Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (David Szpliman)
Task Force Scoping Review Citation
Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, Scapigliati A, Seesink J, Schmidt A, Sempsrott J, Szpliman D, Warner DS, Webber J, Johnson S, Avis S, Mancini MB, Nation K, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Nishiyama C, Ristagno G, Semeraro F, Smyth M, Vaillancourt C, Olasveengen T, Morley P, Perkins GD on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force(s).
Extra Corporeal Membrane Oxygenator (ECMO) in Drowning. Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 7 July 2020. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review of the literatures undertaken by Gavin Perkins and Andrew Schmidt and co-ordinated by Gavin Perkins and Joost Bierens. The findings from the review of basic life support were considered by the Basic Life Support Task Force who contributed to the Task Force insights.
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adults and children who are submerged in water
Intervention: extracorporeal membrane oxygenation (ECMO)
Comparators: no ECMO
Outcomes: Any clinical outcome (e.g. survival, survival with a favourable neurological outcome, hospitilisation), CPR quality, physiological end-points
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Manikin studies will only be included if no human studies are available.
Timeframe: From 2000 onwards. All languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols), narrative reviews, animal studies were excluded. Literature search updated to October 2019.
Inclusion and Exclusion criteria
- Adult and paediatric patients
- Submersion in water (drowning, near drowning)
- Describe ECMO / extracorporeal cardiopulmonary resuscitation
- Studies report clinical outcomes e.g. survival, survival with a favourable neurological outcome, hospitilisation
- Other outcomes: CPR quality, physiology
- Animal studies
- Results reported in the gray literature or abstract only
- Narrative reviews containing no primary data
- Published as an abstract only or in conference proceedings.
- Case studies / series without control groups, unless no or minimal other literature available.
Task Force Insights
1. Why this topic was reviewed.
Drowning is the third leading cause of unintentional injury death worldwide, accounting for over 360 000 deaths annually.[World Health Organization, 2020] Submersion leads to the rapid onset of hypoxia. Extracorporeal membrane oxygenation / extracorporeal cardiopulmonary resuscitation have been used as interventions in severe drowning with refractory hypoxia and / or cardiac arrest. The BLS Task Force and Drowning collaboration considered it timely to undertake a scoping review of the literature to identify any new evidence related to this topic.
2. Narrative summary of evidence identified
The literature search identified 3005 articles (2190 after removal of duplicates). After screening titles and abstracts, 26 studies were identified for full text review.
Thirteen studies were retained which examined the use of extra-corporeal support in 658 adults and children following drowning.[Eich, 2007, 42; Ruttmann, 2007, 594; Coskun, 2010, 1026; Skarda, 2012, 2239; Wanscher, 2012, 1078; Dunne, 2014, 1029; Hilmo, 2014, 1204; Kim, 2014, 77; Champigneulle, 2015, 126; Burke, 2016, 19; Weuster, 2016, 157; Svendsen, 2017, 920; Bauman, 2019, 29] The studies comprised of 2 retrospective observational studies[Champigneulle, 2015, 126; Burke, 2016, 19] and 11case series. [Eich, 2007, 42; Ruttmann, 2007, 594; Coskun, 2010, 1026; Skarda, 2012, 2239; Wanscher, 2012, 1078; Dunne, 2014, 1029; Hilmo, 2014, 1204; Kim, 2014, 77; Weuster, 2016, 157; Svendsen, 2017, 920; Bauman, 2019, 29] Some papers reported overlapping data – Dunne et al[Dunne, 2014, 1029] reported cases from three other case series[Eich, 2007, 42; Coskun, 2010, 1026; Wanscher, 2012, 1078] whilst Coskun et al [Coskun, 2010, 1026] and Eich et al [Eich, 2007, 42] appear to report the same cases.
All papers reported survival status and nine reported neurological outcomes. [Eich, 2007, 42; Coskun, 2010, 1026; Skarda, 2012, 2239; Wanscher, 2012, 1078; Dunne, 2014, 1029; Kim, 2014, 77; Champigneulle, 2015, 126; Weuster, 2016, 157; Svendsen, 2017, 920; Bauman, 2019, 29] Outcome measures reported for neurological outcome were Glasgow Coma Scale,[Wanscher, 2012, 1078; Weuster, 2016, 157] Cerebral Performance Category,[Champigneulle, 2015, 126] or were undefined.
