Door‐to‐Needle Time for Extracorporeal Cardiopulmonary Resuscitation and Neurological Outcomes in Out‐of‐Hospital Cardiac Arrest: A Nationwide Study

Abstract

Background Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for refractory cardiac arrest, and immediate initiation after indication is recommended. However, the practical goals of ECPR preparation (such as the door‐to‐needle time) remain unclear. This study aimed to elucidate the association between the door‐to‐needle time and neurological outcomes of out‐of‐hospital cardiac arrest. Methods and Results This is a post hoc analysis of a nationwide multicenter study on out‐of‐hospital cardiac arrest treated with ECPR at 36 institutions between 2013 and 2018 (SAVE‐J [Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan] II study). Adult patients without hypothermia (≥32 °C) in whom circulation was not returned at ECPR initiation were included. The probability of favorable neurological function at 30 days (defined as Cerebral Performance Category ≤2) was estimated using a generalized estimating equations model, in which institutional, patient, and treatment characteristics were adjusted. Estimated probabilities were then calculated according to the door‐to‐needle time with 3‐minute increments, and a clinical threshold was assumed. Among 1298 patients eligible for this study, 136 (10.6%) had favorable neurological function. The estimated probability of favorable outcomes was highest in patients with 1 to 3 minutes of door‐to‐needle time (12.9% [11.4%–14.3%]) and remained at 9% to 10% until 27 to 30 minutes. Then, the probability dropped gradually with each 3‐minute delay. A 30‐minute threshold was assumed, and shorter door‐to‐extracorporeal membrane oxygenation/low‐flow time and fewer adverse events related to cannulation were observed in patients with door‐to‐needle time <30 minutes. Conclusions The probability of favorable functions after out‐of‐hospital cardiac arrest decreased as the door‐to‐needle time for ECPR was prolonged, with a rapid decline after 27 to 30 minutes. Registration URL: https://center6.umin.ac.jp/cgi‐open‐bin/ctr/ctr_view.cgi?recptno=R000041577; Unique identifier: UMIN000036490.

Keywords

• cardiopulmonary resuscitation
• Cerebral Performance Category
• extracorporeal cardiopulmonary resuscitation