Post arrest care.
\r\n\tMain emphasis should be on its applications. In every field MOFs can be used due to its greater stability and high surface area, but the focus should be on applications.
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"54197",title:"Novel Health Mobile Technology as an Emerging Strategy in Diabetes Management",doi:"10.5772/67508",slug:"novel-health-mobile-technology-as-an-emerging-strategy-in-diabetes-management",body:'The huge developments and advances in mobile phone technology and its applications coupled with equally robust growth of telecommunication technology can serve to give patients a better access to health care information, which can make their life easier and enable efficient self-care. Electronic health services or eHealth is the use of information and communication technologies for health which continues to grow rapidly worldwide. It can also make the web-based health services easier, quicker, accurate, and cost effective. Chronic diseases need to be addressed in every possible way to contain their growth through awareness, education, and implements that enable self-management of the disease by patients. In this aspect, IT technologies together with mobile handsets can play a pivotal role in facilitating the dissemination of information and hence help better management of the disease. The rate by which mobile technology grows is something that cannot be overlooked; for example, a recent study has shown that there will be 11.5 billion connected mobile devices on use worldwide, and the global mobile data traffic will increase 10 times by the year 2019 [1]. Thus, the health care delivery can ride on this growth to reach the patients with innovative health care solutions.
The ever-expanding computing ability of smartphones together with the increasing footprint of the communication network, and the ever pervasive IT can be exploited to bring health care services to the patient’s doorstep. Mobile technology can be used by both the health care service providers and the patients equally [2]. For example, doctors are adopting smartphone apps to seek clinical knowledge and case studies while patients are utilizing the same to have access to health information that will improve their understanding and management of their diseases [3, 4].
Mobile health (mHealth) is a part of the broader field of eHealth that employs mobile phones as the base of health care–related solutions. mHealth services can also make the health services easier, quicker, accurate, and cost effective. WHO defines mHealth as “mobile health (mHealth) is an area of electronic health (eHealth), and it is the provision of health services and information via mobile technologies such as mobile phones and personal digital assistants (PDAs)” [5]. mHealth intends to enable the patient to self-care and helps the health care professionals to remotely follow-up their patients. For supporting the self-care, it would require the device to collect the data and provide advice automatically using embedded software that analyzes the data. On the other hand, remote care would require in addition to data collection, data transmission also. The device will collect the data and transmit it to a portal which the health care professional can access. Any decisions or advices from the health care professional after reviewing the patient data can be automatically communicated to the patient device using the same gateway. While the data can be entered manually by the patients using an appropriate interface, there are already devices available that can communicate the data wirelessly to the mobile phones. However, integrating various biosensors into mobile phones has not been widely followed yet. This may be possibly because of perceived prolonged regulatory approval process, which may be longer than the shelf life of many mobile phone models themselves.
With the emergence of electronic health records (EHRs), digital health services started increasing rapidly. EHRs are the database of patient health information stored in digital form that can be retrieved anytime using a secure access. mHealth systems which are part of digital health can be effectively integrated into hospital-based EHR systems with controlled access given to both patients as well as health care providers. With advances in mobile phone technologies, the functionalities of mobiles phones have increased tremendously. The new generation mobile phones also known as smartphones have several features such as voice calls, video calls, SMS, apps, and web access. These functionalities can be utilized to provide the access to mHealth. Smartphones also can be connected to certain medical devices. The mHealth applications used commonly in disease management programs are smartphone apps. Other features of smartphones can also be utilized for improving the health care. Voice calls, SMS, web/e-mail access through smartphone browser, and third party applications such as WhatsApp are other functionalities that have been explored to mHealth.
Smartphone application, popularly known as app, is a dedicated application developed using the mobile operating software. It provides the user with all the options that are usually available in a desktop computer when accessing a website. Apps use the Internet connection to access database, hospital information system, or even a web portal. Patients enter their daily activities as input data, which will be saved in the phone memory or in a web database. The database may be in the cloud or in the hospital itself depending on the service provider. Apps may provide the automated feedback based on the patient data. There are some apps which provide access to health care worker to review the patient entered data and provide feedback.
The availability of mHealth apps has been increasing rapidly. Presently about 165,000 mHealth apps are available [6]. Various dedicated mHealth applications have been developed for the chronic diseases management recently. Several health care organizations started already using these applications to improve patient awareness. Simplest use of such mHealth application is the follow-up of clinic visits of patients. Patient-centered applications are designed to be used by patients to enhance the patient awareness about their condition, track their health parameters, and help self-management. These apps utilize the GPS tracking, accelerometer, and connectivity features available in most of the smartphones to provide specific functionalities. Common examples of patient-centric applications are diet apps, physical activity monitoring apps, behavior modification apps, and smoking cessation apps.
Clinical decision support systems are apps that are exclusively meant for health care providers. These apps provide access to patient history, current data, and clinical decision support. Clinical decision support systems assist the health care workers in interpreting patient reports and prescribe medications. This will greatly enhance remote treatment and monitoring of patients and will help to decrease the frequency of hospital visits. They also have alerts, reminders, and customized data entry forms for documenting patients’ health information. mHealth applications aim to realize an improved health care system by targeting various aspects of medical care such as health promotion and disease prevention, diagnosis, treatment, and monitoring and supporting health services [7]. Figure 1 illustrates the simplest possible framework of implementation of a mHealth setup in a hospital.
Schematic diagram of implementation of mHealth in a hospital setup.
Health promotion and disease prevention target the modifiable risk factors that contribute to the development and worsening of chronic diseases. These are mostly behavior modification strategies intending to change the poor eating habits, tobacco usage, and lack of physical activity. Behavior modification has been the key target of health promotion and disease prevention strategies. These interventions are meant to promote healthy behavior among patients. With the ability to reach individuals en masse, mHealth apps can address the communities with health promotion and disease prevention strategies and provide strong thrust in initiating healthy behavior. With wireless self-tracking sensors and activity monitors, behavior of the patients can be monitored. This will help in inducing the behavioral change among patients. In addition to the behavior monitoring, patients can be provided with personalized feedbacks that can influence the effect of healthy behavior.
In a meta-analysis, to examine the efficacy of mobile devices to influence the physical activity, it was concluded that mobile technology is an effective platform for influencing the physical activity [8]. The studies included SMS, mobile software, and personal digital assistants (PDAs) as means of intervention. The effect was larger for pedometer step counts. Mobile phone intervention yielded a significant effect while with the PDA, the effect was not significant.
