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ECMO (aka ECPR) for Refractory OHCA

March 8, 2024

Written by Nickolas Srica

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This “brass tacks” summary of a recent systematic review found no improvement in favorable neurologic outcomes or reduction of in-hospital mortality for extracorporeal cardiopulmonary resuscitation (ECPR) when compared to standard advanced cardiac life support (ACLS) for refractory out-of-hospital cardiac arrest (OHCA).

ECMO, more like EC-no, but not so fast…
ECPR is defined as the addition of venoarterial extracorporeal membrane oxygenation (VA ECMO) to CPR. Check out this awesome JournalFeed summary for more detail on how it works! As one might imagine, this is easier said than done to quickly and efficiently setup and takes dedicated trained ECMO teams that are only available in certain centers to begin with.

This was a concise summary of a systematic review of three separate randomized controlled trials (Prague OHCA, ARREST, INCEPTION) that included 418 total adult patients with refractory OHCA randomized to either ECPR or conventional ACLS therapies. The long and short of it is this meta-analysis found no improvement in survival with a favorable neurologic outcome at the shortest follow-up: 26.4% vs 17.2%, RR 1.47 (95%CI 0.91-2.40) or at 6 months: 28.3% vs 18.6%, RR 1.48 (95%CI 0.88-2.49) and showed no significant improvement in in-hospital mortality: RR 0.89 (95%CI 0.724-1.07).

How will this change my practice?
Though the above data may seem clear, there were several considerations the authors mentioned when interpreting these results. Two of these trials were stopped early for different reasons; two of them allowed for crossover between groups; there were differences in how “refractory cardiac arrest” was defined, and there were differences in EMS protocols for OHCA management and time to both ECMO cannulation and initiation at the different centers. More work needs to be done, so for now I will continue to loop in my ECMO team on a case-by-case basis for select patients I think may have potential benefit.

Extracorporeal Cardiopulmonary Resuscitation in Refractory Out-of-Hospital Cardiac Arrest. Acad Emerg Med. 2023 Dec 05;31(2):190-192. doi: 10.1111/acem.14844.

What are your thoughts?