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Pagura L, Fabris E, Rakar S, Gabrielli M, Mazzaro E, Sinagra G, Stolfo D. Does extracorporeal cardiopulmonary resuscitation improve survival with favorable neurological outcome in out-of-hospital cardiac arrest? A systematic review and meta-analysis. J Crit Care 2024; 84:154882. [PMID: 39053234 DOI: 10.1016/j.jcrc.2024.154882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/10/2024] [Accepted: 07/12/2024] [Indexed: 07/27/2024]
Abstract
PURPOSE Extracorporeal cardiopulmonary resuscitation (E-CPR) may improve survival with favorable neurological outcome in patients with refractory out-of-hospital cardiac arrest (OHCA). Unfortunately, recent results from randomized controlled trials were inconclusive. We performed a meta-analysis to investigate the impact of E-CPR on neurological outcome compared to conventional cardiopulmonary resuscitation (C-CPR). METHODS A systematic research for articles assessing outcomes of adult patients with OHCA either treated with E-CPR or C-CPR up to April 27, 2023 was performed. Primary outcome was survival with favorable neurological outcome at discharge or 30 days. Overall survival was also assessed. RESULTS Eighteen studies were included. E-CPR was associated with better survival with favorable neurological status at discharge or 30 days (14% vs 7%, OR 2.35, 95% CI 1.61-3.43, I2 = 80%, p < 0.001, NNT = 17) than C-CPR. Results were consistent if the analysis was restricted to RCTs. Overall survival to discharge or 30 days was also positively affected by treatment with E-CPR (OR = 1.71, 95% CI = 1.18-2.46, I2 = 81%, p = 0.004, NNT = 11). CONCLUSIONS In this meta-analysis, E-CPR had a positive effect on survival with favorable neurological outcome and, to a smaller extent, on overall mortality in patients with refractory OHCA.
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Affiliation(s)
- Linda Pagura
- Cardiac Surgery, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Enrico Fabris
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Serena Rakar
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Marco Gabrielli
- Cardiac Surgery, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Enzo Mazzaro
- Cardiac Surgery, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy; Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
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Heuts S, Ubben JFH, Kawczynski MJ, Gabrio A, Suverein MM, Delnoij TSR, Kavalkova P, Rob D, Komárek A, van der Horst ICC, Maessen JG, Yannopoulos D, Bělohlávek J, Lorusso R, van de Poll MCG. Extracorporeal cardiopulmonary resuscitation versus standard treatment for refractory out-of-hospital cardiac arrest: a Bayesian meta-analysis. Crit Care 2024; 28:217. [PMID: 38961495 PMCID: PMC11223393 DOI: 10.1186/s13054-024-05008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND The outcomes of several randomized trials on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with refractory out-of-hospital cardiac arrest were examined using frequentist methods, resulting in a dichotomous interpretation of results based on p-values rather than in the probability of clinically relevant treatment effects. To determine such a probability of a clinically relevant ECPR-based treatment effect on neurological outcomes, the authors of these trials performed a Bayesian meta-analysis of the totality of randomized ECPR evidence. METHODS A systematic search was applied to three electronic databases. Randomized trials that compared ECPR-based treatment with conventional CPR for refractory out-of-hospital cardiac arrest were included. The study was preregistered in INPLASY (INPLASY2023120060). The primary Bayesian hierarchical meta-analysis estimated the difference in 6-month neurologically favorable survival in patients with all rhythms, and a secondary analysis assessed this difference in patients with shockable rhythms (Bayesian hierarchical random-effects model). Primary Bayesian analyses were performed under vague priors. Outcomes were formulated as estimated median relative risks, mean absolute risk differences, and numbers needed to treat with corresponding 95% credible intervals (CrIs). The posterior probabilities of various clinically relevant absolute risk difference thresholds were estimated. RESULTS Three randomized trials were included in the analysis (ECPR, n = 209 patients; conventional CPR, n = 211 patients). The estimated median relative risk of ECPR for 6-month neurologically favorable survival was 1.47 (95%CrI 0.73-3.32) with a mean absolute risk difference of 8.7% (- 5.0; 42.7%) in patients with all rhythms, and the median relative risk was 1.54 (95%CrI 0.79-3.71) with a mean absolute risk difference of 10.8% (95%CrI - 4.2; 73.9%) in patients with shockable rhythms. The posterior probabilities of an absolute risk difference > 0% and > 5% were 91.0% and 71.1% in patients with all rhythms and 92.4% and 75.8% in patients with shockable rhythms, respectively. CONCLUSION The current Bayesian meta-analysis found a 71.1% and 75.8% posterior probability of a clinically relevant ECPR-based treatment effect on 6-month neurologically favorable survival in patients with all rhythms and shockable rhythms. These results must be interpreted within the context of the reported credible intervals and varying designs of the randomized trials. REGISTRATION INPLASY (INPLASY2023120060, December 14th, 2023, https://doi.org/10.37766/inplasy2023.12.0060 ).