When the effect of mobile apps to promote weight loss and increase physical activity was evaluated in a systematic review, it was found that use of mobile phone apps resulted in a significant weight loss when compared with control group. However, the physical activity did not differ significantly between the groups [9]. A report from Sax Institute, Australia, analyzed seven systematic reviews on physical activity and/or weight loss outcomes and concluded with mixed results [10]. Despite the improvements in healthy behavior after using mHealth, sustaining the changes were often faced with difficulty. Patients tended to drop-off once the intervention was removed. Long-term interventions are limited by the cost of such implementations. Patient behavior monitoring systems should be integrated with the disease management systems to lessen the cost of such interventions. However, patients and care providers may find it too much for every day routine as these systems might require too many data entries and feedbacks. Automated systems can be used to tackle this burden but at the cost of a higher budget.
With the increased use of handheld point of care diagnostic devices, it has become possible to decentralize the diagnostic procedures. Many of these devices are user friendly and can be operated by patients at their home. There are web-connected devices which can capture the patient health data and communicate to the designated portal. If these devices can be integrated with smartphones, it can used to analyze, interpret, and also communicate the data. This will help the patients to carry out the self-diagnosis but still under the monitoring of a health care worker even without having to visit the health care facility.
These connected devices can also be used in primary health centers of remote locations in developing countries where the reach of expert medical care is not easy. The data can be communicated in real-time to receive an expert opinion. This will also help the care providers with more time to review the data and make informed decisions. With the rapid increase in the screen resolution of mobile devices, using mobile screens for viewing diagnostic images has also been explored. Owing to their handy and connectable nature, these devices will be very valuable in remote diagnosis. Kumar et al. [11] used an iPhone-based specific image archiving and forwarding program (i2i telesolutions) to view and report the diagnosis on diabetic retinopathy fundus images in the mobile phones. It was found that the diagnosis using mobile phones matched with that of computer-based technique, and the quality of images on the iPhones was reported high by the ophthalmologists. In a review on smartphones, tablets, and mobile applications for radiology, 11 applications were identified as diagnostic reading applications [12]. It was concluded that the use of smartphone or tablet screens resulted in comparable outcome to the respective gold standards. It may be noted that the mHealth applications that are intended for diagnostic purposes are considered as medical devices by the USFDA and therefore will require prior approval for the clinical use [13]. This could be the reason behind the lower utilization of mHealth for diagnostic purposes when compared to the other forms of mHealth usage. Even some mHealth apps carry the label “not for diagnostic use” to avoid the tougher regulatory journey.
Treatment of chronic diseases requires continuous follow-up and monitoring of the progress. By implementing mHealth, patients can be kept in the loop for appointment reminders, medication reminders, or any other important alerts. Apart from these general service, patient-specific treatment follow-up can be done using specific applications. Patients will report the health information to a designated portal using the point care of care devices connected to web directly or through a smartphone. The health care team will review the patient data and make the necessary changes in the treatment with or without the help of clinical decision support systems. This will greatly help in reducing routine and emergency hospital visits. Dose adjustment of medications while initiating new treatments will require frequent visits to hospital or even frequent phone calls. If web-connected devices are used in such situations, checking the patient health status and adjustment of treatment can be carried out remotely.
Several attempts have been made to study the impact of mHealth technologies in the management of chronic diseases. Diabetes, cardiovascular diseases, chronic lung diseases, osteoarthritis, and mental health are the commonly studied chronic conditions where the mHealth intervention was found to be useful. De Jongh et al. assessed the effects of mobile phone messaging applications designed to facilitate self-management of long-term illnesses, in terms of impact on health outcomes and patients’ capacity to self-manage their condition in a systematic review [14]. The phone messaging interventions provided benefit in supporting the self-management of long-term illnesses. They concluded that the long-term effects, acceptability, costs, and risks of such interventions needed further investigation. mHealth tools facilitated adherence to chronic disease management, but the evidence supporting its current effectiveness was found to be mixed in another systematic review [15]. A review by Sax Institute found that meta analyses and systemic reviews conducted to study the effect of mHealth interventions on cardiovascular disease, chronic lung disease, and mental health produced mixed outcomes [10]. Interestingly, majority of the studies that evaluated the mHealth interventions in chronic diseases included diabetes. Therefore, we decided to focus on effect of mHealth interventions on the various aspects of managing diabetes mellitus.
Diabetes mellitus has been the most common chronic disease affecting human beings as reported by the International Diabetes Federation with more than 366 million people currently affected and is expected to reach 552 million by the year 2030.The high mortality and morbidity as a result of chronic complications which make diabetes the leading cause of blindness, renal failure, ischemic heart disease, and limb amputation [16]. Diabetes mellitus is considered to be costly disease in terms of economic burden since the health care expenditure for diabetes in United States during 2011 was 7.7 billion US dollars with direct costs of 3.4 billion US dollars and indirect costs of 4.3 billion US dollars [17].
Treatment of diabetes needs self-management by patients to achieve stable control of the disease. Diabetes management is often cumbersome and demanding as it requires the patients to do regular home-based glucose monitoring and apply continuous lifestyle modifications. Typical diabetes management plans always include diabetes education and regular follow up of patients in order to achieve the treatment goals. Evolvement of smartphones and their wide reach has paved way for development of various mobile health applications. This has attracted a lot of attention from diabetes health care researchers as it aptly suits for implementing various aspects of diabetes management plans such as patient remote monitoring, data collection, patient education, and medical intervention.
The case study was intended to review the effectiveness of mobile health applications in management of diabetes mellitus using original articles that were published in ISI indexed journals from PubMed database. About 209 scientific articles were captured from the PubMed database starting by the year 2007 till 2014. The search key phrases were “clinical study on use of mobile phones for diabetes,” “clinical study on use of smart phones for diabetes,” “clinical study on use of cell phones for diabetes,” and “clinical study on use of mobile applications for diabetes.” The search resulted in 66, 64, 62, and 17 articles, respectively. From these 209 articles, 131 were found to be duplicate. Of the remaining 78 articles, 25 fulfilled our selection criteria which included original clinical studies evaluating mobile health technology in diabetes mellitus management. These articles were grouped under three categories such as applications used for diabetes treatment, applications used for modifying patient behavior, and applications used for patient education.
A paper-based diary is provided to the patients by diabetes clinics to ensure patients record their blood glucose readings and hypoglycemia events. This is done in conjunction with regular phone calls by the clinical team to support the self-management of patients. Advances in mHealth comes in handy to help the patients to record their data and communicate it to the health care team. A mobile phone–based diabetes digital diary that can be accessed by the health care team via web is a reality now. However, use of such mobile phone–based diabetes diaries resulted in mixed outcomes in clinical studies. When a mobile diary app was used in type 2 diabetes patients for self-titration of insulin dose, there was a significant decrease of Hemoglobin A1c (HbA1c) [18]. However, there was no significant reduction in HbA1c and other glycemic parameters such as Fasting blood glucose (FBG) and Postprandial glucose (PPG) in type 1 diabetes [19].
