Fig. 10.1
Monza’s flow chart for ECMO support in refractory CA
We must emphasize that this flow chart only represents a recommendation, since it is the attending physician’s responsibility to decide whether to initiate ECLS, even in the presence of prolonged no- or low-flow time, based on clinical or anamnestic factors, e.g., the appearance of vital signs, or a good CPR performed by well-trained personnel or with an automated chest compression device.
The first point to assess in our flow chart is the presence of comorbidities precluding ECMO positioning as reported below (Fig. 10.1).
We decided to use a no-flow time of 6 min and a low-flow time of 45 min on the basis of the literature and from our preliminary results [30]. To reduce the no-flow time, we promoted telephone-guided CPR performed by bystanders. To reduce the low-flow time, our ECMO team was alerted for all CA patients when ongoing CPR lasted more than 15 min. In OHCA, the ambulance crew was prompted to leave the scene and begin transport after no more than 15 min of ACLS maneuvers in the absence of an ROSC, to reduce the no-flow time to a minimum.
Finally, an ETCO2 below 10 mmHg measured after 20 min of CPR contraindicated ECMO.
10.4 Conclusion
Sudden CA is a complex event with high mortality rate. We strongly believe that optimal state-of-the-art conventional treatment should constitute the basis for every CA patient. ECLS represents a valuable additional therapeutic option both in achieving ROSC and in post-resuscitation care in highly selected CA patients not responding to the conventional approach.
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