ED-ECPR

The rapid institution of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for patients with prolonged, recurrent cardiac arrest (CA) complicated by severe shock and cases of refractory arrhythmia without return of spontaneous circulation (ROSC) is now termed ECMO-CPR (E-CPR). The use of E-CPR is increasing and there are reported benefits for both out-of-hospital and in-hospital patient populations. Recently, this service has been provided by staff from the hospital Emergency Department. It is likely that the best model of service provision for E-CPR depends on local factors. Currently, there is no unifying or accepted definition for E-CPR 1 and many case series reports include both patients with and without ROSC 2,3 . From analyses of outcomes from cardiac arrest data (without the use of ECMO), the likelihood of recovery from prolonged CA beyond 20 min is negligible for both in- and out-of-hospital populations, and this seems to be a reasonable threshold for the classification of ECMO-CPR. There is a strong correlation in case series between the CPR time and the survival from ECMO with long-term survival without neurological injury becoming rare if CPR has extended beyond 60 min. The SAVE-J study is the best evidence for the use of E-CPR for out-of-hospital cardiac arrests. This large prospective (non-randomized) cohort study showed that good neurological outcome at 6 months occurred in 12.3% of patients who received E-CPR and in 1.5% of patients who did not have access to ECMO following prolonged CA. 2 Propensity studies of retrospective case series suggest that neurological injury (but not survival) may be improved by the use of E-CPR in the in-hospital setting 4 . Attempts to delineate risk prediction algorithms for in-hospital cardiac arrest have consistently identified advanced age and an initial cardiac arrest rhythm other than ventricular tachycardia (VT) or ventricular fibrillation (VF) as highly predictive of poor outcome. E-CPR should be predominately used for younger patients with VT/VF arrests, where there is access to early coronary investigation and intervention and the time to ECMO can be less than one hour. 5 While temperature control is vital in the first 36 h following cardiac arrest, hypothermia is no longer considered beneficial. Partial pressure of oxygen and carbon dioxide may have effects on neurological outcome following cardiac arrest, but more investigation is currently underway. E-cpr Is Not The Same As “Fast” Va Ecmo: The technical skills, equipment preparedness, staffing, and staff training required for an E-CPR program are different from those required for non-CA ECMO initiation. An E-CPR program should work in concert with medical emergency teams that provide early patient assessment for deteriorating patients.