Ins and Outs of Extracorporeal Cardiopulmonary Resuscitation (eCPR) service

Abstract

Sudden cardiac death is one of the leading causes of mortality across the Western world. Even in Europe, over 250,000 patients are affected by out-of-hospital cardiac arrest (OHCA) every year. Only 40% of patients received advanced Cardiopulmonary resuscitation (CPR) from experts and the survival of patients without neurological disability remained extremely low. Reduced no-flow time and low-flow time are the deciding factors that could improve outcomes for the patients with in-hospital cardiac arrest (IHCA) compared to OHCA. Veno-arterial extracorporeal membrane oxygenation (vaECMO) is a method to improve the survival of cardiac arrest patients. Extracorporeal cardiopulmonary resuscitation (eCPR) means the application of extracorporeal membrane oxygenation (ECMO) in patients where conventional CPR was unsuccessful in obtaining adequate return of spontaneous circulation (ROSC). The main objective of eCPR is to restore circulation and gas exchange for organ perfusion, and it allows for the time to be taken to prepare the patient for other major interventions, such as PCI. If eCPR could be initiated within the first hour after cardiac arrest, the outcomes could be significantly better. A list of inclusion and exclusion criteria is strictly to be considered as a relative criteria. The individual condition of the patient and the specific environmental factors have to be taken into account in order to make an appropriate decision of starting eCPR. Timing in eCPR is a crucial factor, which has been shown to have a massive impact on the outcomes of patients following cardiac arrest. Extracorporeal CPR might be most beneficial for patients who initially present with a shockable rhythm. The arterial pH as a surrogate for tissue damage due to prolonged anoxia before extracorporeal life support (ECLS) initiation is another important aspect. A pH below approximately 7.15 can be considered a specific and sensitive factor in predicting hospital mortality. Extracorporeal CPR is a resource-intensive therapy requiring specialized equipment and highly trained multidisciplinary experts. The implementation of prehospital ECLS performed by a trained team could significantly reduce the mean duration from advanced conventional cardiovascular life support to ECLS. Targeting CPR, which provides ECLS under permanent monitoring and consideration of special target values, maybe a promising approach in the future.

Since human organs for transplantations are rare and urgently needed, ECLS should not only be considered as a way to improve survival of patients but also in order to optimize potential for organ donation in patients with no chance of survival.