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Outcomes of patients with refractory out-of-hospital cardiac arrest transported to an ECMO centre compared with transport to non-ECMO centres
Stephen A Bernard, Sarah J Hopkins, Jocasta C Ball, Dion A Stub, Michael W Stephenson, Vinodh B Nanjayya, Vincent A Pellegrino, Jayne Sheldrake, Alexander C Richardson, Karen L Smith
Crit Care Resusc 2022; 24 (1): 7-13
- Stephen A Bernard 1, 2, 3
- Sarah J Hopkins 1, 3
- Jocasta C Ball 1, 3, 4
- Dion A Stub 1, 2, 3, 4
- Michael W Stephenson 1, 3, 5
- Vinodh B Nanjayya 2, 3, 6
- Vincent A Pellegrino 2, 6
- Jayne Sheldrake 2
- Alexander C Richardson 2, 3, 6
- Karen L Smith 1, 3, 5
All authors declare that they do not have any potential conflict of interest in relation to this manuscript.
OBJECTIVE: To compare the outcomes of patients with refractory out-of-hospital cardiac arrest (OHCA) transported to a hospital that provides extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) with patients transported to hospitals without ECPR capability.
DESIGN, SETTING: Retrospective review of patient care records in a pre-hospital and hospital setting. PARTICIPANTS: Adult patients with OHCA who left the scene and arrived with cardiopulmonary resuscitation in progress at 16 hospitals in Melbourne, Australia, between January 2016 and December 2019.
INTERVENTION: For selected patients transported to the ECPR centre, initiation of ECMO.
MAIN OUTCOME MEASURES: Survival to hospital discharge and 12-month quality of life.
RESULTS: There were 223 eligible patients during the study period. Of 49 patients transported to the ECPR centre, 23 were commenced on ECMO. Of these, survival to hospital with good neurological recovery (Cerebral Performance Category [CPC] score 1/2) occurred in 4/23 patients. Four other patients developed return of spontaneous circulation in the ECPR centre before cannulation of whom one survived, giving overall good functional outcome at 12 months survival of 5/49 (10.2%). There were 174 patients transported to the 15 non-ECPR centres and 3/174 (2%) had good functional outcome at 12 months. After adjustment for baseline differences, the odds ratio for good neurological outcome after transport to an ECPR centre compared with a non-ECPR centre was 4.63 (95% CI, 0.97–22.11; P = 0.055).
CONCLUSION: The survival rate of patients with refractory OHCA transported to an ECPR centre remains low. Outcomes in larger cities might be improved with shorter scene times and additional ECPR centres that would provide for earlier initiation of ECMO.
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Statistical analysesAnalyses were performed using Stata 15 (StataCorp, 2017, College Station, TX). Descriptive statistics are presented as frequencies and proportions for categorical data and median and interquartile ranges (IQRs) or mean and standard deviation (SD) for continuous variables. To compare outcomes between ECPR and non-ECPR hospitals, a t test or Wilcoxon rank sum test (numerical values) and χ2 analysis or two-tailed Fisher exact test (categorical values) were performed. Logistical regression was based on baseline characteristics that were significantly different on univariate analysis (age, location, shockable rhythm and paramedic intubation) to calculate an adjusted odds ratio (OR) for outcomes.
Ethics approvalThis study was approved by the Human Research Ethics Committee of the Alfred Hospital (54/19). The collection of data for VACAR was approved by the Monash University Human Research Ethics Committee (Approval No. 21046).
ResultsBetween January 2016 and December 2019, resuscitation was commenced in 12 183 patients in Victoria. In 3944 patient (32.4%), ROSC was achieved at scene or before arrival in the ED (Figure 1). There were 223 cardiac arrest patients (1.8%) who were transported by ambulance and arrived at an ED in Victoria with mCPR in progress, with the majority of these patients (78.0%) transported to a non-ECMO centre. There were six patients with hospital data not available. All patients transported with mCPR were aged > 15 years.
Table 1 compares the baseline characteristics of patients who arrived at the ECPR centre with the non-ECPR centres. Of note, there were significant differences in the two groups for factors that are known to be associated with improved outcomes, such as age, site of arrest, shockable versus non-shockable initial cardiac rhythm, and cardiac arrest in a public place.
Of the 49 patients who arrived at the ECPR centre, the time from arrest onset to arrival at the ECPR centre was a median of 63.9 minutes (IQR, 54.3–82.0). In the ED, ECMO cannulation was attempted in 25 patients and established in 23 patients. In two patients, attempts at percutaneous femoral cannulation were unsuccessful and resuscitation was ceased. The time from commencement of the ECPR procedure to establishment of ECMO flow was not available from the electronic medical record.
Of the 23 patients in whom cannulation was successful and ECMO was commenced, four (17.4%) survived to hospital discharge, all with CPC score 1/2 at the 12-month follow-up (Table 2). Of the 19/23 patients who did not survive to hospital discharge, the causes of death were:
- in six of 19 patients, organ perfusion was not able to be achieved with ECMO, as shown by profound hypotension and increasing lactate levels despite fluid therapy and high dose pressor agents;
- in three of 19 patients, multi-organ system failure developed over the first 24 hours;
- in two of 19 patients, brain death developed over 36 hours;
- in two of 19 patients, major intra-abdominal bleeding occurred that led to the patient becoming unsupportable despite transfusion of blood products; and
- the remaining six of 19 patients had severe hypoxic-ischaemic neurological injury and had active medical treatment withdrawn between 5 and 10 days.
- CPR duration significantly exceeded 45 minutes in patients aged > 35 years and thus was considered too prolonged (13/20);
- major significant comorbidities (three of 20);
- significant airway bleeding (two of 20); and
- age outside the eligibility criteria (two of 20).