**4. Contraindications**

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

out-of-hospital arrests [3, 4].

conventional CPR [10].

**3. Indications**

potentially reversible situations [5].

ence on meaningful outcomes after ECPR.

**2. ECPR is superior to conventional CPR**

perfusion while further treatment is explored.

tions" such as coronary interventions or thrombectomies [13].

cardiac arrest has been managed with out-of-hospital ECPR [4, 14].

ECPR literature is limited, more so for pediatrics. Reports are mainly single center experiences, registry retrospective analyses, and a few meta-analyses. Small sample sizes and lack of standardization impede drawing conclusions on utilization and care processes for ECPR. Regardless, utilization of ECPR continues to expand. The Extracorporeal Life Support Organization (ELSO) reports more than a total of 10,000 ECPR patients since 1990, of which more than 5000 are pediatric or neonatal runs [2]. ECPR cases make up approximately 10% of all ECMO runs recorded over this time frame. Most ECPR cases originate in the intensive care unit, but there is growing literature demonstrating widening the use to emergency room arrests and

With expanding application, ECPR has shown promise to improve outcomes of cardiac arrest. ELSO recognizes that ECMO can be considered for select patients in cardiac arrest. In 2015, the American Heart Association (AHA) cautiously pointed out that while the evidence is still lacking, ECPR may reasonably be considered in

This chapter explores the current utility of ECPR, and provides a literature summary of its indications and limitations. The chapter will also describe current use and outcomes in adults and children. Finally, complications of ECPR will be reviewed. A special focus will highlight neurologic complications and their influ-

ECPR use for victims of cardiac arrest consistently demonstrates a survival benefit over conventional CPR [5–8]. This survival benefit is more pronounced as the duration of CPR increases. In contrast to arrest survivors who only receive conventional CPR, patients rescued with ECPR have higher survival rates at discharge and at 6-12 months post discharge [9]. Arrest victims rescued with ECPR are also more likely to have better neurologic outcome, when compared to patients rescued with

The goal of ECPR is to augment cardiac output during the low flow phase of CPR, restoring oxygenation and perfusion in the setting of cardiac arrest. In some cases ECPR alone may be therapeutic, and in other cases it allows maintenance of

At this time, no universal criteria exist for the deployment of ECPR. AHA recommendations are limited to heart disease amenable to either recovery or transplantation, in a setting where the arrest occurs in a highly supervised environment [11]. Their only other recommendation is for use in out of hospital cardiac arrest in the setting of severe hypothermia if appropriate expertise, equipment, and protocols are available. ELSO recommends ECPR in arrest victims "with an easily reversible event and have had excellent CPR" [12]. The UK Resuscitation Council considers ECPR as a "rescue therapy for patients in whom initial ALS measures are unsuccessful to facilitate specific interven-

Centers that offer ECPR use center-specific processes, based on experience and availability of resources. ECPR is most commonly available to in-hospital cardiac arrest. Arrests in the emergency department can also be managed with ECPR. In some settings with appropriate resources, experience, and planning, out-of-hospital

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Contraindications to ECPR vary between institutions, and a unified consensus does not exist. ECMO-related prognostic factors in the current literature are unreliable with regards to ECPR outcomes. On their own, most of these factors do not provide sufficient evidence to support denial of life-saving ECPR to a victim of arrest. The only absolute contraindications to ECPR are the presence of a valid "Do Not Resuscitate" order and the absence of appropriate staff/equipment to initiate ECPR. All contraindications to ECMO use, such as extreme prematurity, also apply.

Otherwise, a range of situations can be proposed as relative contraindications for ECPR:


**Figure 1.**

*Estimated survival rates for extracorporeal membrane oxygenation (ECPR) patients after every given low-flow time (red line). Survival with conventional CPR (dashes) is demonstrated as a comparison. Wengenmayer T, et al. Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation Crit Care. 2017;21(1):157. Published under terms of the Creative Commons Attribution 4.0 International License.*

#### **5. The ECPR experience**

According to recent reviews of the ELSO registry, ECPR is currently most commonly used in patients who suffer cardiac arrest secondary to a primary cardiac cause [7]. This is independent from patients who fail to wean off cardiopulmonary bypass. These patients include arrests post cardiac surgery, such as surgery for congenital heart disease (CHD). CHD patients rescued with ECPR include both single and two-ventricle patients. This cardiac cohort also includes patients with structurally normal hearts but develop heart failure in the setting of myocarditis, cardiomyopathy, arrhythmias, pulmonary arterial hypertension, and heart transplant graft failures.

