End-tidal carbon dioxide-guided extracorporeal cardiopulmonary resuscitation improves neurological prognosis in patients: a single-center retrospective cohort study
A ressuscitação cardiopulmonar extracorpórea guiada por dióxido de carbono ao final da expiração melhora o prognóstico neurológico em pacientes: um estudo de coorte retrospectivo de centro único
Xiaozu Liao, Chen Gu, Zhou Cheng, Kepeng Liu, Qing Yin, Binfei Li
Abstract
Background
Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an effective intervention for restoring adequate circulatory perfusion after cardiac arrest. Ensuring high-quality Cardiopulmonary Resuscitation (CPR) before initiating Extracorporeal Membrane Oxygenation (ECMO) is critical to mitigate tissue hypoxia and ischemia. This study aimed to evaluate the effect of End-Tidal Carbon Dioxide (ETCO2) Goal-Directed CPR (GDCPR) on neurological function before ECMO using a retrospective case-control analysis.
Methods
The medical records of all patients who received ECPR treated at Zhongshan City People's Hospital were collected between January 2020 and March 2023. In this retrospective cohort study, the patients were divided into Conventional CPR (CCPR) and ETCO2-GDCPR groups based on whether ETCO2 was used as a guide for CPR.
Results
A total of 71 patients were included, of whom 46 comprised the CCPR group and 25 comprised the GDCPR group. Approximately 37% of patients who received ECPR had good cerebral function at discharge, with a higher rate in the GDCPR group (52%) compared with the CCPR group (28%) (p = 0.047). Multivariate analysis showed that the Highest Interleukin-6 (H-IL6) levels after ECMO (Odds Ratio [OR = 1.001], 95% Confidence Interval [95% CI 1.000–1.003], p = 0.005) was a risk factor for neurological function at discharge. The other risk factors for poor prognosis in patients who received ECPR included pre-ECMO CPR protocols (OR = 10.74, 95% CI 1.90–60.48, p = 0.007) and IL6 levels after ECMO (OR = 1.002, 95% CI 1.001–1.003, p = 0.005). ECMO duration (OR = 0.83, 95% CI 0.74–0.94, p = 0.002) was identified as a protective factor. Patients with short ECMO duration have a poor prognosis. The area under the curve for ECMO duration was 0.86 (0.77–0.94, p < 0.01), while that for H-IL6 was 0.19 (0.09–0.29, p < 0.01).
Conclusion
ETCO2-guided ECPR is associated with improved neurological prognosis and patient outcomes. Therefore, monitoring ETCO2 levels should be considered a crucial component of evaluating resuscitation efficacy during CPR.
Keywords
Resumo
Introdução
A Ressuscitação Cardiopulmonar Extracorpórea (ECPR) é uma intervenção eficaz para restaurar a perfusão circulatória adequada após uma parada cardíaca. Garantir a qualidade da Ressuscitação Cardiopulmonar (CPR) antes da implementação da Oxigenação por Membrana Extracorpórea (ECMO) é essencial para mitigar a hipóxia e isquemia tecidual. Este estudo teve como objetivo avaliar o efeito da CPR guiada por metas de dióxido de carbono ao final da expiração (ETCO₂-GDCPR) na função neurológica antes da ECMO, utilizando uma análise retrospectiva caso-controle.
Métodos
Foram coletados os prontuários de todos os pacientes que receberam ECPR no Hospital Popular da Cidade de Zhongshan entre janeiro de 2020 e março de 2023. Neste estudo de coorte retrospectivo, os pacientes foram divididos em dois grupos — CPR Convencional (CCPR) e CPR guiada por ETCO₂ (GDCPR) — com base no uso do ETCO₂ como parâmetro de orientação da CPR.
