Prognostic Evaluation of Mortality after Pediatric Resuscitation Assisted by Extracorporeal Life Support

Abstract

To improve survival rates during cardiopulmonary resuscitation (CPR), some patients are put on extracorporeal life support (ECLS) during active resuscitation (ECPR). Our objective was to assess the clinical outcomes after pediatric ECPR in Switzerland and to determine pre-ECPR prognostic factors for mortality. The present study is a retrospective analysis. The study setting included three pediatric intensive care units in Switzerland that use ECPR. All patients (<16 years old) undergoing ECPR from 2008 to 2016 were included in the study. There were no interventions. Data before ECLS initiation and clinical outcomes were collected. An ECPR score was designed to predict mortality, based on variables significantly different between survivors and non-survivors. Fifty-five patients were included, with a median age of 13.5 months. Eighty percent were cardiac patients. The mortality rate was 75%. Mortality was significantly associated with CPR duration ( p = 0.02), last lactate ( p = 0.05), and last pH ( p = 0.01) before ECLS initiation. Based on these three variables, an ECPR score was designed as follows: CPR duration (in minutes): 1 point if < 40; 2 points if 40; 3 points if 60; 6 points if 105. Lactate (in mmol/L): 1 point if < 8; 2 points if 8; 3 points if 14; 6 points if 18. pH: 1 point if > 7.00; 2 points if 7.00; 3 points if 6.85; 6 points if 6.60. The area under the receiver-operating characteristic curve was 0.74. The positive predictive value of a score 9 was 94%. In our population, a score based on three variables easily available prior to ECLS initiation had good discrimination and could appropriately predict mortality. This score now needs validation in a larger population.

Merging Two Hospitals: The Effects on Pediatric Extracorporeal Cardiopulmonary Resuscitation Outcomes

“…33,34 A recent Swiss ECPR data collection reported a mortality of 75% and a median support duration of 4.4 days (IQR 2.6-6.8), suggesting an increased rate of palliation at 5 days. 35 However, our results show that at 5 days, survival with a favorable neurological outcome is 45%, and even 33% after 10 days. We did not identify an inflection point after which an exceedingly high mortality would make further ECLS futile and justify a decision to palliate purely based on duration of ECLS.…”

Factors Associated With Initiation of Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Population: An International Survey

“…mortality. 16 However, other studies did not find any relationship between ECPR duration and outcomes. 17,18 Therefore, as these studies might be confounded by indication leading to a selection bias, future research including large collaborative randomized controlled trials and observational studies are required to identify the optimal indications for ECPR.…”

Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda

“…Thus, over the subsequent few decades, ECLS was primarily used to support neonates and pediatric patients with acute respiratory and cardiac failure, including children following cardiac surgery. With improvements in technology and experience, indications for the utilization of ECLS have increased rapidly, and include children and adults with acute respiratory failure and shock, as a bridge to decision when prognosis is uncertain, as a bridge to heart and/or lung transplant, and in rescue of patients with cardiac arrest refractory to cardiopulmonary resuscitation (E-CPR) ( 3 – 5 , 7 , 47 , 48 ). Medical conditions that were once absolute contraindications, such as organ failure following stem cell transplant and chimeric antigen T cell therapy (CAR-T), are now reconsidered for support with ECLS ( 28 , 49 ).…”