Management of Sudden Cardiac Arrest in Post-ECMO Children
The management of sudden cardiac arrest in post-ECMO children requires immediate implementation of standard CPR protocols while simultaneously addressing post-ECMO specific complications, with consideration for rapid re-initiation of ECMO (ECPR) in appropriate candidates who fail to respond to conventional resuscitation efforts. 1
Immediate Interventions
- Begin high-quality CPR immediately while simultaneously identifying and addressing potential post-ECMO complications that may have precipitated the arrest 1
- Optimize ventilation and oxygenation by titrating FiO2 to maintain oxygen saturation 94-99%, avoiding both hypoxemia and hyperoxia 1
- Monitor and maintain appropriate PCO2 levels, avoiding severe hypercapnia or hypocapnia which can worsen outcomes 1
- Perform bedside cardiac ultrasonography to identify potentially treatable causes of arrest (pericardial effusion, tamponade, severe hypovolemia) when skilled personnel are available, without interrupting chest compressions 1
Hemodynamic Support
- Address hypotensive shock immediately, as early hypotension after cardiac arrest is associated with lower survival to hospital discharge 1
- Initiate vasoactive medications based on the underlying cardiac pathophysiology 1:
- For low cardiac output: Epinephrine (0.1-1 μg/kg/min) or Dobutamine (2-20 μg/kg/min)
- For vasodilatory shock: Norepinephrine (0.1-2 μg/kg/min) or Dopamine (2-20 μg/kg/min)
- For combined shock: Epinephrine with consideration of adding Milrinone (0.25-0.75 μg/kg/min) for afterload reduction
Arrhythmia Management
- Treat arrhythmias based on their hemodynamic consequences and underlying cause 1
- For ventricular arrhythmias (which may signify serious myocardial dysfunction), consider antiarrhythmic therapy while consulting pediatric cardiac electrophysiology 1, 2
- Avoid QT-prolonging medications in patients with suspected long-QT syndrome 1
- Consider prophylactic lidocaine bolus and/or continuous infusion immediately after ROSC to prevent recurrence of ventricular fibrillation 2
ECMO Re-initiation (ECPR)
- Consider rapid re-initiation of ECMO (ECPR) for patients with:
- ECPR can be effective even after prolonged CPR (up to 60 minutes) in selected patients 3
- Historical data shows 53-64% survival rates when ECMO is used as rescue therapy for post-cardiac surgery cardiac arrest in children 3, 5
Post-ROSC Care
Implement comprehensive post-cardiac arrest care immediately after ROSC 1:
- Continuous monitoring of vital signs, ECG, pulse oximetry, and capnography
- Arterial blood gas analysis, serum electrolytes, glucose, and lactate measurements
- Targeted temperature management for comatose patients, including aggressive fever prevention
- Monitor for and treat seizures, agitation, and hypoglycemia
- Echocardiography to assess cardiac function and guide therapy
The median time from ROSC to rearrest is 3.1 minutes, emphasizing the need for vigilant monitoring in the immediate post-ROSC period 2
Special Considerations
- For patients with pulmonary hypertension, provide adequate oxygenation, minimize stimulation, ensure adequate analgesia/sedation, and consider pulmonary vasodilators 1
- For patients with suspected arrhythmogenic causes of arrest, avoid medications that may exacerbate the underlying condition and consult pediatric cardiac electrophysiology 1
- Consider transfer to a tertiary care center with pediatric cardiac expertise and ECMO capabilities if not already at such a facility 1
Monitoring and Assessment
Implement comprehensive monitoring including 1:
- Continuous cardiac telemetry and ECG
- Continuous core temperature monitoring
- Arterial blood pressure (preferably invasive)
- Capnography and pulse oximetry
- Urine output
- Serial neurological examinations
- Consider continuous EEG monitoring
Perform bedside echocardiography to assess cardiac function, volume status, and response to interventions 1