BLS, ALS, ECPR update2015-2018

G2000
BLS 15:2, AED
Shock, Shock, Shock

G2005
BLS 30:2
Shock, High Quality CPR

G2010
BLS C-A-B, Hands-only-CPR
Post Cardiac Arrest Care

ハイライトAmerican Heart
Association心肺蘇生と
救急心血管治療のための
ガイドラインの成人/小児
の二次救命処置に対する
重点的アップデート2018
American Heart Associationは，本文書の作
成に貢献してくださった以下の方々に感
謝する：Jonathan P. Duff, MD; Ashish R.
Panchal, MD, PhD; Mary Fran Hazinski,
RN, MSN, FAHA; およびAHAガイドライン
の重点的アップデートハイライトプロジェクト
チーム。
2015 年に，International Liaison Committee on Resuscitation（ILCOR）は継続
的なエビデンス評価（CEE）プロセスを開始した。このプロセスは，査読を経
た発表済みの蘇生研究論文の迅速な分析，および『International Consensus
on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care
(ECC) Science With Treatment Recommendations (CoSTR)』提言の策定を行
うことができるように設計されている。継続的なエビデンス評価の目標は，
蘇生エビデンスが発表されてから，American Heart Association（AHA）な
どのILCORメンバーの蘇生協議会によるガイドラインの勧告に移行するま
での期間を短縮することにある。年1回のILCOR CoSTRの要約報告に基づ
き，AHAECC委員会はCPRとECCのためのガイドラインに対する重点的アッ
プデートを年1回発表している。このハイライトは，二次救命処置（ACLS）お
よび小児二次救命処置（PALS）の執筆グループによって発表された，AHA
ガイドラインの重点的アップデート2018に含まれる変更点をまとめたもので
ある。
ILCORの系統的レビューは，ILCORタスクフォースの専門家メンバーが優先し
た蘇生に関する具体的な臨床的疑問を解決するために実施される。今年，優先
的に審議された疑問では，心停止中または心拍再開直後のショック抵抗性心室
細動（VF）または無脈性心室頻拍（無脈性VT）に対する治療としての抗不整脈
薬の使用を取り上げた。その後，ILCORの二次救命処置および小児タスクフォー
スが，系統的レビューによって特定・分析された研究論文の分析，検討，議論を
行った。これらのタスクフォースはCoSTRの提言案を作成して，パブリックコメ
ントを求めるためにILCORのウェブサイト（www.ilcor.org）に掲載し，最終的な
ILCOR CoSTR共同作成の要約は『Circulation』誌と『Resuscitation』誌に同時に
発表された。
AHA ACLSおよびPALSの執筆グループは，病院外および病院内蘇生システム
の構造とリソース，ならびにAHAガイドラインを参照する市民救助者と医療従事
者のリソースおよび訓練の観点から，適切な勧告を決定するためにILCORのコ
ンセンサス勧告を非常に慎重に検討した。AHA ECCの臨床戦略，治療介入，治
療，またはテスト勧告はそれぞれ，AHAおよびAmerican College of Cardiologyに
よって承認された最新の表現を用いて，勧告のクラス（クラス）とエビデンスレベ
ル（LOE）に関連付けられた。その基準と表現を図1に示す。
G2015 2018
update”

(most individuals)
Strong recommendation
Weak recommendation

Cardiac Arrest: CA
•
– Out of Hospital Cardiac Arrest: OHCA
•
– In-Hospital Cardiac Arrest: IHCA
Return of Spontaneous Circulation: ROSC

•
– Asystole
•
– Pulseless Electrical Activity: PEA
•
– Ventricular Fibrillation
•
– Pulseless Ventricular Tachycardia

H&T’s
• Hypoxia
• Hypothermia
• Hypovolemia
• Hydrogen-ion
• Hypo/Hyper-Kalemia
• Trauma
• Tension pneumothorax
• Tamponade
• Thrombosis

BLS up date
• 100 120 /
• 5 6cm
– 5cm 6cm
•
• 60%
(Chest Compression Fraction: CCF)

(ROSC)
compared with faster or slower rates (23, 24).
Chest compression depth is also an important CPR quality
factor related to survival (25). In the present study, chest com-
pression depth declines with increasing chest compression rates.
receive
ered in
depth w
pressio
26), an
A st
senting
chest c
ciated
showed
were g
Two
produc
cardiac
29). In
ﬁlling
of exte
availab
compro
models
Figure 2. Chest compression rate versus chest compression depth. The
stacked bar graph shows the distribution of three categories of chest
compression depth (< 38mm indicated in gray, 38–51mm indicated in
120 /

(ROSC)
Ahamed H. Idris et al. Circulation. 2012;125:3004-3012
Copyright © American Heart Association, Inc. All rights reserved.
100 120 /

Ian G. Stiell et al. Circulation. 2014;130:1962-1970
Copyright © American Heart Association, Inc. All rights reserved.
4.03 5.53cm
4.56cm
→ 5cm
6cm

High Quality CPR
5cm, 6cm
100 120 /

図 2 医療用 BLS アルゴリズム

ALS update
6 1 (10 / )
Asystole/PEA

図 1 心停止アルゴリズム

Question
• VF/VT
• PEA/Asystole
•

• BLS → ALS
BLS primary survey
→ → →AED
A→B→C→D
ALS secondary survey
A:
B: EtCO2
C:
D: differential diagnosis , H&T

