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Extracorporeal Cardiopulmonary Resuscitation in pediatric patients: recent evidence & recommendations

Extracorporeal cardiopulmonary resuscitation, ECPR, is rapid-deployment of veno-arterial extracorporeal membrane oxygenation, ECMO, to provide circulatory support, maintaining systemic perfusion, in the setting of patients suffering refractory cardiac arrest, in whom ongoing conventional cardiopulmonary resuscitation (CPR) is unsuccessful in achieving return of spontaneous circulation (ROSC). In just published recent scientific statement from the American Heart Association on Cardiopulmonary Resuscitation in infants and children with cardiac disease, AHA reports growing use of ECLS in adults and children for treatment of refractory in-hospital cardiac arrest, IHCA. An entire section of the free open access paper focus on recommendations about Mechanical Support in unstable & cardiac arrest pediatric patients. According to AHA, it seems reasonable to initiate ECLS in the child with heart disease in cardiac arrest, if rapid ROSC has not been achieved with CPR (Class IIa; Level of Evidence C). In proper high-resource settings, ECPR can be effective to improve survival in children with heart disease (Class IIa; Level of Evidence B). The possibility to rapidly access the ECMO equipment, the presence of skilled team and proper scene to accommodate them, are factors which could improve ECPR effectiveness (Class IIa; Level of Evidence C).
In particular, the AHA recommendations report available evidence (or lack/absence of evidence) on:

  • impact of duration of conventional CPR before extracorporeal support
  • ECPR deployment location
  • vessels used for ECLS cannulation
  • extracorporeal circuit and management
  • ECMO team & training issues
  • ECLS complications and outcomes
  • hypothermia post ECPR
  • extracorporeal support (in low DO2) or extracorporeal CPR (in cardiac arrest) in single-ventricle CHD after stage 1 Norwood palliation andSuperior CPA/Fontan circulation.

Another recent paper, a retrospective review (Torres-Andres 2018), investigates on factors associated with survival and long term functional outcomes (quality of life) in children treated with ECPR after in-hospital or out-of-hospital, integrating evidence supporting early implementation of extracorporeal support following in-hospital cardiac arrest (IHCA) (still no evidence after out-of-hospital cardiac arrest - OHCA). The article has been critically and extensively evaluated in a nice example of post-publication peer-review through Social Media (Sloniewsky 2018).

In picture 1, the ELSO registry data about neonatal and pediatric ECPR runs and survival (ELSO 2018). In picture 2, cannulation strategies for ExtraCorporeal Cardiopulmonary Resuscitation (Marino BS et al. Circ 2018).

foto 11. ELSO registry data about neonatal and pediatric ECPR (ELSO 2018).

 

foto 22. Cannulation strategies for ExtraCorporeal Cardiopulmonary Resuscitation (Marino BS et al. Circ 2018).

References

Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, et al; American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. 2018 Apr 23. open access
Torres-Andres F, Fink EL, Bell MJ, Sharma MS, Yablonsky EJ, Sanchez-de-Toledo J. Survival and Long-Term Functional Outcomes for Children With Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation. Pediatr Crit Care Med. 2018 Mar 9. ahead of print open access
Sloniewsky DE. Concise Critical Appraisal: Outcomes for Children Treated with ECMO during CPR. SCCM open access
Lasa JJ, Rogers RS, Localio R, Shults J, Raymond T et al. Extracorporeal cardiopulmonary resuscitation (E-CPR) during pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge: a report from the American Heart Association's Get With The Guidelines- Resuscitation (GWTG-R) registry. Circulation. 2016;133:165–176. open access 
Conrad SA, Broman LM, Taccone FS, Lorusso R, Malfertheiner MV et al. The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization. Am J Respir Crit Care Med. 2018 Apr 3. link 
ELSO registry International Summary last update January 2018 link 

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