Smartphone apps can be used to collect the data and upload it to a web-based server. This will make it simpler to integrate the mHealth applications with the web-based health information systems already available in the health care organizations. Effect of web-based patient monitoring and intervention in diabetes management was explored in different studies. Even though the web-based diary intervention improved the patient self-care, many patients expressed frustration over using the app multiple times every day [20].
When patients were given access to online web diary and received optimal recommendations through e-mail or mobile phone after uploading their daily blood glucose readings, there was a significant improvement of HbA1c and postprandial glucose levels after 12 weeks [21], 6 months [22], and 1 year [23]. Hee-Sung [24] evaluated a web-based patient monitoring and nurse’s education through SMS in type 2 diabetic patients. HbA1c levels were found to be significantly decreased. It should be noted that despite having improvements in glycemia after using these mHealth interventions, patients reported frustration with the intervention. Hence, necessity of frequent use of smartphone and websites may lead to a decreased compliance among patients in long term.
A smartphone app (Diabeo) for insulin dose adjustment improved the HbA1c among the patients who used that app along with teleconsultation [25]. When a telehealth system with real-time graphical feedback and remote nurse monitoring through mobile phones was implemented for the dose adjustment of oral hypoglycemic agents in type 2 diabetic patients, it lead to a decrease in the HbA1c levels [26]. The telemonitoring of patients with mobile phones provides a closer and real-time support to the patients. It seems that access to the health care team and timely feedback facilitated the treatment optimization and increased patient compliance.
Treatment of diabetes includes lifelong lifestyle modifications. To successfully implement the lifestyle modifications, continuous patient monitoring strategies are required. However, these strategies often fail to bring the desired lifestyle changes due to the lack of efficient patient monitoring systems. Wide availability of smartphones has brought the patient remote monitoring possible. Patient behavior modification includes monitoring the patient behavior, adherence, and self-care.
Patient behavior monitoring will help the care providers to plan the effective intervention strategy for individual patients. A cellphone-connected glucometer along with telephone and SMS communication was used to monitor the behavioral pattern of adolescent type 1 diabetic patients, resulted in a significant improvement in the self-management profile and a reduction in HbA1c [27]. A telehealthcare program was used to monitor self-management behavior in adult type 2 diabetic patients [28]. They used an online diabetes self-management system with teleconsultant service, in addition to a cell phone–connected glucometer. This improved healthy behaviors, increased glucose monitoring, and a significant reduction in HbA1c. Behavioral monitoring of the patients with the cell phone–based applications was beneficial in inducing lifestyle modifications that lead to a better glycemic control.
Diabetes treatment requires multiple medications and lifestyle changes. This is a huge challenge for both patients and care providers in terms of patient adherence. Diabetic clinics closely follow the patients to make sure that they adhere to the instructions. mHealth technology can be applied effectively for such patient follow-up programs. It is very interesting to note that despite the conventional telephone-based patient follow-up and the SMS communication resulted in similar adherence, the SMS-based follow-up was more effective in decreasing the HbA1c [29]. Mobile phone–based ecological momentary assessment tool to measure the patient adherence behavior [30] was comparable to the traditional self-reported data. This supports the use of mHealth interventions for improving patient behavior and adherence.
Self-care and self-efficacy are the two important patient behaviors that have a direct influence in the diabetes treatment. mHealth applications can be utilized to develop patient support systems to promote self-care and self-efficacy behaviors in patients. When an interactive cell phone technology in which patients would receive recommendation messages after uploading their data were used, the self-care and the self-efficacy scores were significantly improved. However, there was only a negligible decrease in HbA1c levels. This was attributed to the low patient adherence arising out of the lack of user-friendly system [31]. Most of the patients reported positive lifestyle changes when they were asked to record their daily self-care activities in a web-based diary using their mobile phones and received feedback messages [32]. Remote monitoring of the patient activities with care provider feedback is supportive in improving patient self-care.
As patients with diabetes are required to take multiple medications, check their blood glucose levels, and implement lifestyle modifications, awareness about their disease and understanding of the care providers instructions are very important. Lack of awareness about the disease will impact the diabetes treatment by affecting the self-care activity. This is often the reason for treatment failures in many cases. Clinical guidelines on diabetes management include patient education. Patient education using the mHealth technology can prove to be highly useful as the patient can carry the mobile handsets and apply the informational tips whenever needed.
With the availability of audiovisual communications, mHealth technology offers better ways to deliver the patient education effectively. SMS is the simplest form of communication that mHealth technology can utilize for patient education. When unidirectional educational text messages were sent to patients using a specific messaging program (TExT-MED), it increased medication adherence, quality of life, and decreased emergency visits [33]. But there was no improvement in glycemic control. Lack of patient interaction in the unidirectional messaging might have been the reason behind the ineffective glycemic control. However, sending educational SMS according to the patient preference increased the adherence and improved the HbA1c and lipid profiles [34].
Smartphone applications can be a valuable tool in the patient education programs as it can engage the patients more effectively than the unilateral SMSs. Patient specific data are collected through the app, and the educational content is tailored to suit the patient requirement. “Glucose Buddy,” a freely available iPhone diabetes management application, was used in type 1 diabetic patients. It collected patient information and send educational SMSs based on the patient data. Despite a significant improvement in HbA1c, the quality of life and self-care activities were not improved [35]. However, it may be noted that the self-care activities and quality of life do not always correlate with HbA1c in type 1 diabetic patients [36].
A smartphone-based diabetes diary “Diab-Memory” was used to collect and transmit patient data to a remote monitoring center in patients with type 1 diabetes. The app sent reminder messages to patients with analyzed data output and statistical trends. It was well accepted by the patients, and the glycemia improved significantly. ‘Ubiquitous Chronic Disease Care’ (UCDC) system for a Smartphone app for diabetes care was investigated in type 2 diabetic patients [37]. Patients received alarms to remind about daily self-care activities. They also received educational messages after sending their data. This intervention improved the clinical parameters such as HbA1c, Blood Pressure (BP), and lipid profile. The educational messages and reminders supported the patient self-care, whereas the use of smartphone app engaged the patients and helped increasing the patient adherence.
A patient coaching system using mobile diabetes management software was evaluated in diabetes patients. The system sent automated, real-time, educational, behavioral, and motivational messages to patients. The messages were tailored to suit the patients by reviewing the patient entered self-care data. Care providers were either given access to only patient data or patient data along with decision support. Patients showed greater improvement in HbA1c when the care providers with given access to decision support [38]. This study has showed the decision support system when integrated with mHealth can enhance the clinical outcomes in chronic diseases.
