A Systematic Review with Meta-Analysis Investigating the Impact of Targeted Perfusion Parameters during Extracorporeal Cardiopulmonary Resuscitation in Out-of-Hospital and Inhospital Cardiac Arrest

Abstract

Evidence regarding perfusion conditions during extracorporeal cardiopulmonary resuscitation (ECPR) is rare. Therefore, we investigated the impact of perfusion parameters on neurologic outcome and survival in patients with in- or out-of-hospital cardiac arrest (IHCA; OHCA) treated with ECPR. We performed a systematic review with meta-analysis. The focus was set on perfusion parameters and their impact on survival and a goal neurological outcome using the cerebral performance category score of 1–2. We conducted random- and mixed-effects meta-analyses and computed pooled estimates and 95% confidence intervals (CI). We included a total of n = 1,282 ECPR (100%) patients from 20 ECPR studies. The target values of flow and mean arterial pressure (MAP) were frequently available. We transferred flow and MAP target values to high, medium, and low categories. The meta-analysis could not demonstrate a single effect of flow or MAP on outcome variables. In a second mixed-effects model, the combined occurrence of targeted flow and MAP as medium and high showed a significant effect on survival (OHCA: 52%, 95% CI: 29%, 74%; IHCA: 60%, 95% CI: 35%, 85%) and on neurological outcomes (OHCA: 53%, 95% CI: 27%, 78%; IHCA: 62%, 95% CI: 38%, 86%). Random-effects analysis showed also that IHCA led to a significant 11% (p = 0.006; 95% CI: 3%, 18%) improvement in survival and 12% (p = .005; 95% CI: 4%, 21%) improvement in neurological outcomes compared to OHCA. A combination of medium flow and high MAP showed advantages in survival and for neurological outcomes. We also identified improved outcomes for IHCA.

Expert consensus on blood pressure management in critically ill patients

“…In a second mixed-effect model, a combination of medium flow and high MAP showed advantages for survival and neurological outcomes. [54] Several other studies found that higher MAP (65 mmHg or higher) was associated with better neurological outcomes among survivors who received VA-ECMO ECPR. [55 , 56] …”

First experience with the new extracorporeal membrane oxygenation system Colibrì

“…Various pathologies can indicate the use of ECMO, such as cardiac arrest, cardiogenic shock, post-cardiac surgery, low output syndrome, acute respiratory distress syndrome, and pulmonary embolism. 1 Intoxications are another group of indications for ECMO and can lead to cardiac or respiratory failure. 2 The location of implantation of a venovenous (VV) or venoarterial (VA) ECMO is commonly in-hospital.…”

“…However, ECMO systems are increasingly used for inter-hospital transports of patients and extracorporeal cardiopulmonary resuscitation (ECPR). 1 Not only for inter-hospital transportation and ECPR but also for transportation inside the hospital, for example, for CT scans, compact, light, and mobile ECMO systems are important. Currently, different systems are available on the market 3 or as part of clinical studies (DRKS00018967).…”