Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Cardiac Population: In Search of a Standard of Care*

Abstract

Objectives: Although clinical and pharmacologic guidelines exist for the practice of cardiopulmonary resuscitation in children (Pediatric Advanced Life Support), the practice of extracorpo-real cardiopulmonary resuscitation in pediatric cardiac patients remains without universally accepted standards. We aim to explore variation in extracorporeal cardiopulmonary resuscitation procedures by surveying clinicians who care for this high-risk patient population. Design: A 28-item cross-sectional survey was distributed via a web-based platform to clinicians focusing on cardiopulmonary resuscitation practices and extracorporeal membrane oxygenation team dynamics immediately prior to extracorporeal membrane oxygenation cannulation. Settings: Pediatric hospitals providing extracorporeal mechanical support services to patients with congenital and/or acquired heart disease. Subjects: Critical care/cardiology specialist physicians, cardiothoracic surgeons, advanced practice nurse practitioners, respiratory therapists, and extracorporeal membrane oxygenation specialists. Interventions: None. Measurements and Main Results: Survey web links were distributed over a 2-month period with critical care and/or cardiology physicians comprising the majority of respondents (75%). Nearly all respondents practice at academic/teaching institutions (97%), 89% were from U.S./Canadian institutions and 56% reported less than 10 years of clinical experience. During extracorporeal cardiopulmonary resuscitation, a majority of respondents reported adherence to guideline recommendations for epinephrine bolus dosing (64%). Conversely, 19% reported using only one to three epinephrine bolus doses regardless of extracorporeal cardiopulmonary resuscitation duration. Inotropic support is held after extra-corporeal membrane oxygenation cannulation “most of the time” by 58% of respondents and 94% report using afterload reducing/antihypertensive agents “some” to “most of the time” after achieving full extracorporeal membrane oxygenation support. Interruptions in chest compressions are common during active cannulation according to 77% of respondents. Conclusions: The results of this survey identify wide variability in resuscitative practices during extracorporeal cardiopulmonary resuscitation in the pediatric cardiac population. The deviations from established Pediatric Advanced Life Support CPR guidelines support a call for further inquiry into the pharmacologic and logistical care surrounding extracorporeal cardiopulmonary resuscitation. (Pediatr Crit Care Med 2018; 19:125–130)

Establishing and Sustaining an ECPR Program

“…In our institution and in other similar organizations with established extracorporeal life support (ECLS) programs, there is sufficient data to support the benefit of ECPR in children with cardiac disease who have an in-hospital cardiac arrest (see below) ( 3 , 11 , 13 , 16 , 26 – 31 ).…”

“…However, it is important these functional considerations are discussed and appreciated before and during resuscitation, and these place even more pressure on ensuring the system for ECPR is optimal for the performance of each of the phases of ECPR described below. There is variability in practice between institutions that use ECPR for pediatric patients with heart disease; there is a huge opportunity to gain knew insights on what protocols and interventions ensure the optimal quality of extracorporeal cerebral-CPR ( 11 ).…”

Factors Associated With Survival Following Extracorporeal Cardiopulmonary Resuscitation in Children

“…Several studies have shown that survival with conventional CPR lasting >30 minutes ranges between 0% and 15%. [1][2][3][4][5][6] Extracorporeal cardiopulmonary resuscitation (ECPR) is the practice of rapid deployment of extracorporeal membrane oxygenation (ECMO) in patients having refractory cardiac arrest that is unresponsive to conventional CPR measures. Advantages of ECPR include early restoration of stable hemodynamics and adequate systemic output and consequently preservation of endorgan function and prevention of permanent injury.…”

Extracorporeal Cardiopulmonary Resuscitation: One-Year Survival and Neurobehavioral Outcome Among Infants and Children With In-Hospital Cardiac Arrest*

“…In our analysis, epinephrine was often administered with a longer dosing interval than the 3-5 minutes recommended by the AHA (44). Decreased use of epinephrine during ECPR has been reported by some clinicians in attempt to avoid excessive afterload that may affect ECMO flow rates (45).…”