Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department
James L Grijalva, John Dentel, Britton Keeshan, *David M McMullan
Seattle Children's Hospital, Seattle, WA
Objective: Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve survival in patients refractory to conventional cardiopulmonary resuscitation. This observation has resulted in increased use of ECPR in the emergency department (ED-ECPR) during the past decade. Despite increased utilization of ED-ECPR, a survival benefit of ED-ECPR has not been clearly established. The purpose of this study was to determine ED-ECPR survival utilizing a large multi-institutional database and to identify risk factors for mortality in patients who receive ED-ECPR.
Methods: The Extracorporeal Life Support Organization registry was queried for data form all patients who received ECPR in an Emergency Department from 2010-2017. Comparisons were made between survivors and non-survivors. Mann-Whitney U test was used to analyze continuous variables. Chi-squared test was used to compare categorical data.
Results: Five hundred and fifty five patients received ED-ECPR during the study period. Median age was 52.4 years (IQR 38.1-62.9); 90% were adults and 73% were male. Overall survival was 29.1%, with no significant difference in survival between age groups (adult and pediatric patients; 27.2% vs. 34.6%, p=0.25), gender (male vs. female; 25.9% vs. 33.8%, p=0.07) or race (p=0.13). Patients with a diagnosis of sepsis (0%, p=0.003), cardiovascular disease (25.5%, p=0.03), severe hematologic abnormally (5.6%, p=0.03) experienced reduced survival. Non-survivors had higher incidence of gastrointestinal hemorrhage (6.9% vs. 2.0%, p=0.04) , disseminated intravascular coagulation (6.4% vs. 2.0%, p=0.008), CPR while on extracorporeal membrane oxygenation (8.9% vs. 2.0%, p=0.008), severe acidosis (pH<7.20; 24.4% vs. 6.8%, p=0.00), and need for continuous arteriovenous hemodialysis (7.8% vs. 2.7%, p=0.05).
Adult patients who experienced out-of-hospital cardiac arrest had similar survival to those who experienced in-hospital arrest (25.1% vs. 30.1%, p=0.17). However, out-of-hospital cardiac arrest was associated with significantly worse survival than in-hospital cardiac arrest in pediatric (<18 yrs) patients (5.9% vs. 51.4%, p=0.001). No other pre-ECPR risk factors were associated with worse outcome in pediatric patients. In contrast, increased acidosis (pH 7.03 vs. 7.16, p=0.001) and lower bicarbonate (16.4 mEq/L vs. 19 mEq/L, p=0.02) were associated with worse survival in adult E-ECPR patients.
Conclusions: Survival in patients who received ECPR in an Emergency Department is similar to rates reported for patients who received ECPR in locations outside of the Emergency Department (eg. Intensive Care Unit). Out-of hospital cardiac arrest does not appear to be a risk factor for worse survival in adult ED-ECPR patients. In contrast, out-of-hospital cardiac arrest is associated with worse survival in pediatric ED-ECPR patients. These findings support the use of ECPR for out-of hospital cardiac arrest in adult patients.
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