Role of Epinephrine and Extracorporeal Membrane Oxygenation in the Management of Ischemic Refractory Ventricular Fibrillation

Highlights •The Minnesota Resuscitation Consortium has established a protocol for rapid transport of patients with refractory out-of-hospital VF cardiac arrest to the cardiac catheterization laboratory for rapid evaluation and stabilization often requiring ECMO. This protocol provides new challenges to treatment paradigms that were created to rapidly achieve return of spontaneous circulation in the field. •A porcine model of refractory VF cardiac arrest was developed, including initiation of VF using endovascular occlusion of the proximal LAD followed by 5 min of untreated VF. Resuscitation begins with 10 min of high-quality CPR followed by 35 min of ACLS and reconstitution of coronary flow. •A 2 × 2 study design was used with animals randomized to use of epinephrine or placebo during ACLS and then again randomized to ECMO or no ECMO at the time of reinitiation of coronary flow. •ECMO-facilitated coronary reperfusion and hemodynamic stabilization improved 4-h survival compared with CPR-facilitated reperfusion and standard ACLS in a porcine model of refractory VF cardiac arrest. •Repeated epinephrine boluses provided in accordance with standard ACLS protocols increased systemic blood pressure and coronary perfusion pressure but provided no benefit in survival compared with placebo. •Over 50% of the animals receiving ECMO met criteria for decannulation at 4 h, suggesting that rapid cardiac and hemodynamic recovery is possible in severely injured animals treated with ECMO.