Resultados
Um total de 71 pacientes foi incluído, sendo 46 no grupo CCPR e 25 no grupo GDCPR. Aproximadamente 37% dos pacientes que receberam ECPR apresentaram boa função cerebral na alta hospitalar, com uma taxa mais elevada no grupo GDCPR (52%) em comparação ao grupo CCPR (28%) (p = 0,047). A análise multivariada demonstrou que os níveis mais altos de Interleucina-6 após ECMO (H-IL6) (Razão de Chances [OR = 1,001], Intervalo de Confiança de 95% [IC 95% 1,000–1,003], p = 0,005) foram um fator de risco para a função neurológica na alta. Outros fatores de risco para pior prognóstico em pacientes que receberam ECPR incluíram os protocolos de CPR antes da ECMO (OR = 10,74, IC 95% 1,90–60,48, p = 0,007) e os níveis de IL6 após ECMO (OR = 1,002, IC 95% 1,001–1,003, p = 0,005). A duração da ECMO (OR = 0,83, IC 95% 0,74–0,94, p = 0,002) foi identificada como fator protetor. Pacientes com menor tempo de ECMO apresentaram pior prognóstico. A área sob a curva para a duração da ECMO foi 0,86 (0,77–0,94, p < 0,01), enquanto a de H-IL6 foi 0,19 (0,09–0,29, p < 0,01).
Conclusão
A ECPR guiada por ETCO₂ está associada à melhora no prognóstico neurológico e nos desfechos clínicos. Portanto, o monitoramento dos níveis de ETCO₂ deve ser considerado um componente essencial na avaliação da eficácia da CPR.
Palavras-chave
References
1. Panchal AR, Bartos JA, Cabanas JG, et al. Adult Basic and ~ Advanced Life Support Writing Group Part 3: adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366−468.
2. Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med. 2013;41:1186−96.
3. Choi Y, Park JH, Jeong J, Kim YJ, Song KJ, Do Shin S. Extracorporeal cardiopulmonary resuscitation for adult out-of-hospital cardiac arrest patients: time-dependent propensity scoresequential matching analysis from a nationwide populationbased registry. Crit Care. 2023;27:87.
4. Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation. 2017;112:1−10.
5. Cheng A, Duff JP, Kessler D, et al. International Network for Simulation-based Pediatric Innovation Research and Education (INSPIRE) CPR. Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: a randomized simulation-based clinical trial. Resuscitation. 2018;132:33−40.
6. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997;337:301−6.
7. Trillo G, von Planta M, Kette F. ETCO 2 monitoring during low flow states: clinical aims and limits. Resuscitation. 1994;27:1−8.
8. Meaney PA, Bobrow BJ, Mancini ME, et al. CPR Quality Summit Investigators, the American Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation, 128; 2013. p. 2013417−35.
9. Virani SS, Alonso A, Benjamin EJ, et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics −2020 update: a report from the American Heart Association. Circulation. 2020;141:e139−596.
10. Park HJ, Jeong WJ, Moon HJ, et al. Factors associated with highquality cardiopulmonary resuscitation performed by bystander. Emerg Med Int. 2020;2020:8356201.
11. Anderson R, Sebaldt A, Lin Y, Cheng A. Optimal training frequency for acquisition and retention of high-quality CPR skills: a randomized trial. Resuscitation. 2019;135:153−61.
12. Vahedian-Azimi A, Hassan IF, Rahimi-Bashar F, et al. Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study. BMC Emerg Med. 2024;24:36.
13. Richardson SAC, Anderson D, Burrell AJC, et al. Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment − The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study. Scand J Trauma Resusc Emerg Med. 2023;31:100.
14. Kim SJ, Jung JS, Park JH, Park JS, Hong YS, Lee SW. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with outof-hospital cardiac arrest: a propensity-matched study. Crit Care. 2014;18:535.
15. Zheng K, Du L, Cao Y, et al. Monitoring cardiopulmonary resuscitation quality in emergency departments: a national survey in China on current knowledge, attitudes, and practices. BMC Emerg Med. 2022;22:33.
