What are the guidelines to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in cases of refractory cardiac arrest?

Guidelines for Starting Extracorporeal Cardiopulmonary Resuscitation (ECPR)

The use of ECPR for patients with cardiac arrest refractory to standard ACLS is reasonable in select patients when provided within an appropriately trained and equipped system of care. 1

Definition and Purpose of ECPR

• ECPR refers to the initiation of cardiopulmonary bypass during resuscitation of a patient in cardiac arrest, involving cannulation of a large vein and artery and initiation of venoarterial extracorporeal membrane oxygenation 1
• The goal is to support end-organ perfusion while potentially reversible conditions are addressed 1

Patient Selection Criteria

Recommended Criteria:

• Cardiac arrest with potentially reversible etiology 1
• Age typically between 18-75 years 1, 2
• Witnessed cardiac arrest 3, 2
• Initial shockable rhythm (better outcomes compared to non-shockable rhythms) 1, 2
• Bystander CPR performed 3, 4
• No-flow time (time without CPR) ≤5 minutes 3
• Low-flow time (time on conventional CPR) ideally ≤30 minutes 2
• Absence of limiting comorbidities 4
• Absence of severe irreversible brain damage 1
• No terminal malignancy 1

Exclusion Criteria:

• Traumatic origin with uncontrolled bleeding 1
• Known severe irreversible brain damage 1
• Terminal malignancy 1, 4
• Non-cardiac origin such as submersion, drug overdose, asphyxia, exsanguination, sepsis 1
• Irreversible organ failure 1

System Requirements

• ECPR should be performed within an appropriately trained and equipped system of care 1
• Requires a highly trained team, specialized equipment, and multidisciplinary support 1, 5
• ECPR caseload is an important predictor of patient survival 5
• Continuous training is key for evidence-based quality of care 5
• An effective program achieves excellence along other links in the Chain of Survival 1

Implementation Timing and Process

• ECPR should be considered after conventional CPR has failed to achieve ROSC 1
• After cannulation, ECMO flow should be increased immediately with a goal of 3-4 L/min 1
• Arterial blood gases should be monitored from a right radial arterial line 1
• The arteriovenous O₂ difference should be maintained between 3-5 cc O₂/100ml of blood 1

Evidence Supporting ECPR Use

• Two randomized clinical trials have shown improved outcomes with ECPR 1
• The ARREST trial demonstrated significantly improved survival to discharge and 6-month survival for patients receiving ECPR for refractory cardiac arrest with shockable presenting rhythms 1
• The Hyperinvasive Trial showed 22% 180-day neurologically favorable survival in the standard ACLS group compared with 7% in the standard ACLS group in the ARREST trial 1
• Observational studies show that ECPR may improve neurologically favorable survival in patients with refractory cardiac arrest 6

Post-ECPR Management

• Post-cardiac arrest care should be titrated based on arrest etiology, comorbid disease, and illness severity 1
• Early coronary angiography is recommended for patients with suspected cardiac cause of arrest and ST-segment elevation on ECG 1
• Emergent coronary angiography is reasonable for selected patients without ST-elevation but with elevated risk of significant coronary artery disease 1
• Targeted temperature management should be considered for comatose patients 1

Potential Complications

• Vascular injury or malposition of cannulas 5
• Thrombotic complications 5
• Hemolysis 5
• Bleeding events 5

Limitations and Considerations

• ECPR is a complex intervention with high resource requirements 1, 6
• Despite selection criteria, reported survival rates are frequently below 10% 4
• Time-to-ECMO is a critical factor, with better outcomes when shorter 2, 4
• The combination of age, initial rhythm, and low-flow duration can improve patient selection 2