Prognostic indicators of survival and survival prediction model following extracorporeal cardiopulmonary resuscitation in patients with sudden refractory cardiac arrest

Abstract

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) has been considered in selected candidates with potentially reversible causes during a limited period. Candidate selection and the identification of predictable conditions are important factors in determining outcomes during CPR in the emergency department (ED). The objective of this study was to determine the key indicators and develop a prediction model for survival to hospital discharge in patients with sudden cardiac arrest who received ECPR.MethodsThis retrospective analysis was based on a prospective cohort, which included data on CPR with ECPR-related variables. Patients with sudden cardiac arrest who received ECPR at the ED from May 2006 to June 2016 were included. The primary outcome was survival to discharge. Prognostic indicators and the prediction model were analyzed using logistic regression.ResultsOut of 111 ECPR patients, there were 18.9% survivors. Survivors showed younger age, shorter CPR duration (p < 0.05) and had tendencies of higher rate of initial shockable rhythm (p = 0.055) and higher rate of any ROSC event before ECPR (p = 0.066) than non-survivors. Eighty-one percent of survivors showed favorable neurologic outcome at discharge. In univariate analysis, the following factors were associated with survival: no preexisting comorbidities, initial serum hemoglobin level ≥14 g/dL, and mean arterial pressure ≥60 mmHg after ECPR. Based on multivariate logistic regression, predictors for survival in ECPR were as follows: age ≤56 years, no asystole as the initial arrest rhythm, CPR duration of ≤55 min, and any return of spontaneous circulation (ROSC) event before ECPR. The prediction scoring model for survival had a c-statistic of 0.875.ConclusionsWith careful consideration of differences in the inclusion criteria, the prognostic indicators and prediction scoring model for survival in our study may be helpful in the rapid decision-making process for ECPR implementation during CPR in the ED.

Prehospital extracorporeal cardiopulmonary resuscitation for out‐of‐hospital cardiac arrest: A retrospective eligibility study

“…Several studies have sought to determine the factors associated with positive outcomes from ECPR, with varying results. While there is considerable prognostic factor heterogeneity between studies, a short ‘low flow time’, and an initial shockable rhythm, were most consistently associated with improved outcomes . Prehospital ECPR initiation potentially minimises this circulatory low flow time and has also been associated with significantly increased rates of ROSC .…”

“…Group 2 patients had an initial rhythm of pulseless electrical activity (PEA) and had no sustained ROSC with the next rhythm check. While non‐shockable rhythms have often been excluded from ECPR protocols, SAMU de Paris have now included PEA in a prehospital ECPR protocol, and some studies have found this initial rhythm to be a prognostic indicator of survival . Group 3 patients did not satisfy Group 1 or 2 inclusion criteria but had some characteristics that have been associated with positive outcomes after ECPR, such as initial shockable rhythm or transient ROSC .…”

“…While non‐shockable rhythms have often been excluded from ECPR protocols, SAMU de Paris have now included PEA in a prehospital ECPR protocol, and some studies have found this initial rhythm to be a prognostic indicator of survival . Group 3 patients did not satisfy Group 1 or 2 inclusion criteria but had some characteristics that have been associated with positive outcomes after ECPR, such as initial shockable rhythm or transient ROSC . Patients were included in Group 3 if they had either an initial shockable rhythm where the rhythm became non‐shockable or non‐sustained ROSC before three shocks were delivered, or if they had an initial rhythm of asystole and the subsequent rhythm was shockable or non‐sustained ROSC.…”

“…Success has been mixed, with survival rates of 15–60% reported . Many factors could account for this outcome variation including heterogeneity of health systems, populations, interventions and follow up . While ECPR is promising, appropriate patient selection, optimal timing and cost‐effectiveness remain uncertain; although a shorter ‘low‐flow’ time, the CPR duration before ECPR initiation has been found to be associated with survival and positive neurological outcomes .…”

“…Many factors could account for this outcome variation including heterogeneity of health systems, populations, interventions and follow up . While ECPR is promising, appropriate patient selection, optimal timing and cost‐effectiveness remain uncertain; although a shorter ‘low‐flow’ time, the CPR duration before ECPR initiation has been found to be associated with survival and positive neurological outcomes . While prehospital ECPR has been found to be feasible, safe and effective, it has yet to show a survival advantage over hospital initiated ECPR for OOHCA, despite being associated with significantly increased rates of return of spontaneous circulation (ROSC) and shorter periods of circulatory low‐flow …”