ECPR Indications
In the heat of battle, deciding which patients are appropriate candidates for ECPR is probably the single most difficult decision to make. To date, there is simply no way to predict, with any reliability, which patients will have the most functional outcomes. While possibilities are on the horizon, there are currently no reliable technologic devices that can accurately predict which patients will survive with functional neurologic outcomes . Today, “Time-Zero Prognostication” of the arresting patient is an imperfect endeavor at best because it currently relies solely on the information that is provided to you when the patient is delivered to your door. Third-party information from bystanders, questionable quality of initial CPR, variable medic transport times, variations in the quality of medic CPR, and a paucity of information about the patients pre-arrest medical condition are all inherently inaccurate variables. Because of this, we are all going to have to all agree to an accept a certain “flail factor.” The flail factor reflects the percentage of patients who were put on the pump with the best of intentions but later determined to have been poor candidates. With that in mind, here are some of the factors that determine which patients might be good candidates:
Indications
ED ECPR is indicated for any potential reversible cause of cardiac or pulmonary failure (or both) unresponsive to conventional therapy. Conceptually, the decision to consider a patient for ED ECPR is not different from the decision to begin aggressive resuscitation in the first place. That can be broken down into 3 broad ideals:
- The patient was generally healthy prior to the arrest. This requires an attempt at a global assessment of the patient’s pre-arrest condition and is a challenging concept that requires an adept emergency physician with good clinical judgment.
- Overall goals of therapy are curative (as opposed to palliative).
- The event that caused the arrest is thought to be reversible with a specific medical or surgical intervention. The classic example is the patient complaining of chest pain who has electrocardiogram findings of a myocardial infarction and arrests in the ED (or en route to the ED). If traditional resuscitative efforts fail, ECLS would be considered a bridge to allow the time necessary to perform a coronary angiogram with potential percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery.
When we published our first paper, Emergency physician-initiated extracorporeal cardiopulmonary resuscitation, we used very strict inclusion/exclusion criteria:
ECPR is indicated when all other traditional resuscitative strategies have been exhausted and the only alternative is death.
Indications for VV-ECMO in Respiratory Failure
Perhaps the best validated criteria are the ones used in the CESAR Trial:
- Murray Score > 3
- Ventilation < 7 Days
- Age < 65
- Reversibility
