Guidelines for Starting Extracorporeal Cardiopulmonary Resuscitation (ECPR)

Definition and Purpose of ECPR

• The American Heart Association recommends the use of ECPR for patients with cardiac arrest refractory to standard ACLS, when provided within an appropriately trained and equipped system of care 1, 2, 3
• 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, with the goal of supporting end-organ perfusion while potentially reversible conditions are addressed 1

Patient Selection Criteria

• The American Heart Association recommends considering ECPR for cardiac arrest with potentially reversible etiology 4, 5
• Patients with initial shockable rhythm may have better outcomes compared to those with non-shockable rhythms 1
• Absence of severe irreversible brain damage and terminal malignancy are recommended criteria for ECPR 6

System Requirements

• The American Heart Association recommends that ECPR be performed within an appropriately trained and equipped system of care, with a highly trained team and specialized equipment 1, 2

Implementation Timing and Process

• ECPR should be considered after conventional CPR has failed to achieve ROSC, with a goal of increasing ECMO flow to 3-4 L/min after cannulation 1, 5, 7
• Arterial blood gases should be monitored from a right radial arterial line, and the arteriovenous O₂ difference should be maintained between 3-5 cc O₂/100ml of blood 7

Evidence Supporting ECPR Use

• Two randomized clinical trials have shown improved outcomes with ECPR, including the ARREST trial which demonstrated significantly improved survival to discharge and 6-month survival for patients receiving ECPR for refractory cardiac arrest with shockable presenting rhythms 1

Post-ECPR Management

• The American Heart Association recommends post-cardiac arrest care be titrated based on arrest etiology, comorbid disease, and illness severity, with early coronary angiography recommended for patients with suspected cardiac cause of arrest and ST-segment elevation on ECG 1, 8
• Targeted temperature management should be considered for comatose patients 8