42 Improving Patient Selection in International Pediatric ECPR Cohorts

Abstract

To examine the efficacy of duration of cardiopulmonary resuscitation (CPR) and duration of extracorporeal membrane oxygenation (ECMO) as predictors of survival in pediatric extracorporeal cardiopulmonary resuscitation (ECPR) patients outside the United States. We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from the years 2010 to 2020 for pediatric ECPR performed arrest outside the United States comparing survivor data to non-survivor data. Primary outcomes of interest were duration of CPR and duration of ECMO. Secondary outcomes of interest were age, sex, weight, pre-ECPR pH, and pre-ECPR lactate. 17 studies (n = 1848) were included. The average survival rate was 39.9%. In international ECPR cohorts, longer CPR duration (n = 508, 10 studies) was demonstrated to be a significant predictor of survival, with the average survivor having 37.0 ± 28 minutes of CPR and the average non-survivor having 52.6 ± 48 minutes of CPR (Standardized Mean Difference (SMD) = -0.47 [95% CI: -0.77 - -0.17], I2 = 43%). ECMO duration (n = 1563, 12 studies) was not significantly associated with survival, with the average survivor having 98.0 ± 140 minutes and the average non-survivor having 114.3 ± 114 minutes of ECMO (SMD = -0.16 [-0.37 - 0.05], I2 = 49%). Age (p = 0.46) and female sex (p = 0.056) were additionally not significantly associated with survival. Increased weight (p = 0.047), elevated pre-ECPR lactate levels (p = 0.01), and elevated pre- ECPR pH (p < 0.01) were significantly associated with increased mortality. In this cohort of international pediatric ECPR patients from the last ten years, the primary outcome of elevated CPR duration was significantly associated with increased risk of mortality. This suggests ECPR programs should prioritize ECPR initiation earlier in cardiac arrest cases to minimize CPR duration prior to ECPR commencement. In addition, increased weight, elevated, pre-ECPR lactate levels, and elevated pre- ECPR pH were associated with increased risk of mortality. Elevated ECMO duration, age, and sex were not associated with increased risk of mortality. These factors can help provide clinicians with more information on the potential prognosis of patients, appropriate patient selection, and ECPR program effectiveness.