A Multicenter Study of Withdrawal of Therapy in Extracorporeal Cardiopulmonary Resuscitation
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Cardiovascular, Procedures, Ethics End of Life, 2022
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INTRODUCTION: As the use of extracorporeal membrane oxygenation (ECMO) increases after refractory cardiac arrest, known as extracorporeal cardiopulmonary resuscitation (ECPR), understanding factors associated with withdrawal of life sustaining therapy (WLST) is critical to avoid premature withdrawal. We aimed to investigate timing and characteristics of patients with WLST after ECPR. METHODS: The Extracorporeal Life Support Organization (ELSO) database was queried from 2007-2017 for patients > 18 years who died on ECMO due to family request. Data after 2017 were excluded due to a form change. Hemodynamic and lab data was collected ±6 hours prior to cannulation and 24 hours later. Patients were stratified by timing of WLST. Early WLST was defined as < 72 hours on ECPR based on current guidelines for prognostication after cardiac arrest; WLST group included all patients with WLST > 72 hours. RESULTS: 411 ECPR patients had WLST during this period (median age 42, interquartile range 24-80; 31.7% female). WLST occurred in 55.5% (n=228) within 72 hours, with an average trial of 27.7 hrs. There were no demographic or hemodynamic differences between groups prior to cannulation. Early WLST patients had lower pre-ECMO pH (7.14 ± 0.23 vs 7.20 ± 0.17; p=0.014). Twenty-four hours from cannulation, early WLST patients had significantly lower on-ECMO pH (7.35 ± 0.13 vs. 7.42 ± 0.08; p < 0.001), elevated lactate (10.2 ± 9.8 mmol/L vs 4.3 ± 2.9 mmol/L; p=0.009), and higher oxygen requirements (FiO2 61.7% ± 26.4% vs 51.3% ±19.6%; p < 0.001). In multivariable analysis, lactate was no longer significant when other factors were controlled for. While complications accumulated in the WLST patients (infectious: 19 vs. 35%, p < 0.001; renal: 50.8 vs. 95.6%, p < 0.05), there was no significant difference in the occurrence of neurological complication (17 vs 29.5%; p=0.16). CONCLUSIONS: This is the first study to use an international database to analyze WLST in ECPR patients. A significant proportion of WLST in ECPR patients occurs prior to a standard 72-hour trial period. There were few differences prior to cannulation, and early WLST patients were more severely ill at 24 hours. Being more severely ill at that time may contribute to early WLST. These findings merit further evaluation of appropriate patient selection, shared decision making, and duration of ECPR trials prior to WLST.
Meta Tag
Content Type Presentation
Knowledge Area Cardiovascular
Knowledge Area Procedures
Knowledge Area Ethics End of Life
Knowledge Level Advanced
Learning Pathway Cardiothoracic Critical Care
Membership Level Select
Tag Extracorporeal Life Support
Tag Medical Legal Issues
Tag Extracorporeal Membrane Oxygenation ECMO
Tag Cardiothoracic Critical Care
Year 2022
withdrawal of life-sustaining therapy
extracorporeal cardiopulmonary resuscitation
timing of WLST


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