Traumatic and hemorrhagic complications after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

doi:10.1016/j.resuscitation.2020.09.035

Resuscitation

Volume 157, December 2020, Pages 225-229

https://doi.org/10.1016/j.resuscitation.2020.09.035 Get rights and content

Abstract

Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding.

Methods

We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications.

Results

A total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38–58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60–104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval — 2–42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08).

Conclusions

Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA), however it is more invasive than traditional resuscitation. A growing body of literature supports the effectiveness of ECPR as a bridge, maintaining cerebral and organ perfusion while physicians attempt to restore spontaneous circulation and address the underlying etiology of the cardiac arrest. Some ECPR studies have demonstrated up to 50% survival among patients with refractory OHCA.1, 2, 3, 4

ECPR is an invasive procedure that has known complications. Patients who survive to be treated in hospital may receive longer than one hour of chest compressions prior to ECPR initiation, which may increase the likelihood of injuries such as rib fractures, pulmonary contusion, blunt cardiac injury, intraabdominal injury, vascular injury, and pneumothorax.1, 2, 5 One single center study reported that 27% of ECPR patients required urgent surgical intervention for traumatic injury from CPR, and over one third had chest injuries.² Identification of CPR-related injuries is especially important for patients receiving ECPR, as anticoagulation is often initiated at the time of cannulation, placing ECPR patients at risk for life-threatening hemorrhage.

Using a multicenter registry of patients undergoing ECPR, we aimed to describe the incidence of traumatic injuries and hemorrhagic complications, as well as their association with duration of conventional CPR prior to ECPR initiation. Traumatic or hemorrhagic complications were defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. We hypothesized that longer CPR duration prior to ECPR cannulation will be associated with an increased probability of injuries.

Section snippets

Study design and data source

This is a retrospective cohort study using data from the Extracorporeal Resuscitation Outcomes Database (EROD), a multicenter database maintained by the University of Utah. The EROD database commenced in 2016, currently includes 6 sites (4 at the time of data abstraction for the present study), and enrolls out-of-hospital and emergency department (ED) cardiac arrest cases treated with ECPR. Data, including patient demographics, comorbidities, time-stamped management, and hospital-discharge

Patient and ECPR characteristics

A total of 75 patients were entered into EROD during the study period. Seven patients were excluded from the study; four patients who arrested in the intensive care unit or operating room and 3hree patients with missing data for time of arrest or initiation of VA-ECMO. The final study cohort comprised 68 patients. (Table 1). The median age was 51 years (IQR 38.0, 58.0), 19% were female, over two thirds were either overweight or obese (body mass index >25 kg/m²), and 68% had comorbidities. The

Discussion

In this analysis of a multicenter North American registry of ECPR cases, we found that traumatic and hemorrhagic complications are common, occurring in 37% of patients, but did not find a statistically significant relationship between time from arrest to ECPR and these complications. Our data suggest that clinicians involved with ECPR patients should anticipate complications and liberally employ imaging modalities to identify traumatic and hemorrhagic complications.

While the data on injuries

Limitations

Our study has several limitations. First, although this was a multicenter registry, due to the infrequent nature of ECPR for OHCA or ED arrests, our sample size was small. It’s possible that an important difference was not detected due to lack of statistical power. A survey of US ECPR centers reported that 60% of programs that perform ECPR for OHCA complete ≤ 3 cases per year.¹⁸ Further, a review of ECPR for OHCA using the Extracorporeal Life Support Organization registry reported only 217

Conclusions

Traumatic injuries and hemorrhagic complications are common among cardiac arrest patients undergoing ECPR. The duration of CPR may increase these injuries, but further studies with larger sample sizes are required. Clinicians should anticipate traumatic and hemorrhagic complications in the setting of ECPR and consider routine early imaging. The impact of traumatic and hemorrhagic complications on overall outcome remains unknown.

Extracorporeal resuscitation consortium collaborators

Chloe Skidmore (University of Utah), Amanda Melvin (University of Michigan), Rahaf Al Assil (University of British Columbia).

Authors contributions

NJ conceived the study and he and MN drafted manuscript. JET conceived of the EROD database and oversaw its development, data entry and quality, and coordinated among sites. All authors performed data abstraction, entered data into the EROD registry, and critically reviewed and revised the manuscript.

Funding sources/disclosures

This study was not supported by grant or other funding. JET was supported by a career development award (K23HL141596) from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH). KG receives support from NIH/NHLBI (R34 HL130738-02). NJ receives funding from NIH/NHLBI/NINDS (U01HL123008-02, R01HL144624-01, U24NS100654-03) and Medic One Foundation.

Conflicts of interest statement

JET received speakers fees and travel compensation from LivaNova and Philips Healthcare, unrelated to this work. BG has received speakers honoraria from Stryker Corp, unrelated to this work. DFG has received speakers fees from Stryker Corp and BrainCool, Inc, unrelated to this work. LBB has received honoraria, speaker fees, and grants unrelated to this work from Nihon Kohden Corp, United Therapeutics, Philips, NIH, PCORI, BrainCool, Zoll Medical, and Stryker Corp in the last three years. The

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Clinical paperTraumatic and hemorrhagic complications after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Study design and data source

Patient and ECPR characteristics

Discussion

Limitations

Conclusions

Extracorporeal resuscitation consortium collaborators

Authors contributions

Funding sources/disclosures

Conflicts of interest statement

Resuscitation

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Resuscitation

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Lancet

Clinical paper
Traumatic and hemorrhagic complications after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest