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Shih HM, Lin WJ, Lin YC, Chang SS, Chang KC, Yu SH. Extracorporeal cardiopulmonary resuscitation for patients with refractory out-of-hospital cardiac arrest: a propensity score matching, observational study. Sci Rep 2024; 14:9912. [PMID: 38688987 PMCID: PMC11061168 DOI: 10.1038/s41598-024-60620-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 04/25/2024] [Indexed: 05/02/2024] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly performed as an adjunct to conventional cardiopulmonary resuscitation (CCPR) for refractory out-of-hospital cardiac arrest (OHCA). However, the specific benefits of ECPR concerning survival with favorable neurological outcomes remain uncertain. This study aimed to investigate the potential advantages of ECPR in the management of refractory OHCA. We conducted a retrospective cohort study involved OHCA patients between January 2016 and May 2021. Patients were categorized into ECPR or CCPR groups. The primary endpoint assessed was survival with favorable neurological outcomes, and the secondary outcome was survival rate. Multivariate logistic regression analyses, with and without 1:2 propensity score matching, were employed to assess ECPR's effect. In total, 1193 patients were included: 85underwent ECPR, and 1108 received CCPR. Compared to the CCPR group, the ECPR group exhibited notably higher survival rate (29.4% vs. 2.4%; p < 0.001). The ECPR group also exhibited a higher proportion of survival with favorable neurological outcome than CCPR group (17.6% vs. 0.7%; p < 0.001). Multivariate logistic regression analysis demonstrated that ECPR correlated with increased odds of survival with favorable neurological outcome (adjusted odds ratio: 13.57; 95% confidence interval (CI) 4.60-40.06). Following propensity score matching, the ECPR group showed significantly elevated odds of survival with favorable neurological outcomes (adjusted odds ratio: 13.31; 95% CI 1.61-109.9). This study demonstrated that in comparison to CCPR, ECPR may provide survival benefit and increase the odds of favorable neurological outcomes in selected OHCA patients.
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Affiliation(s)
- Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, 2 Yue-Der Road, Taichung City, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Wei-Jun Lin
- Department of Emergency Medicine, China Medical University Hospital, 2 Yue-Der Road, Taichung City, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - You-Cian Lin
- Surgical Department Cardiovascular Division, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Shih-Sheng Chang
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Shao-Hua Yu
- Department of Emergency Medicine, China Medical University Hospital, 2 Yue-Der Road, Taichung City, Taiwan.
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.
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2
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Jouffroy R, Vie AC, Vivien B. Extracorporeal cardiopulmonary resuscitation versus conventional CPR in cardiac arrest: be aware of the temporal selection bias. Crit Care 2024; 28:126. [PMID: 38637881 PMCID: PMC11025236 DOI: 10.1186/s13054-024-04907-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024] Open
Affiliation(s)
- Romain Jouffroy
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique - Hôpitaux de Paris, and Paris Saclay University, Boulogne, France.
| | - Anne-Cécile Vie
- SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, and Paris Cité University, Paris, France
| | - Benoît Vivien
- SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, and Paris Cité University, Paris, France
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3
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Low CJW, Ling RR, Ramanathan K, Chen Y, Rochwerg B, Kitamura T, Iwami T, Ong MEH, Okada Y. Extracorporeal cardiopulmonary resuscitation versus conventional CPR in cardiac arrest: an updated meta-analysis and trial sequential analysis. Crit Care 2024; 28:57. [PMID: 38383506 PMCID: PMC10882798 DOI: 10.1186/s13054-024-04830-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/10/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) may reduce mortality and improve neurological outcomes in patients with cardiac arrest. We updated our existing meta-analysis and trial sequential analysis to further evaluate ECPR compared to conventional CPR (CCPR). METHODS We searched three international databases from 1 January 2000 through 1 November 2023, for randomised controlled trials or propensity score matched studies (PSMs) comparing ECPR to CCPR in both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). We conducted an updated random-effects meta-analysis, with the primary outcome being in-hospital mortality. Secondary outcomes included short- and long-term favourable neurological outcome and survival (30 days-1 year). We also conducted a trial sequential analysis to evaluate the required information size in the meta-analysis to detect a clinically relevant reduction in mortality. RESULTS We included 13 studies with 14 pairwise comparisons (6336 ECPR and 7712 CCPR) in our updated meta-analysis. ECPR was associated with greater precision in reducing overall in-hospital mortality (OR 0.63, 95% CI 0.50-0.79, high certainty), to which the trial sequential analysis was concordant. The addition of recent studies revealed a newly significant decrease in mortality in OHCA (OR 0.62, 95% CI 0.45-0.84). Re-analysis of relevant secondary outcomes reaffirmed our initial findings of favourable short-term neurological outcomes and survival up to 30 days. Estimates for long-term neurological outcome and 90-day-1-year survival remained unchanged. CONCLUSIONS We found that ECPR reduces in-hospital mortality, improves neurological outcome, and 30-day survival. We additionally found a newly significant benefit in OHCA, suggesting that ECPR may be considered in both IHCA and OHCA.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National Unviersity Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National Unviersity Health System, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National Unviersity Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre Singapore, National University Health System, Singapore, Singapore
| | - Ying Chen
- Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- Preventive Services, Graduate School of Medicine, School of Public Health, Kyoto University, Kyoto, Japan
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Yohei Okada
- Preventive Services, Graduate School of Medicine, School of Public Health, Kyoto University, Kyoto, Japan.