Care should be exercised while interpreting the results of these clinical studies, as many of them reported that the patient entered data without any validation. Age could be a significant factor which can influence the effect of mHealth interventions especially in chronic diseases. Educational level and the experience of using smartphones among patients are other important factors that can affect outcome of the implementation of mHealth. These factors also should be taken into account before interpreting the results of studies that evaluated the mHealth-based interventions.
Results of many systematic reviews and meta-analyses indicate that intervention of mHealth applications for most of the chronic diseases resulted in mixed outcomes. However, in our case study, to review the use of mHealth for diabetes has shown positive outcomes from most of the studies (88%) after use of the mobile health applications in various aspects of diabetes treatment such as disease management, behavioral monitoring, and patient education. Even many of the studies have shown that the simple text messages are very effective in improving the clinical and behavioral outcomes. The reason may be that the text messages are easier to handle and can be read by the user whenever they have convenient time. Even though the text message–based interventions were found to be effective in improving clinical outcomes, they were inferior to the relatively complicated smartphone apps. Sending such unidirectional messages by the health care organization may not be able engage the patients effectively as there is no active interaction between the patients and care providers. To overcome this, several smartphone apps with integrated messaging system have been developed. Patients enter their data using the app which then goes to a dedicated repository which the care provider has been given secured access. After reviewing the patient data, the care provider can send instructional or recommendational messages to patient’s mobile using the same app. Some apps even automate this feedback messages; in such cases, the software will analyze the patient data and provide automated feedback.
Patient compliance will be an important factor in long-term mHealth interventions. Many patients may not be comfortable with being monitored remotely. Hence, patient privacy–related issues can be another hurdle in the way of mHealth. However, the biggest challenge is in providing continuous patient support with this technology. This would require adequate infrastructure and trained personnel in place. Cost of such interventions needed to studied with respect to the available options. Cost benefit and cost-effectiveness analysis studies with mHealth technologies are therefore necessary before implementing these systems on large scale.
The authors would like to thank Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh for facilitating the conduction of this work.
ECMO, or extracorporeal membrane oxygenation, is an advanced life support technique that provides cardiac and pulmonary support similar to cardiopulmonary bypass. Venous blood is drained and pumped through a membrane where gas exchange occurs. Oxygenated blood is returned back to the patient either through venous circulation in VV-ECMO (venovenous ECMO) or arterial circulation in VA-ECMO (venoarterial ECMO).
\nECPR (extracorporeal cardiopulmonary resuscitation) is the rapid deployment of VA-ECMO during cardiopulmonary resuscitation (CPR) when conventional CPR fails to provide return of spontaneous circulation (ROSC) [1]. The first reported use of ECMO in CPR was in 1976. Since then, the use of ECPR has become well-described in adults and children, with a continuously expanding list of diagnoses.
\nECPR literature is limited, more so for pediatrics. Reports are mainly single center experiences, registry retrospective analyses, and a few meta-analyses. Small sample sizes and lack of standardization impede drawing conclusions on utilization and care processes for ECPR. Regardless, utilization of ECPR continues to expand. The Extracorporeal Life Support Organization (ELSO) reports more than a total of 10,000 ECPR patients since 1990, of which more than 5000 are pediatric or neonatal runs [2]. ECPR cases make up approximately 10% of all ECMO runs recorded over this time frame. Most ECPR cases originate in the intensive care unit, but there is growing literature demonstrating widening the use to emergency room arrests and out-of-hospital arrests [3, 4].
\nWith expanding application, ECPR has shown promise to improve outcomes of cardiac arrest. ELSO recognizes that ECMO can be considered for select patients in cardiac arrest. In 2015, the American Heart Association (AHA) cautiously pointed out that while the evidence is still lacking, ECPR may reasonably be considered in potentially reversible situations [5].
\nThis chapter explores the current utility of ECPR, and provides a literature summary of its indications and limitations. The chapter will also describe current use and outcomes in adults and children. Finally, complications of ECPR will be reviewed. A special focus will highlight neurologic complications and their influence on meaningful outcomes after ECPR.
\nECPR use for victims of cardiac arrest consistently demonstrates a survival benefit over conventional CPR [5, 6, 7, 8]. This survival benefit is more pronounced as the duration of CPR increases. In contrast to arrest survivors who only receive conventional CPR, patients rescued with ECPR have higher survival rates at discharge and at 6-12 months post discharge [9]. Arrest victims rescued with ECPR are also more likely to have better neurologic outcome, when compared to patients rescued with conventional CPR [10].
\nThe goal of ECPR is to augment cardiac output during the low flow phase of CPR, restoring oxygenation and perfusion in the setting of cardiac arrest. In some cases ECPR alone may be therapeutic, and in other cases it allows maintenance of perfusion while further treatment is explored.
\nAt this time, no universal criteria exist for the deployment of ECPR. AHA recommendations are limited to heart disease amenable to either recovery or transplantation, in a setting where the arrest occurs in a highly supervised environment [11]. Their only other recommendation is for use in out of hospital cardiac arrest in the setting of severe hypothermia if appropriate expertise, equipment, and protocols are available. ELSO recommends ECPR in arrest victims “with an easily reversible event and have had excellent CPR” [12]. The UK Resuscitation Council considers ECPR as a “rescue therapy for patients in whom initial ALS measures are unsuccessful to facilitate specific interventions” such as coronary interventions or thrombectomies [13].
\nCenters that offer ECPR use center-specific processes, based on experience and availability of resources. ECPR is most commonly available to in-hospital cardiac arrest. Arrests in the emergency department can also be managed with ECPR. In some settings with appropriate resources, experience, and planning, out-of-hospital cardiac arrest has been managed with out-of-hospital ECPR [4, 14].
\nContraindications to ECPR vary between institutions, and a unified consensus does not exist. ECMO-related prognostic factors in the current literature are unreliable with regards to ECPR outcomes. On their own, most of these factors do not provide sufficient evidence to support denial of life-saving ECPR to a victim of arrest. The only absolute contraindications to ECPR are the presence of a valid “Do Not Resuscitate” order and the absence of appropriate staff/equipment to initiate ECPR. All contraindications to ECMO use, such as extreme prematurity, also apply.
\nOtherwise, a range of situations can be proposed as relative contraindications for ECPR:
Severe neurological impairment prior to cardiac arrest: Exact definitions of impairment will vary between providers and institutions. In a similar vein, conditions that place a patient at high risk for severe neurologic injury despite good CPR (such as severe primary pulmonary hypertension or patients with cavopulmonary circulation) may be a reason to not offer ECPR. Determinations to preclude a child from ECMO candidacy may involve a discussion with family, and should contain an understanding the perceived and expected quality of the child’s life.
