**1. Background**

ECMO, or extracorporeal membrane oxygenation, is an advanced life support technique that provides cardiac and pulmonary support similar to cardiopulmonary bypass. Venous blood is drained and pumped through a membrane where gas exchange occurs. Oxygenated blood is returned back to the patient either through venous circulation in VV-ECMO (venovenous ECMO) or arterial circulation in VA-ECMO (venoarterial ECMO).

ECPR (extracorporeal cardiopulmonary resuscitation) is the rapid deployment of VA-ECMO during cardiopulmonary resuscitation (CPR) when conventional CPR fails to provide return of spontaneous circulation (ROSC) [1]. The first reported use of ECMO in CPR was in 1976. Since then, the use of ECPR has become welldescribed in adults and children, with a continuously expanding list of diagnoses.

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

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 potentially reversible situations [5].

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 influence on meaningful outcomes after ECPR.

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

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 conventional CPR [10].

### **3. Indications**

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 perfusion while further treatment is explored.

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

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

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

and expected quality of the child's life.

appropriate choice should the patient arrest.

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

1.Severe neurological impairment prior to cardiac arrest: Exact definitions of impairment will vary between providers and institutions. In a similar vein, conditions that place a patient at high risk for severe neurologic injury despite good CPR (such as severe primary pulmonary hypertension or patients with cavopulmonary circulation) may be a reason to not offer ECPR. Determinations to preclude a child from ECMO candidacy may involve a discussion with family, and should contain an understanding the perceived

2.Known irreversible disease process: When cardiac arrest occurs in the setting of a known irreversible and untreatable disease process, ECPR will only prolong suffering. Providers must work with the appropriate subspecialists to understand primary disease prognosis in order to determine if ECPR is an

3.Severe immunosuppressed state: While literature is limited, certain groups of severely immunocompromised patients tend to do worse on ECMO. Patients with immunosuppression in the setting of solid organ transplantation or highdose steroid regimens may have outcomes comparable to the general population. In contrast, patients with solid tumors, hematological malignancies, or acquired immunodeficiency syndrome (AIDS) do much worse on ECMO. In one study, survival to discharge was 7–20% [15]. This highlights the need to understand primary disease prognosis, and determine ECMO candidacy prior

4.Severe coagulopathy: Management of ECMO post-resuscitation requires use of anticoagulation to maintain appropriate circuit function. In cases of severe coagulopathy, the physician must balance the management of the coagulopathy and the circuit anticoagulation. If the coagulopathy is difficult to treat,

devastating and fatal hemorrhagic side effects may occur [16].

time. This decision will also likely be patient-dependent.

5.Prolonged total arrest time: There is no consensus on a cut-off time, but as shown in **Figure 1**, prolonged low-flow states are associated with lower survival [17]. Neurologic outcomes are also worse. The impact is magnified if combined with failure to initiate chest compressions in a timely fashion after arrest. While a prolonged resuscitation may be not futile, each institution must consider its capabilities and available resources before establishing a cutoff

6.Lack of access for cannulation: Anatomic or other vascular anomalies that preclude successful cannulation render a patient a non-candidate for ECPR.

**4. Contraindications**

for ECPR:

to arrest.
