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Neuroprognostication Under ECMO After Cardiac Arrest: Are Classical Tools Still Performant?

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An Invited Commentary to this article was published on 09 May 2022

Abstract

Background

According to international guidelines, neuroprognostication in comatose patients after cardiac arrest (CA) is performed using a multimodal approach. However, patients undergoing extracorporeal membrane oxygenation (ECMO) may have longer pharmacological sedation and show alteration in biological markers, potentially challenging prognostication. Here, we aimed to assess whether routinely used predictors of poor neurological outcome also exert an acceptable performance in patients undergoing ECMO after CA.

Methods

This observational retrospective study of our registry includes consecutive comatose adults after CA. Patients deceased within 36 h and not undergoing prognostic tests were excluded. Veno-arterial ECMO was initiated in patients < 80 years old presenting a refractory CA, with a no flow < 5 min and a low flow ≤ 60 min on admission. Neuroprognostication test performance (including pupillary reflex, electroencephalogram, somatosensory-evoked potentials, neuron-specific enolase) toward mortality and poor functional outcome (Cerebral Performance Categories [CPC] score 3–5) was compared between patients undergoing ECMO and those without ECMO.

Results

We analyzed 397 patients without ECMO and 50 undergoing ECMO. The median age was 65 (interquartile range 54–74), and 69.8% of patients were men. Most had a cardiac etiology (67.6%); 52% of the patients had a shockable rhythm, and the median time to return of an effective circulation was 20 (interquartile range 10–28) minutes. Compared with those without ECMO, patients receiving ECMO had worse functional outcome (74% with CPC scores 3–5 vs. 59%, p = 0.040) and a nonsignificant higher mortality (60% vs. 47%, p = 0.080). Apart from the neuron-specific enolase level (higher in patients with ECMO, p < 0.001), the presence of prognostic items (pupillary reflex, electroencephalogram background and reactivity, somatosensory-evoked potentials, and myoclonus) related to unfavorable outcome (CPC score 3–5) in both groups was similar, as was the prevalence of at least any two such items concomitantly. The specificity of each these variables toward poor outcome was between 92 and 100% in both groups, and of the combination of at least two items, it was 99.3% in patients without ECMO and 100% in those with ECMO. The predictive performance (receiver operating characteristic curve) of their combination toward poor outcome was 0.822 (patients without ECMO) and 0.681 (patients with ECMO) (p = 0.134).

Conclusions

Pending a prospective assessment on a larger cohort, in comatose patients after CA, the performance of prognostic factors seems comparable in patients with ECMO and those without ECMO. In particular, the combination of at least two poor outcome criteria appears valid across these two groups.

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Authors and Affiliations

  1. Department of Adult Intensive Care Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland

    Nawfel Ben-Hamouda, Zied Ltaief, Lucas Liaudet & Mauro Oddo

  2. Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland

    Nawfel Ben-Hamouda, Zied Ltaief, Matthias Kirsch, Jan Novy, Lucas Liaudet, Mauro Oddo & Andrea O. Rossetti

  3. Department of Cardiovascular Surgery, Lausanne University Hospital, Lausanne, Switzerland

    Matthias Kirsch

  4. Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland

    Jan Novy & Andrea O. Rossetti

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  1. Nawfel Ben-Hamouda
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  2. Zied Ltaief
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Contributions

NBH: data collection, statistics, analysis, and drafting of the manuscript. ZL: contribution to data collection and revision of the manuscript. MK, JN, LL, MO: revision of the manuscript. AOR: supervision, data analysis and interpretation, and revision of the manuscript.

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Correspondence to Nawfel Ben-Hamouda.

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This article is related to the commentary available at https://doi.org/10.1007/s12028-022-01517-z.

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Ben-Hamouda, N., Ltaief, Z., Kirsch, M. et al. Neuroprognostication Under ECMO After Cardiac Arrest: Are Classical Tools Still Performant?. Neurocrit Care 37, 293–301 (2022). https://doi.org/10.1007/s12028-022-01516-0

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