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Open Access 01-12-2024 | ECMO | Research

Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study

Authors: Shutaro Isokawa, Toru Hifumi, Keita Hirano, Yu Watanabe, Katsuhiro Horie, Kijong Shin, Kasumi Shirasaki, Masahiro Goto, Akihiko Inoue, Tetsuya Sakamoto, Yasuhiro Kuroda, Shiori Tomita, Norio Otani, The SAVE-J II study group

Published in: Annals of Intensive Care | Issue 1/2024

Abstract

Background

Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database.

Methods

This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013–2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes.

Results

A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count (< 10 × 10⁴/μL vs > 10 × 10⁴/μL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252–2.777], p = 0.002).

Conclusions

In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety.

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Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest. JAMA. 2022;327(8):737. https://doi.org/10.1001/jama.2022.1025.CrossRefPubMedPubMedCentral

Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807–16. https://doi.org/10.1016/S0140-6736(20)32338-2.CrossRefPubMedPubMedCentral

Suverein MM, Delnoij TSR, Lorusso R, et al. Early extracorporeal CPR for refractory out-of-hospital cardiac arrest. N Engl J Med. 2023;388(4):299–309. https://doi.org/10.1056/nejmoa2204511.CrossRefPubMed

Leick J, Liebetrau C, Szardien S, et al. Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Clin Res Cardiol. 2013;102(9):661–9. https://doi.org/10.1007/s00392-013-0580-3.CrossRefPubMed

Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med. 2013;41(5):1186–96. https://doi.org/10.1097/CCM.0b013e31827ca4c8.CrossRefPubMed

Kim SJ, Jung JS, Park JH, Park JS, Hong YS, Lee SW. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Crit Care. 2014;18(5):1–15. https://doi.org/10.1186/s13054-014-0535-8.CrossRef

Lee JJ, Han SJ, Kim HS, et al. Out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal membrane oxygenation: focus on survival rate and neurologic outcome. Scand J Trauma Resusc Emerg Med. 2016;24(1):1–9. https://doi.org/10.1186/s13049-016-0266-8.CrossRef

Ha TS, Yang JH, Cho YH, et al. Clinical outcomes after rescue extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Emerg Med J. 2017;34(2):107–11. https://doi.org/10.1136/emermed-2015-204817.CrossRefPubMed

Kashiura M, Sugiyama K, Tanabe T, Akashi A, Hamabe Y. Effect of ultrasonography and fluoroscopic guidance on the incidence of complications of cannulation in extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a retrospective observational study. BMC Anesthesiol. 2017;17(1):1–7. https://doi.org/10.1186/s12871-016-0293-z.CrossRef

10.

Otani T, Sawano H, Natsukawa T, et al. D-dimer predicts bleeding complication in out-of-hospital cardiac arrest resuscitated with ECMO. Am J Emerg Med. 2018;36(6):1003–8. https://doi.org/10.1016/j.ajem.2017.11.016.CrossRefPubMed

11.

Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;2015(86):88–94. https://doi.org/10.1016/j.resuscitation.2014.09.010.CrossRef

12.

Li C, Cai T, Xie H, et al. Risk factors and outcomes for patients with bleeding complications receiving extracorporeal membrane oxygenation: An analysis of the Chinese Extracorporeal Life Support Registry. Artif Organs. 2022. https://doi.org/10.1111/aor.14321.CrossRefPubMedPubMedCentral

13.

Nguyen ML, Gause E, Mills B, et al. Traumatic and hemorrhagic complications after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Resuscitation. 2020;157:225–9. https://doi.org/10.1016/j.resuscitation.2020.09.035.CrossRefPubMedPubMedCentral

14.

Inoue A, Hifumi T, Sakamoto T, et al. Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan. Crit Care. 2022;26(1):1–11. https://doi.org/10.1186/s13054-022-03998-y.CrossRef

15.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med. 2016;375(17):1649–59. https://doi.org/10.1056/nejmsa1600011.CrossRefPubMed

16.

Hifumi T, Inoue A, Takiguchi T, et al. Variability of extracorporeal cardiopulmonary resuscitation practice in patients with out-of-hospital cardiac arrest from the emergency department to intensive care unit in Japan. Acute Med Surg. 2021;8(1):1–10. https://doi.org/10.1002/ams2.647.CrossRef

17.

Park IH, Yang JH, Jang WJ, et al. Clinical significance of low-flow time in patients undergoing extracorporeal cardiopulmonary resuscitation: results from the rescue registry. J Clin Med. 2020;9(11):1–12. https://doi.org/10.3390/jcm9113588.CrossRef

18.

Schopka S, Philipp A, Lunz D, et al. Single-center experience with extracorporeal life support in 103 nonpostcardiotomy patients. Artif Organs. 2013;37(2):150–6. https://doi.org/10.1111/j.1525-1594.2012.01544.x.CrossRefPubMed

19.

Son AY, Khanh LN, Joung HS, et al. Limb ischemia and bleeding in patients requiring venoarterial extracorporeal membrane oxygenation. J Vasc Surg. 2021;73(2):593–600. https://doi.org/10.1016/j.jvs.2020.05.071.CrossRefPubMed

20.

Ellouze O, Abbad X, Constandache T, et al. Risk factors of bleeding in patients undergoing venoarterial extracorporeal membrane oxygenation. Ann Thorac Surg. 2021;111(2):623–8. https://doi.org/10.1016/j.athoracsur.2020.02.012.CrossRefPubMed

21.