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, MUMC+), P. Debyelaan 25, 6229HX, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands.
| | - Johannes F H Ubben
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Michal J Kawczynski
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, MUMC+), P. Debyelaan 25, 6229HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
| | - Andrea Gabrio
- Department of Methodology and Statistics, University Maastricht, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), University Maastricht, Maastricht, The Netherlands
| | - Martje M Suverein
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Petra Kavalkova
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Medical School, General University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Daniel Rob
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Medical School, General University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Arnošt Komárek
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Statistics, Charles University in Prague, Prague, Czech Republic
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, MUMC+), P. Debyelaan 25, 6229HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jan Bělohlávek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Medical School, General University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, MUMC+), P. Debyelaan 25, 6229HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism, University Maastricht, Maastricht, The Netherlands
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DeMasi S, Donohue M, Merck L, Mosier J. Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: Lessons learned from recent clinical trials. J Am Coll Emerg Physicians Open 2024; 5:e13129. [PMID: 38434097 PMCID: PMC10904351 DOI: 10.1002/emp2.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/05/2024] Open
Abstract
Cardiac arrest is a leading contributor to morbidity and mortality in the United States. Survival has been historically dependent on high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. However, a large percentage of patients remain in refractory cardiac arrest despite adherence to structured advanced cardiac life support algorithms in which these factors are emphasized. Veno-arterial extracorporeal membrane oxygenation is becoming an increasingly used rescue therapy for patients in refractory cardiac arrest to restore oxygen delivery by extracorporeal CPR (ECPR). Recently published clinical trials have provided new insights into ECPR for patients who sustain an outside hospital cardiac arrest (OHCA). In this narrative review, we summarize the rationale for, results of, and remaining questions from these recently published clinical trials. The existing observational data combined with the latest clinical trials suggest ECPR improves mortality in patients in refractory arrest. However, a mixed methods trial is essential to understand the complexity, context, and effectiveness of implementing an ECPR program.
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Affiliation(s)
- Stephanie DeMasi
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Megan Donohue
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lisa Merck
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Jarrod Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and SleepDepartment of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
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Cheng P, Wang H, Guo L, Wang M, Xu H, Gu P, Wu J, Yang M. Survival and neurological function in patients treated with extracorporeal membrane oxygenation and therapeutic hypothermia: a protocol for updating a systematic review. BMJ Open 2024; 14:e081207. [PMID: 38531575 PMCID: PMC10966782 DOI: 10.1136/bmjopen-2023-081207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/08/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION The widespread application of extracorporeal membrane oxygenation (ECMO) has enhanced clinical outcomes for patients experiencing cardiac arrest. However, its effectiveness is still limited and falls short of the desired level. Therapeutic hypothermia, which maintains body temperatures between 32°C and 36°C in cardiac arrest patients treated with ECMO, has been proposed as a potential means of neuroprotection and increased survival rates. Nevertheless, it remains controversial, and its impact on patient complications has yet to be fully understood. Thus, this paper aims to update the protocol for a systematic review of patients treated with ECMO and therapeutic hypothermia, in order to explore its effects on survival and neurological function. METHOD AND ANALYSIS This protocol has been developed in compliance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols 2015. The following databases will be systematically searched: PubMed, Web of Science, Cochrane Library, Embase, Ovid, CNKI, Wanfang and China Biology Medicine Disc. The database search strategy will use a combination of subject terms and free-text keywords. The search will encompass articles from the inception of each database up to 15 June 2023. Inclusion criteria encompass randomised controlled trials, cohort studies, case-control studies and quasi-experimental studies. Two researchers will independently review articles and extract relevant data based on these criteria. Any disagreements will be resolved through discussion. Data analysis will be performed using Review Manager software. ETHICS AND DISSEMINATION Since no patient data were collected in this study, ethical approval was not required. Research findings will be released in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023435353.
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Affiliation(s)
- Pengfei Cheng
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haizhen Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Luyao Guo
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Meiling Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - He Xu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Peipei Gu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jinjing Wu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Minfei Yang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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