Known irreversible disease process: When cardiac arrest occurs in the setting of a known irreversible and untreatable disease process, ECPR will only prolong suffering. Providers must work with the appropriate subspecialists to understand primary disease prognosis in order to determine if ECPR is an appropriate choice should the patient arrest.
Severe immunosuppressed state: While literature is limited, certain groups of severely immunocompromised patients tend to do worse on ECMO. Patients with immunosuppression in the setting of solid organ transplantation or high-dose steroid regimens may have outcomes comparable to the general population. In contrast, patients with solid tumors, hematological malignancies, or acquired immunodeficiency syndrome (AIDS) do much worse on ECMO. In one study, survival to discharge was 7–20% [15]. This highlights the need to understand primary disease prognosis, and determine ECMO candidacy prior to arrest.
Severe coagulopathy: Management of ECMO post-resuscitation requires use of anticoagulation to maintain appropriate circuit function. In cases of severe coagulopathy, the physician must balance the management of the coagulopathy and the circuit anticoagulation. If the coagulopathy is difficult to treat, devastating and fatal hemorrhagic side effects may occur [16].
Prolonged total arrest time: There is no consensus on a cut-off time, but as shown in Figure 1, prolonged low-flow states are associated with lower survival [17]. Neurologic outcomes are also worse. The impact is magnified if combined with failure to initiate chest compressions in a timely fashion after arrest. While a prolonged resuscitation may be not futile, each institution must consider its capabilities and available resources before establishing a cutoff time. This decision will also likely be patient-dependent.
Lack of access for cannulation: Anatomic or other vascular anomalies that preclude successful cannulation render a patient a non-candidate for ECPR.
Estimated survival rates for extracorporeal membrane oxygenation (ECPR) patients after every given low-flow time (red line). Survival with conventional CPR (dashes) is demonstrated as a comparison. Wengenmayer T, et al. Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation Crit Care. 2017;21(1):157. Published under terms of the Creative Commons Attribution 4.0 International License.
According to recent reviews of the ELSO registry, ECPR is currently most commonly used in patients who suffer cardiac arrest secondary to a primary cardiac cause [7]. This is independent from patients who fail to wean off cardiopulmonary bypass. These patients include arrests post cardiac surgery, such as surgery for congenital heart disease (CHD). CHD patients rescued with ECPR include both single and two-ventricle patients. This cardiac cohort also includes patients with structurally normal hearts but develop heart failure in the setting of myocarditis, cardiomyopathy, arrhythmias, pulmonary arterial hypertension, and heart transplant graft failures.
\nA variety of non-cardiac causes of arrest have also been supported by ECPR. These include arrests in the setting of septic and other forms of non-cardiogenic shock. Arrests that occur in the setting of pneumonia, ARDS, acute airway compromise, toxic ingestions, severe hypothermia, and trauma have also been supported with ECPR.
\nIn some situations where the cause of arrest is unclear, ECPR allows for preserving the patient while the diagnosis can be clarified. For example, ECMO support allows for time to perform head imaging or other diagnostic testing that helps with clarifying treatment or prognostication. If a negative prognosis is uncovered, there is time to involve palliative care, if desired, and allows family another opportunity for closure.
\nSome institutions have reported ECPR use as a temporary measure for organ perfusion while organ procurement organizations work to facilitate organ placement [18, 19]. This is usually in situations where brain death is quickly identified after placement on ECMO. Viability of the organs is preserved, and the transplanted organs have a high rate of good functional recovery [20].
\nThe real-life application of ECPR varies between centers [21]. At a minimum, a core group that consists of a code team, a cannulation team (surgeon or interventionalist to cannulate), and an ECMO specialist must be available. Support staff including additional nursing, pharmacy, and OR staff may be needed. Location of the cannulation procedure will depend on center experience and appropriateness of available space. For example, the procedure can happen in the intensive care unit, in the catheterization lab, or in the operating room. Some centers have reported experience with cannulating in other locations, such as in the emergency department, in the IR suite, or on regular hospital wards. Most reported experiences follow a similar algorithm.
\nCannulation technique for ECPR depends on anatomy, experience and training of the cannulating provider, and circumstances necessitating support [22]. In almost all cases, ECPR patients require VA cannulation. If the patient has an open sternum, central cannulation is the easiest approach. In smaller children, the right carotid artery and internal jugular vein are the most common choice. In adults and adult-sized children, femoral cannulation is technically feasible. Femoral cannulation can limit the no-flow time due to minimal or no interruptions in compressions. Placed cannulas should support at least 120-150 mL/kg/min flow in order to provide an appropriate cardiac index in smaller children. In larger children and adults, the cannulas should support 3.5 to 5 L/min depending on the underlying etiology of cardiac arrest. If cannula sizes are deemed to be insufficient for flow, additional venous drainage can be added.
\nThe goal of post arrest care is to safeguard neurologic function and prevent secondary organ injury, while working towards the diagnosis and management of the cause of arrest. The AHA recommends adopting a systems-based, protocolized, goal-directed approach to the management of post-arrest patients [23]. This includes ECPR patients.
\nTable 1 highlights the most important care recommendations from the AHA, and Table 2 includes monitoring modalities to be considered. These are based on the best available evidence, which may be limited to expert opinion in some cases. All recommendations are continuously reviewed and updated by the AHA as more evidence becomes available.
\nManagement goal | \nReasoning | \n
---|---|
Maintain normal oxygenation | \nElevated PO2 contributes to oxidative stress, and adult studies associate hyperoxia with decreased survival [24]. Hypoxia is associated with worse neurologic and overall outcomes. | \n
Maintain normocarbia | \nHypocapnia has been associated with worse outcomes in adults, and hypercapnia has been associated with decreased survival in pediatrics [24]. | \n
Maintain normotension | \nPost-ROSC hypotension is associated with decreased survival to discharge and worse neurologic outcomes [25]. Severe hypertension may adversely affect cardiac output, and has also been associated with neurologic injury [26]. | \n
Targeted temperature management | \nAggressively avoid hyperthermia, which is associated with poor outcomes [27]. At this time, there is insufficient evidence to recommend hypothermia over goal-directed normothermia. | \n
Post arrest care.