16. Paiva EF, Paxton JH, O’Neil BJ. The use of end-tidal carbon dioxide (ETCO(2)) measurement to guide management of cardiac arrest: a systematic review. Resuscitation. 2018;123:1−7.
17. Touma O, Davies M. The prognostic value of end tidal carbon dioxide during cardiac arrest: a systematic review. Resuscitation. 2013;84:1470−9.
18. Naruke T, Inomata T, Imai H, et al. End-tidal carbon dioxide concentration can estimate the appropriate timing for weaning off from extracorporeal membrane oxygenation for refractory circulatory failure. Int Heart J. 2010;51:116−20.
19. McILwain RB, Timpa JG, Kurundkar AR, et al. Plasma concentrations of inflammatory cytokines rise rapidly during ECMOrelated SIRS due to the release of preformed stores in the intestine. Lab Invest. 2010;90:128−39. 20. Short BL. The effect of extracorporeal life support on the brain: a focus on ECMO. Semin Perinatol. 2005;29:45−50.
21. Caprarola SD, Ng DK, Carroll MK, et al. Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation. Pediatr Res. 2022;92:549−56.
22. Xiong XY, Liu L, Yang QW. Functions and mechanisms of microglia/macrophages in neuroinflammation and neurogenesis after stroke. Prog Neurobiol. 2016;142:23−44.
23. Lasek-Bal A, Jedrzejowska-Szypulka H, Student S, et al. The importance of selected markers of inflammation and bloodbrain barrier damage for short-term ischemic stroke prognosis. J Physiol Pharmacol. 2019;70(2).
24. Pawluk H, Grzesk G, Ko»odziejska R, et al. Effect of IL6 and hsCRP serum levels on functional prognosis in stroke patients undergoing IV-thrombolysis: retrospective analysis. Clin Interv Aging. 2020;15:1295−303.
25. Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation. 2017;112:1−10.
26. Mourad M, Eliet J, Zeroual N, et al. Pulse pressure and end-tidal carbon dioxide for monitoring low native cardiac output during veno-arterial ECLS: a prospective observational study. Crit Care. 2020;24:569.
27. Olander C-H, Vikholm P, Schiller P, Hellgren L. End-tidal carbon € dioxide impacts brain and kidney injury in experimental extracorporeal cardiopulmonary resuscitation (ECPR). Shock. 2021; 55:563−9.
28. Yeh T-C, Chang H-H, Ger L-P, Wang J-O, Kao S, Ho S-T. Clinical risk factors of extracorporeal membrane oxygenation support in older adults. PLoS One. 2018;13:e0195445.
29. Gupta P, Robertson MJ, Beam B, et al. Relationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis. Minerva Anestesiol. 2015;81:619−27.
30. Li Z, Gao J, Wang J, et al. Mortality risk factors in patients receiving ECPR after cardiac arrest: development and validation of a clinical prognostic prediction model. Am J Emerg Med. 2024;76:111−22.
31. Puleo F, Arvanitakis M, Gossum AV, Preiser J-C. Gut failure in the ICU. Semin Respir Crit Care Med. 2011;32:626−38.
32. Wang B, Huang Q, Zhang W, Li N, Li J. Lactobacillus plantarum prevents bacterial translocation in rats following ischemia and reperfusion injury. Dig Dis Sci. 2011;56:3187−94.
33. Tran A, Rochwerg B, Fan E, et al. Prognostic factors associated with favourable functional outcome among adult patients requiring extracorporeal cardiopulmonary resuscitation for outof-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2023;193:110004.
34. Grasselli G, Scaravilli V, Di Bella S, et al. Nosocomial infections during extracorporeal membrane oxygenation: incidence, etiology, and impact on patients’ outcome. Crit Care Med. 2017; 45:1726−33.
35. Schmidt M, Burrell A, Roberts L, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36:2246−56.
Submitted date:
07/17/2024
Accepted date:
12/24/2024
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email