Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) has gradually come to be regarded as an effective therapy, but the hospital mortality rate after ECPR is still high and unpredictable. The present study tested whether age-adjusted Charlson comorbidity index (ACCI) can be used as an objective selection criterion to ensure the most efficient utilization of medical resources. Adult patients (age ≥ 18 years) receiving ECPR at our institution between 2006 and 2015 were included. Data regarding ECPR events and ACCI characteristics were collected immediately after the extracorporeal membrane oxygenation (ECMO) setup. Adverse events during hospitalization were also prospectively collected. The primary endpoint was survival to hospital discharge. The second endpoint was the short-term (2-year) follow-up outcome. A total of 461 patients included in the study were grouped into low ACCI (ACCI 0–3) (240, 52.1%) and high ACCI (ACCI 4–13) (221, 47.9%) groups. The median ACCI was 2 (interquartile range (IQR): 1–3) and 5 (IQR: 4–7) for the low and high ACCI groups, respectively. Cardiopulmonary resuscitation (CPR)-to-ECMO duration was comparable between the groups (42.1 ± 25.6 and 41.3 ± 20.7 min in the low and high ACCI groups, respectively; p = 0.754). Regarding the hospital survival rate, 256 patients (55.5%) died on ECMO support. A total of 205 patients (44.5%) were successfully weaned off ECMO, but only 138 patients (29.9%) survived to hospital discharge (32.1% and 27.6% in low and high ACCI group, p = 0.291). Multivariate logistic regression analysis revealed CPR duration before ECMO run (CPR-to-ECMO duration) and a CPR cause of septic shock to be significant risk factors for hospital survival after ECPR (p = 0.043 and 0.014, respectively), whereas age and ACCI were not (p = 0.334 and 0.164, respectively). The 2-year survival rate after hospital discharge for the 138 hospital survivors was 96% and 74% in the low and high ACCI groups, respectively (p = 0.002). High ACCI before ECPR does not predict a poor outcome of hospital survival. Therefore, ECPR should not be rejected solely due to high ACCI. However, high ACCI in hospital survivors is associated with a higher 2-year mortality rate than low ACCI, and patients with high ACCI should be closely followed up.
Highlights
Extracorporeal membrane oxygenation (ECMO) rescue under cardiopulmonary resuscitation (CPR) can dramatically increase the survival rates of patients who are previously considered to be unsavable
According to the histogram of adjusted Charlson comorbidity index (CCI) (ACCI), the study patients were grouped into low ACCI (ACCI 0–3) and high ACCI (4–13) groups
The data from the present study indicate that the ACCI may be effective as a predictive model, but only in those surviving after the index Extracorporeal CPR (ECPR); it is not a investigated
Summary
Extracorporeal membrane oxygenation (ECMO) rescue under cardiopulmonary resuscitation (CPR) can dramatically increase the survival rates of patients who are previously considered to be unsavable. Objective selection criteria are mandatory to avoid unnecessary use of ECMO, and to focus limited medical resources on the patients with the highest possible chance of survival. The ACCI has been validated [14] in clinical scenarios, such as cancer [15,16], heart failure [17], infectious disease, emergency surgery [18], intensive care units (ICUs), and even the cost-effectiveness analysis of health care systems [13,19]. We considered whether the ACCI could be used as a useful inclusion/exclusion criterion for patients with ECPR
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