Extracorporeal Cardiopulmonary Resuscitation, are we choosing the right patients?

Background: Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an emerging treatment for cardiac arrest refractory to conventional CPR. Despite accepted criteria for ECPR [age<60, witnessed arrest and immediate bystander CPR, 30 minutes or less from beginning of CPR to extracorporeal membrane oxygenation (ECMO) connection, no severe co-morbidity, reversible cause] choosing the right patients for this procedure can be challenging.

Methods: An observational study of 23 consecutive patients who were considered for ECMO during active CPR, including 12 patients who received ECMO (9 for in hospital and 3 for out of hospital cardiac arrest) and 11 patients for whom ECMO was declined. The aim of the study was to examine the selection criteria and mortality rate after ECPR.

Results: Of the 12 ECMO patients, 2 (17%) survived. All patients for whom ECMO was declined died. Among the ECMO patients who died, severe co-morbidities were presented in 4 patients, non-reversible causes of cardiac arrest in 5 patients, ECMO delayed beyond 60 minutes in 5 patients and no bystander CPR in 1 patient. (Each patient could have more than one reason per patient). Reasons that ECMO was declined included prolonged CPR (6 patients), advanced age (1 patient), severe comorbidity (5 patients), irreversible cause (3 patients) and unwitnessed arrest (4 patients).

Conclusion: The findings indicate that while exclusion criteria are used to appropriately decline ECMO for some patients during CPR, other patients are provided with ECMO despite the presence of contraindications which were not discovered prior to ECMO. Despite the urgency and difficulty of making decisions during resuscitation, choosing the "right" patients is essential to achieve a reasonable success rate.