Continuous telemetry | \nAssists with close monitoring of rhythm status | \n
---|---|
Exhaled CO2 monitor | \nAllows for capturing CO2 changes early | \n
Continuous pulse oximetry | \nAssists with maintaining normoxia | \n
Cerebral NIRS (near-infrared spectrometry) monitor | \nMay be useful in identifying periods of increased vulnerability to developing neurologic injury [28] | \n
Electroencephalogram (EEG) | \nDiscontinuous or isoelectric tracings are associated with worse neurologic outcome. EEG data in this setting is limited but may be useful in prognostication in consort with other criteria. | \n
Arterial blood pressure monitor | \nAssists with close monitoring of hemodynamics thus avoiding hypotension | \n
Central venous pressure monitor | \nAssists with assessment of volume status | \n
Continuous temperature monitor | \nRectal or bladder monitor: may allow for capturing temperature changes early | \n
Monitoring modalities.
Critical care management of post-ECPR ECMO patients should involve a multidisciplinary team that includes ECMO nurse/therapist, bedside staff, intensivists, and surgeons. Post arrest management should be implemented per local protocols. Like all ECMO patients, sedation, ventilation, anticoagulation, nutrition, and infection control should be cautiously monitored:
Neurological/Sedation: Soon after resuscitation, it is imperative to determine the patient’s neurologic status, as this will guide further decision making and management. Close monitoring of the neurologic exam is imperative. Evaluate for signs of seizures, and EEG should be obtained if there is any suspicion. Near-infrared spectroscopy (NIRS) monitors can be used to follow cerebral oxygenation, possibly serving as an indicator of neurological activity and overall perfusion. In infants, routine bedside head ultrasounds should be considered, since these are simple and inexpensive assessments that can provide important information about development of neurologic injury. For all patients, head imaging such as with computed topography should be considered as indicated by exam and other clinical findings. Analgesia and sedation should be appropriately used to provide comfort; muscle relaxants use should be minimized to cases of safety or medical concerns.
Cardiovascular: Continuous cardiac and hemodynamic monitoring is important. Peripheral perfusion should be monitored, especially in patients with femoral cannulation. Volume must be judiciously used to maintain cardiac preload. Systemic vascular resistance should be balanced to the patient’s needs, with judicious use of inotropy if cardiac contractility needs augmentation. All patients should be monitored for need for LV decompression as discussed below. In patients with absent pulsatility, the LV must be monitored for clot formation.
Pulmonary: Maintain functional residual capacity to facilitate oxygenation of pulmonary blood flow, balancing that with allowing for lung rest. Gentle pulmonary toilet is warranted, balancing secretion clearance with avoiding trauma and bleeding.
Gastrointestinal/Renal: Nutrition should be considered as indicated; we promote early enteral feeding if able. Gastric drainage and stool output must be monitored for bleeding. Urine output should be monitored closely, with promotion of diuresis as needed. In case of renal failure, hemofiltration or dialysis must be considered.
Infection: Routine indicators of infection are unreliable: vital signs are influenced or controlled by the circuit, and lab parameters can be affected by the circuit. Assessment of the patient must include diligent monitoring of all sites of cannula or line insertion, as well as all wounds. Routine monitoring of CBC with differential is recommended. Surveillance cultures, as well as antibiotic prophylaxis, should be done per institutional protocol.
Most ECMO centers have their own institutional protocols for ECMO anticoagulation, usually an amalgam of center experience, ELSO guidelines, and published literature. We suggest utilizing an anticoagulation expert when setting up such a protocol, and recommend reviewing institutional practices regularly with the goal of keeping up-to-date with the literature.
\nAnticoagulation in this patient population starts with the cannulation procedure. A bolus of unfractionated heparin (typically 50–100 units per kg) is given directly to the patient prior to cannula placement. Afterwards, an unfractionated heparin infusion is started, usually 28–30 units/kg/hr. in neonates and infants, and 20 units/kg/hr. in larger children. Of note, neonates may need higher doses of unfractionated heparin secondary to naturally lower antithrombin III (ATIII) plasma concentrations. Less heparin may be required in patients who have a coagulopathy.
\nAnticoagulation monitoring differs between centers [29, 30]. Labs can include partial thromboplastin time (PTT), anti-Xa, and thromboelastography (TEG). ATIII levels may be monitored dependent on the clinical situation. Platelets, fibrinogen, and plasma free hemoglobin are adjunct values that can be monitored, and can help with management of a circuit’s anticoagulation. The patient’s coagulable state must be taken into consideration, and this may alter dosing and target lab values. Table 3 lists the most common parameters used in monitoring anticoagulation.
\nLab parameter | \nDescription | \nGoals | \n
---|---|---|
Activated Clotting Time (ACT) | \nAssesses whole blood clotting | \nNormal: 80–160 sec ECMO target: 180–240 seconds | \n
Activated Partial Thromboplastin Time (aPTT) | \nAssesses the intrinsic pathway | \nNormal: 30–40 sec ECMO target: 1.5x normal | \n
Anti-Xa level | \nAssesses clotting activity | \nECMO target: 0.35–0.70 units/ml | \n
Thromboelastography (TEG) | \nAssessment of whole blood clotting, fibrinolysis and platelet activity | \n
Monitoring anticoagulation.
Some centers report the use of direct thrombin inhibitors, such as bivalirudin, as an alternative to unfractionated heparin infusions [31]. Direct thrombin inhibitors (DTI) have the advantage of not requiring ATIII for action and can inhibit clot-bound thrombin. However, DTIs do not act on the contact pathway, which may be an issue in low-flow parts of a circuit (such as a bridge or a pigtail for lab draws). DTIs are titrated to a PTT of 1.5–2 times normal, and so it is important to establish a baseline value prior to use.
\nPatients managed with ECMO, more so in the setting of cardiac disease or ECPR, can develop myocardial dysfunction and left heart failure [32]. In ECMO patients who develop poor left heart function, the team must work to offload the heart [33]. This is necessary to prevent complications such as worsening cardiac function or pulmonary edema [34].
\nManagement of ECMO-related LV distension should start with exclusion of poor cannula positioning and eliminating mechanical issues with the ECMO circuit [35]. Pump function should be adjusted to maintain appropriate flows. LV distension can be secondary to volume overload, and so volume status should be addressed accordingly. In case of poor cardiac muscle function, inotropes to improve contractility and vasodilators to decrease LV afterload can be utilized.