Figure 2. Forest Plot of Subgroup Analyses of Survival to Hospital Discharge in the Propensity-Matched Cohort
P Value for
Interaction
Favors No
Intubation
Favors
Intubation
0.6 1.21.0
Risk Ratio (95% CI)
Survival to Hospital Discharge, No. of
Patients With Outcome/Total Patients (%)
IntubationSubgroup
Initial rhythm
Risk Ratio
(95% CI)
<.001
.38
<.001
<.001
.002
No Intubation
Respiratory insufficiencyb
Time of matching, mina
Illness category
Location
217/1130 (19.2) 296/1146 (25.8)Other 0.74 (0.63-0.88)
758/2550 (29.7) 903/2585 (34.9)Operating room,
postanesthesia care unit,
or interventional unit
0.85 (0.79-0.92)
2161/13384 (16.1) 2406/13556 (17.7)Intensive care unit 0.91 (0.86-0.97)
1432/12331 (11.6) 1684/12263 (13.7)Floor without telemetry 0.85 (0.79-0.90)
1570/9373 (16.8) 1987/9342 (21.3)Floor with telemetry 0.79 (0.74-0.83)
914/4546 (20.1) 1131/4422 (25.6)Emergency department 0.79 (0.73-0.85)
4506/28469 (15.8) 5777/28492 (20.3)No 0.78 (0.75-0.81)
2546/14845 (17.2) 2630/14822 (17.7)Yes 0.97 (0.92-1.02)
118/676 (17.5) 132/659 (20.0)Trauma 0.87 (0.79-1.09)
910/4708 (19.3) 984/4623 (21.3)Surgical noncardiac 0.91 (0.84-0.98)
632/2197 (28.8) 747/2274 (32.8)Surgical cardiac 0.88 (0.80-0.96)
2695/20017 (13.5) 2834/19979 (14.2)Medical noncardiac 0.95 (0.91-1.00)
2697/15716 (17.2) 3710/15779 (23.5)Medical cardiac 0.73 (0.70-0.77)
483/3158 (15.3) 616/3158 (19.5)10-15 0.78 (0.70-0.87)
2248/14937 (15.0) 2693/14937 (18.0)5-9 0.84 (0.79-0.88)
4321/25219 (17.1) 5098/25219 (20.2)0-4 0.85 (0.82-0.88)
5266/36639 (14.4) 5799/36668 (15.8)Nonshockable 0.91 (0.88-0.94)
1786/6675 (26.8) 2608/6646 (39.2)Shockable 0.68 (0.65-0.72)
7052/43314 (16.3) 8407/43314 (19.4)Overall 0.84 (0.81-0.87)
Risk ratios with 95% confidence intervals for predefined subgroup analyses.
The P value represents the type III P value for the interaction between
intubation and a given subgroup. The dashed vertical line represents
a
The minute at which patients in the intubation group were intubated and
matched with a patient not intubated before or within that same minute.
b
Evidence of acute or chronic respiratory insufficiency within 4 hours up to the
a
Patients being intubated at any given minute (from 0-15 minutes; intubation
group) were matched with patients at risk of being intubated within the same
minute (ie, still receiving resuscitation; no intubation group) based on
and hospital characteristics.
b
A cerebral performance category score of 1 (mild or no neurological deficit)
or 2 (moderate cerebral disability) at hospital discharge was considered a good
functional outcome.
Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival
Lars W Andersen et. Al, JAMA. 2017 02 07;317(5);494-506. doi: 10.1001/jama.2016.20165.

BLS
Airway
Breathing
Circulation
Defibrilator http://www.j-circ.or.jp/cpr/qa.html

• 0.3mg or 0.1mg 3
•
• Mg
•
• ECMO (VV VA)

• ABC (BLS)
• 0.01mg/kg
– 0.5mg
– 0.3mg
•
• 5 10
– 5 10ml/kg
– 10ml/kg

ECPR
Extracorporeal Cardiopulmonary Resuscitaion
CPR

PCPS? ECMO?
PCPS
Percutaneous Cardiopulmonary Support
ECMO / ECLA
Extra Corporeal Membranous Oxygenation
Extra Corporeal Lung Assist
Veno-Venous ECMO
Veno-Arterial ECMO (= PCPS)
ECLS: Extra Corporeal Life Support

定義
• ECLS：Extra Corporeal Life Support
– 体外補助循環を用いて、自己循環の回復と、可逆
的な背景疾患を治療する
• E-CPR：Extracorporeal Cardio
Pulmonary Resuscitation
– 心停止の間に行うECLS

Extracorporeal Life Support Organization (ELSO)
Guidelines for ECPR Cases
Introduction
www.elso.org

Percutaneous Initiation of CardiopulmonaryBypass
Steven J. Phillips, M.D., Bruce Ballentine, C.P., Dianne Slonine, C.P.,
Jeff Hall, C.C.P., John Vandehaar, C.C.P., Chamnahn Kongtahworn, M.D.,
Robert H. Zeff, M.D., James R. Skinner, M.D.,
Kevin Reckmo, C.P., and Dave Gray, C.C.P.
ABSTRACT Improved technology has allowed us Technique
to develop support pumps that can be applied rap-
idly and safely. A system utilizing thin-walled(4mm
inner diameter)percutaneously inserted sheaths has
been designed for rapid bedside arterial and cen-
tral venous cannulation to establish femoral arterial
and venous cardiopulmonary bypass. The system
utilizes two 30-cm-longlarge-bore,thin-walled (end
and side holes)venous cannulas and a single 15-cm-
long (end hole) arterial reperfusion cannula, which
is connected to a pediatric oxygenator and a vortex
pump head. Five patients with refractory cardiac ar-
rest who could not be resuscitated by conventional
means were revived with this system. Application
time was approximately five minutes. This system
appears to be an easily applied and reliable short-
term mechanical support device.
Percutaneous cannulation of a femoral artery
and both femoral veins is carried out as follows.
Sodium heparin, 300 units per kilogram of body
weight, is administered. With a standard groin
aseptic preparation, draping, and local anes-
thesia, the femoral artery and veins are punc-
tured using an angiographic needle [2, 31.
A 0.96 mm x 125cm guidewire*is introduced
through the needle into the vessel. A 12F in-
troducer (dilator-sheath) assemblyt is passed
into the vessel in the following manner. The
skin at the guidewire puncture site is incised for
2 to 3 mm to facilitate insertion of the sheath.
The tapered end of the 12F introducer (dilator-
sheath) is passed over the exposed guidewire
and slipped down the wire to the skin line. The
introducer (dilator-sheath) is pushed through
224 The Annals of Thoracic Surgery Vol 36 No 2 August 1983
U L
Ann Thorac Surg 1983;36:223-225

V-A ECMO
↓
↓
for severe cardiac failure, (usually with associated
only after cardiac surgery
a transitory form of ECMO support in which small
inserted percutaneously. It is an emergent resuscitative
MO-CPR).
nula
Access
cannula

V-V ECMO (Femoro-atrial)
↓
↓

V-A V-V ECMO
V-A ECMO V-V ECMO
↓
↑
: cSvO2 60 65% 65-70%
(recirculation)
10cm
(A) (V) (V) (V)
cSvO2 :

