This episode of PEM Currents discusses ECPR (Extracorporeal Cardiopulmonary Resuscitation), an advanced procedure used in cases of cardiac arrest when traditional CPR fails. ECPR involves using ECMO (Extracorporeal Membrane Oxygenation) to take over heart and lung functions, offering a last-resort option that is becoming more common in large pediatric hospitals. While ECPR shows promise in improving survival rates, particularly in pediatric patients with conditions like congenital heart disease, it is resource-intensive and carries significant risks. Establishing an ECPR program requires robust infrastructure, multidisciplinary teamwork, and extensive training. The episode highlights the importance of understanding eCPR as a critical therapy for both in-hospital and out-of-hospital cardiac arrests.
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References
Gajkowski EF, Herrera G, Hatton L, et al. ELSO guidelines for adult and pediatric extracorporeal membrane oxygenation circuits. ASAIO J. 2022; 68:133–152.
Stratton, M., & Edmunds, K. (2024). Extracorporeal Cardiopulmonary Resuscitation. Pediatric Emergency Care, 40(8), 618-622.
ECC Committee, Subcommittees, and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(suppl):IV1–IV203.
Yannopoulos D, Kalra R, Kosmopoulos M, et al. Rationale and methods of the advanced R2Eperfusion STrategies for refractory cardiac ARREST (ARREST) trial. Am Heart J. 2020;229:29–39.
Bartos JA, Yannopoulos D. Starting an extracorporeal cardiopulmonary resuscitation program: success is in the details. Resuscitation. 2023; 187:109792.
Transcript
Note: This transcript was partially completed with the use of the Descript AI
Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and this episode is all about eCPR, an emerging, resource intensive, but life saving technique that can be activated in situations where there was a witnessed out of hospital cardiac arrest with continuous CPR in process or an in hospital cardiac arrest.
Now, I know that this isn’t readily available, but it is becoming more common in large children’s hospitals, and I thought that this would be a good time to share an overview. So, eCPR, extracorporeal cardiopulmonary resuscitation, is an advanced medical procedure used in cases of cardiac arrest where traditional CPR has failed.
Refractory CPR is a situation where the team has not obtained return to spontaneous circulation in 30 minutes. Now, some centers are using 15 minutes in their guidelines, but 30 is what I’m familiar with. And here’s a basic overview of the eCPR process. So first, the patient has ongoing, high quality CPR.
Some sample objective markers of high quality CPR could include an end tidal CO2 greater than 10 millimeters of mercury, and or pH greater than 7, and or intermittent organized breathing. cardiac rhythms. If the patient meets criteria, then the multidisciplinary ECMO, extracorporeal membrane oxygenation team, is activated.
The patient will undergo cannulation, where large catheters are inserted into an artery and vein, like the femoral, to connect them to the heart lung machine. ECMO will take over the function of the heart and lungs, circulating and oxygenating the blood externally. The patient will remain on ECMO while the underlying causes of the cardiac arrest are addressed.
These could include severe sepsis. asthma, heart failure, and more. If the patient’s heart function recovers, they’re gradually weaned off of ECMO. If not, further interventions, including potential transplantation, may be considered. eCPR is typically performed in specialized centers with highly trained personnel in well coordinated teams.
It is a last resort for patients who would otherwise have a very low chance of survival. Now the evidence behind the benefits of eCPR are encouraging. There are some observational studies and meta analyses which generally support its use, showing increased survival rates in cases of refractory cardiac arrest.
One of the landmark studies, the ARREST trial, compared traditional CPR with early eCPR in adults and found significantly improved survival rates among those treated with eCPR. Now, this study did take place in a single center with a mature eCPR system already in place. So eCPR itself is not a standalone intervention.
It’s part of a comprehensive system of care that requires robust infrastructure and and coordination. When we turn the focus to pediatric patients, the data is unsurprisingly more limited, but compelling. For instance, eCPR is well established as a bridge therapy in pediatric patients with congenital heart disease and increasingly used in in hospital cardiac arrests.
One review of pediatric eCPR cases demonstrated a 73 percent survival rate, and the majority of these survivors maintained their pre arrest neurological baseline. And ultimately, Most of the data thus far is in in hospital arrest. And that makes sense. It’s easier, if easy is a relative term, to coordinate ECMO initiation when the patient is already in the hospital.
It’s much more logistically difficult when the patient arrests out of the hospital and then presents to the emergency department with CPR ongoing via EMS personnel and then to get transitioned to ECMO. And because this process is so resource intensive, It’s important to consider the risks, which are significant.
The process of cannulation itself, which again involves placing large bore catheters in arteries and veins to connect to the ECMO circuit, can lead to complications such as distal ischemia, thrombosis, and hemorrhage. Maintaining the ECMO circuit requires continuous monitoring on anticoagulation, adding additional layers of complexity and the concern of intracranial hemorrhage.
So again, that’s why eCPR is reserved for specific cases where the potential benefits clearly outweigh the risks and the patient meets the standardized criteria accepted by the facility in which it’s deployed. Now, where I work, we have eCPR available, but you may work at a place in which it’s not yet available or currently being developed.
The first and most obvious step is that the facility has to have an established ECMO center. Then developing an eCPR program involves building a comprehensive system of care that extends out into the community as well. So we need to include pre hospital providers, the emergency medicine teams. ECMO proceduralists, the ECMO perfusionists, and intensive care unit clinicians.
One of the key lessons from existing eCPR programs is the importance of rigorous training and simulation. So for instance, large scale simulation programs have been shown to improve adherence to activation protocols and reduce activation times. Of course, both of those are critical to the success of eCPR.
These simulations focus on the coordination of care across multiple divisions within the hospital, ensuring that everyone involved knows their role and can act swiftly when times of the essence. Looking forward, the future of eCPR is bright, but it needs to be available in more centers. We need to refine our systems of care and develop more precise inclusion criteria.
And to spread what has already been learned, about the rigorous simulation and systems based training. And of course, there needs to be more data on outcomes in pediatrics. Future prospective studies should focus on outcomes across a broad array of pediatric patients. This will provide the evidence needed for institutions to support the monumental financial and resource cost to set up eCPR programs in the first place.
Well, that’s all for this episode on extracorporeal cardiopulmonary resuscitation, eCPR. I hope that it provided a basic overview and some context. for this emerging therapy. eCPR is becoming more readily available, and we should all have an understanding of why it is such a pivotal therapy for in and out of hospital cardiac arrest in children.
If you have any feedback on this episode, or the show in general, send them my way. I’ll take an email, a direct message on X, or you can, as the kids say, send Like, rate, and leave a review, or if you found the content helpful, just share it with a colleague. And most of all, thank you for listening. I have been producing this podcast for a dozen years, and I continue to enjoy sharing new knowledge with all of you.
For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.
