Systematic review and meta-analysis comparing low-flow duration of extracorporeal and conventional cardiopulmonary resuscitation

Abstract

Objectives After cardiac arrest, a key factor determining survival outcomes is low-flow duration. Our aims were to determine the relation of survival and low-flow duration of extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation and if these two therapies have different short term survival curves in relation to low-flow duration. Methods We searched Embase, Medline, Web of Science, and Google Scholar from inception up to April 2021. A linear mixed effect model was used to describe the course of survival over time, based on study-specific and time-specific aggregated survival data. Results We included 42 observational studies reporting on 1,689 extracorporeal cardiopulmonary resuscitation and 375,751 conventional cardiopulmonary resuscitation procedures. Of the included studies, 25 included adults, 13 included children, and four included both. In adults, survival curves decline rapidly over time (extracorporeal cardiopulmonary resuscitation 37.2%-29.8%-23.8%-19.1% versus conventional cardiopulmonary resuscitation-shockable 36.8%-7.2%-1.4%-0.3% for 15–30-45–60 min low-flow, respectively). extracorporeal cardiopulmonary resuscitation was associated with a statistically significant slower decline in survival than conventional cardiopulmonary resuscitation with initial shockable rhythms (conventional cardiopulmonary resuscitation-shockable). In children, survival curves decline rapidly over time (extracorporeal cardiopulmonary resuscitation 43.6%-41.7%-39.8%-38.0% versus CCPR-shockable 48.6%-20.5%-8.6%-3.6% for 15–30-45–60 min low-flow, respectively). extracorporeal cardiopulmonary resuscitation was associated with a statistically significant slower decline in survival than conventional cardiopulmonary resuscitation-shockable. Conclusions The short-term survival of extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation-shockable patients both decline rapidly over time, in adults as well as in children. This decline of short-term survival in relation to low-flow duration in extracorporeal cardiopulmonary resuscitation was slower than in conventional cardiopulmonary resuscitation. Trial registration Prospero: CRD42020212480, 02-10-2020

Refractory out‐of‐hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta‐analysis of randomized trials

“…This possibly reflects the complexity of translating the beneficial effect observed in RCTs conducted in single‐center experiences 8,9 to different centers where extracorporeal CPR was not routine clinical practice or the level of expertise and logistical organization was not homogeneous. Other reasons include higher than expected survival in patients with refractory OHCA treated with conventional CPR and higher time from cardiac arrest to ECMO flow compared to previous single‐center RCTs (Table 1), a factor strongly influencing survival and neurological outcome 33,34 …”

Extracorporeal CPR after the INCEPTION trial: No one steps twice into the same river

“…Along the same lines, high-performing systems have optimized logistics and pathways, mainly reflected by lowflow times, a critical aspect for the success of ECPR. 1,12 In the INCEPTION trial, time between hospital arrival and cannulation initiation and between cannulation initiation and ECMO flow were 16 and 20 min. 9 Such delays reflect the overall system efficacy, logistics, team experience, and caseload.…”

“…All these potential confounders were not controlled by study design in the INCEPTION trial, while single‐center RCTs were intrinsically more homogeneous. Along the same lines, high‐performing systems have optimized logistics and pathways, mainly reflected by low‐flow times, a critical aspect for the success of ECPR 1,12 . In the INCEPTION trial, time between hospital arrival and cannulation initiation and between cannulation initiation and ECMO flow were 16 and 20 min 9 .…”

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest – current status

“…Patients presenting with a shockable rhythm have the best chance of survival, particularly when cardiac arrest is witnessed, immediate basic life support is started and defibrillation attempts are performed using a public automated external defibrillator (AED) [3]. However, when return of spontaneous circulation does not occur within 15 min of advanced circulatory life support (ACLS), the cardiac arrest is considered refractory and the probability of survival rapidly declines [4]. In these cases, the application of venoarterial extracorporeal membrane oxygenation can restore circulation and organ perfusion.…”