A variety of non-cardiac causes of arrest have also been supported by ECPR. These include arrests in the setting of septic and other forms of noncardiogenic shock. Arrests that occur in the setting of pneumonia, ARDS, acute airway compromise, toxic ingestions, severe hypothermia, and trauma have also been supported with ECPR.

In some situations where the cause of arrest is unclear, ECPR allows for preserving the patient while the diagnosis can be clarified. For example, ECMO support allows for time to perform head imaging or other diagnostic testing that helps with clarifying treatment or prognostication. If a negative prognosis is uncovered, there is time to involve palliative care, if desired, and allows family another opportunity for closure.

Some institutions have reported ECPR use as a temporary measure for organ perfusion while organ procurement organizations work to facilitate organ placement [18, 19]. This is usually in situations where brain death is quickly identified after placement on ECMO. Viability of the organs is preserved, and the transplanted organs have a high rate of good functional recovery [20].

#### **6. Application of ECPR**

#### **6.1 Process**

The real-life application of ECPR varies between centers [21]. At a minimum, a core group that consists of a code team, a cannulation team (surgeon

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**6.2 ECMO cannulation**

venous drainage can be added.

**6.3 Initial management: post arrest care**

*Extracorporeal Cardiopulmonary Resuscitation DOI: http://dx.doi.org/10.5772/intechopen.83658*

reported experiences follow a similar algorithm.

or interventionalist to cannulate), and an ECMO specialist must be available. Support staff including additional nursing, pharmacy, and OR staff may be needed. Location of the cannulation procedure will depend on center experience and appropriateness of available space. For example, the procedure can happen in the intensive care unit, in the catheterization lab, or in the operating room. Some centers have reported experience with cannulating in other locations, such as in the emergency department, in the IR suite, or on regular hospital wards. Most

Cannulation technique for ECPR depends on anatomy, experience and training of the cannulating provider, and circumstances necessitating support [22]. In almost all cases, ECPR patients require VA cannulation. If the patient has an open sternum, central cannulation is the easiest approach. In smaller children, the right carotid artery and internal jugular vein are the most common choice. In adults and adult-sized children, femoral cannulation is technically feasible. Femoral cannulation can limit the no-flow time due to minimal or no interruptions in compressions. Placed cannulas should support at least 120-150 mL/kg/min flow in order to provide an appropriate cardiac index in smaller children. In larger children and adults, the cannulas should support 3.5 to 5 L/min depending on the underlying etiology of cardiac arrest. If cannula sizes are deemed to be insufficient for flow, additional

The goal of post arrest care is to safeguard neurologic function and prevent secondary organ injury, while working towards the diagnosis and management of *Extracorporeal Cardiopulmonary Resuscitation DOI: http://dx.doi.org/10.5772/intechopen.83658*

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

According to recent reviews of the ELSO registry, ECPR is currently most commonly used in patients who suffer cardiac arrest secondary to a primary cardiac cause [7]. This is independent from patients who fail to wean off cardiopulmonary bypass. These patients include arrests post cardiac surgery, such as surgery for congenital heart disease (CHD). CHD patients rescued with ECPR include both single and two-ventricle patients. This cardiac cohort also includes patients with structurally normal hearts but develop heart failure in the setting of myocarditis, cardiomyopathy, arrhythmias, pulmonary arterial hypertension, and heart trans-

*Estimated survival rates for extracorporeal membrane oxygenation (ECPR) patients after every given low-flow time (red line). Survival with conventional CPR (dashes) is demonstrated as a comparison. Wengenmayer T, et al. Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation Crit Care. 2017;21(1):157. Published under terms of the Creative Commons Attribution 4.0 International License.*

A variety of non-cardiac causes of arrest have also been supported by ECPR. These include arrests in the setting of septic and other forms of noncardiogenic shock. Arrests that occur in the setting of pneumonia, ARDS, acute airway compromise, toxic ingestions, severe hypothermia, and trauma have also

In some situations where the cause of arrest is unclear, ECPR allows for preserving the patient while the diagnosis can be clarified. For example, ECMO support allows for time to perform head imaging or other diagnostic testing that helps with clarifying treatment or prognostication. If a negative prognosis is uncovered, there is time to involve palliative care, if desired, and allows family another opportunity

Some institutions have reported ECPR use as a temporary measure for organ perfusion while organ procurement organizations work to facilitate organ placement [18, 19]. This is usually in situations where brain death is quickly identified after placement on ECMO. Viability of the organs is preserved, and the transplanted

The real-life application of ECPR varies between centers [21]. At a minimum, a core group that consists of a code team, a cannulation team (surgeon

organs have a high rate of good functional recovery [20].

