Impact of Age-Adjusted Charlson Comorbidity on Hospital Survival and Short-Term Outcome of Patients with Extracorporeal Cardiopulmonary Resuscitation

Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter?

OBJECTIVES

The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database.

DESIGN

Retrospective analysis of the Extracorporeal Life Support Organization registry.

PATIENTS

Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81).

CONCLUSIONS

This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.

Optimal postoperative delirium prediction after coronary artery bypass grafting surgery: a prospective cohort study

Background

Postoperative delirium (POD) presents as a serious neuropsychiatric syndrome in patients undergoing off-pump coronary artery bypass grafting (OPCABG) surgery. This is correlated with higher mortality, cognitive decline, and increased costs. The Age-adjusted Charlson Comorbidity Index (ACCI) is recognized as an independent predictor for mortality and survival rate. The purpose of our study is to estimate the predictive value of the ACCI on the POD in patients undergoing OPCABG surgery.

Methods

This prospective cohort study enrolled patients undergoing OPCABG surgery between December 2020 and May 2021 in Qilu Hospital. Patients were divided into the low-ACCI group (score, 0-3) and the high-ACCI group (score ≥4) according to their ACCI scores. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and CAM were used to diagnose POD within 7 days after surgery. The general, laboratory, and clinical data of the patients were recorded and collected. The characteristic ROC curve was applied to further assess the predictive value of the ACCI for POD in patients following OPCABG surgery.

Results

A total of 89 patients were enrolled, including 45 patients in the low-ACCI group and 44 patients in the high-ACCI group. The incidence of POD was higher in the high-ACCI group than in the low-ACCI group (45.5% vs. 15.6%, P = 0.003). Multivariate logistic regression analyses showed that the ACCI (OR, 2.433; 95% CI, 1.468-4.032; P = 0.001) was an independent risk factor for POD. The ACCI accurately predicted POD in patients following OPCABG surgery with an AUC of 0.738, and the Hosmer-Lemeshow goodness of fit test yielded X2 = 5.391 (P = 0.145).

Conclusion

The high-ACCI group showed a high incidence of POD. The ACCI was an independent factor associated with POD in patients following OPCABG surgery. In addition, the ACCI could accurately predict POD in patients following OPCABG surgery.

Clinical Trial Registration

ClinicalTrials.gov, identifier CHiCTR2100052811.

Urine output as one of the most important features in differentiating in-hospital death among patients receiving extracorporeal membrane oxygenation: a random forest approach

BACKGROUND

It is common to support cardiovascular function in critically ill patients with extracorporeal membrane oxygenation (ECMO). The purpose of this study was to identify patients receiving ECMO with a considerable risk of dying in hospital using machine learning algorithms.

METHODS

A total of 1342 adult patients on ECMO support were randomly assigned to the training and test groups. The discriminatory power (DP) for predicting in-hospital mortality was tested using both random forest (RF) and logistic regression (LR) algorithms.

RESULTS

Urine output on the first day of ECMO implantation was found to be one of the most predictive features that were related to in-hospital death in both RF and LR models. For those with oliguria, the hazard ratio for 1 year mortality was 1.445 (p < 0.001, 95% CI 1.265-1.650).

CONCLUSIONS

Oliguria within the first 24 h was deemed especially significant in differentiating in-hospital death and 1 year mortality.

Age adjusted Charlson comorbidity index (a-CCI) AS a tool to predict 30-day post-operative outcome in general surgery patients

INTRODUCTION

Age adjusted Charlson comorbidity index (a-CCI) is an established scoring system to predict long-term mortality. However, its role in predicting 30-day post-operative outcome in general surgery patients is not well elucidated.

METHODS

This was a prospective observational study. Consecutive patients operated under general anaesthesia between January 2019 and December 2020 were enrolled. Their a-CCI was calculated and stratified as Grade 0 comorbidities (a-CCI score = 0), Grade A comorbidities (a-CCI score = 1 and 2) and Grade B comorbidities (a-CCI score ≥ 3). Post-operative complications were graded according to Clavien Dindo (CD) grading system and classified as minor complications (CD Grades I and II), major complications (CD Grades III-IV) and mortality (CD Grade V). Binary logistic regression and multi-nominal logistic regression analysis were done and relative risk ratios were calculated.