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.
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Low CJW, Ramanathan K, Ling RR, Ho MJC, Chen Y, Lorusso R, MacLaren G, Shekar K, Brodie D. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis. THE LANCET. RESPIRATORY MEDICINE 2023; 11:883-893. [PMID: 37230097 DOI: 10.1016/s2213-2600(23)00137-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Although outcomes of patients after cardiac arrest remain poor, studies have suggested that extracorporeal cardiopulmonary resuscitation (ECPR) might improve survival and neurological outcomes. We aimed to investigate any potential benefits of using ECPR over conventional cardiopulmonary resuscitation (CCPR) in patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). METHODS In this systematic review and meta-analysis, we searched MEDLINE via PubMed, Embase, and Scopus from Jan 1, 2000, to April 1, 2023, for randomised controlled trials and propensity-score matched studies. We included studies comparing ECPR with CCPR in adults (aged ≥18 years) with OHCA and IHCA. We extracted data from published reports using a prespecified data extraction form. We did random-effects (Mantel-Haenszel) meta-analyses and rated the certainty of evidence using the Grading of Recommendations, Assessments, Developments, and Evaluations (GRADE) approach. We rated the risk of bias of randomised controlled trials using the Cochrane risk-of-bias 2.0 tool, and that of observational studies using the Newcastle-Ottawa Scale. The primary outcome was in-hospital mortality. Secondary outcomes included complications during extracorporeal membrane oxygenation, short-term (from hospital discharge to 30 days after cardiac arrest) and long-term (≥90 days after cardiac arrest) survival with favourable neurological outcomes (defined as cerebral performance category scores 1 or 2), and survival at 30 days, 3 months, 6 months, and 1 year after cardiac arrest. We also did trial sequential analyses to evaluate the required information sizes in the meta-analyses to detect clinically relevant reductions in mortality. FINDINGS We included 11 studies (4595 patients receiving ECPR and 4597 patients receiving CCPR) in the meta-analysis. ECPR was associated with a significant reduction in overall in-hospital mortality (OR 0·67, 95% CI 0·51-0·87; p=0·0034; high certainty), without evidence of publication bias (pegger=0·19); the trial sequential analysis was concordant with the meta-analysis. When considering IHCA only, in-hospital mortality was lower in patients receiving ECPR than in those receiving CCPR (0·42, 0·25-0·70; p=0·0009), whereas when considering OHCA only, no differences were found (0·76, 0·54-1·07; p=0·12). Centre volume (ie, the number of ECPR runs done per year in each centre) was associated with reductions in odds of mortality (regression coefficient per doubling of centre volume -0·17, 95% CI -0·32 to -0·017; p=0·030). ECPR was also associated with an increased rate of short-term (OR 1·65, 95% CI 1·02-2·68; p=0·042; moderate certainty) and long-term (2·04, 1·41-2·94; p=0·0001; high certainty) survival with favourable neurological outcomes. Additionally, patients receiving ECPR had increased survival at 30-day (OR 1·45, 95% CI 1·08-1·96; p=0·015), 3-month (3·98, 1·12-14·16; p=0·033), 6-month (1·87, 1·36-2·57; p=0·0001), and 1-year (1·72, 1·52-1·95; p<0·0001) follow-ups. INTERPRETATION Compared with CCPR, ECPR reduced in-hospital mortality and improved long-term neurological outcomes and post-arrest survival, particularly in patients with IHCA. These findings suggest that ECPR could be considered for eligible patients with IHCA, although further research into patients with OHCA is warranted. FUNDING None.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore.
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Maxz Jian Chen Ho
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Ying Chen
- Agency for Science, Technology, and Research (A*StaR), Singapore
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Brisbane, QLD, Australia; Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia; Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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5
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Moynihan KM, Dorste A, Alizadeh F, Phelps K, Barreto JA, Kolwaite AR, Merlocco A, Barbaro RP, Chan T, Thiagarajan RR. Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature. Crit Care Med 2023; 51:843-860. [PMID: 36975216 DOI: 10.1097/ccm.0000000000005866] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). STUDY SELECTION Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. DATA EXTRACTION Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. DATA SYNTHESIS Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. CONCLUSIONS Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.
