Elsevier

Resuscitation

Volume 80, Issue 10, October 2009, Pages 1124-1129
Resuscitation

Clinical paper
Outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) following refractory pediatric cardiac arrest in the intensive care unit☆

https://doi.org/10.1016/j.resuscitation.2009.07.004Get rights and content

Abstract

Aim

To describe our experience using extracorporeal cardiopulmonary resuscitation (ECPR) in resuscitating children with refractory cardiac arrest in the intensive care unit (ICU) and to describe hospital survival and neurologic outcomes after ECPR.

Methods

A retrospective chart review of a consecutive case series of patients requiring ECPR from 2001 to 2006 at Arkansas Children's Hospital. Data from medical records was abstracted and reviewed. Primary study outcomes were survival to hospital discharge and neurological outcome at hospital discharge.

Results

During the 6-year study period, ECPR was deployed 34 times in 32 patients. 24 deployments (73%) resulted in survival to hospital discharge. Twenty-eight deployments (82%) were for underlying cardiac disease, 3 for neonatal non-cardiac (NICU) patients and 3 for paediatric non-cardiac (PICU) patients. On multivariate logistic regression analysis, only serum ALT (p-value = 0.043; OR, 1.6; 95% confidence interval, 1.014–2.527) was significantly associated with risk of death prior to hospital discharge. Blood lactate at 24 h post-ECPR showed a trend towards significance (p-value = 0.059; OR, 1.27; 95% confidence interval, 0.991–1.627). The Hosmer–Lemeshow tests (p-value = 0.178) suggested a good fit for the model. Neurological evaluation of the survivors revealed that there was no change in PCPC scores from a baseline of 1–2 in 18/24 (75%) survivors.

Conclusions

ECPR can be used successfully to resuscitate children following refractory cardiac arrest in the ICU, and grossly intact neurologic outcomes can be achieved in a majority of cases.

Introduction

Since closed-chest cardiac massage was introduced, cardiopulmonary resuscitation (CPR) has been widely instituted for cardiac arrest.1, 2 Several reports have demonstrated only a higher rate (63–70%) of return of spontaneous circulation (ROSC) after CPR,3, 4, 5 with much lower survival to discharge rates (10–27%) for cardiac arrests in children.1, 3, 4, 5 More recently, a 4-year review of the National Registry of Cardiopulmonary Resuscitation revealed a rate of survival to discharge of 27% for pediatric in-hospital cardiac arrest, with 65% of survivors having a good neurologic outcome.5 For those patients requiring prolonged resuscitation the outcomes are even more dismal.1, 6, 7, 8

Due to the low survival rates after prolonged CPR, more aggressive methods have been suggested to improve its success.9, 10 Recently, institution of extracorporeal life support (ECLS) has been proposed for selected cases of cardiac arrest when conventional CPR fails. Case series from many institutions have reported reasonable success with extracorporeal CPR (ECPR) in terms of both short-term survival and neurologic outcome.7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 This study represents our institutional experience with ECPR instituted during active chest compressions following in-hospital pediatric cardiac arrest. We hypothesized that ECPR is effective in resuscitating children with refractory cardiac arrests in the ICU and is often associated with good neurologic outcomes.

Section snippets

Materials and methods

A retrospective chart review, approved by the Institutional Review Board of University of Arkansas for Medical Sciences was performed. The study population included all patients (0–20 years of age) admitted to Arkansas Children's Hospital who were resuscitated from cardiac arrest during active chest compressions by means of veno-arterial ECLS between January 2001 and March 2006. Patients were identified through a review of the institutional ECLS database and the institutional CPR database. This

Statistics

Continuous variables are presented as median (range) whereas categorical variables are presented as percentages. Statistical analysis was performed in three steps: univariate analysis was first used to examine the relationship between the categorical and continuous variables and the primary outcome variable using the Wald test. From the univariate analysis, all variables at a p-value ≤ 0.20 in the univariate analysis were entered for multivariate analysis. Stepwise logistic regression with

Results

During the 6-year study interval, 329 in-hospital cardiac arrests occurred at our institution. Fig. 1 shows the yearly distribution of ECPR events and survival to discharge over the study period. Four additional patients required ECLS after an episode of CPR, with cannulation for ECLS occurring after ROSC. These four patients were excluded from the study. None of these four patients survived to hospital discharge.

During the study period 32 patients underwent 34 ECLS deployments. Surgical

Discussion

This series of patients resuscitated with ECPR both supports and complements prior single-institution reports.7, 11, 12, 13Table 4 shows other published pediatric series of ECPR patients17 and their reported outcomes. As in previous studies, patients with cardiac disease were more likely to survive to hospital discharge after ECPR deployment than patients with other disease processes. Also similar to previous studies,7, 13 survival to hospital discharge was not significantly associated with

Study limitations

As a retrospective non-randomized study this analysis has limitations. Due to small sample size the study is subject to selection or ascertainment bias despite having included consecutive patients during the study period in the study with a definitive primary outcome. Despite our multivariate analysis results, the factors behind such an encouraging survival rate in our study cohort are not clear from the current data and remain speculative. Even though we have neurological outcome data at the

Conclusions

In conclusion, ECLS instituted for selected refractory pediatric in-hospital cardiac arrest patients is feasible and effective. Based on our experience, we suggest that ECPR be more widely considered as an emergency resuscitative tool. Many questions regarding this use of ECLS technology remain to be answered, including the patient populations most likely to benefit, technical and system factors associated with best outcomes, and detailed neurodevelopmental follow-up. The recent meta-analysis

Conflict of interest statement

None of the authors have any conflict of interest that could inappropriately influence (bias) this work.

Financial disclosure

Supported in part by NIHCHD grant support—5 U10 HD050009.

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    ☆

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.07.004.

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