Impact of Advanced Cardiac Life Support Medications on Discharge Neurological Function for Survivors of Cardiac Arrest When Using ECPR

BACKGROUND: While the immediate goal of cardiopulmonary resuscitation is to achieve return of spontaneous circulation, the patient-centered goal is to minimize neurological injury. Several medications used during cardiac arrest have been associated with poor neurological outcomes. For patients cannulated for veno-arterial extracorporeal membrane oxygenation during cardiac arrest, termed extracorporeal cardiopulmonary resuscitation, the patient-centered impact of these medications has not yet been described. METHODS: We conducted a retrospective Extracorporeal Life Support Organization registry-based analysis. The primary outcome was cerebral performance category (CPC) score at hospital discharge. Cumulative odds models assessed the association between either (1) binary receipt of a medication or (2) the number of epinephrine milligrams given, and CPC score. The model reports the probability of having a score lower than each CPC level. To minimize bias in the receipt of advanced cardiovascular life support drugs, we used inverse probability treatment weights. RESULTS: Antiarrhythmics were associated with better neurological outcomes (amiodarone: CPC ≤ 1 [odds ratio [OR], 1.28 [95% CI, 1.00–1.65]; P =0.048] and CPC ≤ 2 [OR, 1.38 [95% CI, 1.06–1.78]; P =0.015]; lidocaine: CPC ≤ 1 [OR, 1.69 [95% CI, 1.32–2.17]; P <0.001], CPC ≤ 2 [OR, 1.82 [95% CI, 1.39–2.38]; P <0.001], CPC ≤ 3 [OR, 1.76 [95% CI, 1.30–2.40]; P <0.001]). Intraarrest sodium bicarbonate administration resulted in a lower likelihood of a CPC < 2 to 3 (CPC ≤ 2 [OR, 0.63 [95% CI, 0.49–0.81]; P <0.001], CPC ≤ 3 [OR, 0.65 [95% CI, 0.49–0.86]; P =0.003]). There was no significant difference in CPC score among adults who received intraarrest calcium. The unweighted cumulative effects model demonstrated a dose-dependent increasing relationship between epinephrine doses and harm for all CPC levels (OR, 0.89–0.94; P <0.001 for all). CONCLUSIONS: Our data support that increasing doses of epinephrine and nonantiarrhythmic advanced cardiovascular life support medications both worsen the probability of neurologically intact survival for patients who undergo extracorporeal cardiopulmonary resuscitation.