**5. The ECPR experience**

**Figure 1.**

plant graft failures.

for closure.

**6.1 Process**

been supported with ECPR.

**6. Application of ECPR**

**128**

or interventionalist to cannulate), and an ECMO specialist must be available. Support staff including additional nursing, pharmacy, and OR staff may be needed. Location of the cannulation procedure will depend on center experience and appropriateness of available space. For example, the procedure can happen in the intensive care unit, in the catheterization lab, or in the operating room. Some centers have reported experience with cannulating in other locations, such as in the emergency department, in the IR suite, or on regular hospital wards. Most reported experiences follow a similar algorithm.

### **6.2 ECMO cannulation**

Cannulation technique for ECPR depends on anatomy, experience and training of the cannulating provider, and circumstances necessitating support [22]. In almost all cases, ECPR patients require VA cannulation. If the patient has an open sternum, central cannulation is the easiest approach. In smaller children, the right carotid artery and internal jugular vein are the most common choice. In adults and adult-sized children, femoral cannulation is technically feasible. Femoral cannulation can limit the no-flow time due to minimal or no interruptions in compressions. Placed cannulas should support at least 120-150 mL/kg/min flow in order to provide an appropriate cardiac index in smaller children. In larger children and adults, the cannulas should support 3.5 to 5 L/min depending on the underlying etiology of cardiac arrest. If cannula sizes are deemed to be insufficient for flow, additional venous drainage can be added.

#### **6.3 Initial management: post arrest care**

The goal of post arrest care is to safeguard neurologic function and prevent secondary organ injury, while working towards the diagnosis and management of


#### **Table 1.**

*Post arrest care.*


**Table 2.** *Monitoring modalities.*

the cause of arrest. The AHA recommends adopting a systems-based, protocolized, goal-directed approach to the management of post-arrest patients [23]. This includes ECPR patients.

**Table 1** highlights the most important care recommendations from the AHA, and **Table 2** includes monitoring modalities to be considered. These are based on the best available evidence, which may be limited to expert opinion in some cases. All recommendations are continuously reviewed and updated by the AHA as more evidence becomes available.

#### **6.4 Initial management: A systems approach**

Critical care management of post-ECPR ECMO patients should involve a multidisciplinary team that includes ECMO nurse/therapist, bedside staff, intensivists, and surgeons. Post arrest management should be implemented per local protocols. Like all ECMO patients, sedation, ventilation, anticoagulation, nutrition, and infection control should be cautiously monitored:

1.Neurological/Sedation: Soon after resuscitation, it is imperative to determine the patient's neurologic status, as this will guide further decision making

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*Extracorporeal Cardiopulmonary Resuscitation DOI: http://dx.doi.org/10.5772/intechopen.83658*

formation.

trauma and bleeding.

dialysis must be considered.

**6.5 Initial management: Anticoagulation**

of keeping up-to-date with the literature.

and management. Close monitoring of the neurologic exam is imperative. Evaluate for signs of seizures, and EEG should be obtained if there is any suspicion. Near-infrared spectroscopy (NIRS) monitors can be used to follow cerebral oxygenation, possibly serving as an indicator of neurological activity and overall perfusion. In infants, routine bedside head ultrasounds should be considered, since these are simple and inexpensive assessments that can provide important information about development of neurologic injury. For all patients, head imaging such as with computed topography should be considered as indicated by exam and other clinical findings. Analgesia and sedation should be appropriately used to provide comfort; muscle relaxants use should

2.Cardiovascular: Continuous cardiac and hemodynamic monitoring is important. Peripheral perfusion should be monitored, especially in patients with femoral cannulation. Volume must be judiciously used to maintain cardiac preload. Systemic vascular resistance should be balanced to the patient's needs, with judicious use of inotropy if cardiac contractility needs augmentation. All patients should be monitored for need for LV decompression as discussed below. In patients with absent pulsatility, the LV must be monitored for clot

3.Pulmonary: Maintain functional residual capacity to facilitate oxygenation of pulmonary blood flow, balancing that with allowing for lung rest. Gentle pulmonary toilet is warranted, balancing secretion clearance with avoiding

4.Gastrointestinal/Renal: Nutrition should be considered as indicated; we promote early enteral feeding if able. Gastric drainage and stool output must be monitored for bleeding. Urine output should be monitored closely, with promotion of diuresis as needed. In case of renal failure, hemofiltration or

