Arterial oxygen and carbon dioxide tension and acute brain injury in extracorporeal cardiopulmonary resuscitation patients: Analysis of the extracorporeal life support organization registry

J Heart Lung Transplant. 2023 Apr;42(4):503-511. doi: 10.1016/j.healun.2022.10.019. Epub 2022 Nov 5.

Abstract

Background: Acute brain injury (ABI) remains common after extracorporeal cardiopulmonary resuscitation (ECPR). Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO2) and carbon dioxide (PaCO2) on ABI occurrence.

Methods: We retrospectively analyzed adult (≥18 years old) ECPR patients in the Extracorporeal Life Support Organization registry from 1/2009 through 12/2020. Composite ABI included ischemic stroke, intracranial hemorrhage (ICH), seizures, and brain death. The registry collects 2 blood gas data pre- (6 hours) and post- (24 hours) cannulation. Blood gas parameters were classified as: hypoxia (<60mm Hg), normoxia (60-119mm Hg), and mild (120-199mm Hg), moderate (200-299mm Hg), and severe hyperoxia (≥300mm Hg); hypocarbia (<35mm Hg), normocarbia (35-44mm Hg), mild (45-54mm Hg) and severe hypercarbia (≥55mm Hg). Missing values were handled using multiple imputation. Multivariable logistic regression analysis was used to assess the relationship of PaO2 and PaCO2 with ABI.

Results: Of 3,125 patients with ECPR intervention (median age=58, 69% male), 488 (16%) experienced ABI (7% ischemic stroke; 3% ICH). In multivariable analysis, on-ECMO moderate (aOR=1.42, 95%CI: 1.02-1.97) and severe hyperoxia (aOR=1.59, 95%CI: 1.20-2.10) were associated with composite ABI. Additionally, severe hyperoxia was associated with ischemic stroke (aOR=1.63, 95%CI: 1.11-2.40), ICH (aOR=1.92, 95%CI: 1.08-3.40), and in-hospital mortality (aOR=1.58, 95%CI: 1.21-2.06). Mild hypercarbia pre-ECMO was protective of composite ABI (aOR=0.61, 95%CI: 0.44-0.84) and ischemic stroke (aOR=0.56, 95%CI: 0.35-0.89).

Conclusions: Early severe hyperoxia (≥300mm Hg) on ECMO was a significant risk factor for ABI and mortality. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.

Keywords: ECPR; extracorporeal membrane oxygenation; neurological injury.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Brain Injuries* / blood
  • Brain Injuries* / epidemiology
  • Brain Injuries* / etiology
  • Carbon Dioxide* / blood
  • Cardiopulmonary Resuscitation* / adverse effects
  • Cardiopulmonary Resuscitation* / statistics & numerical data
  • Extracorporeal Membrane Oxygenation* / adverse effects
  • Extracorporeal Membrane Oxygenation* / statistics & numerical data
  • Female
  • Humans
  • Hyperoxia* / blood
  • Hyperoxia* / epidemiology
  • Hyperoxia* / etiology
  • Intracranial Hemorrhages / blood
  • Intracranial Hemorrhages / epidemiology
  • Intracranial Hemorrhages / etiology
  • Ischemic Stroke / blood
  • Ischemic Stroke / epidemiology
  • Ischemic Stroke / etiology
  • Male
  • Middle Aged
  • Oxygen* / blood
  • Registries / statistics & numerical data
  • Retrospective Studies
  • United States / epidemiology

Substances

  • Carbon Dioxide
  • Oxygen