Establishing and Sustaining an ECPR Program

Abstract

The use of extracorporeal support after failed return of a spontaneous ciruculation during cardiopulmonary resuscitation (ECPR) is well described. There are 4 distinct phases for resuscitation with ECPR and the time spent in each phase is critical for successful outcome. Recommendations for ECPR previously published by the American Heart Association provide the context for implementing a consistent and well-rehearsed system for ECPR, by people with the knowledge, experience and resources to deploy ECPR in the most optimal time frame possible in selected patient populations. In this manuscript we review the current status of ECPR for acute cardiac failure and the components we believe are necessary to develop and sustain a reliable and resilient program.

Keywords: cardiac arrest; cardiopulmonary arrest; extracorporeal life support; reliability; resilience; resuscitation.

Figure 1

Intervals of resuscitation phases with conventional CPR and ECPR. A cardiac arrest event can be deconstructed in a pre-event interval (Interval −1), and 4 intervals following T = 0, the start of cardiopulmonary arrest (CPA). Interval 1 is the interval between the start of cardiopulmonary arrest and start of conventional cardiopulmonary resuscitation (CPR) measures, ideally less than 1 min. Interval 2 starts with the start of conventional CPR which includes C-A-B or A-B-C and if needed early defibrillation. During Interval 2, with ongoing high quality CPR, if there is no return of spontaneous circulation (ROSC) or the likelyhood of ROSC is low or if there are functional considerations that limit the effectiveness of conventional CPR, the decision to call for ECPR must be made (5–10 min from T = 0). Interval 3 starts with the launch of ECPR, while ongoing high quality conventional CPR continues. During Interval 3, a group page is used to deploy the team, prepare the cannulation location, notify the blood bank, move the patient in the correct location, position, prepare anatomical site for cannulation, cannulate artery and vein, prepare clear primed circuit. If there is no ROSC with ongoing conventional CPR, ECMO flow is started, pump flows are increased gradually. Interval 3 stops and Interval 4 starts when target flows are achieved to return of extracorporeal circulation (ROEC). If ROSC occurs during Interval 3, conventional CPR stops, and the intensive care physicians decides if the pharmacological support is sufficient to continue during the post-cardiac arrest phase, or if VA ECMO cannulation should still continue. A post-event debrief session is conducted after ROC (either once sustained ROSC or ROEC). Ideally Intervals 1+2+3 are 30 min or less.