Dataset Information

Clinical experience of whole-body computed tomography as the initial evaluation tool after extracorporeal cardiopulmonary resuscitation in patients of out-of-hospital cardiac arrest.

ABSTRACT:

Background

The routine application of whole-body CT after extracorporeal cardiopulmonary resuscitation (ECPR) in out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. We aimed to evaluate the benefit of CT in this context.

Methods

We retrospectively analyzed all OHCA patients who had received ECPR between January 2006 to May 2019. Electronic records were reviewed to filter out patients who had a whole-body CT as their first clinical evaluation after ECPR. CT findings and major hospital outcomes were evaluated.

Results

From January 2006 to May 2019, 700 patients had received ECPR in our institution. We identified 93 OHCA patients who received whole-body CT as the first clinical evaluation after ECPR. 22.6% of those had no acute findings detected on CT requiring immediate treatment. In the remaining 77.4%, CT had findings that might lead to alterations in clinical course. Most important findings were myocardial infarction (57.0%), hypoxic brain injury (29.0%), sternal/rib fractures (16.1%), aortic dissection (7.5%), pulmonary embolism (5.4%), and cardiac tamponade (5.4%). There were no significant differences in ICU/hospitalization days, time on ECMO support, survival and neurological outcomes between those with and without immediate CT. In our OHCA cohort, there were 27 patients with CT evidence of hypoxic brain injury, of whom 22.2% (n?=?2) managed to wean from ECMO support, 14.8% (n?=?4) survived to discharge, but only 3.7% (n?=?1) survived with good neurological outcome. Hypoxic brain injury on CT has a 95% specificity in predicting poor neurological outcome, with a false positive rate of only 3.7%. Logistic regression suggested a potential correlation between CT findings of hypoxic brain injury and poor neurological outcome [Odds ratio (OR)?=?12.53 (1.55 to 10.1), p?=?0.02)].

Conclusions

Routine whole-body CT after ECPR in OHCA patients appears to have a limited role, as the majority is caused by ACS. However, it may be a useful tool when CPR-related injury or non-ACS causes of OHCA are suspected, as well as in cases where the cause of OHCA is unknown. On the contrary, routine brain CT may be a valuable tool in guiding anticoagulant therapy during ECMO and in aiding outcome prediction.

SUBMITTER: Yang KJ

PROVIDER: S-EPMC7291474 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Publications

Clinical experience of whole-body computed tomography as the initial evaluation tool after extracorporeal cardiopulmonary resuscitation in patients of out-of-hospital cardiac arrest.

Yang Kelvin Jeason KJ Wang Chih-Hsien CH Huang Yu-Cheng YC Tseng Li-Jung LJ Chen Yih-Sharng YS Yu Hsi-Yu HY

Scandinavian journal of trauma, resuscitation and emergency medicine 20200611 1

<h4>Background</h4>The routine application of whole-body CT after extracorporeal cardiopulmonary resuscitation (ECPR) in out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. We aimed to evaluate the benefit of CT in this context.<h4>Methods</h4>We retrospectively analyzed all OHCA patients who had received ECPR between January 2006 to May 2019. Electronic records were reviewed to filter out patients who had a whole-body CT as their first clinical evaluation after ECPR. CT ...[more]

PMID: 32527321

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Project description:BACKGROUND:The prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR. METHODS:We included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002-2011. RESULTS:A total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n?=?1285, 92%) or with refractory OHCA (n?=?108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5-9] vs. 7 [5-10] min, p?=?0.8; ROSC, 15 [9-22] vs. 27 [20-41] min, p?<?0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2-5.8]; p?<?0.001), witnessed OHCA (OR, 3.7 [2.0-7.1]; p?<?0.001), shockable rhythm (OR, 3.0 [1.9-4.7]; p?<?0.001), younger age (OR, 1.2 [1.1-1.2]; p?<?0.001), and later calendar year (OR, 1.4 [1.2-1.6]; p?<?0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p?<?0.001). Four of 28 refractory OHCA patients with duration of resuscitation >?60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p?=?0.7). CONCLUSIONS:Survival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.

Project description:IntroductionExtracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding.MethodsWe examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications.ResultsA total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38-58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60-104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval - 2-42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08).ConclusionsTraumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Project description:Background The role of computed tomography (CT) scans after extracorporeal membrane oxygenation (ECMO) implantation in patients with refractory cardiac arrest has not been frequently investigated. Early CT scan findings may have many meaningful findings and contribute significantly to patients’ outcome. In this study, we sought to determine whether early CT scans in such patients indirectly improved in-hospital survival. Methods A computerized search of the electronic medical records systems of 2 ECMO centers was conducted. A total of 132 patients who had undergone extracorporeal cardiopulmonary resuscitation (ECPR) between September 2014 and January 2022 were included in the analysis. The patients were divided into 2 groups based on whether they underwent early CT scans (the treatment group) or did not undergo early CT scans (the control group). The findings of early CT scans and in-hospital survival were investigated. Results A total of 132 patients had undergone ECPR with 71 were male, 61were female and mean age: 48.0±14.3 years. Early CT scans did not improve patient’s in-hospital survival [hazard ratio (HR): 0.705; P=0.357]. Overall, a smaller proportion of patients survived in the treatment group (22.5%) than the control group (42.6%; P=0.013). In total, 90 patients were matched in terms of age, initial shockable rhythm, Sequential Organ Failure Assessment (SOFA) score, cardiopulmonary resuscitation (CPR) duration, ECMO duration, percutaneous coronary intervention, and cardiac arrest location. In the matched cohort, fewer patients survived in the treatment group (28.9%) than the control group (37.8%; P=0.371), but the difference was not significant. According to a log-rank test, in-hospital survival did not differ significantly before and after matching (P=0.69, and P=0.63, respectively). Thirteen patients (18.3%) had complications during transportation, among which a drop in blood pressure was the most common. Conclusions The in-hospital survival rate between treatment and control group was not different, however, early CT scan after ECPR could help clinicians to gain important information to guide clinical practice.

Dataset Information

Clinical experience of whole-body computed tomography as the initial evaluation tool after extracorporeal cardiopulmonary resuscitation in patients of out-of-hospital cardiac arrest.

Background

Methods

Results

Conclusions

Publications

Clinical experience of whole-body computed tomography as the initial evaluation tool after extracorporeal cardiopulmonary resuscitation in patients of out-of-hospital cardiac arrest.

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