ECLS – where are we now? Young ones

Extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (ECPR) is an effective therapy to improve outcomes for children who experience cardiopulmonary arrest. Survival after ECLS varies between 60% and 75%. For ECPR survival is lower, with 40% to 50% of children surviving ECPR. After ECPR good neurological outcomes are seen in 40% to 60% of children. This contrasts with adult patients where neurological outcomes after ECPR are poor. Given these findings the American Heart Association has included ECPR in their 2015 guidelines for children who experience an in hospital cardiac arrest (IHCA).  Several modifiable and non-modifiable factors have been identified as influencing outcomes after ECPR. Location (in-hospital versus out-of-hospital[OHCA]) of cardiac arrest as well as pre ECLS CPR duration impact survival. For children, OHCA is generally viewed as a contraindication. However patients who achieve intermittent output during their OHCA may still qualify for ECPR, particularly if they show signs of good cerebral perfusion during the CPR event. Whether the duration of pre ECLS CPR impacts survival is debated, with studies showing conflicting evidence for and against an observable effect. Duration of in-hospital CPR should therefore not serve as a decision making guide whether ECLS is offered to patients or not.   Post resuscitation care equally raises challenges: targeting normothermia has become a clinical standard, but what oxygenation (which can be independently selected via ECLS) should be aimed for remains unclear.  The organisational structure of a hospital-based ECPR program influences patient survival and must be tailored to the respective institution's ECLS experience. ECPR eligibility should be anticipated, possibly for any patient entering the hospital. There must be clear agreements for inclusion and exclusion criteria, the latter including severe cerebral injury (hypoxic, metabolic or haemorrhagic), end stage terminal illness or uncontrollable haemorragic disease.  ECPR confers a clear survival benefit for children, but due to logistic requirements remains challenging to implement.