Tonna Joseph E, Selzman Craig H, Bartos Jason A, Presson Angela P, Ou Zhining, Jo Yeonjung, Becker Lance, Youngquist Scott T, Thiagarajan Ravi R, Johnson M Austin, Rycus Peter, Keenan Heather T
Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT.
Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT.
Crit Care Explor. 2022 Jul 25;4(7):e0733. doi: 10.1097/CCE.0000000000000733. eCollection 2022 Jul.
It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes.
To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival.
Observational cohort study using case-mix adjusted survival analysis.
Adult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019.
Generalized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR.
Case-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44-64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08-1.55; = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11- 1.61; = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05-1.84; = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04-1.45; = 0.015) versus medium- and low-volume centers.
Modifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesis-generating associations are causal in nature.
目前尚不清楚医院层面的体外心肺复苏（ECPR）病例数量，或插管后临床管理与生存结局之间的关系。
描述接受ECPR患者的复苏后管理实践差异以及医院层面的年度病例数量，并确定这些管理实践与医院生存率之间的关联。
采用病例组合调整生存分析的观察性队列研究。
2008年至2019年从体外生命支持组织注册中心接受ECPR的18岁及以上成年患者。
使用广义估计方程逻辑回归来确定与医院生存相关的因素，并考虑中心聚类情况。分析的因素包括开始体外膜肺氧合（ECMO）后的特定临床管理干预措施，如冠状动脉造影、ECMO上左心室的机械卸载（额外放置外周心室辅助装置、主动脉内球囊泵或手术引流）、在动脉回流插管远端放置动脉灌注导管（以减轻腿部缺血）；潜在可改变的ECMO血流动力学指标（动脉搏动性、平均动脉压、ECMO流量）；以及成人ECPR的医院层面年度病例数量。
病例组合调整后的患者层面管理实践在各医院之间差异很大。我们分析了7488名成年人（29%存活）；中位年龄55岁（四分位间距，44 - 64岁），其中68%为男性。调整后的ECMO医院生存率与左心室机械卸载（优势比[OR]，1.3；95%置信区间，1.08 - 1.55；P = 0.005）、冠状动脉造影（OR，1.34；95%置信区间，1.11 - 1.61；P = 0.002）以及在回流插管远端放置动脉灌注导管（OR，1.39；95%置信区间，1.05 - 1.84；P = 0.022）相关。病例组合调整后，各医院的生存率差异为44%，在每年进行超过12例ECPR病例的中心生存率更高（OR，1.23；95%置信区间，1.04 - 1.45；P = 0.015），而中低病例数量中心的生存率较低。
可改变的ECMO管理策略和年度病例数量在各医院之间存在差异，似乎与生存率相关，应成为未来研究的重点，以检验这些产生假设的关联在本质上是否具有因果关系。