E-CPR G2015
• ECPR CPR
• ECPR
CPR
• ECPR PCI

Articles
or next decision.13,15,22–25
The improving results in various
applications have encouraged the use of extracorporeal
life-support in cardiac arrested patients and offered
better neurological preservation.7,10,26,27
However, com-
parison with results derived from conventional CPR in
different institutions with heterogeneous causes might
be of restricted applicability.
In our study, longer CPR duration was associated with
poor prognosis. Compared with ventricular tachycardia
or ventricular fibrillation as the initial rhythm, those
who showed pulseless electrical activity or asystole had
extracorporeal CPR r
responders, but the p
survival difference. Si
original registry was i
further examination in
extracorporeal life-su
spontaneous circulat
warranted.
The quality of CPR m
between the two group
approach could reduc
factors inherent in
limitation is that b
unmeasured or unk
incorporated into the
The difference in su
ventional and extraco
to some extent to o
occurred even in a ran
We tried to reduce obs
the patients in both g
subsequent decision w
condition, not simp
Conversely, fewer pa
group could survive
number of subse
extracorporeal CPR
differential effect of
analysis, later percut
similar in the ext
conventional CPR-M
Previous studies h
hypothermia (34°C) f
extracorporeal life-su
Since our observation
institutional review b
0
0 100 200
Time (days)
Number at risk
Extracorporeal CPR-M
Conventional CPR-M
46
46
15
7
15
6
7
3
300 400
0·2
0·4
0·6
1·0
0·8
Cumulativesurvival
ECPR-M
CCPR-M
log-rank p=0·003
Figure 3: Kaplan-Meier plot of the survival curves in the extracorporeal CPR-M and conventional CPR-M
groups for 1 year
s began from
nsity score. If
nd the other
selected as a
en four cases
orporeal CPR
were selected
extracorporeal
e matched by
4:4 blocks. A
ch within the
from further
ved down the
were included.
ed 1:1 pairs in
conventional
th χ² test (or
ariables with
discharge was
R to the day of
at survived to
-event) on the
o compare the
orporeal and
ational cohort,
age, sex, initial
CPR location)
o estimate the
up to 30 days
end. Log-rank
d to compare
oups. Hazard
. The survival
PR to death in
s the duration
30 days, and
s regarded as
the propensity
hicago, USA).
represent the
extracorporeal
extracorporeal
used to draw
CPR patients
n a 50% risk
n either group
l power (given Role of the funding source
Extracorporeal CPR group Conventional CPR group
N 59 113
Duration of extracorporeal membrane oxygenation (h)
Mean (SD) 110 (128) ..
Median (range) 69 (2–771) ..
Weaned off extracorporeal
membrane oxygenation, n (%)
29 (49·2) ..
CPC status at discharge
1 or 2*, n (%) 14 (23·7) 12 (10·6)
Odds ratio (95% CI, p value) 2·6 (95% CI 1·1–6·7, p=0·02*) 2·6 (95% CI 1·1–6·7, p=0·02*)
CPC status at 1 year
1 or 2, n (%) 9 (15·3) 10 (8·9)
Odds ratio (95% CI, p value) 1·9 (95% CI 0·6–5·4, p=0·20) 1·9 (95% CI 0·6–5·4, p=0·20)
CPC=Cerebral–performance category score. *p<0·05.
Table 3: Outcome of the extracorporeal CPR group and conventional CPR group
ECPR
CCPR
<30 30–45
40
50
30
Survivaltodischarge(%)
20
10
0
45–60
Time (min)
>60
20%
41·7%
30% 30%
17·7%
8·7%
5·6%
Figure 1: Relation between CPR duration and the survival rate to discharge
ECPR=extracorporeal CPR. CCPR=conventional CPR.
Hazard ratio 95% CI p
Ventricular tachycardia/
ventricular fibrillation
0·58 0·40–0·83 0·003
Use of extracorporeal
membrane oxygenation
0·50 0·33–0·74 0·001
CPR duration (+1 min) 1·007 1·003–1·011 0·002
Age (+1 year) 1·01 0·99–1·02 0·07
Men 1·04 0·72–1·5 0·83
Period C (midnight) 1·05 0·71–1·5 0·82
Intensive scenario 1·1 0·78–1·6 0·58
Intensive scenario=intensive care unit, operating room, or catheterisation room.
Table 4: Multivariate Cox regression analysis for the factors associated
with the survival to hospital discharge
Cardiopulmonary resuscitation with assisted extracorporeal
life-support versus conventional cardiopulmonary
resuscitation in adults with in-hospital cardiac arrest:
an observational study and propensity analysis
Yih-Sharng Chen*, Jou-Wei Lin*, Hsi-Yu Yu,Wen-Je Ko, Jih-Shuin Jerng,Wei-Tien Chang,Wen-Jone Chen, Shu-Chien Huang, Nai-Hsin Chi,
Chih-HsienWang, Li-Chin Chen, Pi-RuTsai, Sheoi-ShenWang, Juey-Jen Hwang, Fang-Yue Lin
Summary
Background Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in
patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with
conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to
assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of
cardiac origin.
Methods We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged
18–75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared
with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise
potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary
endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with
ClinicalTrials.gov, number NCT00173615.
Findings Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min,
113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched
patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0·0001) and a better
1-year survival than those who received conventional CPR (log rank p=0·007). Between the propensity-score matched
groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0·51, 95% CI 0·35–0·74,
p<0·0001), 30-day survival (HR 0·47, 95% CI 0·28–0·77, p=0·003), and 1-year survival (HR 0·53, 95% CI 0·33–0·83,
p=0·006) favouring extracorporeal CPR over conventional CPR.
Interpretation Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients
with in-hospital cardiac arrest of cardiac origin.
Funding National Science Council, Taiwan.
Introduction
Sudden cardiac arrest still has a low survival rate despite
the introduction of cardiopulmonary resuscitation
(CPR),1
and this rate has remained unchanged since
1993.2,3
Investigations have also shown that survival rate
declines rapidly when the duration of CPR exceeds
10 min, and even more rapidly if it exceeds 30 min.3–5
Extracorporeal life-support as a device for cardiac
received CPR of more than 10 min. We also aimed to
assess whether the survival benefit of extracorporeal CPR
over conventional CPR seen in previous studies7–9
might
have been due to selection bias.
Methods
Setting
National Taiwan University Hospital, in Taipei, is an
Lancet 2008; 372: 554–61
Published Online
July 7, 2008
DOI:10.1016/S0140-
6736(08)60958-7
See Comment page 512
*These authors contributed
equally
Department of Surgery
(Y-S Chen MD, H-YYu MD,
W-J Ko MD, S-C Huang MD,
N-H Chi MD, C-HWang MD,
P-RTsai RN, S-SWang MD,
F-Y Lin MD),Department of
Medicine (J-S Jerng MD,
W-J Chen MD, L-C Chen RN,
J-J Hwang MD), and Department
of Emergency (W-T Chang MD),
NationalTaiwan University
Hospital,Taipei,Taiwan; and
Cardiovascular Center, National
Taiwan University Hospital
Yun-Lin Branch, Dou-Liou City,
Yun-Lin,Taiwan (J-W Lin MD,
J-J Hwang)
Correspondence to:
Fang-Yue Lin, Department of
Surgery, NationalTaiwan
University Hospital,Taipei 100,
Taiwan
yschen1234@gmail.com
Lancet, 2008. 372(9638): p. 554-61.
院内心停止についてのE-CPRは，退院および1年後の予後
は通常のCPRと比較して予後が良好だった．