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Affiliation(s)
- Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kayla Phelps
- Department of Pediatrics, Children's Hospital New Orleans, Louisiana State University, New Orleans, LA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anthony Merlocco
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
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6
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Extracorporeal cardiopulmonary resuscitation for cardiac arrest: An updated systematic review. Resuscitation 2023; 182:109665. [PMID: 36521684 DOI: 10.1016/j.resuscitation.2022.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an updated systematic review on the use of extracorporeal cardiopulmonary resuscitation (ECPR) compared with manual or mechanical cardiopulmonary resuscitation during cardiac arrest. METHODS This was an update of a systematic review published in 2018. OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for randomized trials and observational studies between January 1, 2018, and June 21, 2022. The population included adults and children with out-of-hospital or in-hospital cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed bias. The certainty of evidence was evaluated using GRADE. RESULTS The search identified 3 trials, 27 observational studies, and 6 cost-effectiveness studies. All trials included adults with out-of-hospital cardiac arrest and were terminated before enrolling the intended number of subjects. One trial found a benefit of ECPR in survival and favorable neurological status, whereas two trials found no statistically significant differences in outcomes. There were 23 observational studies in adults with out-of-hospital cardiac arrest or in combination with in-hospital cardiac arrest, and 4 observational studies in children with in-hospital cardiac arrest. Results of individual studies were inconsistent, although many studies favored ECPR. The risk of bias was intermediate for trials and critical for observational studies. The certainty of evidence was very low to low. Study heterogeneity precluded meta-analyses. The cost-effectiveness varied depending on the setting and the analysis assumptions. CONCLUSIONS Recent randomized trials suggest potential benefit of ECPR, but the certainty of evidence remains low. It is unclear which patients might benefit from ECPR.
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Piscitello GM, Bermea RS, Stokes JW, Gannon WD, Kanelidis AJ, Konopka M, Shappell C, Frye LK, Lyons PG, Siegler M, Parker WF. Clinician Ethical Perspectives on Extracorporeal Membrane Oxygenation in Practice. Am J Hosp Palliat Care 2022; 39:659-666. [PMID: 34414798 PMCID: PMC8858336 DOI: 10.1177/10499091211041079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is an expensive and scarce life sustaining treatment provided to certain critically ill patients. Little is known about the informed consent process for ECMO or clinician viewpoints on ethical complexities related to ECMO in practice. METHODS We sent a cross-sectional survey to all departments providing ECMO within 7 United States hospitals in January 2021. One clinician from each department completed the 42-item survey representing their department. RESULTS Fourteen departments within 7 hospitals responded (response rate 78%, N = 14/18). The mean time spent consenting patients or surrogate decision-makers for ECMO varied, from 7.5 minutes (95% CI 5-10) for unstable patients to 20 minutes (95% CI 15-30) for stable patients (p = 0.0001). Few clinician respondents (29%) report patients or surrogate decision-makers always possess informed consent for ECMO. Most departments (92%) have absolute exclusion criteria for ECMO such as older age (43%, cutoffs ranging from 60-75 years), active malignancy (36%), and elevated body mass index (29%). A significant minority of departments (29%) do not always offer the option to withdraw ECMO to patients or surrogate decision-makers. For patients who cannot be liberated from ECMO and are ineligible for heart or lung transplant, 36% of departments would recommend the patient be removed from ECMO and 64% would continue ECMO support. CONCLUSION Adequate informed consent for ECMO is a major ethical challenge, and the content of these discussions varies. Use of categorical exclusion criteria and withdrawal of ECMO if a patient cannot be liberated from it differ among departments and institutions.
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Affiliation(s)
| | - Rene S. Bermea
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John W. Stokes
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Whitney D. Gannon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Megan Konopka
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Claire Shappell
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Laura K. Frye
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin, Madison, WI, USA
| | - Patrick G. Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, MO, USA
| | - Mark Siegler
- Department of Medicine, University of Chicago, IL, USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, IL, USA
| | - William F. Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, IL, USA
- Section of Pulmonary and Critical Care, University of Chicago, IL, USA
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8
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Agbafe V, Fugett J, Gall A, Dhamija A, Asad F, Abbas K, Hayanga JA. Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation. Perfusion 2022; 38:791-800. [PMID: 35320025 DOI: 10.1177/02676591221083789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.
