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to conventional CPR regardless of the rhythm , there was a greater benefit in patients with an initial shockable rhythm [ 6 ]. The methodology in these clinical trials has an important impact on their findings ; as a result , despite conflicting data , many providers still feel ECPR has a role in appropriately selecting patients .
Consequently , many centers are expanding their extracorporeal membrane oxygenation ( ECMO ) programs to include ECPR . However , given the resource-intensive nature of ECPR , including the requirement for 24 / 7 availability of both ECMO specialists and cannulating physicians , and ongoing uncertainty regarding the best ways to implement ECPR , the growth of ECPR has been variable . Many ECMO centers do not have established ECPR programs , as current literature is inconsistent , resource allocation is significant , bed availability is often limited , and staffing may be insufficient to support such a program . Despite these limitations and uncertainty , we propose that highvolume ECMO centers should consider establishing a limited ECPR program based on local cardiac-arrest care needs using the strategy implemented at our center even in the absence of pre-existing 24 / 7 cannulation capacity .
Description
We propose three specific recommendations for ECMO programs as they seek to develop an ECPR program . First , it is most effective to focus ECPR development at centers with larger ECMO volumes , since adult ECMO patients at centers with greater than 30 annual ECMO cases have been shown to have improved survival rates [ 7 ]. Furthermore , a recent analysis of the Extracorporeal Life Support Organization Registry found a possible survival benefit among ECPR patients who received ECPR at centers with greater than 12 ECPR cases per year [ 8 ]. We recommend that the development of ECPR programs be focused at high-volume centers ( those centers with greater than 30 ECMO cases per year ), such as our center .
Second , given the inherent logistical challenges in offering ECPR , we propose that high-volume ECMO centers can begin building an ECPR program by offering ECPR when ECMO specialists and the cannulation team are generally already in-house , such as during regular daytime hours . This “ part-time ” approach to ECPR delivery allows institutions to carefully select cases and begin to develop the protocols and infrastructure to support such patients . Such infrastructure could then be used to justify the resources and staffing required to create a comprehensive , 24 / 7 ECPR program .
Third , it is crucial for every ECPR program to have precise selection criteria and protocols . There is currently insufficient evidence to establish universal selection criteria for ECPR [ 1 ], however , certain principles do exist that can inform initial program development , which are summarized in Table 1 . Here , we present two cases considered for ECPR that we believe reflect these principles and demonstrate that offering such a service is both realistic and beneficial to select patients .
Case 1 : In-Hospital Cardiac Arrest ( IHCA )
A male patient in his 50s with a history of hypertension presented to the emergency department with chest pain . During
Table 1 . Suggested selection criteria for new ECPR programs .
No-flow time Low-flow time Witnessed and unwitnessed arrests
Age Initial cardiac rhythm
triage , the patient went into VF , and Advanced Cardiovascular Life Support ( ACLS ) was initiated . ROSC could not be obtained despite nearly 15 attempts at defibrillation and ongoing CPR , and the patient was emergently placed on peripheral venoarterial ( VA ) -ECMO . He ultimately received approximately 50 min of CPR prior to achieving full VA-ECMO support . The patient went emergently to the catheterization laboratory , where he was found to have an occluded proximal left anterior descending artery ( LAD ). In the catheterization lab , a drugeluting stent was placed in the LAD and an Impella CP was placed for left ventricular unloading . Immediately after revascularization , he was successfully defibrillated into normal sinus rhythm . The patient underwent targeted temperature management to 36 ° Cfor24h .
His overall hospital course was complicated by cardiogenic shock , the placement of a semi-permanent pacemaker due to persistent bradycardia , hypoxic-ischemic encephalopathy , agitation , pneumonia , and tracheostomy placement in the setting of acute respiratory failure . After approximately 72 h of support , both the Impella CP device and VA-ECMO circuit were removed .
His tracheostomy site was decannulated and he was discharged on hospital day 33 . At follow-up , he is fully independent in activities of daily living , driving , and has returned to work consistent with a Cerebral Performance Category of 1 .
Case 2 : Out-of-Hospital Cardiac Arrest ( OHCA )
A female patient in her 20s , G1P0 at 7 weeks gestation , with a history of pulmonary embolism and a hypercoagulable state , was prescribed enoxaparin sodium for anticoagulation , but due to insurance issues had a lapse in adherence . She presented emergently by ambulance after being found down . Emergency Medical Services ( EMS ) initially reported a bradycardic rhythm , but during transport , she became pulseless . An ACLS response for pulseless electrical activity arrest was initiated and a LUCAS device was placed for mechanical chest compressions . Unfortunately , due to the rural location of the patient , the time between her initial pulselessness and her arrival at the ECMO center was prolonged to approximately 60 min .
A shock team consult was emergently performed . On further history , the patient may have had approximately 20 min of cardiac arrest without bystander CPR before pulselessness was recognized . She then had CPR for an additional 40 min . Ultrasound evaluation showed thrombosed femoral arteries bilaterally and the decision was made to end all resuscitative measures and the patient expired .
Discussion
5 min or less 60 min or less Witnessed arrests with bystander CPR Under 60 / 65 years Shockable rhythms
These two cases highlight key selection criteria and features of developing a successful ECPR program . In developing an