Elsevier

Resuscitation

Volume 131, October 2018, Pages 91-100
Resuscitation

Review
Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review

https://doi.org/10.1016/j.resuscitation.2018.07.029Get rights and content

Abstract

Aim

To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children.

Methods

The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.

Results

We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.

Conclusions

There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.

Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced rescue therapy, where an extracorporeal circuit is employed, to support circulation in patients with cardiac arrest refractory to conventional CPR [1]. ECPR maintains vital organ perfusion while potential reversible causes of the cardiac arrest can be identified and treated.

ECPR is recognized by the American Heart Association (AHA) [2,3] and the European Resuscitation Council (ERC) [4,5] as a therapy which can be considered in select cardiac arrest patients, when rapid expert deployment is possible. However, the benefits of applying ECPR are not clear and optimal patient selection and timing of the therapy are not well-understood [6]. Furthermore, the ethical considerations related to using and studying ECPR are complex [7]. Given the recent increase in the availability and usage of ECPR for cardiac arrest [[8], [9], [10]], there is a need for a review of the evidence to guide the international consensus on ECPR in cardiac arrest.

The objective of this systematic review was to inform the update of the International Liaison Committee on Resuscitation (ILCOR) treatment recommendations by assessing the use of ECPR, compared to manual or mechanical cardiopulmonary resuscitation (CPR), for OHCA and IHCA of all causes in adults and children.

Section snippets

Protocol and registration

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11]. The PRISMA checklist is provided in the Supplementary Contents. The protocol and amendments were prospectively submitted to the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42018085404). The protocol is provided in the Supplementary Contents. The review was commissioned by ILCOR.

Eligibility criteria

We used the PICO (Population, Intervention, Comparison,

Study selection

The search strategy identified 7458 records of which 74 records were eligible for full-text review. The Kappa for identifying records during the initial screening of the first search was 0.38 prompting review by a third reviewer. A PRISMA diagram of the study selection process is presented in Fig. 1. No randomized clinical trials were identified. Twenty-five observational studies met all of the inclusion criteria and none of the exclusion criteria. [[16], [17], [18], [19], [20], [21], [22], [23]

Discussion

In this systematic review, we identified studies comparing the use of ECPR to manual or mechanical CPR for OHCA and IHCA in adult and pediatric patients. We identified 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. No randomized clinical trials were identified, though several are ongoing as noted on the International Clinical Trials Registry Platform. Results from studies in OHCA were inconsistent. Studies in

Conclusions

There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low. Future investigations should be cautious of issues related to internal validity. Randomized clinical trials are needed to better inform clinical practice.

Conflicts of interest

None of the authors have any conflicts of interest to report. Dr. Andersen was compensated by the American Heart Association on behalf of ILCOR for his work related to this systematic review. Dr. Deakin is the ILCOR domain lead for “Defibrillation”, a member of the ERC and Treasure of the Resuscitation Council (UK). Dr. Guerguerian is the vice-chair of the Pediatric Task Force for Get With The Guidelines. Dr. Donnino is supported by grant K24HL127101 and R01HL136705 from the National Heart,

Acknowledgements

The authors would like to thank Teruko Kishibe, St. Michael’s Hospital, Toronto, ON, Canada, for preparing and conducting the systematic searches.

International Liaison Committee On Resuscitation Task Force Investigators

Besides the authors Michael W. Donnino, Charles Deakin, Lars W. Andersen, and Jerry Nolan, members of the International Liaison Committee on Resuscitation Advanced Life Support Task Force include: Jasmeet Soar, Clifton Callaway, Bernd Boettiger, Tonia Nicholson, Edison Paiva, Michael Parr, Tzong-Luen Wang, Brian O’Neil, Peter Morley, Katherine Berg, Michelle Welsford, Ian Drennan, Joshua Reynolds, Robert Neumar, and Claudio Sandroni.

Besides the author Anne-Marie Guerguerian, members of the

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