E-CPR
groups wer
(age and CP
supplement
supporting t
In the sa
tients with
ECMO deplo
vice. Only t
off ECMO w
category sta
vived to hos
tive status.
hesitate to r
hospital CP
duration of
The orga
score or LO
outcome in
event. Both
of shock dam
ECPR and th
come.
Patients
the worst ou
and this mig
of the coron
ibility of the
of our ACS p
imal lesions
might lead
ischemic m
Figure 2. Relationship between probability of survival-to-hospital discharge and cardiopulmonary
resuscitation (CPR) duration. ECPR, extracorporeal membrance oxygenation for CPR.
Table 6. Comparison of conventional CPR groups with ECPR groups
In-Hospital
Prolonged
CPR (Ͼ10 mins) No.
Duration, Mins
(Mean Ϯ SD, Median)
Age, Yr
(Mean Ϯ SD, Median)
Survival
(%) p
• OHCA 25
5
•
Chen Y-S, et al Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary
resuscitation. Critical care medicine. 2008 Sep;36(9);2529-35

E-CPR ?
•
• ?
•
• PCAS

od Flow Table
4.5
3.5
2.7
2.0
1.5
Venous
cannula
al
la
hru Single
ressure drop of
2321191715
11.09.58.47.556.823
10.08.57.46.555.821
9.27.76.35.755.019
8.57.05.95.054.317
8.06.55.44.553.815
ArterialCannulae(Fr)
Venous Cannulae (Fr)
Flow (l/min) thru any two cannulae
connected in parallel at Combined
pressure drop of 60 mm.Hg.
eous Cannulae Dimensions and flows I

(V-V ECMO)
Venovenous extracorporeal life support via percutaneous cannulation in 94 patients
Pranikoff, Thomas;Hirschl, Ronald B;Remenapp, Robert;Fresca Swaniker;Bartlett, Robert H
Chest; Mar 1999; 115, 3; ProQuest Nursing & Allied Health Source
pg. 818

• 94 176/188 (94%)
•
6 6
3 3%
1 1
VA ECMO 3 3%
Percutaneous cannulation may be utilized to
provide venovenous ECLS in adult

This is particularly important during ECMO during cardiopulmonary
resuscitation when it is not possible to ascertain which vessel is punctured
using blind puncturing of the vessels. It is important to identify the common
femoral above the bifurcation of the femoral into superficial and deep femoral
artery (profunda femoris).
Extracorporeal Life Support Organization (ELSO)
Ultrasound Guidance for Extra-corporeal Membrane Oxygenation
Veno- Arterial ECMO specific guidelines
Authors:
Vinodh Bhagyalakshmi Nanjayya MBBS, MD, EDIC, FCICM, DDU (Melbourne, Australia)
Deirdre Murphy MB BCh BAO, MRCPI, FCARCSI, FCICM, PGDipEcho, DDU
(Melbourne, Australia)
Editors:
Nicolas Brechot, MD, PhD (Paris, France)
Eddy Fan, MD, PhD (Toronto, Canada)
Vin Pellegrino, MBBS, FRACP, FCICM (Melbourne, Australia)
Dan Brodie, MD (New York, United States)

E-CPRのために・・・
質の高い胸骨圧迫！

You are here: Home / The Logistics of ECMO / Extra-Corporeal Cardiopulmonary Resuscitation (ECPR)
Extra-Corporeal Cardiopulmonary Resuscitation
(ECPR)
The ED ECPR Algorithm: A 3-Staged Approach
When patients present to the ED in the peri-arrest phases of
cardiovascular collapse, decisive action by the emergency
physician can make the diﬀerence between life and death.
Additionally, critical information necessary to determine
whether a patient is a candidate for aggressive intervention is
often unavailable or becomes available piecemeal. At the same
time, we know that successful neurologic outcomes are
inversely associated with the time it takes to reestablish brain
perfusion (either intrinsic perfusion with ROSC or extracorporeal perfusion with ECLS).
Therefore, we developed a 3-stage algorithm for early initiation of ECPR at our
institution.
The ECPR algorithm typically involves 2 physicians. With the ﬁrst physician supervising
ACLS (AKA the “code doc”), the second doctor is responsible for percutaneous femoral
venous and arterial access (AKA the “line doc”). On average, it takes 20 to 30 minutes to
complete all 3 stages, which provides enough time to allow the patient to achieve ROSC
via traditional means. Concomitantly, the critical care ECLS nursing team is called, and
the portable ECLS unit is brought from the intensive care unit to the ED. Here is a
schematic:
SEARCH THE SITE
S U B S C R I B E O N I T U N E SC O N TA C TA B O U T U SS E A R C HT H E P O D C A S T S
http://edecmo.org/logistics/ecpr/

• E-CPR 1-3L/min
• VV SaO2>85%, SvO2>60%
• V-A ECMO
100 – 150 ml/kg/min
80 – 100 ml/kg/min
60 – 80 ml/kg/min

• V-V ECMO
– :
–
• V-A ECMO
– : +
– 60-80 mmHg
– > 10mmHg

P1( ) -50 mmHg
P2( ) : 400 mmHg
P3( ) : 350 mmHg
P4( ) : 5 mmHg
P2-P3 < 50 mmHg

• Rest Lung ( V-V ECMO
– FiO2 < 0.4
– PIP < 25 cmH2O
– PEEP < 10 cmH2O
– CMV : 10 / 0.5
– :
• ECMO
V/Q 1.0 1L 1L
V-A

CRRT
• V-A
–
• V-V
–
!

• TH/TTM
•
• ECMO PK ? !
– (fentanylELSO ECPR Supplement to the ELSO General Guidelines
Version 1.3 December 2013 Page 3
continue as for all other ECMO uses. Because ECPR required rapid cannulation and ECMO
access, correct connection of the arterial and venous cannulae to the corresponding limbs
should be checked using a “Time-Out’ system prior to ECMO flow.
B. Patient Management on ECMO: CNS protection during and after CPR is critical. Therapies
known to improve survival and CNS outcomes after CPR such as:
1. Total body hypothermia should be included. Cooling should be achieved by applying ice
to the head during CPR and for 48 – 72 hours after ECMO cannulation.
2. Neurological exams should be performed following discontinuation of neuromuscular
blocking agents after hemodynamic stability is achieved in collaboration with the neurologist.
C. Management of Left Atrial Hypertension: Evaluation for LA hypertension should be
undertaken soon after the patient is placed on ECMO and LA decompression should be
considered if left atrial pressure is thought to be elevated.

