Extracorporeal Cardiopulmonary Resuscitation (ECPR) Guidelines

Introduction to ECPR

• The American Heart Association recommends the use of ECPR in selected patients with cardiac arrest when provided within an adequately trained and equipped system of care, with a Class 2a, Level of Evidence B recommendation 1
• ECPR is a complex intervention that requires highly trained equipment, specialized equipment, and multidisciplinary support within the healthcare system 2

Patient Selection for ECPR

• Patients between 18-75 years old with cardiac arrest of cardiac origin, conventional CPR for more than 10 minutes without ROSC, and a potentially reversible condition may be considered for ECPR 2
• Patients with fewer comorbidities and younger age may also be considered for ECPR 3

ECPR Implementation and Outcomes

• The use of ECPR for patients with refractory cardiac arrest is reasonable in selected patients when provided within an adequately trained and equipped system of care, with a Class 2a, Level of Evidence B recommendation 1
• The ARREST study demonstrated significantly improved survival to discharge and at 6 months for patients who received ECPR for refractory cardiac arrest with initial defibrillable rhythms 1
• The Hyperinvasive study included patients with all initial rhythms and required only 5 minutes of ACLS before enrollment, showing a neurologically favorable survival at 180 days of 22% in the standard ACLS group 1

Special Considerations for ECPR

• During cardiac catheterization, it is reasonable to use ECPR as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during the procedure (Class 2b, LOE C-LD) 4
• ECPR should be implemented within a program that achieves excellence in all links of the Chain of Survival 1
• Ethical and practical aspects should be considered to determine which patients should receive ECPR support 4

Ventilation Strategies After ECPR

• After achieving ROSC, a lung-protective ventilation strategy with a PEEP of 5-10 cmH2O and target tidal volumes of 6-8 mL/kg of predicted body weight may be used 5, 6, 7
• The American Heart Association recommends minimizing or eliminating PEEP during cardiac arrest resuscitation to prevent hemodynamic compromise, with brief disconnection from the ventilator circuit recommended when auto-PEEP is suspected 5
• To minimize auto-PEEP, consider using smaller tidal volumes (6-8 mL/kg), maintaining slower respiratory rates, and considering permissive hypercapnia, which can reduce the risk of barotrauma and improve outcomes 5
• For patients with asthma or COPD who develop cardiac arrest, using even lower respiratory rates and tidal volumes, and allowing longer expiratory times can help prevent air trapping 5
• The following situations have recommended PEEP levels:

5, 6

• Monitor for signs of hemodynamic compromise with PEEP, and assess for adequate oxygenation (target SaO2 92-97%), and avoid hyperventilation with hypocapnia as it may worsen global brain ischemia through cerebral vasoconstriction (Class III, LOE C) 6, 7