5.Infection: Routine indicators of infection are unreliable: vital signs are influenced or controlled by the circuit, and lab parameters can be affected by the circuit. Assessment of the patient must include diligent monitoring of all sites of cannula or line insertion, as well as all wounds. Routine monitoring of CBC with differential is recommended. Surveillance cultures, as well as antibiotic

Most ECMO centers have their own institutional protocols for ECMO anticoagulation, usually an amalgam of center experience, ELSO guidelines, and published literature. We suggest utilizing an anticoagulation expert when setting up such a protocol, and recommend reviewing institutional practices regularly with the goal

Anticoagulation in this patient population starts with the cannulation procedure. A bolus of unfractionated heparin (typically 50–100 units per kg) is given directly to the patient prior to cannula placement. Afterwards, an unfractionated heparin infusion is started, usually 28–30 units/kg/hr. in neonates and infants, and 20 units/ kg/hr. in larger children. Of note, neonates may need higher doses of unfractionated heparin secondary to naturally lower antithrombin III (ATIII) plasma concen-

trations. Less heparin may be required in patients who have a coagulopathy.

prophylaxis, should be done per institutional protocol.

be minimized to cases of safety or medical concerns.

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

**Management goal Reasoning**

Maintain normal oxygenation

Targeted temperature management

Maintain normotension

**Table 1.** *Post arrest care.*

the cause of arrest. The AHA recommends adopting a systems-based, protocolized, goal-directed approach to the management of post-arrest patients [23]. This

**Continuous telemetry Assists with close monitoring of rhythm status**

goal-directed normothermia.

neurologic and overall outcomes.

Maintain normocarbia Hypocapnia has been associated with worse outcomes in adults, and hypercapnia has been associated with decreased survival in pediatrics [24].

May be useful in identifying periods of increased vulnerability to

neurologic outcome. EEG data in this setting is limited but may be

useful in prognostication in consort with other criteria.

developing neurologic injury [28]

Elevated PO2 contributes to oxidative stress, and adult studies associate hyperoxia with decreased survival [24]. Hypoxia is associated with worse

Post-ROSC hypotension is associated with decreased survival to discharge and worse neurologic outcomes [25]. Severe hypertension may adversely affect cardiac output, and has also been associated with neurologic injury [26].

Aggressively avoid hyperthermia, which is associated with poor outcomes [27]. At this time, there is insufficient evidence to recommend hypothermia over

Electroencephalogram (EEG) Discontinuous or isoelectric tracings are associated with worse

Arterial blood pressure monitor Assists with close monitoring of hemodynamics thus avoiding hypotension

Continuous temperature monitor Rectal or bladder monitor: may allow for capturing temperature changes early

Exhaled CO2 monitor Allows for capturing CO2 changes early Continuous pulse oximetry Assists with maintaining normoxia

Central venous pressure monitor Assists with assessment of volume status

**Table 1** highlights the most important care recommendations from the AHA, and **Table 2** includes monitoring modalities to be considered. These are based on the best available evidence, which may be limited to expert opinion in some cases. All recommendations are continuously reviewed and updated by the AHA as more

Critical care management of post-ECPR ECMO patients should involve a multidisciplinary team that includes ECMO nurse/therapist, bedside staff, intensivists, and surgeons. Post arrest management should be implemented per local protocols. Like all ECMO patients, sedation, ventilation, anticoagulation, nutrition, and infec-

1.Neurological/Sedation: Soon after resuscitation, it is imperative to determine the patient's neurologic status, as this will guide further decision making

**130**

includes ECPR patients.

*Monitoring modalities.*

**Table 2.**

Cerebral NIRS (near-infrared spectrometry) monitor

evidence becomes available.

**6.4 Initial management: A systems approach**

tion control should be cautiously monitored:

and management. Close monitoring of the neurologic exam is imperative. Evaluate for signs of seizures, and EEG should be obtained if there is any suspicion. Near-infrared spectroscopy (NIRS) monitors can be used to follow cerebral oxygenation, possibly serving as an indicator of neurological activity and overall perfusion. In infants, routine bedside head ultrasounds should be considered, since these are simple and inexpensive assessments that can provide important information about development of neurologic injury. For all patients, head imaging such as with computed topography should be considered as indicated by exam and other clinical findings. Analgesia and sedation should be appropriately used to provide comfort; muscle relaxants use should be minimized to cases of safety or medical concerns.

