Disclaimer: 

Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (ECPR) is the application of extracorporeal membrane oxygenation (ECMO) in patients where conventional cardiopulmonary resuscitation (CCPR) measures are unsuccessful in achieving a sustained return of spontaneous circulation (ROSC) (Sustained ROSC is deemed to have occurred when chest compressions are not required for 20 consecutive minutes following cardiac arrest.).¹ The primary purpose of ECPR is to restore the circulation and gas exchange. By providing organ perfusion, it provides time for the delivery of interventions necessary to regain an adequate native circulation. These may include percutaneous coronary intervention (PCI) and recovery from myocardial stunning, pulmonary thrombectomy, rewarming, or toxin clearance.

Extracorporeal cardiopulmonary resuscitation is a time-sensitive, complex intervention that requires teamwork, clearly defined roles, and well trained healthcare providers.² Extracorporeal cardiopulmonary resuscitation can be deployed both for patients with in-hospital cardiac arrest and out of hospital cardiac arrest (OHCA). ECPR should be considered after 10–15 minutes of unsuccessful conventional resuscitation efforts,² because organization and preparation for ECPR will take some time and it has been clearly shown that time to ECMO correlates with neurologic outcome.^3,4

Currently, there are no published randomized controlled trials comparing outcomes of ECPR to CCPR. Observational studies comparing ECPR to historical controls and case matched controls have demonstrated favorable results for ECPR.^5–9 However, these studies are heterogeneous and survival ranges from 15% to 50%. Among adult ECPR patients recorded in the international ELSO dataset, survival to hospital discharge is 29%.¹⁰

At the time being, we do not know whether the number of neurologic injured patients will increase with growing use of ECPR. A major task for the future will be to develop better neuroprognostication tools. In the current observational studies in selected populations,^5,8–10 >85% of survivors of cardiac arrest treated with ECPR had neurologic outcomes fall into favorable neurologic performance categories (cerebral performance categories 1 or 2).^5,8,9 Future trials involving ECPR should endeavor to report neurologic outcomes as well as mortality.

This document contains numerous additional literature references, organized by topic, found in the Supplemental Digital Content 1, https://links.lww.com/ASAIO/A584.