Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)?

Abstract

Purpose: Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest. Methods: We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data. Results: We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR ( P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) ( P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time. Conclusions: Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.

Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation

“…There has been continued interest in targeted temperature management (TTM) and hypothermia for ECPR patients, with evidence both for and against targeted normothermia and hypothermia. 23–26 A meta-analysis of ECPR studies has suggested that there is no difference in neurologic outcome between patients subjected to TTM versus non-TTM practices, 27 and we echo this finding for our cohort’s neurologic outcome, ABI, and mortality. There is a paucity of multicenter studies examining PaCO 2 and ABI specifically in ECPR patients, and a larger sample would permit multivariable analysis using temperature, PaCO 2 , and CPR practices.…”

Accidental Hypothermia: 2021 Update

“…Post-resuscitation hyperthermia should be avoided [ 145 ]. The timing of ECPR and the optimum target temperature following ECPR, are unknown [ 152 , 153 ].…”

The impact of different targeted temperatures on out-of-hospital cardiac arrest outcomes in patients receiving extracorporeal membrane oxygenation: a nationwide cohort study

“…Targeted temperature management (TTM) is recommended for patients with out-of-hospital cardiac arrest (OHCA) who remain comatose after the return of spontaneous circulation (ROSC) [1,2]. In the setting of extracorporeal membrane oxygenation (ECMO) for OHCA, TTM was also associated with good neurological outcomes and is recommended in the Extracorporeal Life Support Organization guidelines [3][4][5][6][7]. Attempts at improving cardiac arrest care have seen an increase in the use of ECMO, which, when combined with TTM, is an intensive care strategy requiring a large investment in logistics [8].…”