Early withdrawal of life sustaining therapy in extracorporeal cardiopulmonary resuscitation (ECPR): Results from the Extracorporeal Life Support Organization registry

Aims: Although extracorporeal cardiopulmonary resuscitation (ECPR) improves survival outcomes in refractory cardiac arrest, morbidity and mortality remain significantly high. Information on causes of death in ECPR is limited; however, some evidence suggests withdrawal of life sustaining therapy (WLST) is a major factor in ECPR-associated mortality. We sought to describe the patients experiencing WLST after ECPR.

Methods: The international Extracorporeal Life Support Organization (ELSO) Registry was retrospectively queried for patients more than 18 years old supported with ECPR who underwent WLST due to family request from 2007 to 2017. These patients were split into groups for descriptive and multivariable analysis: early (WLST < 72 hours from cannulation) and routine WLST.

Results: Overall, 411 ECPR patients experienced WLST (median age 42 years IQR = 28-51; 31.7% female) over the 10-year period. 55.5% (n = 228) underwent early WLST with a median ECPR duration of 24 hours (IQR = 7-48) versus routine WLST (median = 147 hours; IQR = 105-238). In multivariable regression analysis, lower arterial blood gas pH (aOR = -3.1; 95% CI = 2.18-2.8; p = 0.04), arterial oxygen saturation (aOR = 1.12; 95% CI = 1.01-1.23; p = 0.02), and higher peak inspiratory pressure (aOR = 0.84; 95% CI = 0.71-1.00; p = 0.05) were independently associated with early WLST. Early WLST patients experienced higher rates of all ECMO-related complications except for infections.

Conclusions: More than half of ECPR patients experienced early WLST within 72 hours. The patients with early WLST had worse markers of severe critical illness at 24 hours and experienced higher rates of complications. Further research should include an appropriate control group to better adjust confounders for ECPR-associated death and focus on prognostication.