\nIf offloading the left heart cannot be achieved medically, and cardiac output remains compromised, the institution of an interventional approach may be required. Several interventional decompression strategies have been described and are listed in Table 4. Evidence-based guidelines are lacking with regards of absolute indications, timing of intervention, and management method. The following is a non-comprehensive list of indications from the literature:
Elevated LA pressure and LVEDP despite maximal medical management
Severe distension of LA or LV (can include LV thrombus in setting of stasis)
Poor left outflow tract ejection/closed aortic valve
Refractory pulmonary edema or pulmonary hemorrhage
Aortic valve regurgitation
Elevated LV wall stress
LV or RV dysfunction
Strategy | \nReference | \n
---|---|
Intra-aortic balloon pump | \nAso et al. [36] | \n
Pulmonary artery vent | \nFouilloux et al. [37] | \n
Percutaneous trans-septal LA decompression | \nAiyagari et al. [38], O’Byrne et al. [39] | \n
Trans-septal LA decompression with BAS and LA vent insertion | \nEastaugh et al. [40] | \n
Transaortic vent | \nHong et al. [41] | \n
Static over-the-wire balloon dilation | \nBaruteau et al. [42], Eastaugh et al. [40] | \n
Blade balloon septostomy | \nJohnston et al. [43] | \n
Atrial stenting | \nHaynes et al. [44] | \n
Direct surgical LA or LV venting | \nGuirgis et al. [45], Sandrio et al. [46] | \n
Interventional decompression strategies for ECMO-related left heart dysfunction.
Several authors have discussed the essential components of an ECMO program, which are needed before ECPR can be offered as a treatment option [21, 47]. With ECPR, time is of the essence. In order to successfully offer ECPR, a well-established protocol needs to be in-place and needs to be followed each time. There are several reported characteristics of a successful ECPR program, independent of the quality and capability of the ECMO team. An ideal team should be able to respond to situations in a consistent manner while maintaining that quality despite negative situations or hardship.
\nConsistency is maintained by continued training of all members of the team. Ongoing training must be both theoretical and hands-on. Simulation is a unique, effective way to incorporate the necessary training and dispense it to all members of the team in a way that can model real-life situations [48, 49, 50, 51, 52]. Leaders of the team must be able to keep up with the most up-to-date literature in ECMO and ECPR. Continued improvement of team performance is also assisted with maintaining quality improvement projects focused on outcomes-based factors related to each institution. On-the-spot debriefing after each event is a good way to identify concerns that need to be addressed.
\nECPR, like all other forms of extracorporeal life support, is associated with a host of mechanical and non-mechanical complications. Frequency and severity for most ECPR-specific complications are not reported in the literature at this time –reports generally include all ECMO patients as a single group. The ELSO website has a comprehensive list of reported ECMO and ECPR complications, including mechanical, neurologic, cardiovascular, infectious, immunologic, hematologic, metabolic, pulmonary, and renal [53].
\nHere we will highlight some of the better studied complications.
\nNeurologic complications on ECMO have been extensively documented due to their significant burden and influence on outcomes. In pediatric patients treated with ECMO, there is a 7% prevalence of intracranial hemorrhages and a 6% prevalence of cerebral infarctions. Overall ECMO survival drops by half in patients who develop neurological injury. Survivors have multiple long-term morbidities, including seizures and global developmental delay.
\nECPR specific neurologic injuries are more prevalent and more significant than with routine ECMO. The ELSO database reports 12% incidence of seizures, 11.8% incidence of hemorrhage or infarct, and 11% incidence of brain death. Hemorrhages and infarcts were associated with lower survival. Severe acidosis, non-cardiac arrest etiology, and on ECMO CPR were risk factors for the neurologic injuries. Unfortunately, registry datasets are not granular and more specific associations are difficult to identify.
\nLiterature reporting of neurodevelopmental outcomes post ECMO and ECPR is limited, and there is a varied approach to assessment and documentation [54]. However, overall trends appear encouraging. Favorable neurologic outcomes have been shown in up-to 65% of ECPR survivors. Favorable outcomes in these reports are defined as normal function or mild cerebral disability, showing that a good quality of life is attainable for arrest patients treated with ECPR. Further work is needed to uncover determinants of good outcomes.
\nAcute kidney injury (AKI) is common in critically ill patients, and patients treated with ECMO are especially prone to developing AKI. ECMO patients with AKI and subsequent fluid overload have a higher risk of longer ECMO runs and greater mortality [7]. Fluid overload management differs between centers, and includes fluid restriction, diuresis, slow continuous ultrafiltration (SCUF). None of these methods are efficient in removing solutes, and so continuous renal replacement therapy may be needed when fluid overload coincides with AKI. It should be noted that aggressive early CRRT may be associated with worse outcome [55], and indicates that judicious fluid management must always be an ongoing balance tailored to each patient.
\nECPR is superior to conventional CPR. Overall survival to discharge in pediatric patients treated with ECPR in the ELSO registry is approximately 40%; Table 5 shows a breakdown of this data. Other reports of ECPR survival vary across the literature, and the quoted numbers range between 23%-55%. In contrast, overall reported survival rates for conventional CPR in pediatrics range between 16 to 30%. The large range of variability is due to differences between institutional experience, expertise, and reporting on these patients. Superior survival rates persist with longer term follow-up and have been demonstrated up-to 12 months after discharge.
\n\n | Total runs | \nSurvive ECLS | \nSurvival to discharge | \n
---|---|---|---|
Neonatal ECPR | \n1718 | \n1140 (66%) | \n708 (41%) | \n
Pediatric ECPR | \n3946 | \n2262 (57%) | \n1675 (42%) | \n
Total | \n5664 | \n3402 (60%) | \n2383 (42%) | \n
ECPR runs per the ELSO database, 1990–2018 [56].
A major indicator of quality of life in survivors of ECPR is neurologic outcome. While work is limited, there is indication that these outcomes may be positive, and perhaps better than in patients rescued by conventional CPR. Several reviews have shown that survival with minimal neurologic damage was more frequent in patients rescued with ECPR. This trend remained true even after performing propensity score matching for patients across these groups.
\nSeveral pre-ECMO factors have been identified as important to determining outcomes of ECPR. Disease process leading to arrest is one such factor. Post-cardiac surgery patients, or patients who arrest in the setting of another primary cardiac process, have consistently demonstrated the best survival when rescued with ECPR versus conventional CPR. Patients who arrest in the setting of neonatal respiratory disease also have favorable outcomes. Patients who arrest in the setting of sepsis have higher mortality rates than patients with a pure cardiac process, but have better survival than if managed with CPR alone [57]. Patients with arrest in the setting of a respiratory illness also do well [58]. Patients with gastrointestinal conditions, who are usually patients with complex multiorgan disorders, tend to have worse outcomes. Patients with oncologic disease and other immunosuppressed processes also do worse [15].