IV infusions and boluses of morphine (10–30 mg/hr) and midazolam
(10–30 mg/hr) titrated to a Richmond Agitation Sedation Scale (RASS) of
−3 to −4 and a bispectral index (BIS) of 40–45
with
Propofol IV (10–200 mg/hr)
Dexmedetomidine IV (1 mcg/kg bolus and 0.1–1.5 mcg/kg/min)
Fentanyl IV (50–300 mcg/hour) if morphine is discontinued for clinical reasons
Thiopentone IV (100–200 mg/hour)
Shekar et al. BMC Anesthesiology 2012, 12:29
STUDY PROTOCOL Open Access
ASAP ECMO: Antibiotic, Sedative and Analgesic
Pharmacokinetics during Extracorporeal
Membrane Oxygenation: a multi-centre study to
optimise drug therapy during ECMO
Kiran Shekar1*
, Jason A Roberts2
, Susan Welch3
, Hergen Buscher3
, Sam Rudham3
, Fay Burrows3
,
Sussan Ghassabian4
, Steven C Wallis2
, Bianca Levkovich5
, Vin Pellegrino5
, Shay McGuinness6
, Rachael Parke6
,
Eileen Gilder6
, Adrian G Barnett7
, James Walsham8
, Daniel V Mullany1
, Yoke L Fung1
, Maree T Smith4
and John F Fraser1
Abstract
Background: Given the expanding scope of extracorporeal membrane oxygenation (ECMO) and its variable impact
on drug pharmacokinetics as observed in neonatal studies, it is imperative that the effects of the device on the
drugs commonly prescribed in the intensive care unit (ICU) are further investigated. Currently, there are no data to
confirm the appropriateness of standard drug dosing in adult patients on ECMO. Ineffective drug regimens in these
critically ill patients can seriously worsen patient outcomes. This study was designed to describe the
pharmacokinetics of the commonly used antibiotic, analgesic and sedative drugs in adult patients receiving ECMO.
Methods/Design: This is a multi-centre, open-label, descriptive pharmacokinetic (PK) study. Eligible patients will be
adults treated with ECMO for severe cardiac and/or respiratory failure at five Intensive Care Units in Australia and
New Zealand. Patients will receive the study drugs as part of their routine management. Blood samples will be
taken from indwelling catheters to investigate plasma concentrations of several antibiotics (ceftriaxone,
meropenem, vancomycin, ciprofloxacin, gentamicin, piperacillin-tazobactum, ticarcillin-clavulunate, linezolid,
fluconazole, voriconazole, caspofungin, oseltamivir), sedatives and analgesics (midazolam, morphine, fentanyl,
propofol, dexmedetomidine, thiopentone). The PK of each drug will be characterised to determine the variability of
PK in these patients and to develop dosing guidelines for prescription during ECMO.
Discussion: The evidence-based dosing algorithms generated from this analysis can be evaluated in later clinical
studies. This knowledge is vitally important for optimising pharmacotherapy in these most severely ill patients to
maximise the opportunity for therapeutic success and minimise the risk of therapeutic failure.
Trial registration: ACTRN12612000559819
Keywords: ECMO, Pharmacokinetics, Pharmacodynamics, Antibiotics, Sedatives, Analgesics, Therapeutic failure,
Drug toxicity

V-A ECMO
.....................................................................................................................................................................................
.....................................................................................................................................................................................
CLINICAL RESEARCH
Myocardial disease
Predicting survival after ECMO for refractory
cardiogenic shock: the survival after
veno-arterial-ECMO (SAVE)-score
MatthieuSchmidt1,2*,AidanBurrell1,3,LloydRoberts3,MichaelBailey1,3,JayneSheldrake3,
Peter T. Rycus4, Carol Hodgson1,3, Carlos Scheinkestel3, D. Jamie Cooper1,3,
Ravi R. Thiagarajan4,5,6, Daniel Brodie7, Vincent Pellegrino1,3, and David Pilcher1,3
1
Australianand NewZealandIntensiveCareResearchCentre, Department ofEpidemiologyand PreventiveMedicine, School ofPublic Health, Monash University, Melbourne,Australia;
2
Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hoˆpital de la Pitie´–Salpeˆtrie`re, Assistance Publique–Hoˆpitaux de Paris, Universite´ Pierre et
MarieCURIE,PARIS647bddel’Hopital,Paris75651,France;3
IntensiveCareDepartment,AlfredHospital,Melbourne,Australia;4
ExtracorporealLifeSupportOrganization,AnnArbor,
MI, USA; 5
Department of Cardiology,Children’s Hospital, Boston, USA; 6
Department of Pediatrics,Harvard Medical School, Boston, USA; and 7
Division of Pulmonaryand Critical Care
Medicine, Columbia College of Physicians and Surgeons, New York, USA
Received 26 December 2014; revised 5 April 2015; accepted 29 April 2015; online publish-ahead-of-print 1 June 2015
Rationale Extracorporeal membrane oxygenation (ECMO) may provide mechanical pulmonary and circulatory support for
patients with cardiogenic shock refractory to conventional medical therapy. Prediction of survival in these patients
may assist in management of these patients and comparison of results from different centers.
Aims Toidentify pre-ECMO factors which predict survival from refractorycardiogenic shock requiring ECMO and create the
survival after veno-arterial-ECMO (SAVE)-score.
Methods
and results
Patientswithrefractorycardiogenicshocktreatedwithveno-arterialECMObetweenJanuary2003andDecember2013
wereextractedfromtheinternationalExtracorporealLifeSupportOrganizationregistry.Multivariablelogisticregression
was performed using bootstrapping methodology with internal and external validation to identify factors independently
associated with in-hospital survival. Of 3846 patients with cardiogenic shock treated with ECMO, 1601 (42%) patients
were alive at hospital discharge. Chronic renal failure, longer duration of ventilation prior to ECMO initiation,
pre-ECMO organ failures, pre-ECMO cardiac arrest, congenital heart disease, lower pulse pressure, and lower serum
bicarbonate (HCO3) were risk factors associated with mortality. Younger age, lower weight, acute myocarditis, heart
transplant, refractory ventricular tachycardia or fibrillation, higher diastolic blood pressure, and lower peak inspiratory
pressure were protective. The SAVE-score (area under the receiver operating characteristics [ROC] curve [AUROC]
0.68 [95%CI 0.64–0.71]) was created. External validation of the SAVE-score in an Australian population of 161 patients
European Heart Journal (2015) 36, 2246–2256
doi:10.1093/eurheartj/ehv194
byguestonOctober26,2016http://eurheartj.oxfordjournals.org/Downloadedfrom
Figure 3 Individual observed survival regarding the survival after veno-arterial-extracorporeal membrane oxygenation-score within 95% confi-
dence interval.Eachdotrepresentstheobservedsurvivalproportionateachscorevalue inthestudy population (n ¼ 3846) usedtoderivethesur-
vival afterveno-arterial-extracorporealmembraneoxygenation-score.Curvedblacklinesrepresent95and 99%confidenceintervals forpredicted
survival at each score level.
Predicting survival after ECMO for refractory cardiogenic shock 2253
byguesthttp://eurheartj.oxfordjournals.org/Downloadedfrom
Figure 4 Graphic representation of the survival after veno-arterial-extracorporeal membrane oxygenation-score, the SAPS II and the sepsis-
related organ failure assessment performances in the validation cohort (n ¼ 161). Model discrimination and calibration were assessed using the
area under the receiver operating characteristics curve (i.e. c) and the Hosmer-Lemeshow C-statistic with associated P-value, respectively.
M. Schmidt et al.2254
byguestonOctober26,2016http://eurheartj.oxfordjournals.org/Downloadedfrom
Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score
European Heart Journal (2015) 36, 2246–2256

