부산대학교 도서관

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) in patients with refractory cardiac arrest is rapidly becoming a common strategy worldwide. Despite its benefits, ECPR is still associated with significant morbidity, including a high prevalence of brain injury/ischemia. ECPR raises a variety of ethical concerns when discontinuing treatment, however, there is little information about the withholding/withdrawal of life-sustaining therapy (WLST) decision for out-of-hospital cardiac arrest (OHCA) patients after ECPR.Hypothesis: We tested whether early WLST is obtained in OHCA patients with ECPR, and examined the differences in patient characteristics between ECPR/OHCA patients with or without WLST.Methods: We conducted a post-hoc analysis of data from the SAVE-J II study (a retrospective, multicenter study of ECPR in Japan from 2013 to 2018). Inclusion criteria: Patients who underwent ECPR for OHCA with internal causes. Exclusion criteria: death in the emergency department (without admission), diagnosis of brain hemorrhage/acute aortic dissection as cause of arrest. The dates and reasons for the decisions were recorded. Further, differences between ECPR/OHCA patients with or without WLST were compared using univariable analysis.Results: We included 1651 patients in the analysis; WLST was decided in 506 (31%) of patients at a median of two days. WLST was decided within three days in 291 patients (18%). Reasons for WLST decision were perceived unfavorable neurological prognosis (285/477 [59.7%]), perceived unfavorable cardiac/pulmonary prognosis (99/477 [20.7%]), inability to maintain extracorporeal cardiopulmonary support (71/477 [14.8%]), complications (12/477 [2.5%]), and others (10/477 [2%]). Older age (WLST vs. non-WLST, median [IQR]: 63 [51-71] vs. 61 [49-68], p=0.001) and daily hemodialysis before the collapse (7.7% vs. 4.7%, p=0.015) were factors in the WLST decision. Patients with WLST had higher 1 month mortality (505/506 [99.8%] vs. 889/1145 [77.6%], p<0.001).Conclusion: About one-third of ECPR/OHCA patients had WLST decided at a median of two days, mainly for perceived unfavorable neurological prognoses reason. Decisions and neurological assessments for ECPR/OHCA patients need further analysis.