2025 Pediatric Surgery Update Course - Updates in ECMO & eCPR Use

ECPR is extracorporeal cardiopulmonary resuscitation, which adds ECMO or extracorporeal life support to conventional CPR to increase outcomes.

Out-of-hospital cardiac arrest ECPR in kids is not often performed and probably has bad outcomes based on adult literature.

For cold water drowning ECPR, outcomes are pretty low despite having a robust program.

Potassium level is used to determine if avalanche victims or cold water drowning victims got cold first or hypoxic first, with a cutoff at 8.

ECPR candidates need witnessed arrest (specifically for out-of-hospital) and reversible pathology, as ECMO is a bridge to gain time, not a destination that fixes anything.

In one institution, after the second dose of epinephrine during cardiac arrest, they activate ECPR and mobilize all teams.

ELSO data shows survival to ECLS for ECPR is 70% in neonatal and 60% in pediatric cases, with survival to discharge at 40% in both groups.

ECPR improves survival to hospital discharge in pediatric cardiac arrests compared to conventional CPR, with survival to discharge at 40% and favorable neurologic outcome at 30%.

For meningococcal sepsis, ECPR outcomes are in the single digits no matter what intervention is used.

Strongest predictors of post-ECPR mortality include polymyositis, neurologic complications including stroke and seizures, and renal failure.

Septic patients require massive amounts of volume to support them through ECMO, and most times central cannulation is needed to drain enough from the venous system.

During CPR, patients can be cannulated through the neck and then transitioned to central cannulation once flowing and oxygenating better.

Current data shows stroke rate of 10% (range 2.2% to 10.4%) with cervical cannulation for ECPR.

Stroke risk is not insignificant in older kids and adolescents when cannulating the neck, especially if there is not a complete circle of Willis.

Femoral approach requires a distal perfusion cannula, preferably with a chimney configuration.

Over half of patients in a seven-year median follow-up study had some vascular findings after neck cannulation that were perhaps actionable into adulthood, including dilation and narrowing of different percentages.

Oncology patients and patients with active bleeding are increasingly being considered as ECPR candidates, with oncology teams often stating they can treat the underlying condition.

CPR coaches showing cardiac output and end-tidal CO2 monitoring with constant team circulation and compressor changes are key to maintaining quality compressions during ECPR.

The younger the patient, the easier it is to cannulate the vessels during ECPR.

A two-attending model for ECPR cannulation is beneficial, with one attending performing cannulation while the second checks the circuit, ensures correct cannulas are available, and guides the scrub tech.