V-A ECMO
• >-3
–
– ECMO , ,CNS
– CRF
– 30
– HCO3<15
• >3
–
–
– 18 52
– <20mmHg
Deriva
after v
memb
Survival p
clinicians i
toryindica
the EuroS
implemen
in-hospita
shock. Th
equates to
................................................................................
Table 4 The survival after veno-arterial-
extracorporeal membrane oxygenation-score
Parameter Score
Acute cardiogenic shock diagnosis group (select one or more)
Myocarditis 3
Refractory VT/VF 2
Post heart or lung transplantation 3
Congenital heart disease 23
Other diagnoses leading to cardiogenic
shock requiring VA-ECMO
0
Age (years)
18–38 7
39–52 4
53–62 3
≥63 0
Weight (kg)
≤65 1
65–89 2
≥90 0
Acute pre-ECMO organ failures (select one or more if required)
Liver failurea
23
Central nervous system dysfunctionb
23
Renal failurec
23
Chronic renal failured
26
Duration of intubation prior to initiation of ECMO (h)
≤10 0
11–29 22
≥30 24
Peak inspiratory pressure ≤20 cmH2O 3
Pre-ECMO cardiac arrest 22
Diastolic blood pressure before ECMO
≥40 mmHge
3
Pulse pressure before ECMO
≤20 mmHge
22
HCO3 before ECMO ≤15 mmol/Le
23
Constant value to add to all calculations
of SAVE-score
26
Total score 235 to 17
Total SAVE-score Risk class Survival (%)
Hospital survival by risk class
.5 I 75
1–5 II 58
24 to 0 III 42
29 to 25 IV 30
≤210 V 18
An online calculator is available at www.save-score.com
VT, ventricular tachycardia; VF, ventricular fibrillation.
a
Liver failure was defined as billirubin ≥33 mmol/L or elevation of serum
aminotransferases (ALT or AST).70 UI/L.
b
CNS dysfunction combined neurotrauma, stroke, encephalopathy, cerebral
embolism, as well as seizure and epileptic syndromes.
c
Renaldysfunctionisdefinedasacuterenalinsufficiency(e.g.creatinine .1.5 mg/dL)
with or without RRT.
d
Chronic kidney disease is defined as either kidney damage or glomerular filtration
rate ,60 mL/min/1.73 m2
for ≥3 months.
e
Worse value within 6 h prior ECMO cannulation.
Figure
accordin
brane o
ation ini
percent
veno-ar
vival pe
N ¼ num
after ve
values.

http://www.save-score.com
SAVESurvival After Veno-arterial ECMO
The SAVE Score has been developed by ELSO
and The Department of Intensive Care at The
Alfred Hospital, Melbourne. It is designed to
assist prediction of survival for adult patients
undergoing Extra-Corporeal Membrane
Oxygenation for refractory cardiogenic shock. It
should not be considered a substitute for clinical
assessment.
For more information see: Predicting survival
after ECMO for refractory cardiogenic shock:
the survival after veno-arterial-ECMO (SAVE)-
score
Age (years): 18-38
39-52
53-62
≥63
Weight (kg): <65
65-89
≥90
Pulse pressure pre ECMO ≤20
mmHg
Diastolic BP pre ECMO ≥40 mmHg
Pre-ECMO cardiac arrest
Peak inspiratory pressure ≤20
cmH2O
Intubation duration pre
ECMO (hrs)
≤10
11-29
≥30
Acute renal failure
Chronic renal failure
HCO3 pre ECMO ≤15 mmol/L
Central nervous system dysfunction
Liver failure
The patient's SAVE
Score is
Diagnosis:
Myocarditis
Refractory VT/VF
Post heart or lung transplantation
Congenital heart disease
Other diagnoses
Cardiac:
Respiratory:
Renal:
Other organ failures pre ECMO:
i
i
i
i
i
i
i
i

V-V ECMO
• ECMO
– P/F <80mmHg
– Murray Score ≧3
– pH<7.2 CO2
• ECMO
– P/F <150mmHg
– Murray Score ≧2
–

Murray
0 1 2 3 4
PaO2/FiO2
on 100% O2
≥40 kPa
300 mmHg
30-40 kPa
225-299 mmHg
23-30 kPa
175-224 mmHg
13-23 kPa
100-174 mmHg
<13 kPa
<100 mmHg
CXR quadrants Normal 1 2 3 4
PEEP
(cmH2O)
≤5 6-8 9-11 12-14 ≥15
Compliance
(ml/cmH2O)
≥80 60-79 40-59 20-39 ≤19
Murray Score
!
Papworth ECMO coordinator: 01480 830541

