Out-of-hospital cardiac arrest patients with an initial non-shockable rhythm could be candidates for extracorporeal cardiopulmonary resuscitation: a retrospective study

Abstract

Background Extracorporeal cardiopulmonary resuscitation (ECPR) is a promising treatment for refractory out-of-hospital cardiac arrest (OHCA). Most studies evaluating the effectiveness of ECPR include patients with an initial shockable rhythm. However, the effectiveness of ECPR for patients with an initial non-shockable rhythm remains unknown. This retrospective single-center study aimed to evaluate the effectiveness of ECPR for patients with an initial non-shockable rhythm, with reference to the outcomes of OHCA patients with an initial shockable rhythm. Methods Adult OHCA patients treated with ECPR at our center during 2011–2018 were included in the study. Patients were classified into the initial shockable rhythm group and the non-shockable rhythm group. The primary outcome was the cerebral performance category (CPC) scale score at hospital discharge. A CPC score of 1 or 2 was defined as a good outcome. Results In total, 186 patients were eligible. Among them, 124 had an initial shockable rhythm and 62 had an initial non-shockable rhythm. Among all patients, 158 (85%) were male, with a median age of 59 (interquartile range [IQR], 48–65) years, and the median low flow time was 41 (IQR, 33–48) min. Collapse was witnessed in 169 (91%) patients, and 36 (19%) achieved return of spontaneous circulation (ROSC) transiently. Proportion of female patients, presence of bystander cardiopulmonary resuscitation, and collapse after the arrival of emergency medical service personnel were significantly higher in the non-shockable rhythm group. The rate of good outcomes at hospital discharge was not significantly different between the shockable and non-shockable groups (19% vs. 16%, p = 0.69). Initial shockable rhythm was not significantly associated with good outcome after controlling for potential confounders (adjusted odds ratio 1.58, 95% confidence interval: 0.66–3.81, p = 0.31). In the non-shockable group, patients with good outcomes had a higher rate of transient ROSC, and pulmonary embolism was the leading etiology. Conclusions The outcomes of patients with an initial non-shockable rhythm are comparable with those having an initial shockable rhythm. OHCA patients with an initial non-shockable rhythm could be candidates for ECPR, if they are presumed to have reversible etiology and potential for good neurological recovery.

Transient return of spontaneous circulation related to favourable outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study

“…It has been reported that extracorporeal cardiopulmonary membrane oxygenation (ECMO) assisted resuscitation, also known as extracorporeal resuscitation (ECPR), is potentially effective for refractory CPA. 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 The 2020 American Heart Association guidelines for Class IIb recommend the use of ECPR for refractory CPA with a potentially reversible aetiology. 8 While ideal candidates for ECPR initiation and its optimal timing are currently being investigated, the outcome-related factors in patients who receive ECPR are similar to those of OHCA patients who achieve ROSC with conventional CPR, such as younger age, shorter arrest duration (time from arrest to ECMO initiation), witnessed arrest, and shockable initial cardiac rhythm.…”

“… 8 While ideal candidates for ECPR initiation and its optimal timing are currently being investigated, the outcome-related factors in patients who receive ECPR are similar to those of OHCA patients who achieve ROSC with conventional CPR, such as younger age, shorter arrest duration (time from arrest to ECMO initiation), witnessed arrest, and shockable initial cardiac rhythm. 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 In addition, recent ECPR-related studies have reported that the experience of transient ROSC before ECMO initiation was also associated with favourable outcomes in refractory CPA; however, the numbers of included patients were relatively small. Furthermore, details concerning when transient ROSC was achieved (before or after hospital arrival) were not reported in these studies.…”

“…Furthermore, details concerning when transient ROSC was achieved (before or after hospital arrival) were not reported in these studies. 18 , 19 , 20 , 21 Therefore, the relationship between the presence or absence of transient ROSC before ECMO initiation and outcomes has not been well understood. Moreover, even if transient ROSC is achieved, it remains largely unclear what timing concerning ROSC, i.e., before or after hospital arrival, is most prognostic.…”

Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan

“…In previous studies that used detailed clinical data of more than 100 patients with OHCA who received ECPR, the proportion of favorable neurological outcome at discharge was 6–39% [ 3 – 6 , 8 , 9 , 12 – 14 , 17 , 27 , 28 ]. This study included different types of patients, and favorable neurological outcome was observed in 16.7% and 9.2% of patients who had shockable rhythm and PEA, respectively.…”

A novel extracorporeal cardiopulmonary resuscitation strategy using a hybrid emergency room for patients with pulseless electrical activity

“…Diek et al reported that the survival rate of patients with PEA for ECPR was 23.8% [ 20 ]. Because shockable rhythms are a good candidate for ECPR [ 2 , 3 ], non-shockable rhythms may also be a candidate for ECPR [ 21 ]. Patients with PEA with witnesses were more likely to have a fatal pulmonary embolism [ 7 ], and favourable outcomes were expected by inducing ECMO [ 8 , 9 ].…”