A systematic review of current ECPR protocols. A step towards standardisation

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Our goal was to identify the best protocol for survival with good neurological outcome through the evaluation of current inclusion criteria, exclusion criteria, cannulation strategies and additional therapeutic measures. METHODS: A systematic literature search was used to identify eligible publications from PubMed, Embase, Web of Science and Cochrane for articles published from 29 June 2009 until 29 June 2019. RESULTS: The selection process led to a total of 24 eligible articles, considering 1723 patients in total. A good neurological outcome at hospital discharge was found in 21.3% of all patients. The most consistent criterion for inclusion was refractory cardiac arrest (RCA), used in 21/25 (84%) of the protocols. The preferred cannulation method was the percutaneous Seldinger technique (44%). CONCLUSION: ECPR is a feasible option for cardiac arrest and should already be considered in an early stage of CPR. One of the key findings is that time-to-ECPR seems to be correlated with good neurological survival. An important contributing factor is the definition of RCA. Protocols defining RCA as >10 ​min had a mean good neurological survival of 26.7%. Protocols with a higher cut-off, between 15 and 30 ​min, had a mean good neurological survival of 14.5%. Another factor contributing to the time-to-ECPR is the preferred access technique. A percutaneous Seldinger technique combined with ultrasonography and fluoroscopic guidance leads to a reduced cannulation time and complication rate. Conclusive research around prehospital cannulation still needs to be conducted.