RESULT

A total of 925 patients were enrolled. The mean age was 42.75 (14-85 ± 10) years. 31% of our patients had complications within 30 days of surgery which included mortality in 2.7%. Compared with patients with Grade 0 comorbidities, the odds of getting complications is 1.2 times more in patients with Grade A comorbidities and 1.84 times more in patients with Grade B comorbidities (P = 0.205, 0.001 respectively). In comparison to patients with Grade 0 co-morbidities, risk of mortality is 3 and 17.86 times more in patients with Grade A and Grade B comorbidities (P = 0.121 and < 0.001 respectively).

CONCLUSION

a-CCI has clinical relevance in general surgical patients and can predict early post-operative outcome. It should be a part of our armamentarium for pre-operative assessment of surgical patients.

The impact of on-site cardiac rhythm on mortality in patients supported with extracorporeal cardiopulmonary resuscitation: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used in patients with out-of-hospital or in-hospital cardiac arrest in whom conventional cardiopulmonary resuscitation remains unsuccessful. The aim of this study was to analyze the impact of initial cardiac rhythm-detected on-site of the cardiac arrest-on mortality.

METHODS

We performed a retrospective cohort study of patients who received ECPR in our tertiary care cardiac arrest center. Patients were divided into three groups depending on their cardiac rhythm: shockable rhythm, pulseless electrical activity, and asystole. The primary endpoint was mortality within the first 7 days after ECPR deployment. Secondary endpoints were mortality within 28 days and the impact of pre-ECPR potassium, serum lactate, pH, and pCO₂ on mortality. The association of the initial cardiac rhythm and the location of arrhythmia detection (patient monitored in hospital [category: monitored], not monitored but hospitalized [in-hospital], not monitored, not hospitalized [out-of hospital]) with the primary and secondary outcome was examined by means of univariable and multivariable logistic regression.

RESULTS

Sixty-five patients could be included in the final analysis. Thirty-two patients (49.2%, 95%CI 36.6%-61.9%) died within the first 7 days. In terms of 7-day-mortality patients differed in the initial cardiac rhythm (p = 0.040) and with respect to the location of arrhythmia detection (p = 0.002). Shockable cardiac rhythm (crude OR 0.21; 95%CI 0.03-0.98) and pulseless electrical activity (0.13; 0.02-0.61) as the initial rhythm on-site showed better odds for survival compared to asystole. However, this association did neither persist in adjusted analysis nor pairwise comparison.

DISCUSSION

The study could not demonstrate a better outcome with shockable rhythm after ECPR. More homogeneous and adequately powered cohorts are needed to better understand the impact of cardiac rhythm on patient outcomes after ECPR.

Successful extracorporeal membrane oxygenation resuscitation of patient with cardiogenic shock induced by phaeochromocytoma crisis mimicking hyperthyroidism: A case report

A 29-year-old woman presented to the emergency department with the acute onset of palpitations, shortness of breath, and haemoptysis. She reported having an abortion (56 days of pregnancy) 1 week before admission because of hyperthyroidism diagnosis during pregnancy. The first diagnoses considered were cardiomyopathy associated with hyperthyroidism, acute left ventricular failure, and hyperthyroidism crisis. The young woman’s cardiocirculatory system collapsed within several hours. Hence, venoarterial extracorporeal membrane oxygenation (VA ECMO) was performed for this patient. Over the next 3 days after ECMO was established, repeat transthoracic echocardiography showed gradual improvements in biventricular function, and later the patient recovered almost completely. The patient’s blood pressure increased to 230/130 mm Hg when the ECMO catheter was removed, and then the diagnosis of phaeochromocytoma was suspected. Computed tomography showed a left suprarenal tumour. The tumour size was 5.8 cm × 5.7 cm with central necrosis. The vanillylmandelic acid concentration was 63.15 mg/24 h. Post-operation, pathology confirmed phaeochromocytoma. To our knowledge, this is the first case report of a patient with cardiogenic shock induced by phaeochromocytoma crisis mimicking hyperthyroidism which was successfully resuscitated by VA ECMO.

Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival

Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.