Most studies reported the use of Venous-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) for patients who were in cardiac arrest, [Eich, 2007, 42; Ruttmann, 2007, 594; Coskun, 2010, 1026; Skarda, 2012, 2239; Wanscher, 2012, 1078; Dunne, 2014, 1029; Hilmo, 2014, 1204; Champigneulle, 2015, 126; Weuster, 2016, 157; Svendsen, 2017, 920] whilst three studies reported using VA-ECMO for patients in cardiac arrest and Venous-Venous ECM0 (VV-ECMO) for respiratory failure.[Kim, 2014, 77; Burke, 2016, 19; Bauman, 2019, 29] Most uses of ECMO appeared in the context of patients who had been submerged in cold water leading to hypothermia (core temperature range 13-31C).[Eich, 2007, 42; Ruttmann, 2007, 594; Coskun, 2010, 1026; Skarda, 2012, 2239; Champigneulle, 2015, 126; Weuster, 2016, 157] Where reported, the duration of submersion ranged between 15-90 minutes. [Eich, 2007, 42; Ruttmann, 2007, 594; Coskun, 2010, 1026; Skarda, 2012, 2239; Hilmo, 2014, 1204; Champigneulle, 2015, 126; Weuster, 2016, 157] The duration of ECMO treatment was between 2-260 hours.[Coskun, 2010, 1026; Wanscher, 2012, 1078; Champigneulle, 2015, 126; Weuster, 2016, 157]
The Extracorporeal Life Support Organisation registry reported on the use of ECMO amongst 251 patients treated for drowning from multiple centres around the world between 1986-2015.[Burke, 2016, 19] Survival to discharge (71.4%) was highest for patients who did not experience a cardiac arrest. Survival was 57.0% for patients who required cardiopulmonary resuscitation prior to ECMO and 23.4% in patients who received ECPR. Survival rates across the other studies for patients with cardiac arrest ranged from 10% to 100%. Survival with a favourable neurological outcome was between 5 to 57%. Outcomes were better for patients who required ECMO for respiratory support rather than conventional ? E-CPR.[Kim, 2014, 77]
Factors reported as associated with worse outcomes were requirement for E-CPR,[Burke, 2016, 19] hyperkalaemia,[Skarda, 2012, 2239; Dunne, 2014, 1029] hypoxia as the primary cause of cardiac arrest,[Dunne, 2014, 1029; Svendsen, 2017, 920] asystole as an initial rhythm,[Coskun, 2010, 1026] submersion duration > 10 minutes,[Skarda, 2012, 2239] low pH,[Coskun, 2010, 1026] renal failure,[Burke, 2016, 19] requirement for CPR whilst on ECMO.[Burke, 2016, 19] Factors associated with good outcomes were profound hypothermia (core body temperature < 26C) and normal potassium.[Champigneulle, 2015, 126]
3. Narrative Reporting of the task force discussions
The evidence base identified in this scoping review, suggests that a systematic review on this topic should be considered.
Extracorporeal oxygenation to treat cardiac arrest or severe respiratory failure caused by drowning is feasible. The evidence identified supports the ILCOR treatment recommendation that suggests “extracorporeal cardiopulmonary resuscitation (ECPR) may be considered as a rescue therapy for selected patients with cardiac arrest when conventional cardiopulmonary resuscitation is failing in settings where this can be implemented (weak recommendation, very-low certainty of evidence)”. Similarly, the evidence identified for severe respiratory failure, is consistent with guidelines suggesting the use of ECMO in selected patients with severe ARDS (weak recommendation, very low certainty of evidence).[Griffiths, 2019, e000420]
Further research is required to refine the indications and optimal timing for initiating E-CPR and ECMO in adults and children who develop cardiac arrest and / or severe lung injury after drowning.
Current knowledge gaps include but are not limited to:
Optimal timing and case selection for initiation of E-CPR / ECMO.
Studies in low resource settings were lacking.
References listed alphabetically by first author last name in this citation format (Circulation)
Bauman, B. D., et al. (2019). "Treatment of Hypothermic Cardiac Arrest in the Pediatric Drowning Victim, a Case Report, and Systematic Review." Pediatric Emergency Care 29: 29.
Burke, C. R., et al. (2016). "Extracorporeal life support for victims of drowning." Resuscitation 104: 19.
Champigneulle, B., et al. (2015). "Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience." Resuscitation 88: 126.
Coskun, K. O., et al. (2010). "Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients." Artificial Organs 34(11): 1026.
Dunne, B., et al. (2014). "Extracorporeal-assisted rewarming in the management of accidental deep hypothermic cardiac arrest. A systematic review of the literature." Heart Lung and Circulation 23(11): 1029.
Eich, C., et al. (2007). "Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the "Utstein Style for Drowning"." Resuscitation 75(1): 42.
Griffiths, M. J. D., et al. (2019). "Guidelines on the management of acute respiratory distress syndrome." BMJ Open Respir Res 6(1): e000420.
Hilmo, J., et al. (2014). ""Nobody is dead until warm and dead": prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas--a retrospective study from northern Norway." Resuscitation 85(9): 1204.
Kim, K. I., et al. (2014). "Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure." Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine 22: 77.
Ruttmann, E., et al. (2007). "Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest." Journal of Thoracic & Cardiovascular Surgery 134(3): 594.
Skarda, D., et al. (2012). "Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: is meaningful survival a reasonable expectation?" Journal of Pediatric Surgery 47(12): 2239.
Svendsen, O. S., et al. (2017). "Outcome After Rewarming From Accidental Hypothermia by Use of Extracorporeal Circulation." Annals of Thoracic Surgery 103(3): 920.
Wanscher, M., et al. (2012). "Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Praesto Fjord boating accident." Resuscitation 83(9): 1078.
Weuster, M., et al. (2016). "The Use of Extracorporeal Membrane Oxygenation Systems in Severe Accidental Hypothermia After Drowning: A Centre Experience." ASAIO Journal 62(2): 157.
World Health Organization (2020) Drowning.