Clinical paperPrognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest
Introduction
Despite considerable advances in cardiopulmonary resuscitation (CPR) during the past decade, survival with functional recovery to hospital discharge has remained disappointingly low for OHCA, ranging from 5% to 10%.1, 2 When appropriate CPR is provided for more than 20–30 min without return of spontaneous circulation, the cardiac arrest is considered refractory, with the survival rate being as low as 1%.3, 4
Providing venous arterial extracorporeal membrane oxygenation assistance in addition to CPR for refractory OHCA improves hemodynamic and oxygenation until treatment of the underlying cause for cardiac arrest and cardiac recovery.5, 6 The use of extracorporeal CPR (ECPR) for refractory OHCA has been rapidly adopted at many centers.7, 8, 9, 10, 11
Current guidelines recommend considering ECPR in select cardiac arrest patients, in settings where it can be rapidly implemented.12 However, formal criteria defining the OHCA population that may benefit from ECPR remains to be determined.5, 13 Prognostic factors for successful ECPR include shockable initial cardiac rhythm, bystander CPR attempt, shorter low-flow duration, and higher pH and lower lactate values on hospital admission.14
Other baseline clinical features might help identify refractory OHCA individuals that are potential candidates for ECPR, including gasping, pupillary light reaction, and increased level of consciousness. Gasping during conventional CPR for OHCA occurs frequently and is associated with increased long-term survival and functional recovery.15, 16 Earlier studies have already reported on the prognostic significance of pupillary light reaction during CPR.17, 18 Although infrequently reported in the literature,19, 20 most healthcare professionals have had experience of CPR-induced consciousness encompassing spontaneous eye opening, increased jaw tone, speech, and body movement,21 which might be associated with improved survival to hospital discharge.22 Yet, evidence on the prognostic significance of these clinical features is anecdotal or limited to a few case reports.23
This study aimed to examine the prognostic value of gasping, pupillary light reaction, and increased level of consciousness before or throughout conventional CPR for individuals undergoing ECPR for refractory OHCA.
Section snippets
Study design
We analyzed de-identified individual participant data from three primary cohort studies of refractory OHCA individuals treated with ECPR. The rationale, data collection methods, verification procedures, and primary outcomes have been reported in detail elsewhere.14, 24, 25 Briefly, the database for the three observational studies consisted of consecutive, prospectively enrolled refractory OHCA patients. The studies were conducted in France in the 2010s (Appendix 1). The participating centers
Study sample
Of 20,630 individuals experiencing OHCA during the study period. Of these, 434 were treated with ECPR following refractory OHCA. Overall, 61% of individuals with documented values yielded signs of life before or throughout conventional CPR, including pupillary light reaction (48%), gasping (32%), or increased level of consciousness (13%) (Table 1).
Primary endpoint
The thirty-day survival rate was 16% (69/434). Sixty-three (15%) individuals survived with favorable neurological outcome by 30 days of OHCA. In
Discussion
Prognostication of refractory OHCA in the prehospital setting is essential for early identification of ideal candidates for ECPR. Yet, currently available prognostic criteria have unsatisfactorily resolved the issue of selecting the OHCA population that may benefit from ECPR.5 Using the original data from three primary cohort studies, we documented the prognostic value of signs of life before or throughout conventional CPR in predicting 30-day survival with favorable neurological outcomes for
Conclusion
The assessment of signs of life occurring before or throughout conventional CPR substantially improves the accuracy of a multivariable prognostic model in predicting 30-day survival with favorable neurological outcome for individuals with refractory OHCA. The lack of any sign of life throughout resuscitation might obviate the provision of ECPR for patients without shockable cardiac rhythm. Yet, prospective evaluation is warranted to determine the effectiveness and safety of incorporating the
Funding
This research was funded by an unrestricted grant from the Emergency Department Research Association at Grenoble Alpes University Hospital. The sponsor was not involved in the study protocol development and did not have any role in the conduct of data collection, analysis and interpretation, or publication of the results. GD, JL, MN, and RA had full access to all data in the study. GD, JL, and LL had final responsibility for the decision to submit for publication.
Conflict of interest
The authors declare that they have no conflict of interest relevant to this study.
Authors’ contribution
Guillaume Debaty: Conceptualization, Methodology, Validation, Investigation, Writing–Original Draft, Writing–Review and Editing. Lionel Lamhaut: Conceptualization, Methodology, Validation, Investigation, Writing, Review and Editing. Romain Aubert: Conceptualization, Methodology, Validation, Investigation, Writing. Mathilde Nicol: Conceptualization, Methodology, Validation, Investigation, Writing. Caroline Sanchez: Conceptualization, Methodology, Validation, Investigation, Writing. Olivier
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgments
The authors thank all emergency physicians, intensive care units physicians and surgeons for including patients in the three databases. Statistical analysis was performed within the Grenoble Alpes Data Institute (ANR-15-IDEX-02). The authors also thank Linda Northrup for her assistance in preparing and editing the manuscript.
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