V-V ECMO
Predicting Survival after Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Failure The Respiratory Extracorporeal Membrane Oxygenation
Survival Prediction (RESP) Score; American journal of respiratory and critical care medicine. 2014 Jun 1;189(11);1374-82
ORIGINAL ARTICLE
Predicting Survival after Extracorporeal Membrane Oxygenation
for Severe Acute Respiratory Failure
The Respiratory Extracorporeal Membrane Oxygenation Survival
Prediction (RESP) Score
Matthieu Schmidt1,2
, Michael Bailey1,3
, Jayne Sheldrake3
, Carol Hodgson1,3
, Cecile Aubron1
, Peter T. Rycus4
,
Carlos Scheinkestel3
, D. Jamie Cooper1,3
, Daniel Brodie4,5
, Vincent Pellegrino1,3
, Alain Combes2
, and David Pilcher1,3
1
Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public
Health, Monash University, Melbourne, Australia; 2
Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and
Nutrition, Hôpital de la Pitié–Salpêtrière, Assistance Publique–H ôpitaux de Paris, Paris, France; 3
Intensive Care Department, Alfred
Hospital, Melbourne, Australia; 4
Extracorporeal Life Support Organization, Ann Arbor, Michigan; and 5
Division of Pulmonary and
Critical Care Medicine, Columbia College of Physicians and Surgeons, New York, New York
Abstract
Rationale: Increasing use of extracorporeal membrane oxygenation
(ECMO) for acute respiratory failure may increase resource
requirementsandhospitalcosts.Betterpredictionofsurvivalinthese
patients may improve resource use, allow risk-adjusted comparison
of center-specific outcomes, and help clinicians to target patients
most likely to benefit from ECMO.
Objectives: To create a model for predicting hospital survival at
initiation of ECMO for respiratory failure.
Methods: Adult patients with severe acute respiratory failure
treated by ECMO from 2000 to 2012 were extracted from the
Extracorporeal Life Support Organization (ELSO) international
registry. Multivariable logistic regression was used to create the
Respiratory ECMO Survival Prediction (RESP) score using
bootstrapping methodology with internal and external
validation.
Measurements and Main Results: Of the 2,355 patients included
in the study, 1,338 patients (57%) were discharged alive from
hospital. The RESP score was developed using pre-ECMO variables
independently associated with hospital survival on logistic
regression, which included age, immunocompromised status,
duration of mechanical ventilation before ECMO, diagnosis, central
nervous system dysfunction, acute associated nonpulmonary
infection, neuromuscular blockade agents or nitric oxide use,
bicarbonate infusion, cardiac arrest, PaCO2
, and peak inspiratory
pressure. The receiver operating characteristics curve analysis of the
RESP score was c = 0.74 (95% confidence interval, 0.72–0.76).
External validation, performed on 140 patients, exhibited excellent
discrimination (c = 0.92; 95% confidence interval, 0.89–0.97).
Conclusions: The RESP score is a relevant and validated tool to
predict survival for patients receiving ECMO for respiratory failure.
Keywords: predictive score model; extracorporeal membrane
oxygenation; acute respiratory distress syndrome; outcome; adult
Extracorporeal membrane oxygenation
(ECMO) has been proposed as a possible
therapeutic option for patients with severe
acute respiratory distress syndrome (ARDS)
who have refractory hypoxemia or
excessively high inspiratory airway
pressures and are unable to tolerate volume-
and pressure-limited strategies (1, 2). Its
successful use for the most severe ARDS
(Received in original form November 17, 2013; accepted in final form April 1, 2014)
Supported by a 2013 ELSO Research Grant. M.S. was supported by the French Intensive Care Society; the Fonds de Dotation Recherche en Santé
Respiratoire, 2012; the Collège des Enseignants de Réanimation Médicale; and the Fonds d’Etude et de Recherche du Corps Médical des H ôpitaux de Paris.
Author Contributions: Conception and design, M.S., D.P., V.P., and M.B. Acquisition of data, M.S., D.P., P.T.R., and D.B. Analysis of data, M.S., M.B., D.P.,
and J.S. Interpretation of data, M.S. and D.P. Drafting the manuscript, M.S., D.P., M.B., C.A., C.H., and A.C. Revision of the manuscript for important
intellectual content, C.A., C.H., C.S., D.J.C., D.B., V.P., and A.C. Final approval, M.S., M.B., J.S., C.H., C.A., P.T.R., C.S., D.J.C., D.B., V.P., D.P., and A.C.
Correspondence and requests for reprints should be addressed to Matthieu Schmidt, M.D., The Australian and New Zealand Intensive Care Research Centre,
under the ROC curve of 0.73 (95% CI,
0.65–0.80) in the viral pneumonia group
and 0.73 (95% CI, 0.71–0.76) in the othe
diagnostic groups, respectively.
Predicted hospital survival in the
external validation cohort according to
RESP score is described in Figure 1B.
Overall observed survival was much lo
in risk class V and VI (i.e., RESP score
22) than in risk class III, II, and I
(i.e., RESP score > 21) (15.5 vs. 91.5%
respectively). The external validation of
RESP score on the PRESERVE dataset
exhibited excellent performance (c = 0.
[95% CI, 0.89–0.97]) in contrast to mu
poorer discrimination of the SAPS II (
0.60 [95% CI, 0.51–0.70]) and SOFA sc
(c = 0.58 [95% CI, 0.48–0.67]) in the
PRESERVE data. Graphic representatio
of the RESP score, SAPS II, and SOFA
discrimination performance is shown i
Figure E4.
Discussion
To our knowledge, this is the largest re
of patients who have received ECMO f
severe acute respiratory failure and
comprises 2,355 patients from multiple
countries over a 13-year period. This la
population has allowed creation of a w
calibrated and discriminatory survival
model comprising twelve pre-ECMO
variables (RESP score; http://www.
respscore.com).
Prognostic Factors of Hospital
Discharge
Our study suggests that the diagnosis gr
has a strong impact on survival. Althou
scarce (35 cases in 12 yr), ECMO for ac
severe asthma exhibited a very high surv
rate (33 of 35, 94%). Similarly, viral
Table 3: The RESP Score at ECMO Initiation
Parameter Score
Age, yr
18 to 49 0
50 to 59 22
>60 23
Immunocompromised status* 22
Mechanical ventilation prior to initiation of ECMO
,48 h 3
48 h to 7 d 1
.7 d 0
Acute respiratory diagnosis group (select only one)
Viral pneumonia 3
Bacterial pneumonia 3
Asthma 11
Trauma and burn 3
Aspiration pneumonitis 5
Other acute respiratory diagnoses 1
Nonrespiratory and chronic respiratory diagnoses 0
Central nervous system dysfunction†
27
Acute associated (nonpulmonary) infection‡
23
Neuromuscular blockade agents before ECMO 1
Nitric oxide use before ECMO 21
Bicarbonate infusion before ECMO 22
Cardiac arrest before ECMO 22
PaCO2
, mm Hg
,75 0
>75 21
Peak inspiratory pressure, cm H2O
,42 0
>42 21
Hospital Survival by Risk Class
Total RESP Score Risk Class Survival
>6 I 92%
3 to 5 II 76%
21 to 2 III 57%
25 to 22 IV 33%
<26 V 18%
Definition of abbreviations: ECMO = extracorporeal membrane oxygenation; RESP = Respiratory
ECMO Survival Prediction.
An online calculator is available at www.respscore.com.
*“Immunocompromised” is defined as hematological malignancies, solid tumor, solid organ
transplantation, human immunodeficiency virus, and cirrhosis.
†
“Central nervous system dysfunction” diagnosis combined neurotrauma, stroke, encephalopathy,
ORIGINAL ARTICL
risk models in ECMO (9, 15, 16). More
detailed biologic and chronic health data
may have enhanced the accuracy of our
model (15). Fifth, all items of the RESP score
were not recorded in the external validation
dataset (i.e., neuromuscular blocker use,
plateau pressure instead of peak pressure).
Finally, it is worth remembering that the
RESP score has been developed on patients
already on ECMO. It has not been validated
for prediction of survival in a more general
population of patients with severe acute
respiratory failure where ECMO has not
(yet) been instituted.
In conclusion, the overall hospital
survival of 2,355 patients with severe
acute respiratory failure extracted from
an international cohort over a 13-year
period was 57%. The RESP score offers,
through 12 simple pre-ECMO items,
a relevant and validated tool to predict
survival for patients receiving ECMO for
Figure 3. Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score
calculated for the 1,021 patients who had incomplete data and had not initially been included in the
score development. Observed survival is expressed as mean and standard deviation. Missing RESP
score variables were allocated zero score. Dark gray = 2,355 patients used to develop score; light
gray = 1,021 patients (i.e., remainder who have one or more missing values for the score).
ORIGINAL ARTICLE

