Extracorporeal Life Support for Drowning Victims

Source: Burke CR, Chan T, Brogan TV, et al. Extracorporeal life support for victims of drowning. Resuscitation. 2016; 104: 19– 23; doi: 10.106/j.resuscitation.2016.04.005Investigators from several children’s hospitals in the United States and Canada reviewed data from the Extracorporeal Life Support Organization (ELSO) registry to determine survival rates and risk factors for death following treatment with extracorporeal life support (ECLS) in drowning victims. The ELSO registry includes information on patients treated at over 400 international centers. For the study, investigators extracted data from the ELSO registry on patients of all ages who were treated with ECLS after drowning between 1986 and 2015. A standardized form was used to abstract data on eligible patients from the registry including demographic information; clinical course; pre-ECLS support; mode, timing, and duration of ECLS; complications; and outcome. Study patients were placed into 3 categories based on their condition: ECLS without cardiac arrest (No Arrest); ECLS after cardiac arrest with return of spontaneous circulation (Arrest), and ECLS during CPR (ECPR). The primary outcome was survival to hospital discharge or transfer; survival rates were compared in children and adults and by ECLS category (No Arrest, Arrest, and ECLS). Multivariate logistic regression was used to identify risk factors for death among study participants.Data were analyzed on 247 drowning victims treated with ECLS. Overall survival was 51.4%. Of these, 49 were adults (>18 years old) and 198 were children. There was no significant difference in survival rates between children and adults (54.0% and 40.8%, respectively). Overall, 34.8% of study participants were classified as being in the Arrest group, 31.2% were in the ECPR group and 34.0% had no arrest prior to initiating ECLS. There was a significant trend in survival rate by patient category (P < .001). Participants in the No Arrest category had the highest survival rate (71.4%), followed by those in the Arrest (57%) and ECPR (23.4%) groups; mean age varied in the 3 groups (4.2 years, 8.9 years, and 5.9 years, respectively; P = .044) and duration of ECLS was also significantly different in the 3 groups (mean duration 155 hours, 87 hours, and 25 hours, respectively; P < .001).Clinical characteristics statistically associated with death in study patients included being in the ECPR group (OR = 2.46), renal failure (OR = 5.61), and the need for CPR during ECLS (OR = 6.73). Patients treated with venovenous ECLS (used for patients with respiratory failure) had a statistically lower chance of death than participants treated with venoarterial ECLS who had cardiopulmonary failure.The authors conclude that ECLS may improve survival rates after drowning. Survival appears improved if there was no cardiac arrest prior to or during ECLS. Based on the results, the authors suggest that early initiation of ECLS before respiratory failure deteriorates to cardiac arrest may improve outcomes.Dr Okada has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Unintentional drowning continues to be an international public health concern. Despite advances in technology and equipment, and hospital initiatives in quality of care and education, survival after drowning with cardiac arrest is dismal (2%–8%).1 Survival to hospital discharge after ECLS for drowning is not much better: 10% in small case series.2 Though the data from the current study are retrospective, the authors present compelling evidence from a large database that suggests the early use of ECLS following drowning may improve survival to discharge. A word of caution: as with any study using registry data, important predictors of outcome (eg, duration of submersion) were unavailable. Moreover, above and beyond mortality, morbidity from drowning and near-drowning is of major consequence.3 Therefore the lack of assessment (or report) of neurologic outcome after discharge in this study is a significant omission.As pediatricians, we play a pivotal role in preventing drownings by providing families with anticipatory guidance and resources, and supporting community legislation. The American Academy of Pediatrics is committed to reducing the loss associated with unintentional drowning. The AAP policy statement “Prevention of Drowning” summarizes current recommendations and provides links to helpful resources.3 Prevention remains our best opportunity for improving drowning outcomes.

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