Association between Extracorporeal Membrane Oxygenation (ECMO) and Mortality in the Patients with Cardiac Arrest: A Nation-Wide Population-Based Study with Propensity Score Matched Analysis

We attempted to determine the impact of extracorporeal membrane oxygenation (ECMO) on short-term and long-term outcomes and find potential resource utilization differences between the ECMO and non-ECMO groups, using the National Health Insurance Service database. We selected adult patients (≥20 years old) with non-traumatic cardiac arrest from 2007 to 2015. Data on age, sex, insurance status, hospital volume, residential area urbanization, and pre-existing diseases were extracted from the database. A total of 1.5% (n = 3859) of 253,806 patients were categorized into the ECMO group. The ECMO-supported patients were more likely to be younger, men, more covered by national health insurance, and showed, higher usage of tertiary level and large volume hospitals, and a lower rate of pre-existing comorbidities, compared to the non-ECMO group. After propensity score-matching demographic data, hospital factors, and pre-existing diseases, the odds ratio (ORs) of the ECMO group were 0.76 (confidence interval, (CI) 0.68–0.85) for 30-day mortality and 0.66 (CI 0.58–0.79) for 1-year mortality using logistic regression. The index hospitalization was longer, and the 30-day and 1-year hospital costs were greater in the matched ECMO group. Although ECMO support needed longer hospitalization days and higher hospital costs, the ECMO support reduced the risk of 30-day and 1-year mortality compared to the non-ECMO patients.

Prognostic implications of pre-existing medical comorbidity in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P < 0.001). Seventy-six (14%) subjects died within 30 days of index diagnosis and 185 (34%) subjects experienced severe shock. The median duration of hospitalization was 7 days (IQR 3-14 days). In multivariable logistic regression, CCI was not associated with 30-day mortality or severe shock. In multivariable Poisson regression, CCI (IRR 1.17, 95% CI 1.16-1.18, P < 0.001) was associated with duration of hospitalization. Increased burden of pre-existing medical comorbidity was not independently associated with 30-day mortality or severe shock at index presentation, but was associated with increased duration of hospitalization after diagnosis of TC.

Can we predict patient outcome before extracorporeal membrane oxygenation for refractory cardiac arrest?

Background

Refractory cardiac arrest resistant to conventional cardiopulmonary resuscitation (C-CPR) has a poor outcome. Although previous reports showed that extracorporeal cardiopulmonary resuscitation (E-CPR) can improve the clinical outcome, there are no clinically applicable predictors of patient outcome that can be used prior to the implementation of E-CPR. We aimed to evaluate the use of clinical factors in patients with refractory cardiac arrest undergoing E-CPR to predict patient outcome in our institution.

Methods

This is a single-center retrospective study. We report 112 patients presenting with refractory cardiac arrest resistant to C-CPR between January 2012 and November 2017. All patients received E-CPR for continued life support when a cardiogenic etiology was presumed. Clinical factors associated with patient outcome were analyzed. Significant pre-ECMO clinical factors were extracted to build a patient outcome risk prediction model.

Results

The overall survival rate at discharge was 40.2, and 30.4% of patients were discharged with good neurologic function. The six-month survival rate after hospital discharge was 36.6, and 25.9% of patients had good neurologic function 6 months after discharge. We stratified the patients into low-risk (n = 38), medium-risk (n = 47), and high-risk groups (n = 27) according to the TLR score (low-flow Time, cardiac arrest Location, and initial cardiac arrest Rhythm) that we derived from pre-ECMO clinical parameters. Compared with the medium-risk and high-risk groups, the low-risk group had better survival at discharge (65.8% vs. 42.6% vs. 0%, p < 0.0001) and at 6 months (60.5% vs. 38.3% vs. 0%, p = 0.0001). The low-risk group also had a better neurologic outcome at discharge (50% vs. 31.9% vs. 0%, p = 0.0001) and 6 months after discharge (44.7% vs. 25.5% vs. 0%, p = 0.0003) than the medium-risk and high-risk groups.

Conclusions

Patients with refractory cardiac arrest receiving E-CPR can be stratified by pre-ECMO clinical factors to predict the clinical outcome. Larger-scale studies are required to validate our observations.

Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Adult Patients

Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out-of-hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra-aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.