ECPR
Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced form of life support when conventional cardiopulmonary resuscitation (CCPR) efforts fall short or are not sufficient enough to provide adequate support. Out of hospital cardiac arrest (OHCA) and in hospital cardiac arrest (IHCA) are associated with high mortality. In the instances where refractory cardiac arrest (r-CA) occurs, the case can be made that providing ECPR may be beneficial when inclusion criteria are met. A few important additional factors to consider come into play.
Discussion around what constitutes refractory cardiac arrest is ongoing. One study defines r-CA as cardiac arrest that persists despite continuous CCPR lasting 10-30 minutes or after three unsuccessful defibrillation attempts.
Each year, approximately 356,000 people suffer from OHCA, and 209,000 from IHCA in the United States. A systematic review and meta-analysis by D’Arrigo et al. reported that the overall survival to discharge of ECPR-treated IHCA patients was 37.7% and that 84.4% of survivors had good neurologic outcomes, whereas 17.7% IHCA patients treated with CCPR survived to discharge.
ELSO registry data demonstrates the increase of hospitals providing ECPR. In 2011, 208 ECMO centers were in existence around the world. Ten years later, the amount of centers providing ECLS more than doubled to 543. ECPR data also paints an interesting picture with 20,746 total cases worldwide, of which over half (12,990) have occurred within the last five years. Overall survival outcomes show that 10,449 (50%) survived ECLS and 7,345 (35%) survived to discharge or transfer. Regional ECPR data are presented below.
The awareness and implementation of ECPR is quickly gaining attention around the world with a focus of inclusion and exclusion criteria, along with program development and team training.
Current Data & Trends
Total ECPR Cases
Total ECPR Survival to Discharge %
Extracorporeal Cardio Pulmonary Resuscitation
ECPR Guidelines
Standardized guidelines are important to understand when evaluating a patient who may be a candidate for extracorporeal cardiopulmonary resuscitation. ELSO has formed helpful guidelines for Adult and Pediatric ECPR. Visit the resources below to review.
Hospital Readiness
Preparation as a medical institution for ECPR is complex and involves key stakeholders from many departments. As with ECMO program development, a full understanding of what is required to function with the capability to implement ECPR is essential.
Evaluate the following to identify hospital readiness:
Administration supportive of including ECPR into an ECMO program.
An organized structure in place for rapid ECMO team activation within the hospital.
A team of physicians who are trained and credentialed to cannulate.
A team of physicians who are trained to care for ECMO patients of all modalities, which includes providing interventions for any complications that occur when a patient is supported with ECLS.
An ECMO Specialist team trained and prepared to provide all aspects of care within the role for a patient supported with ECLS.
A nursing team able to effectively care for and provide direct patient management 24/7.
In the event that a medical institution does not provide full ECLS care with an established ECMO program, identification of need and the ability to transfer out to a higher level of care facility that is able to provide appropriate interventions to bridge the patient to full recovery is necessary.
Read more about ECMO program development here.
The value of appropriate team preparation and training to provide ECPR in a hospital or region is vital to longevity and positive patient outcomes.
Consideration of the following is recommended:
Identify a team who will care for and manage the patient supported with ECLS after ECPR.
Educate, train and prepare all involved team members.
Identify and implement organized systems for patient consult, evaluation, cannulation, initial care & management, ongoing care through either recovery to discharge or transfer to another facility.
Lead quarterly wet labs and simulation with all members of the ECPR team with a debrief to ensure appropriate processes, response times and management strategies are met for ECPR.
TEAM PREPARATION
ECPR Guide
Coming soon!
ECPR Articles
Prague OHCA Secondary Analysis
Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal.
Published August, 2022. Read here.
Prague OHCA Study
Extracorporeal versus conventional cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a secondary analysis of the Prague OHCA trial.
Published October, 2012. Read here.
The CHEER Trial
Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion.
Published October, 2014. Read here.
ArrestTrial
Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomized controlled trial. Published December, 2020. Read here.
EROCA
Extracorporeal cardiopulmonary resuscitation for Refractory Out of hospital Cardiac Arrest - results of a randomized feasibility trial of expedited prehospital transport.
Published 2021. Read here.
