Extracorporeal membrane oxygenation for cardiac arrest: what, when, why, and how

ABSTRACT

Introduction

Extracorporeal membrane oxygenation (ECMO) facilitated resuscitation was first described in the 1960s, but only recently garnered increased attention with large observational studies and randomized trials evaluating its use.

Areas Covered

In this comprehensive review of extracorporeal cardiopulmonary resuscitation (ECPR), we report the history of resuscitative ECMO, terminology, circuit configuration and cannulation considerations, complications, selection criteria, implementation and management, and important considerations for the provider. We review the relevant guidelines, different approaches to cannulation, postresuscitation management, and expected outcomes, including neurologic, cardiac, and hospital survival. Finally, we advocate for the participation in national/international Registries in order to facilitate continuous quality improvement and support scientific discovery in this evolving area.

Expert Opinion

ECPR is the most disruptive technology in cardiac arrest resuscitation since high-quality CPR itself. ECPR has demonstrated that it can provide up to 30% increased odds of survival for refractory cardiac arrest, in tightly restricted systems and for select patients. It is also clear, though, from recent trials that ECPR will not confer this high survival when implemented in less tightly protocoled settings and within lower volume environments. Over the next 10 years, ECPR research will explore the optimal initiation thresholds, best practices for implementation, and postresuscitation care.

KEYWORDS:

• Extracorporeal cardiopulmonary resuscitation
• extracorporeal membrane oxygenation
• extracorporeal life support
• cardiac arrest
• resuscitation

Article highlights

• While not a new technology, ECMO facilitated resuscitation has recently grown with large case series, new programs, and multiple randomized trials.

• Extracorporeal cardiopulmonary resuscitation (ECPR) can be performed by multiple providers and within multiple settings, including the emergency department, intensive care unit, and pre-hospital environments.

• The hemodynamic support provided by ECMO facilitates diagnostic studies and interventions to reverse the cause of cardiac arrest, that are otherwise difficult or impossible during conventional resuscitations.

• Ideal patients for ECPR are young and healthy with initial shockable rhythms and immediate high-quality CPR, who can be cannulated within 60 minutes. Many patients outside these strict characteristics may benefit from ECPR, though the expected survival may be less.

• ECPR programs are best developed from existing high volume ECMO programs. Expected survival will reflect patient selection and subsequent care. Survival in the international Extracorporeal Life Support Organization (ELSO) Registry is 30%.

• Participation in a standardized, multi-center quality reporting and/or data collection platform will facilitate outcome tracking, continuous quality improvement, and scientific advancement.

Declaration of interest

J Tonna is the Chair of the Registry Committee of the Extracorporeal Life Support Organization (ELSO). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Authorship

Study design: MB, CO, JT; Data acquisition and analysis: MB, CO; Drafting the manuscript: MB, CO, JT; JT revised the article for important intellectual content, and approved the final manuscript for publication.

Additional information

Funding

J Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute [K23 HL141596]. None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript.