Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan.
Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-0042, Japan.
Crit Care. 2023 Jun 27;27(1):252. doi: 10.1186/s13054-023-04534-2.
Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR.
We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined.
We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p < 0.001). Primary cerebral disorders as cause of cardiac arrest and higher severity of illness at intensive care unit admission were associated with WLST decisions.
For approximately one-third of ECPR/OHCA patients, WLST was decided during admission, mainly because of perceived unfavorable neurological prognoses. Decisions and neurological assessments for ECPR/OHCA patients need further analysis.
体外心肺复苏（ECPR）迅速成为治疗难治性心脏骤停患者的常用治疗策略。尽管 ECPR 有很多益处，但当停止治疗时，它会引发各种伦理问题。对于 ECPR 后院外心脏骤停（OHCA）患者是否停止/撤回生命支持治疗（WLST），几乎没有相关信息。
我们对日本 ECPR 的 SAVE-J II 研究进行了二次分析，该研究是一项回顾性多中心研究。纳入因医学原因接受 OHCA 行 ECPR 的成年患者。记录 WLST 决策的发生率、原因和时机。比较有和无 WLST 决策患者的结局。进一步分析与 WLST 决策相关的因素。
共纳入 1660 例患者，其中 510 例（30.7%）有 WLST 决策。第一天 WLST 决策最多，ICU 入院后中位数 2 天做出 WLST 决策。WLST 的原因包括：不良神经预后（300/510 [58.8%]）、不良心肺预后（105/510 [20.5%]）、无法维持体外心肺支持（71/510 [13.9%]）、并发症（10/510 [1.9%]）、心脏骤停前合并症恶化（7/510 [1.3%]）和其他原因。有 WLST 决策的患者 30 天生存率较低（WLST 组 36/506 [7.1%]，无 WLST 组 386/1140 [33.8%]，p<0.001）。心脏骤停的主要原因为原发性脑疾病和 ICU 入院时疾病严重程度较高与 WLST 决策相关。
大约三分之一的 ECPR/OHCA 患者在入院期间决定 WLST，主要是因为不良的神经预后。需要进一步分析 ECPR/OHCA 患者的决策和神经评估。
