation,1 extracorporeal life support (ECLS) may be considered for providing an adequate circulation.2 Nevertheless, ECLS represents only a symptomatic treatment in the absence of a functioning cardiac pump; treatment of the cause of cardiac arrest is still required.3 A 50-year-old male with refractory ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) was treated at home by a mobile intensive care unit team. Since ROSC was not achieved after 30 min of prehospital resuscitation despite 20 external shocks and 900 mg IV amiodarone, the patient was admitted to an ICU for implementation of ECLS (Cardiohelp Maquet© ), which was started with an initial rate of 4 l min−1 (4000 rev min−1 ), resulting in a mean arterial blood pressure of 65 mmHg. However, VF persisted despite five additional shocks. Since adequate tissue perfusion was ensured by ECLS, potassium chloride 3 g was injected intravenously in order to stop the VF. Less than 1 min later, the patient presented with a stable sinus cardiac rhythm, and progressively recovered spontaneously efficient circulatory function. Coronary angiography revealed an occlusion of the right coronary artery, which was treated by angioplasty and endovascular stent implementation. ECLS was removed on day 2 and the patient weaned from mechanical ventilation on day 6, and discharged on day 11 with a cerebral performance category (CPC) score of 2. The primary objective of cardiopulmonary resuscitation is to maintain sufficient flow while the cause of cardiac arrest is treated. When cardiac arrest is due to refractory VF, and both repeated external electric shocks and drugs are ineffective, the number of delivered shocks is associated with non-survival.4 After ECLS implementation, although it is unknown if persistent VF is harmful it seems rational to restore a normal cardiac rhythm as soon as possible. During cardiac surgery, high potassium-containing cardioplegic solutions are usually infused after the start of cardiopulmonary bypass to arrest the heart, so that surgical procedures can be performed more easily.5 This procedure is safe because extracorporeal circulation maintains an effective tissue perfusion during heart arrest. Therefore, for our patient presenting with refractory VF, since ECLS ensured an effective tissue perfusion, we similarly decided to inject potassium chloride as a cardioplegic treatment. This therapy was efficient and the VF was immediately terminated; moreover, this enabled a rapid return of normal sinus rhythm.
The use of potassium to treat persistent VF has been described during cardiothoracic surgery6 and in a pig model of cardiac arrest,7 but to the best of our knowledge, our case is the first to describe potassium administration to stop refractory VF, while effective tissue perfusion was ensured using ECLS. Further studies are required to evaluate the efficiency of this treatment for patients in refractory VF treated with ECLS. Conflict of interest statement
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All authors have no financial and personal relationships with other people or organizations that could inappropriately influence their work. References
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1. Le Guen M, Nicolas-Robin A, Carreira S, et al. Extracorporeal life support following out-of-hospital refractory cardiac arrest. Crit Care 2011;15:R29. 2. Cave DM, Gazmuri RJ, Otto CW, et al. Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S720–8. 3. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S729–67. 4. Van Alem AP, Post J, Koster RW. VF recurrence: characteristics and patient outcome in out-of-hospital cardiac arrest. Resuscitation 2003;5:181–8. 5. Liu Y, Zhang SL, Duan WX, et al. The myocardial protective effects of a moderate-potassium blood cardioplegia in pediatric cardiac surgery: a randomized controlled trial. Ann Thorac Surg 2012;94:1295–301. 6. Watanabe G, Yashiki N, Tomita S, Yamaguchi S. Potassium-induced cardiac resetting technique for persistent ventricular tachycardia and fibrillation after aortic declamping. Ann Thorac Surg 2011;91:619–20. 7. Lee HY, Lee BK, Jeung KW, et al. Potassium induced cardiac standstill during conventional cardiopulmonary resuscitation in a pig model of prolonged ventricular fibrillation cardiac arrest: a feasibility study. Resuscitation 2013;84:378–83.