\nTime to full support is another important predictor of survival of patients rescued with ECPR [17]. Longer time spent in a low flow state is associated with drastic drops on survival to hospital discharge. Post-discharge, patients with longer low flow times have worse neurologic outcomes and higher post-discharge mortality. Duration in a low flow state is a highly modifiable factor, and should be minimized in order to achieve the best outcomes. It is important to establish ECMO candidacy for all high risk patients, so that ECMO can be deployed quickly in the setting of an arrest. In centers that offer ECPR, a rapid response team must be available at all times, in order to minimize the time needed to establish ECMO flow. This team must be highly trained and very adaptable, highlighting the need for an ongoing development program for any center that offers ECPR. In addition to the presence of a rapid response team, ECMO equipment must be readily available for utilization at all times. During the resuscitation, pauses in compressions are needed to allow for cannula insertion. Duration and frequency of such pauses must be limited as much as possible, since any no-flow time dramatically decreases survival as well.
\nIt is important to note that prolonged resuscitation may not be futile if ECPR is utilized, highlighting the importance of choosing the right patients for ECPR therapy [59].
\nLocation of arrest can influence survival. Arrests that occur in the intensive care unit, have the best outcomes post management with ECPR. Outside the intensive care unit, outcomes worsen, perhaps related to the quality of resuscitation provided and the duration it may take to establish access for ECMO. Locations where ECPR can be offered will be dependent on institutional logistics and resource availability. Regardless, there should be advance coordination to ensure the equipment and personnel needed can be deployed smoothly. Literature has shown that it is possible to successfully offer ECPR in the emergency department with such arrangements.
\nOn-ECMO complications also influence survival, regardless whether it is a planned run or ECPR [57]. Neurologic complications are associated with high mortality post-ECPR. Inability to achieve and maintain adequate perfusion while on ECMO, noted by metabolic and lactic acidosis, has been tied to worse outcomes [60, 61]. Similarly, cardiac arrest during the ECMO run is also associated with poor outcomes. Renal failure and the need for renal replacement therapy have an association with inferior outcomes [58]. Severe coagulopathy and DIC also worsen survival – maintaining anticoagulation for the circuit and avoidance of fatal hemorrhage is a fine balance, and coagulopathy raises the risk of fatal hemorrhages [16, 62].
\nOut of hospital cardiac arrests (OHCA) have very high mortality rates and very poor neurologic outcomes for both pediatric and adult patients [63, 64]. As a result, there has been growing interest in applying ECPR to OHCA. Overall survival rates vary for OHCA ECPR. Reported survival rates range from 12 to 30%, but patient numbers are very limited and there is extreme selection bias in this cohort [4]. ELSO reports that about half of all OHCA ECPR were reported in Europe, followed by the Asia-Pacific region, and lastly North America [65]. Almost all published experience is exclusively adult experience [66].
\nApplication of ECPR for OHCA varies across different centers. Some institutions provide a “scoop and run” strategy, with quick transport to the emergency department for cannulation in select patients with OHCA [67]. Other centers have a different approach, with the ability to “stay and treat” by initiating ECPR on the scene of the OHCA [68]. The different styles of application are dependent on availability of resources, feasibility, and local experience.
\nProvision of ECPR to OHCA presents challenges with cost-effectiveness, optimal candidacy, and timing of deployment. However, if done in settings with the appropriate resources utilizing an aggressive strategy with optimum patient selection, survival can possibly be favorable [14]. However, evidence remains inconclusive and requires further study [66].
\nECPR has emerged as an exciting rescue therapy, promising to improve outcomes of cardiac arrest. It has shown superiority over conventional CPR, with better survival to discharge and better longer-term survival. It has also shown better neurologic outcomes. As overall experience grows, we expect to see increased uses and even better outcomes.
\nNonetheless, this is an emerging field and there is a lot left to learn. Especially in pediatrics, knowledge gaps include:
Ideal ECPR candidacy
Definition of refractory arrest, i.e. how long should conventional CPR continue before ECPR should be considered
Inclusion and exclusion criteria for higher risk populations, including immunosuppressed patients and trauma patients
Inclusion and exclusion criteria for out-of-hospital cardiac arrest
Assessment of futility in possible ECPR candidates
Team preparedness: specific nature of training to maintain ECPR team competency to decrease low flow time
Optimal approach to comprehensive post arrest care for ECPR patients
Approach to neuroprotection and neuroprognostication post-ECPR
Functional and neurodevelopmental post-discharge status of patients rescued with ECPR, and how to improve such outcomes
At this time, most ECMO and ECPR research is observational in nature. Generalization of pediatric data is hindered by the heterogeneity of patient ages and diagnosis, as well as variability of practice between different institutions. Because of the small numbers of patients overall and per institution, the field is ripe with opportunity for collaborative work. International registries and large research collaboratives may be able to provide enough patients to power larger investigations. More data will help empower decisions to treat children with ECPR, refine the caliber of care they receive, and improve their future quality of life.
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\\n\\nIf you are interested in publishing your book with IntechOpen, please submit your book proposal by completing the Publishing Proposal Form.
\\n\\nNot sure if this is the right option for you? Please refer back to the main Publish with IntechOpen page or feel free to contact us directly at book.department@intechopen.com
\\n"}]'},components:[{type:"htmlEditorComponent",content:'Without sacrificing the quality of carefully edited and produced peer-reviewed content, Compacts are published as part of IntechOpen’s book collection but on a faster schedule, typically 4-6 weeks after acceptance. With an average of 132,000 visitors per week, publishing in Compacts not only guarantees high visibility but also facilitates international content sharing. As a fully Open Access publisher, the utilization of a CC BY NC 4.0 license means that other researchers will never have to pay permission fees and can adapt, use, and further build upon the material published in Compacts, eliminating any barriers to the further development of scientific research.
\n\nCOMPACTS-SHORT FORM MONOGRAPH
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\n\nIntechOpen has collaborated with Enago, through its sister company, Ulatus – one of the world’s leading providers of book translation services. The services are designed to convey the essence of your work seamlessly to readers from across the globe in their own language. Enago’s expert translators incorporate cultural nuances in translations to make the content relevant for local audiences while retaining the original meaning and style. With a high degree of linguistic and subject expertise, Enago translators are equipped to handle all complex and multiple overlapping themes encompassed in a single book to deliver a superior quality of translation.
\n\nIntechOpen Authors that wish to use this service will receive a 20% discount on all translation work. For more information or a quote, please visit: https://www.enago.com/intech.
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\n\nSee a complete overview and description of the steps involved in the publishing process here.
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\n\nIf you are interested in publishing your book with IntechOpen, please submit your book proposal by completing the Publishing Proposal Form.
\n\nNot sure if this is the right option for you? Please refer back to the main Publish with IntechOpen page or feel free to contact us directly at book.department@intechopen.com
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