What is the appropriate age range for using extracorporeal membrane oxygenation (ECMO) in cardiac arrest resuscitation (E-CPR)?

ECMO Age Criteria for Cardiac Arrest Resuscitation

For ECPR (extracorporeal CPR) during cardiac arrest, the appropriate age range is 18 to 75 years based on the most rigorous guideline evidence, though some protocols extend the upper limit to 80 years. 1, 2

Age-Based Recommendations

Adults (Primary Focus)

The 2015 AHA Guidelines establish clear age boundaries:

• Lower limit: 18 years (consistently applied across all major studies)
• Upper limit: 75 years (most common cutoff) 1, 2
• Some protocols extend to 80 years as the maximum 1

These age criteria appear in the inclusion/exclusion tables from multiple landmark studies reviewed by the AHA:

• Chen 2008: excluded <18 or >75 years
• Shin 2011: excluded <18 or >80 years
• Lin 2010: excluded <18 or >75 years
• Sakamoto 2014: excluded <20 or ≥75 years 1

Evidence Supporting Age Restrictions

The 2019 ILCOR consensus reinforces that age matters significantly for outcomes. 3 A large ELSO registry analysis of 5,120 adult ECPR patients demonstrated:

• Age 65-74 years: 32% decreased odds of survival (aOR 0.68,95% CI 0.57-0.81)
• Age >75 years: 46% decreased odds of survival (aOR 0.54,95% CI 0.41-0.69)
• No survival difference between ages 18-49 and 50-64 4

This represents the largest analysis of age effects on ECPR outcomes and shows a clear inflection point at age 65, even after controlling for illness severity and comorbidities.

Pediatric Considerations

For children, the evidence is more limited but suggests:

• Minimum age: typically >16 years for OHCA protocols 1
• Neonates and children can be considered for IHCA with cardiac disease 5
• Pediatric ECPR survival is approximately 38% overall, but outcomes for out-of-hospital pediatric cardiac arrest remain poor (6% survival in recent series) 6, 7, 5

Clinical Application Algorithm

When evaluating ECPR candidacy, apply these age-based criteria:

1. Automatic exclusion if:

   • Age <18 years (for adult protocols)
   • Age >75-80 years (depending on institutional protocol)

2. Heightened scrutiny for ages 65-75:

   • Recognize significantly decreased survival probability
   • Require absence of major comorbidities
   • Ensure witnessed arrest with short no-flow time
   • Confirm reversible cardiac etiology

3. Optimal candidates (ages 18-64):

   • Standard ECPR evaluation criteria apply
   • Focus on other prognostic factors (witnessed arrest, cardiac origin, CPR duration <60 minutes)

Important Caveats

The 2019 AHA Focused Update emphasizes that ECPR should only be considered for "selected patients" in settings with rapid expert deployment. 8 The age criteria from published series represent observational data with critical risk of bias from confounding—younger patients were systematically selected for ECPR, which influences apparent outcomes.

All guideline recommendations are Class IIb (may be considered) with very low certainty evidence, as no randomized trials exist. 2, 8 The age cutoffs reflect expert consensus based on observational studies rather than definitive evidence.

The rationale for age restrictions relates to:

• Decreased physiologic reserve with aging
• Higher comorbidity burden
• Reduced likelihood of neurologically intact survival
• Resource allocation considerations in the absence of reversible pathology

Bottom line: Use 18-75 years as your standard age range for ECPR candidacy, recognizing that survival probability decreases substantially after age 65, and outcomes become increasingly unfavorable after age 75. 1, 2, 4