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Affiliation(s)
- Victor Agbafe
- 12266University of Michigan Medical School, Ann Arbor, MI, USA
| | - James Fugett
- Department of Cardiovascular and Thoracic Surgery, 5631West Virginia University, Morgantown, WV, USA
| | - Ashley Gall
- 12355West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, 5631West Virginia University, Morgantown, WV, USA
| | - Fatima Asad
- 12355West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kamil Abbas
- Immunology & Medical Microbiology, 5631West Virginia University, Morgantown, WV, USA
| | - Jeremiah A Hayanga
- Department of Cardiovascular and Thoracic Surgery, 5631West Virginia University, Morgantown, WV, USA
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9
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Owyang CG, Donnat C, Brodie D, Gershengorn HB, Hua M, Qadir N, Tonna JE. Similarities in extracorporeal membrane oxygenation management across intensive care unit types in the United States: An analysis of the Extracorporeal Life Support Organization Registry. Artif Organs 2022; 46:1369-1381. [PMID: 35122290 DOI: 10.1111/aor.14193] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/21/2021] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) use in the United States occurs often in cardiothoracic ICUs (CTICU). It is unknown how it varies across ICU types. METHODS We identified 10,893 ECMO runs from the Extracorporeal Life Support Organization (ELSO) Registry across 2018 and 2019. Primary outcome was ECMO case volume by ICU type (CTICU vs. non-CTICU). Adjusting for pre-ECMO characteristics and case mix, secondary outcomes were on-ECMO physiologic variables by ICU location stratified by support type. RESULTS CTICU ECMO occurred in 65.1% and 55.1% (2018 and 2019) of total runs. A minority of total runs related to cardiac surgery procedures (CTICU: 21.7% [2018], 18% [2019]; non-CTICU: 11.2% [2018], 13% [2019]). After multivariate adjustment, non-CTICU ECMO for cardiac support associated with lower 4- and 24-hour circuit flow (3.9 liters per minute [LPM] vs. 4.1 LPM, p<0.0001; 4.1 LPM vs. 4.3 LPM, p<0.0001); for respiratory support, lower on-ECMO mean fraction of inspired oxygen ([Fi O2 ], 67% versus 69%, p=0.02) and lower respiratory rate (14 versus 15, p<0.0001); and, for extracorporeal cardiopulmonary resuscitation (ECPR), lower ECMO flow rates at 24 hours (3.5 liters per minute [LPM] versus 3.7 LPM, p=0.01). CONCLUSIONS ECMO mostly remains in CTICUs though a minority is associated with cardiac surgery. Statistically significant but clinically minor differences in on-ECMO metrics were observed across ICU types.
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Affiliation(s)
- Clark G Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York.,Department of Emergency Medicine, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York
| | - Claire Donnat
- Department of Statistics, Stanford University, Stanford
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians & Surgeons.,Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City.,Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City
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10
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Hillerson D, Whiteside HL, Dugan AJ, Coots RD, Tribble TA, Abdel-Latif A, Ogunbayo GO, Duncan MS, Gupta VA. Predicting mortality in nonsurgical patients before cannulation for veno-arterial extracorporeal life support: Development and validation of the LACT-8 score. Catheter Cardiovasc Interv 2022; 99:1115-1124. [PMID: 35114052 DOI: 10.1002/ccd.30106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We sought to derive and validate a model to predict inpatient mortality after veno-arterial extracorporeal life support (VA-ECLS) based on readily available, precannulation clinical data. BACKGROUND Refractory cardiogenic shock supported by VA-ECLS is associated with high morbidity and mortality. METHODS VA-ECLS cases at our institution from January 2014 through July 2019 were retrospectively reviewed. Exclusion criteria were cannulation: (1) at another institution; (2) for primary surgical indication; or (3) for extracorporeal cardiopulmonary resuscitation. Multivariable logistic regression compared those with and without inpatient mortality. Multiple imputation was performed and optimism-adjusted area under the curve (oAUC) values were computed. RESULTS VA-ECLS cases from August 2019 through November 2020 were identified as a validation cohort. In the derivation cohort (n = 135), the final model included Lactate (mmol/L), hemoglobin (g/dl; Anemia), Coma (Glasgow Coma Scale [GCS] < 8) and resusciTATEd cardiac arrest (LACTATE score; oAUC = 0.760). In the validation cohort (n = 30, LACTATE showed similar predictability [AUC = 0.710]). A simplified (LACT-8) score was derived by dichotomizing lactate (>8) and hemoglobin (<8) and summing together the number of components for each patient. LACT-8 performed similarly (derivation, oAUC = 0.724; validation, AUC = 0.725). In the derivation cohort, both scores outperformed SAVE (oAUC = 0.568) and SOFA (oAUC = 0.699) scores. A LACT-8 ≥ 3 had a specificity for mortality of 97.9% and 92.9%, in the derivation and validation cohorts, respectively. CONCLUSIONS The LACT-8 score can predict inpatient mortality prior to before cannulation for VA-ECLS. LACT-8 can be implemented utilizing clinical data without the need for an online calculator.
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Affiliation(s)
- Dustin Hillerson
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Hoyle L Whiteside
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Adam J Dugan
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Riley D Coots
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Thomas A Tribble
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Ahmed Abdel-Latif
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Gbolahan O Ogunbayo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Meredith S Duncan
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Vedant A Gupta
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
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