Aubron C, DePuydt J, Belon F, et al. Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. Ann Intensive Care. 2016;6:1. https://doi.org/10.1186/s13613-016-0196-7.CrossRef

22.

Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in adult patients. J Am Heart Assoc. 2020;9(7):1–12. https://doi.org/10.1161/JAHA.119.015291.CrossRef

23.

Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett RH. Extracorporeal life support: experience with 2,000 patients. ASAIO J. 2015;61(1):2–7. https://doi.org/10.1097/MAT.0000000000000150.CrossRefPubMedPubMedCentral

24.

Dalia AA, Lu SY, Villavicencio M, et al. Extracorporeal cardiopulmonary resuscitation: outcomes and complications at a quaternary referral center. J Cardiothorac Vasc Anesth. 2020;34(5):1191–4. https://doi.org/10.1053/j.jvca.2019.12.016.CrossRefPubMed

25.

Lunz D, Calabrò L, Belliato M, et al. Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study. Intensive Care Med. 2020;46(5):973–82. https://doi.org/10.1007/s00134-020-05926-6.CrossRefPubMed

26.

Extracorporeal Life Support Organization (ELSO) ELSO Registry Data Definitions. Published 2018. https://www.elso.org/portals/0/files/elso registry data definitions 02_13_23.pdf

27.

Patricio D, Peluso L, Brasseur A, et al. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. Crit Care. 2019;23(1):1–10. https://doi.org/10.1186/s13054-019-2320-1.CrossRef

28.

Bartos JA, Carlson K, Carlson C, et al. Surviving refractory out-of-hospital ventricular fibrillation cardiac arrest: critical care and extracorporeal membrane oxygenation management. Resuscitation. 2018;2018(132):47–55. https://doi.org/10.1016/j.resuscitation.2018.08.030.CrossRef

29.

30.

Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023;27(1):1–45. doi: https://doi.org/10.1186/s13054-023-04327-7

31.

Zhang L, Liu W, Liu J, et al. Heparin loading dose in patients undergoing extracorporeal cardiopulmonary resuscitation. J Cardiothorac Vasc Anesth. 2023;000:1–7. https://doi.org/10.1053/j.jvca.2023.02.003.CrossRef

32.

Iwashita Y, Yukimitsu M, Matsuduki M, Yamamoto A, Ishikura K, Imai H. Use of a fixed, body weight-unadjusted loading dose of unfractionated heparin for extracorporeal cardiopulmonary resuscitation. J Intensive Care. 2015;3(1):1–5. https://doi.org/10.1186/s40560-015-0098-z.CrossRef

33.

Yannopoulos D, Bartos JA, Martin C, et al. Minnesota Resuscitation Consortium’s advanced perfusion and reperfusion cardiac life support strategy for out-of-hospital refractory ventricular fibrillation. J Am Heart Assoc. 2016;5(6):1–10. https://doi.org/10.1161/JAHA.116.003732.CrossRef

34.

Lorusso R, Shekar K, MacLaren G, et al. ELSO interim guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients. ASAIO J. 2021;67(8):827–44. https://doi.org/10.1097/MAT.0000000000001510.CrossRefPubMed

35.

Dennis M, Zmudzki F, Burns B, et al. Cost effectiveness and quality of life analysis of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Resuscitation. 2019;2019(139):49–56. https://doi.org/10.1016/j.resuscitation.2019.03.021.CrossRef

36.

Lamhaut L, Tea V, Raphalen JH, et al. Coronary lesions in refractory out of hospital cardiac arrest (OHCA) treated by extra corporeal pulmonary resuscitation (ECPR). Resuscitation. 2018;2018(126):154–9. https://doi.org/10.1016/j.resuscitation.2017.12.017.CrossRef

37.

Nagao K, Hayashi N, Kanmatsuse K, et al. Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital. J Am Coll Cardiol. 2000;36(3):776–83. https://doi.org/10.1016/S0735-1097(00)00779-8.CrossRefPubMed

38.

Tanaka D, Hirose H, Cavarocchi N, Entwistle JWC. The impact of vascular complications on survival of patients on venoarterial extracorporeal membrane oxygenation. Ann Thorac Surg. 2016;101(5):1729–34. https://doi.org/10.1016/j.athoracsur.2015.10.095.CrossRefPubMed

39.

Richardson AC, Tonna JE, Nanjayya V, et al. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement from the Extracorporeal Life Support Organization. ASAIO Journal. 2021;1:221–8. https://doi.org/10.1097/MAT.0000000000001344.CrossRef

40.

Lee JH, Ko RE, Park TK, Cho YH, Suh GY, Yang JH. Association between a multidisciplinary team approach and clinical outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation in the emergency department. Kor Circ J. 2021;51(11):908–18. https://doi.org/10.4070/KCJ.2021.0167.CrossRef

Title: Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study
Authors: Shutaro Isokawa
Toru Hifumi
Keita Hirano
Yu Watanabe
Katsuhiro Horie
Kijong Shin
Kasumi Shirasaki
Masahiro Goto
Akihiko Inoue
Tetsuya Sakamoto
Yasuhiro Kuroda
Shiori Tomita
Norio Otani
The SAVE-J II study group
Publication date: 01-12-2024
Publisher: Springer International Publishing
Keywords: ECMO
ECMO
Cardiopulmonary Resuscitation
Interventional Radiology
Published in: Annals of Intensive Care / Issue 1/2024
Electronic ISSN: 2110-5820
DOI: https://doi.org/10.1186/s13613-024-01253-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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