Abstract
Background
Extra-corporeal life support (ECLS) is a life-saving intervention for patients with
hypothermia induced cardiac arrest or severe cardiovascular instability. However,
its application is highly variable due to a paucity of data in the literature to guide
practice. Current guidelines and recommendations are based on expert opinion, single
case reports, and small case series. Combining all of the published data in a patient-level
analysis can provide a robust assessment of the influence of patient characteristics
on survival with ECLS.
Objective
To develop a prediction model of survival with good neurologic outcome for accidental
hypothermia treated with ECLS.
Methods
Electronic searches of PubMed, EMBASE, CINAHL were conducted with a hand search of
reference lists and major surgical and critical care conference abstracts. Studies
had to report the use of ECLS configured with a circuit, blood pump and oxygenator
with an integrated heat exchanger. Randomized and observational studies were eligible
for inclusion. Non-human, non-English and review manuscripts were deemed ineligible.
Study authors were requested to submit patient level data when aggregate or incomplete
individual patient data was provided in a study. Survival with good neurologic outcome
was categorized for patients to last follow-up based on the reported scores on the
Cerebral Performance Category (1 or 2), Glasgow Outcome Scale (4 or 5) and Pediatric
Overall Performance Category (1 or 2). A one-stage, individual patient data meta-analysis
was performed with a mixed-effects multi-level logistic regression model reporting
odds ratio (OR) with a 95% confidence interval (CI).
Results
Data from 44 observational studies and 40 case reports (n = 658) were combined and
analyzed to identify independent predictors of survival with good neurologic outcome.
The survival rate with good neurologic outcome of the entire cohort was 40.3% (265
of 658). ECLS rewarming rate (OR: 0.93; 95% CI: 0.88, 0.98; p = .007), female gender
(OR: 2.78; 95% CI: 1.69, 4.58; p < 0.001), asphyxiation (OR: 0.19; 95% CI: 0.11, 0.35;
p < 0.001) and serum potassium (OR: 0.62; 95% CI: 0.53, 0.73; p < 0.001) were associated
with survival with a good neurologic outcome. The logistic regression model demonstrated
excellent discrimination (c-statistic: 0.849; 95% CI: 0.823, 0.875).
Conclusions
The use of extracorporeal life support in the treatment of hypothermic cardiac arrest
provides a favourable chance of survival with good neurologic outcome. When used in
a weighted scoring system, asphyxiation, serum potassium and gender can help clinicians
prognosticate the benefit of resuscitating hypothermic patients with ECLS.
Keywords
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Article info
Publication history
Published online: March 26, 2018
Accepted:
March 20,
2018
Received in revised form:
March 16,
2018
Received:
February 1,
2018
Identification
Copyright
© 2018 Elsevier B.V. All rights reserved.
