11.3 Extracorporeal CPR (ECPR) Overview

What ECPR Is (Simple Definition)

Extracorporeal cardiopulmonary resuscitation (ECPR) means initiating extracorporeal membrane oxygenation (ECMO)—or a similar mechanical circulatory support circuit—during cardiac arrest when conventional CPR has not achieved ROSC. A trained team surgically or percutaneously places large cannulas, blood is pumped through an artificial lung (oxygenator), and oxygenated blood is returned to the patient, temporarily replacing the work of the heart and lungs.

In plain language: the machine buys time when the native circulation cannot, so the team can reverse the cause (e.g., post-operative cardiac failure, myocarditis, refractory shockable arrest in a suitable candidate) or bridge to recovery, further procedure, or decision-making.

ECPR is not:

• A substitute for starting CPR within 10 seconds
• An excuse for poor compression fraction while people "wait for ECMO"
• Available in every ED, every ambulance, or every hospital
• Appropriate for every OHCA or every prolonged unwitnessed arrest without selection

2025 PALS-Oriented Recommendation Frame

Aligned with 2025 AHA/AAP pediatric advanced life support guidance at exam level:

ECPR may be considered for infants and children with in-hospital cardiac arrest (IHCA) that is refractory to conventional CPR, in selected populations, when ECPR protocols and institutional expertise exist.

Unpack each clause—exams love these modifiers:

1. May be considered — reasonable option, not a mandate for every arrest.
2. Infants and children — pediatric recommendation space; adult ECPR programs exist separately with their own criteria.
3. IHCA — strongest teaching focus is in-hospital arrest where teams, sterile equipment, and cannulation skill can mobilize quickly. This is not a blanket endorsement of ECPR for every OHCA.
4. Refractory to conventional CPR — you still deliver excellent standard PALS first and ongoing; ECPR is for failure of conventional care, not a first-line replacement.
5. Selected populations — patients most likely to benefit; cardiac disease populations (e.g., cardiac ICU, peri-operative congenital heart disease, acute myocarditis in ECMO-capable centers) often show better outcome associations in the literature informing guidelines.
6. Protocols and expertise exist — pre-defined activation criteria, trained cannulators, primed equipment pathways, blood bank/ICU support, and governance. Without that system, "we should do ECPR" is aspiration, not a plan.

Who Is More Likely to Be Considered—and Who Is Not

Populations more often considered (exam-level)

• Children with known cardiac disease in centers that routinely perform pediatric ECMO
• IHCA in the cardiac ICU, catheterization lab, or operating room with immediate ECMO capability
• Arrest that is witnessed, with high-quality CPR ongoing and a potentially reversible cause
• Situations where conventional CPR is optimized but ROSC is not achieved and cannulation can occur rapidly

Settings / situations where ECPR is generally not the exam default

• Routine out-of-hospital cardiac arrest without an organized ECPR-capable system and selection pathway
• Hospitals without ECMO/ECPR programs, trained personnel, or transfer agreements that make timely support realistic
• Arrest where resources cannot deliver cannulation without destroying CPR quality for prolonged periods
• Expectation that ECPR erases the need to treat H's and T's or to defibrillate VF

Some mature regional systems do offer selected OHCA ECPR pathways for adults or rare pediatric cases; that does not mean every field cardiac arrest should delay transport or CPR for speculative ECMO. Know your system.

Why cardiac populations often fare better

Children with structural or myocardial disease may arrest from a pump problem that ECMO can bridge while the myocardium recovers or while a procedure (e.g., residual lesion repair, arrhythmia control, transplant evaluation) is arranged. Teams in cardiac centers also practice ECPR activations frequently, which shortens time-to-support—a key determinant of neurologic outcome. General pediatric wards without ECMO culture rarely match those process times.

Systems Requirements (What "Expertise Exists" Means)

ECPR is a system, not a single physician hero moment.

If your hospital lacks these pieces, the correct PALS behavior is still excellent conventional resuscitation and timely transfer when appropriate—not improvised large-vessel cannulation by untrained teams mid-code.

When to Call Early—and What Continues Meanwhile

Call early when the pieces fit

ECPR takes time to assemble. Waiting until the team is exhausted and end-tidal CO₂ has been near zero for a prolonged period often means the neurologic window has closed. In ECPR-capable centers, activation discussions often begin when:

• The child is in a high-risk cardiac environment and arrests, or
• High-quality CPR is ongoing without ROSC and the patient meets pre-agreed criteria, or
• A reversible process is suspected that needs a bridge (e.g., fulminant myocarditis pathway in an ECMO center)

Exact minute-by-minute cutoffs vary by institution—exams test the concept of early activation in equipped systems, not a single universal stopwatch number.

While ECPR is mobilizing, conventional care is non-negotiable

• Rate 100–120/min, full depth and recoil, minimize interruptions
• Rhythm checks ~ every 2 minutes; shock VF/pVT with correct energy (2 J/kg then 4 J/kg, ≤10 J/kg or adult max)
• Epinephrine 0.01 mg/kg IV/IO every 3–5 minutes as indicated
• Airway, oxygen, ventilation without hyperventilation
• Treat reversible causes (Section 11.1)
• Physiology-directed improvements when arterial line/ETCO₂ available (Chapter 7)

Do not create long hands-off periods for "ECMO prep photos," chaotic equipment piles on the chest, or debate that stops compressions. The best bridge to ECPR is excellent CPR right now.

Ethical and systems notes (exam awareness)

ECPR is resource-intensive. Guidelines and ethics discussions note limited data for perfect patient selection, consent challenges during arrest, cost, equity, and the need for institutional governance. For the provider exam, remember: selection + system + concurrent high-quality CPR—not "ECMO for everyone" and not "never consider ECMO even in a cardiac ICU with a ready team."

Clinical scenario (synthesis)

A toddler with known complex congenital heart disease arrests in a pediatric cardiac ICU. The team delivers immediate high-quality CPR, epinephrine on the nonshockable pathway, optimized ventilation, and cause search. After multiple cycles without ROSC, the unit's ECPR protocol is activated; a cannulation team arrives while compressions continue with minimal interruptions. ECMO flow is established; native output later returns as myocardial stunning recovers. This is the archetype: IHCA, cardiac population, refractory arrest, existing expertise, early call, CPR never abandoned.

Contrast: a prolonged unwitnessed OHCA brought to a hospital without ECMO capability. The right focus remains superb conventional PALS and post-arrest care if ROSC occurs—not delaying care for nonexistent ECPR.

Bottom line for 11.3: ECPR = ECMO during refractory arrest to buy time. May be considered for selected pediatric IHCA when protocols and expertise exist, with stronger outcome signals in many cardiac populations. It is not standard for every OHCA. Activate early when appropriate, build systems deliberately, and never replace high-quality conventional CPR fundamentals while the circuit is coming.