Romain Jouffroy Q1 Lionel Lamhaut Pascal Philippe Kim An Pierre Carli Benoît Vivien ∗ Service d’anesthésie réanimation – SAMU, Hôpital Universitaire Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris, Université Paris Descartes Paris V, 149 rue de Sèvres, 75015 Paris, France ∗ Corresponding
author. E-mail address: [email protected] (B. Vivien) 25 December 2013
http://dx.doi.org/10.1016/j.resuscitation.2013.12.038 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Jouffroy R, et al. A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2013.12.038
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ARTICLE IN PRESS
RESUS 5986 1
Resuscitation xxx (2014) xxx.e1
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
1
Letter to the Editor
2
A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? 3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Sir, For refractory cardiac arrest, defined by the absence of return of spontaneous circulation (ROSC) after 30 min of cardiopulmonary resuscitation,1 extracorporeal life support (ECLS) may be considered for providing an adequate circulation.2 Nevertheless, ECLS represents only a symptomatic treatment in the absence of a functioning cardiac pump; treatment of the cause of cardiac arrest is still required.3 A 50-year-old male with refractory ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) was treated at home by a mobile intensive care unit team. Since ROSC was not achieved after 30 min of prehospital resuscitation despite 20 external shocks and 900 mg IV amiodarone, the patient was admitted to an ICU for implementation of ECLS (Cardiohelp Maquet© ), which was started with an initial rate of 4 l min−1 (4000 rev min−1 ), resulting in a mean arterial blood pressure of 65 mmHg. However, VF persisted despite five additional shocks. Since adequate tissue perfusion was ensured by ECLS, potassium chloride 3 g was injected intravenously in order to stop the VF. Less than 1 min later, the patient presented with a stable sinus cardiac rhythm, and progressively recovered spontaneously efficient circulatory function. Coronary angiography revealed an occlusion of the right coronary artery, which was treated by angioplasty and endovascular stent implementation. ECLS was removed on day 2 and the patient weaned from mechanical ventilation on day 6, and discharged on day 11 with a cerebral performance category (CPC) score of 2. The primary objective of cardiopulmonary resuscitation is to maintain sufficient flow while the cause of cardiac arrest is treated. When cardiac arrest is due to refractory VF, and both repeated external electric shocks and drugs are ineffective, the number of delivered shocks is associated with non-survival.4 After ECLS implementation, although it is unknown if persistent VF is harmful it seems rational to restore a normal cardiac rhythm as soon as possible. During cardiac surgery, high potassium-containing cardioplegic solutions are usually infused after the start of cardiopulmonary bypass to arrest the heart, so that surgical procedures can be performed more easily.5 This procedure is safe because extracorporeal circulation maintains an effective tissue perfusion during heart arrest. Therefore, for our patient presenting with refractory VF, since ECLS ensured an effective tissue perfusion, we similarly decided to inject potassium chloride as a cardioplegic treatment. This therapy was efficient and the VF was immediately terminated; moreover, this enabled a rapid return of normal sinus rhythm.
The use of potassium to treat persistent VF has been described during cardiothoracic surgery6 and in a pig model of cardiac arrest,7 but to the best of our knowledge, our case is the first to describe potassium administration to stop refractory VF, while effective tissue perfusion was ensured using ECLS. Further studies are required to evaluate the efficiency of this treatment for patients in refractory VF treated with ECLS. Conflict of interest statement
46 47 48 49 50 51 52
53
All authors have no financial and personal relationships with other people or organizations that could inappropriately influence their work. References
54 55 56
57
1. Le Guen M, Nicolas-Robin A, Carreira S, et al. Extracorporeal life support following out-of-hospital refractory cardiac arrest. Crit Care 2011;15:R29. 2. Cave DM, Gazmuri RJ, Otto CW, et al. Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S720–8. 3. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S729–67. 4. Van Alem AP, Post J, Koster RW. VF recurrence: characteristics and patient outcome in out-of-hospital cardiac arrest. Resuscitation 2003;5:181–8. 5. Liu Y, Zhang SL, Duan WX, et al. The myocardial protective effects of a moderate-potassium blood cardioplegia in pediatric cardiac surgery: a randomized controlled trial. Ann Thorac Surg 2012;94:1295–301. 6. Watanabe G, Yashiki N, Tomita S, Yamaguchi S. Potassium-induced cardiac resetting technique for persistent ventricular tachycardia and fibrillation after aortic declamping. Ann Thorac Surg 2011;91:619–20. 7. Lee HY, Lee BK, Jeung KW, et al. Potassium induced cardiac standstill during conventional cardiopulmonary resuscitation in a pig model of prolonged ventricular fibrillation cardiac arrest: a feasibility study. Resuscitation 2013;84:378–83.
Romain Jouffroy Q1 Lionel Lamhaut Pascal Philippe Kim An Pierre Carli Benoît Vivien ∗ Service d’anesthésie réanimation – SAMU, Hôpital Universitaire Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris, Université Paris Descartes Paris V, 149 rue de Sèvres, 75015 Paris, France ∗ Corresponding
author. E-mail address: [email protected] (B. Vivien) 25 December 2013
http://dx.doi.org/10.1016/j.resuscitation.2013.12.038 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Jouffroy R, et al. A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2013.12.038
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77
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89 90 91
92