V-V ECMO
• >-2
– >60
–
– CNS
–
–
–
• >3
– <48
–
–
–
under the ROC curve of
0.65–0.80) in the viral p
and 0.73 (95% CI, 0.71–
diagnostic groups, respec
Predicted hospital
external validation coho
RESP score is described
Overall observed surviv
in risk class V and VI (
22) than in risk class I
(i.e., RESP score > 21
respectively). The extern
RESP score on the PRE
exhibited excellent perf
[95% CI, 0.89–0.97]) in
poorer discrimination o
0.60 [95% CI, 0.51–0.70
(c = 0.58 [95% CI, 0.48
PRESERVE data. Graph
of the RESP score, SAP
discrimination perform
Figure E4.
Discussion
To our knowledge, this
of patients who have re
severe acute respiratory
comprises 2,355 patient
countries over a 13-yea
population has allowed
calibrated and discrimin
model comprising twelv
variables (RESP score; h
respscore.com).
Prognostic Factors o
Discharge
Our study suggests that
has a strong impact on
scarce (35 cases in 12 y
severe asthma exhibited
Table 3: The RESP Score at ECMO Initiation
Parameter Score
Age, yr
18 to 49 0
50 to 59 22
>60 23
Immunocompromised status* 22
Mechanical ventilation prior to initiation of ECMO
,48 h 3
48 h to 7 d 1
.7 d 0
Acute respiratory diagnosis group (select only one)
Viral pneumonia 3
Bacterial pneumonia 3
Asthma 11
Trauma and burn 3
Aspiration pneumonitis 5
Other acute respiratory diagnoses 1
Nonrespiratory and chronic respiratory diagnoses 0
Central nervous system dysfunction†
27
Acute associated (nonpulmonary) infection‡
23
Neuromuscular blockade agents before ECMO 1
Nitric oxide use before ECMO 21
Bicarbonate infusion before ECMO 22
Cardiac arrest before ECMO 22
PaCO2
, mm Hg
,75 0
>75 21
Peak inspiratory pressure, cm H2O
,42 0
>42 21
Hospital Survival by Risk Class
Total RESP Score Risk Class Survival
>6 I 92%
3 to 5 II 76%
21 to 2 III 57%
25 to 22 IV 33%
<26 V 18%
Definition of abbreviations: ECMO = extracorporeal membrane oxygenation; RESP = Respiratory
ECMO Survival Prediction.
An online calculator is available at www.respscore.com.
*“Immunocompromised” is defined as hematological malignancies, solid tumor, solid organ
transplantation, human immunodeficiency virus, and cirrhosis.
†
“Central nervous system dysfunction” diagnosis combined neurotrauma, stroke, encephalopathy,
ORIGIN
Predicting Survival after Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Failure The Respiratory Extracorporeal Membrane Oxygenation
Survival Prediction (RESP) Score; American journal of respiratory and critical care medicine. 2014 Jun 1;189(11);1374-82

1. 20 75
2. VF/ VT
3. ACLS 15
1.ER 45
2.ER 15 ACLS
3. < 30℃
4. ADL
5.

SAVE-J study
2008 10 - 2011 9
ECPR Non-ECPR p
登録症例数 260 194
平均年齢（歳） 56.3 58.1 NS
性別［男性］（％） 90.4 88.7 NS
目撃あり（％） 71.5 77.8 NS
バイスタンダーCPR（％） 48.8 46.4 NS
119番通報∼病院到着［平均］（分） 29.8 30.5 NS
原因疾患：急性冠症候群（％） 63.5 59.3 NS
発症１ヵ月後 CPC1-2（％） 12.3% 1.5% <0.01
発症６ヵ月後 CPC1-2（％） 11.2% 2.6% <0.01
T Sakamoto et al. Resuscitation 85 (2014) 762–768

ECMO(VA+VV)
– 40
– 30
– 5−10
– 56
–
Fig 1. Pooled estimate rate and 95%
conﬁdence interval (%) for complications
of extracorporeal membrane oxygenation.
(AKI ¼ acute kidney injury; LEA ¼ lower
extremity amputation; LEF ¼ lower extrem-
ity fasciotomy or compartment syndrome;
LEI ¼ lower extremity ischemia; Re-Thx ¼
rethoracotomy for bleeding or tamponade;
RRT ¼ renal replacement therapy.)
614 CHENG ET AL Ann Thorac Surg
COMPLICATIONS OF ECMO 2014;97:610–6
ADULTCARDIAC

•
ACT
• Serum leakage
•
▪ Re-insert pump head
▪ Turn on pump to 1000rpm & remove clamp
▪ Gradually increase rpm’s
Note on HAND CRANKING the pump
 Clamp lines.
 Disconnect the pressure sensor and venous oximeter cables
 Open the safety bar
 Press on both locks on the joints of the safety bar and fold it upwards..
 Take the disposable PUMP out of the CARDIOHELP:
 Fix the disposable to the CARDIOHELP Emergency Drive hand crank
 Fit the disposable under the locating lug from below.
 Open the lower locking device. Swing the disposable right up to the
pump drive and release the lower locking device so that it fixes the
disposable
 Unfold the hand crank handle.
 Open the clamp on the venous side and turn the hand crank clockwise
 When RPM is > 1500, unclamp lines and increase RPM
Hand crank

ABG PaO2>150mmHg
FiO2 1.0
↓
V-V ECMO

•
• VA-ECMO, E-CPR ?
•
•
–
–
•
• VAP

• Sshould be inserted and connected at the time of cannulation, or as soon
as practical later
• After arrival in ICU, the ultrasonic flow probe should be used to confirm
that there is flow in the extension tubing
Doppler examination of the blood flow in the back-flow cannula is indicated if
deteriorating leg perfusion is observed in the cannulated leg.
Access Cannula
(Venous)
Tubing to backflow
cannula
Return Cannula
(Arterial)

BLS, ALS, ECPR update2015-2018

BLS, ALS, ECPR update2015-2018

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BLS, ALS, ECPR update2015-2018