Comparison of Extracorporeal and Conventional Cardiopulmonary Resuscitation

A Retrospective Propensity Score Matched Study

Daniel Patricio; Lorenzo Peluso; Alexandre Brasseur; Olivier Lheureux; Mirko Belliato; Jean-Louis Vincent; Jacques Creteur; Fabio Silvio Taccone

Disclosures

Crit Care. 2019;23(27) 

In This Article

Abstract and Introduction

Abstract

Background: The potential benefit of extracorporeal cardiopulmonary resuscitation (ECPR) compared to conventional CPR (CCPR) for patients with refractory cardiac arrest (CA) remains unclear.

Methods: This study is a retrospective analysis of a prospective database of CA patients, which includes all consecutive adult patients admitted to the Department of Intensive Care after CA between January 2012 and December 2017. The decision to initiate ECPR was made by the attending physician and ECPR performed by the ECPR team, which is composed of ICU physicians. A propensity score was derived using a logistic regression model, including characteristics that varied between groups with a p < 0.10 and were potentially related to outcome. Primary outcomes were survival to ICU discharge and favorable 3-month neurologic outcome, assessed by a Cerebral Performance Category (CPC) score of 1–2.

Results: From a total of 635 patients with CA during the study period (ECPR, n = 112), 80 ECPR patients were matched to 80 CCPR patients. The time from arrest to termination of CPR (i.e., return of spontaneous circulation [ROSC], extracorporeal membrane oxygenation [ECMO] initiation, or death) was 54 ± 22 and 54 ± 19 min in the ECPR and CCPR groups, respectively. ROSC rates were 77/80 (96%) for ECPR and 30/80 (38%) for CCPR (p < 0.001). Survival to ICU discharge was 18/80 (23%) vs. 14/80 (18%) in the ECPR and CCPR groups, respectively (p = 0.42). At 3 months, 17/80 (21%) ECPR patients and 9/80 (11%) CCPR patients had a favorable outcome (p = 0.11). Cox regression analysis stratified by matched pairs showed a significantly higher neurologic outcome rate in the ECPR group than in the CCPR group (log-rank test p = 0.003).

Conclusions: ECPR after CA may be associated with improved long-term neurological outcome.

Introduction

Since the first use of cardiopulmonary resuscitation (CPR), remarkable technological and scientific progress has been made in this field. Interventions, such as early defibrillation and implementation of targeted temperature management (TTM), have helped improve outcomes for patients with CA.[1,2] However, the rates of survival to hospital discharge of these patients remain low. Recent studies have shown a survival rate of around 20% for patients after in-hospital CA (IHCA) and 10% after out-of-hospital CA (OHCA).[3] These findings may vary depending on the specific emergency medical system (EMS) in use and are essentially based on use of conventional CPR (CCPR).

"No-flow" (i.e., time from arrest to the first chest compression) and "low-flow" (i.e., duration of CCPR) times are important determinants of patient outcome following CA. Immediately initiated bystander CPR remains imperative for reducing no-flow time. Guidelines have highlighted the importance of telephone-assisted bystander guidance in providing prompt chest compressions to CA victims.[1] The early arrival of EMS staff to provide CPR and advanced life support (ALS) can reduce the low-flow time. Nevertheless, when CCPR is prolonged, even if adequately delivered, the probability of return of spontaneous circulation (ROSC) progressively decreases. In one study, Mosca et al. reported that CPR maneuvers lasting for more than 45 min were associated with hospital survival of less than 2%, most of the patients dying without achieving ROSC.[4] In this setting, in particular for patients who have received the best possible resuscitation (i.e., short no-flow time, bystander CPR, shockable rhythms refractory to defibrillation), there would be a high possibility of good cardiac and neurological recovery in case of ROSC, which make these patients as the best potential candidates for extracorporeal cardiopulmonary resuscitation (ECPR).

In patients with CA, ECMO may provide greater global blood flow than CCPR and thus possibly decrease post-anoxic cellular damage.[3,5] ECPR could also be considered as a "bridge" to appropriate treatment (i.e., coronary angiography or cardiac surgery) of the underlying cause of CA, which would not be feasible during CCPR.[6] With ECPR, the patient's heart is put "at rest," allowing for partial or full recovery and minimizing the need for vasopressors and/or inotropic agents. Reversible causes of CA can be more easily identified and treated, if applicable. This approach may also translate into improved neurological outcomes because the total anoxic time is reduced and cerebral circulation guaranteed by the ECMO blood flow. In some selected cases of refractory CA, implementation of ECPR has increased survival rates up to 45% for IHCA and 30% for OHCA.[3] Moreover, survival rates of 33% for IHCA and 37% for OHCA have been reported with ECPR in patients with CA of cardiac origin and as a result of drug intoxication.[7] Nevertheless, although ECPR is easily administered for patients with IHCA, when the equipment if available, its use for patients with OHCA remains problematic and its efficacy in this setting is still controversial.

The aim of this study was to compare the effects of ECPR on survival and long-term neurological outcome when compared to CCPR using a propensity score matching method.

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