ECPR in Children without Cardiac Disease…Virtue or Folly?
Ethan L. Sanford MD, Shawn Jackson MD PhD, Justin L. Lockman MD MSEd
Original article
Loaec M, Himebauch AS, Reeder R, Alvey JS, Race JA, Su L, Lasa JJ, Slovis JC, Raymond TT, Coleman R, Barney BJ, Kilbaugh TJ, Topjian AA, Sutton RM, Morgan RW; American Heart Association’s (AHA) Get With The Guidelines-Resuscitation (GWTG-R) Investigators. Outcomes of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories. Crit Care Med. 2024 Apr 1;52(4):551-562. doi: 10.1097/CCM.0000000000006153. Epub 2023 Dec 29. PMID: 38156912; PMCID: PMC11810531.
Today’s PAAD is on a topic close to my (ELS) heart but sometimes feels like it’s ripping the ventricles apart. Extracorporeal Cardiopulmonary Resuscitation (ECPR) is the application of ECMO for patients with refractory cardiac arrest (generally thought to be >30 minutes) or within 20 minutes of unstable return of spontaneous circulation (ROSC). Immediately, we note there is likely a big difference in outcomes between a child who achieves ROSC and is subsequently cannulated versus someone in cardiac arrest throughout the entire cannulation. ECPR is difficult to study due to these innumerable permutations of patient substrate and what occurs during a cardiac arrest. Survival in children with a cardiac indication for ECPR is around 50-60% with a majority of these having favorable neurologic outcome.1 In non-cardiac patients, survival drops to the 25-40% range with neurologic outcomes that are more difficult to characterize2, 3, but certainly include a significant amount of neurologic injury. The reasons for these differences aren’t completely understood, but theories include: 1) difference in levels of systemic illness prior to cardiac arrest, 2) lack of adequate oxygen/CO2 exchange during arrest for children with pulmonary cause, 3) ease of access for cannulation (open or recently opened chest), and 4) differences in experience/facility with cannulation process for cardiac surgeons and cardiac ICU teams who perform ECPR more regularly. Adults primarily arrest due to cardiac pathology. The success of ECPR among adults has increased deployment of ECPR even in emergency department and out-of-hospital settings in adult care models. Pediatrics evidence supporting such practice is lacking.
In today’s PAAD, Loaec M et al.4 seek to better analyze outcomes in children with non-cardiac disease with in-hospital cardiac arrest who undergo ECPR versus conventional CPR. The study design allows epidemiologic assessment of pediatric non-cardiac ECPR and a statistically adjusted comparison of ECPR outcomes to conventional CPR. Such comparison is important. Frequently, ECPR survival numbers are quoted in isolation with the inherent presumption that the alternative to ECPR is 0% survival. This is not the case.
The authors analyzed data from 159 children who received ECPR and 716 who received conventional CPR. The Get With The Guidelines-Resuscitation (GWTG-R) database includes self-reported data from multiple centers to determine best practices in American Heart Association (AHA) Pediatric Advanced Life Support (PALS). The authors used inverse probability of treatment weighting to create balance among many potential confounders – especially CPR duration – which may affect the relationship between either ECPR or conventional CPR and outcomes. Subsequent logistic regression found no difference in survival to hospital discharge with ECPR (AOR 1.42, 95% CI 0.84-2.40, p=0.19). Similarly, survival with favorable neurologic outcome was not significantly different between groups (88.6% for conventional CPR versus 78.9% in ECPR). Finally, a Bayesian analysis calculated an 85% probability of treatment benefit versus 7% probability of harm from ECPR.
These data likely amplify the ‘Rorschach ink blot test’ of how individuals subjectively view ECPR. Currently, the AHA guidelines do not endorse or discourage ECPR use for non-cardiac pediatric populations.5 Suppose the results of today’s PAAD were without any possible confounding and were statistically significant. On one hand, a 5 percent improvement in survival with ECPR (though possibly with worse neurologic outcomes) is everything if your child is in the 5%. On the other hand, ECMO is one of the most resource-intensive medical interventions in the history of humanity. Increased utilization among populations who we know will, as a group, suffer poor outcomes regardless of the intervention may be viewed as inappropriate triaging of resources (e.g., platelets which are consumed rapidly in ECMO and frequently in shortage). In the absence of resource limitations, ECPR may bear a separate toll on parents and medical teams. Parents frequently struggle to accept brain death or a prognosis of poor neurologic function. The addition of an ECMO circuit which preserves other organ function further confounds the scenario. Parents may view the withdrawal of ECMO as abandonment, challenging the therapeutic alliance between our teams and families. For some members of the medical team, particularly nurses and ECMO specialists constantly at the bedside, the distress of caring for children whom they believe will suffer poor neurologic outcomes and witnessing their parents suffering loss may lead to burnout and compassion fatigue. And whether burned out staff might affect the overall performance of a pediatric ECPR/ECMO program is unclear and likely variable, but warrants consideration.
These dilemmas have resulted in variations among ECPR practices across the country.6 Some pediatric centers do not routinely offer ECPR for non-cardiac indications. Some allow it in only pre-specified settings. Some leave the decision to whoever is running the code. Some promote utilization in all cases, with suggested triggers (such as, “if no ROSC by the second dose of epi, activate ECPR.”) Someday, we hope data elucidates which children and scenarios carry the best chance of neurologically functional survival after ECPR. Until then, like much of medicine, prevention of disease (in this case, cardiac arrest) is better than rescue from catastrophe. ECPR for an unanticipated failed airway or mediastinal mass anesthetic gone awry is unlikely to result in a good outcome. Alternatively, a well-prepared ECMO team that gains vascular access or has a discrete plan for ECMO before a high-risk procedure may be lifesaving. And for centers utilizing ECPR, we strongly encourage the use of multidisciplinary simulation to build strong systems, enhance communication between experts, and improve outcomes when possible.
What are your thoughts on ECPR for non-cardiac pediatric patients? Does your center forbid or promote it? Email Myron at myasterster@gmail.com and he will post in a Friday Reader Response.
References
1. Gardner MM, Morgan RW, Reeder R, et al. Trends in Cardiac Arrest Outcomes & Management in Children with Cardiac Illness Category Compared to Non-Cardiac Illness Category: An Analysis from the AHA Get With The Guidelines®-Resuscitation Registry. Resuscitation. Dec 2024;205:110430. doi:10.1016/j.resuscitation.2024.110430
2. Bembea MM, Ng DK, Rizkalla N, et al. Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries. Crit Care Med. Apr 2019;47(4):e278-e285. doi:10.1097/CCM.0000000000003622
3. Gardner MM, Morgan RW, Reeder R, et al. Trends in Cardiac Arrest Outcomes & Management in Children with Cardiac Illness Category Compared to Non-Cardiac Illness Category: An Analysis from the AHA Get With The Guidelines(R)-Resuscitation Registry. Resuscitation. Dec 2024;205:110430. doi:10.1016/j.resuscitation.2024.110430
4. Loaec M, Himebauch AS, Reeder R, et al. Outcomes of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories. Critical care medicine. Apr 1 2024;52(4):551-562. doi:10.1097/ccm.0000000000006153
5. Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. Jan 2021;147(Suppl 1)doi:10.1542/peds.2020-038505D
6. Rice-Townsend SE, Brogan TV, DiGeronimo RJ, et al. Characteristics of pediatric non-cardiac eCPR programs in United States and Canadian hospitals: A cross-sectional survey. J Pediatr Surg. Dec 2022;57(12):892-895. doi:10.1016/j.jpedsurg.2022.04.020