Association of Cardiac Arrest and Cannulation Location on Outcomes of Extracorporeal Cardiopulmonary Resuscitation for Children Who Experience Out-of-Hospital Cardiac Arrest and Cardiac Arrest in the Emergency Department

Abstract

Objective Extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR). Single institution retrospective studies demonstrate improved short and long-term survival in adult patients who receive ECPR in the emergency department (ED). However, the impact of ECPR on pediatric patients who are brought into an ED has yet to be elucidated. The primary aim of this study is to characterize pediatric patients who experience out-of-hospital cardiac arrest or cardiac arrest in the ED, and examine associations of cardiac arrest and location of ECPR cannulation with mortality. Methods We conducted a retrospective analysis of data from the Extracorporeal Life Support Organization (ELSO) registry. We included all pediatric patients (age > 28 days to < 18 years) who had refractory out-of-hospital cardiac arrest (OHCA) or cardiac arrest in the ED (EDCA) between 2010 and 2019 and received ECPR. We descriptively summarized patient, cardiac arrest, and ECPR cannulation characteristics. We employed logistic regression to examine associations of location of cardiac arrest (OHCA vs. EDCA) and ECPR cannulation location (ED vs. non-ED) on in-hospital mortality. We adjusted models for age, sex, race, diagnosis of drowning, and history of congenital cardiac anomalies. We additionally included a covariate for the location of cardiac arrest in the cannulation location model. Results We included N=140 pediatric patients in analyses. N=121 (88%) had a witnessed cardiac arrest. N=66 (47%) patients arrested prior to hospital arrival, of which N=43 (31%) arrested at an outside hospital and N=23 (16%) arrested outside a hospital environment. N=49 (35%) patients underwent ECPR cannulation in the ED and the remaining N=91 (65%) were cannulated elsewhere in the hospital. Overall survival was 31%. In adjusted analyses, OHCA compared to EDCA was associated with 3.9 greater odds of mortality (95% confidence interval [CI] 1.61, 9.81). The location of ECPR cannulation was not associated with mortality (OR 1.8, 95% CI 0.75, 4.3). ConclusionsThe use of ECPR for pediatric patients with refractory OHCA is associated with poor overall survival and high odds of mortality, compared to patients with EDCA. The location of ECPR cannulation remains highly variable but does not appear to be associated with mortality after accounting for covariates, including arrest location. Based on these findings, ECPR should be considered for pediatric patients who experience EDCA. Further studies are needed to identify pre-cannulation predictors of survival for OHCA patients, as data suggest this patient population may not benefit from ECPR.