Immediate post-ECPR management strategies in the prehospital and critical care transport medicine environments

Despite advancements in care, out-of-hospital cardiac arrest has a low survival rate. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown improved outcomes in select cases, notably in the ARREST trial. However, ECPR is resource-intensive and limited to specialized centers, restricting access in many regions. Estimates suggest only 2-10% of out-of-hospital cardiac arrest patients are ECPR candidates. Advanced systems initiating ECPR in prehospital environments or non-ECMO-capable centers have shown promise. As ECPR utilization increases, so does the need for transport to ECMO-capable centers. Unlike conventional out-of-hospital cardiac arrest care, high-quality evidence for post-resuscitation management of ECPR patients is lacking. This review provides suggestions for the immediate post-resuscitation management (4-6 h) of ECPR patients in prehospital settings, the critical care transport medicine environment, and at non-ECMO-capable centers. Goals include treating the precipitating cause of cardiac arrest, maintaining end-organ perfusion, optimizing oxygen delivery, promoting myocardial recovery, and preventing complications associated with V-A ECMO. Continued research is needed to establish evidence-based protocols that ensure the safe and effective management of ECPR patients.