Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is expected to improve the neurological outcomes of patients with refractory cardiac arrest; however, it is invasive, expensive, and requires substantial human resources. The ability to predict neurological outcomes would assist in patient selection for ECPR. To develop and validate a prediction model for neurological outcomes of patients with out-of-hospital cardiac arrest with shockable rhythm treated with ECPR. This prognostic study analyzed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multi-institutional nationwide cohort study that included 87 emergency departments in Japan. All adult patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR between June 2014 and December 2017 were included. Patients were randomly assigned to the development and validation cohorts based on the institutions. The analysis was conducted between November 2019 and August 2020. Age (<65 years), time from call to hospital arrival (≤25 minutes), initial cardiac rhythm on hospital arrival (shockable), and initial pH value (≥7.0). The primary outcome was 1-month survival with favorable neurological outcome, defined by Cerebral Performance Category 1 or 2. In the development cohort, a simple scoring system was developed to predict this outcome using a logistic regression model. The diagnostic ability and calibration of the scoring system were assessed in the validation cohort. A total of 916 patients were included, 458 in the development cohort (median [interquartile range {IQR}] age, 61 [47-69] years, 377 [82.3%] men) and 458 in the validation cohort (median [IQR] age, 60 [49-68] years; 393 [85.8%] men). The cohorts had the same proportion of favorable neurological outcome (57 patients [12.4%]). The prediction scoring system was developed, attributing a score of 1 for each clinical predictor. Patients were divided into 4 groups, corresponding to their scores on the prediction model, as follows: very low probability (score 0), low probability (score 1), middle probability (score 2), and high probability (score 3-4) of good neurological outcome. The mean predicted probabilities in the groups stratified by score were as follows: very low, 1.6% (95% CI, 1.6%-1.6%); low, 4.4% (95% CI, 4.2%-4.6%); middle, 12.5% (95% CI, 12.1%-12.8%); and high, 30.8% (95% CI, 29.1%-32.5%). In the validation cohort, the C statistic of the scoring system was 0.724 (95% CI, 0.652-0.786). The predicted probability was evaluated as well calibrated to the observed favorable outcome in both cohorts by visual assessment of the calibration plot. In this study, the scoring system had good discrimination and calibration performance to predict favorable neurological outcomes of patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR.
Highlights
The model had good performance and was well calibrated. Meaning These findings suggest that this model may be useful for predicting the neurological outcomes of patients with out-of-hospital cardiac arrest and shockable rhythm treated with Extracorporeal cardiopulmonary resuscitation (ECPR)
In this study, the scoring system had good discrimination and calibration performance to predict favorable neurological outcomes of patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR
The present study aimed to develop and validate a prediction rule for the neurological outcomes among patients with OCHA and shockable rhythm who are treated with ECPR
Summary
Extracorporeal cardiopulmonary resuscitation (ECPR) is a potentially favorable option for patients with out-of-hospital cardiac arrest (OHCA) and refractory ventricular fibrillation (VF).[1,2,3,4,5] this method is invasive, expensive, and requires substantial human resources.[1,2,3,6,7] it is essential to assess appropriate candidates immediately after hospital arrival.In a previous systematic review,[8] several factors, such as initial shockable rhythm during resuscitation (odds ratio [OR], 2.29; 95% CI, 1.53-3.42), have been reported to be associated with the outcome after OHCA; relative effect measurements, such as odds ratios, cannot be directly interpreted and used to decide a treatment strategy in the clinical setting. The actual probability or the predictive accuracy (eg, the likelihood ratio) for the outcome is necessary to support decision-making. Clinical prediction rules, such as the CHADS2 (congestive heart failure, hypertension, age Ն75 years, diabetes, and stroke [doubled])[9] score for atrial fibrillation and the CURB-65 (confusion, urea, respiratory rate, blood pressure, and age Ն65 years)[10] for pneumonia, have been used to and quickly estimate the probability of outcome. A clinical prediction rule is necessary to estimate the neurological outcomes in patients with OHCA treated with ECPR.
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