Grunau Brian, Reynolds Joshua, Scheuermeyer Frank, Stenstom Robert, Stub Dion, Pennington Sarah, Cheskes Sheldon, Ramanathan Krishnan, Christenson Jim
Prehosp Emerg Care. 2016 Sep-Oct;20(5):615-22. doi: 10.3109/10903127.2016.1149652. Epub 2016 Mar 28.
Extracorporeal cardiopulmonary resuscitation (ECPR) may improve outcomes for refractory out-of-hospital cardiac arrest (OHCA). Transport of intra-arrest patients to hospital however, may decrease CPR quality, potentially reducing survival for those who would have achieved return-of-spontaneous-circulation (ROSC) with further on-scene resuscitation. We examined time-to-ROSC and patient outcomes for the optimal time to consider transport.
From a prospective registry of consecutive adult non-traumatic OHCA's, we identified a hypothetical ECPR-eligible cohort of EMS-treated patients with age ≤ 65, witnessed arrest, and bystander CPR or EMS arrival < 10 minutes. We assessed the relationship between time-to-ROSC and survival, and constructed a ROC curve to illustrate the ability of a pulseless state to predict non-survival with conventional resuscitation.
Of 6,571 EMS-treated cases, 1,206 were included with 27% surviving. Increasing time-to-ROSC (per minute) was negatively associated with survival (adjusted OR 0.91; 95%CI 0.89-0.93%). The yield of survivors per minute of resuscitation increased from commencement and started to decline in the 8th minute. Fifty percent and 90% of survivors had achieved ROSC by 8.0 and 24 min, respectively, at which times the probability of survival for those with initial shockable rhythms was 31% and 10%, and for non-shockable rhythms was 5.2% and 1.6%. The ROC curve illustrated that the 16th minute of resuscitation maximized sensitivity and specificity (AUC = 0.87, 95% CI 0.85-0.89).
Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.
体外心肺复苏（ECPR）可能改善难治性院外心脏骤停（OHCA）的预后。然而，将心脏骤停患者转运至医院可能会降低心肺复苏质量，可能减少那些通过进一步现场复苏可实现自主循环恢复（ROSC）的患者的生存几率。我们研究了实现ROSC的时间及考虑转运的最佳时间对患者预后的影响。
从连续成年非创伤性OHCA的前瞻性登记中，我们确定了一个假设符合ECPR条件的队列，这些患者为接受紧急医疗服务（EMS）治疗的年龄≤65岁、有目击者的心脏骤停患者，且旁观者进行心肺复苏或EMS到达时间<10分钟。我们评估了实现ROSC的时间与生存之间的关系，并构建了一条ROC曲线，以说明无脉状态预测传统复苏不能存活的能力。
在6571例接受EMS治疗的病例中，1206例被纳入研究，27%存活。实现ROSC的时间（每分钟增加）与生存呈负相关（校正后的比值比为0.91；95%可信区间为0.89 - 0.93%）。从复苏开始每分钟的存活者产出量增加，在第8分钟开始下降。分别有50%和90%的存活者在8.0分钟和24分钟时实现了ROSC，此时初始可电击心律患者的存活概率分别为31%和10%，非可电击心律患者的存活概率分别为5.2%和1.6%。ROC曲线表明，复苏第16分钟时敏感性和特异性达到最大值（曲线下面积 = 0.87，95%可信区间为0.85 - 0.89）。
应在专业现场复苏8至24分钟之间考虑进行ECPR转运，16分钟时平衡了早期和晚期转运的风险与益处。如果在转运过程中能维持高质量心肺复苏，对于初始非可电击心律的患者，在此时间窗内更早转运可能更可取。
