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ECPR program , high-volume ECMO centers can begin to offer ECPR assessments during the hours when ECMO specialists ( such as perfusionists ) and cannulating physicians are already in-house , as in these cases . By offering ECPR services during selective hours , high-volume ECMO centers can begin to establish positive outcomes and the infrastructure required for ECPR . At our center , ECPR evaluations are offered during weekday daytime hours , which is when both perfusionists and cannulating physicians are in-house . Staffing has been organized to ensure a cannulating physician is always available outside of the operating room during this period to provide these services . To facilitate greater utilization of ECPR evaluations , we have publicized the availability of this service to hospital staff , and we encourage clinicians to contact the ECPR team early even if there is uncertainty regarding the patient ’ s candidacy for ECPR . We recommend teams call for an ECPR evaluation within 5 min of cardiac arrest for any patient without clear contraindications to ECPR .
When considering staffing for a new ECPR team , we recommend including an intensivist , perfusionist , cannulating physician ( typically a cardiac surgeon ), and a cardiologist ( either a critical care cardiologist or a heart failure cardiologist ). These roles may overlap with preexisting cardiogenic shock teams , and combining these two teams is an efficient method of staffing a new ECPR program . When considering bed and ECMO capacity for a new program , we suspect that annual ECMO volume is an effective indicator of readiness to start a new ECPR program , as high annual ECMO volume implies capacity and familiarity to treat this population of patients .
In general , it would be advisable to have at least three ECMO circuits available prior to starting a part-time ECPR program , to ensure capacity for at least two simultaneous patients and one backup circuit . For those ECMO centers without cardiogenic shock teams , the development of a new ECPR program should occur in concert with other efforts to improve the care of patients who require any form of temporary mechanical circulatory support . Once established , a successful part-time ECPR program can look to measures of ECPR volume to assess readiness for a full-time ECPR program , as a high monthly volume of ECPR cases may indicate a sufficiently high case volume to justify full-time ECPR services .
To improve ECPR outcomes , several factors should be carefully considered during the assessment process and built into protocols ( Table 1 ): time without CPR (“ no-flow ” time ), time with CPR (“ low-flow ” time ), shockable rhythm , age , and witnessed collapse [ 9 ]. The importance of no-flow time is reflected in these two cases , as the IHCA patient experienced extremely short no-flow time , while in the OHCA case , no-flow time was prolonged . In cases where no-flow time is clearly discernible , we recommend including upper limits on no-flow time , such as 5 min [ 9 ]. Other centers have made a witnessed cardiac arrest with bystander CPR a requirement for ECPR consideration , which is a reasonable requirement for nascent programs building protocols and optimizing outcomes [ 10 ]. Similarly , limiting low-flow time to under 60 min has been associated with positive ECPR outcomes [ 9 ]. In cases of OHCA , close coordination with EMS is required when developing ECPR programs to ensure appropriate patient selection and rapid transfer of care . Given evidence of improved outcomes at centers with dedicated post-cardiac arrest services , it is crucial to coordinate the transport of patients quickly to such a center [ 10 ].
Finally , these two cases highlight the importance of integrating shock and cannulation teams early . We suggest that ECPR teams should be notified of potential OHCA patients prior to patient arrival if feasible . Notifying the ECPR team after initial resuscitative efforts are unsuccessful introduces significant delays in ECPR that can negatively affect outcomes , and we suggest early evaluation , such as within 5 – 10 min of CPR initiation , even if the patient ultimately achieves ROSC and does not require ECPR . This is a particularly useful approach in the setting of reversible causes of cardiac arrest , as demonstrated in the IHCA case . Regarding other potential prognostic factors ( such as age and shockable rhythm ) [ 9 ], centers elsewhere have incorporated these factors into their ECPR protocols . Early ECPR programs may choose to focus a program on patients under the age of 60 / 65 years old and those with a shockable rhythm [ 10 ]. These protocols should be continuously modified to reflect both institutional trends and the most recent evidence regarding ECPR .
These two cases serve as illustrative examples of how a high-volume ECMO center can start an ECPR program . In summary , we recommend building ECPR programs at highvolume ECMO centers ; such programs may initially exist as part-time programs with strict patient selection criteria , with the anticipation of program evolution as the literature in this space develops . Through this process , ECMO centers can develop protocols , local expertise , and the infrastructure needed to care for these complex patients . Over time , through a successful “ part-time ” ECPR program , institutional support may develop to support fully comprehensive ECPR services that can evolve in concert with changing clinical evidence .
Acknowledgements . The authors would like to acknowledge the Cardiovascular Critical Care department , Cardiovascular Medicine department , and Cardiac Surgery department for their support in the development of an ECPR program at our ECMO center . We would also like to acknowledge other support departments including palliative care , physical therapy , occupational therapy , nutritional specialists , and our entire nursing community .
Conflict of interest The authors declare that there is no conflict of interest .
Funding
This research received no specific grant from any funding agency in the public , commercial , or not-for-profit sectors .
Data availability All data are included or referenced within the article .
Ethics Ethical approval was not required .