Key result
Early ECPR strategy linked to ~21 percentage point higher neurologically favorable survival in refractory OHCA.
Why the study?
Out of hospital cardiac arrest mortality rates remain very high with poor neurological outcomes in survivors, prompting a comparison of two historical ECPR management strategies for refractory OHCA.
Does an aggressive early ECPR management strategy with stringent patient selection improve survival with good neurological function compared to a standard ECPR strategy in patients with refractory out-of-hospital cardiac arrest?
Cohort (n=156)
Does an aggressive early ECPR management strategy with stringent patient selection improve survival with good neurological function compared to a standard ECPR strategy in patients with refractory out-of-hospital cardiac arrest?
An aggressive ECPR strategy combining early initiation (after 20 minutes), stringent patient selection, and epinephrine limitation is feasible and significantly improves neurologically intact survival in refractory out-of-hospital cardiac arrest.
Answers are grounded in this paper and cite their sources.
Pre-hospital ECPR may be feasible for refractory OHCA; leaves open survival benefit pending randomized trials.
Background Out of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies. Methods We consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28. Findings A total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20min (p<0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P<0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2. Interpretation Our data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.
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Lamhaut et al. (2017) conducted a cohort in Refractory out-of-hospital cardiac arrest (OHCA) (n=156). Period 2 ECPR strategy (early ECPR initiation after 20 min of resuscitation, stringent patient selection, epinephrine dose limitation, deployment of ECPR team with initial response team) vs. Period 1 ECPR strategy (ECPR indicated in selected patients after 30 min of advanced life support; in- or pre-hospital implementation based on estimated transportation time and team availability) was evaluated on Survival with good neurological function (Cerebral Performance Category score 1 and 2) at ICU discharge or day 28 (p=<0.001). An aggressive early ECPR strategy (Period 2) improved survival with good neurological function (CPC 1-2) compared to a standard ECPR strategy (29% vs 8%, P<0.001) in refractory OHCA.
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