Implementation of a regional extracorporeal membrane oxygenation program for out-of-hospital cardiac arrest: results of the prospective observational study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Out-of-hospital cardiac arrest (OHCA) (n=233). Intervention: Extracorporeal cardiopulmonary resuscitation (eCPR) / ECMO cannulation vs. Routed OHCA patients who did not receive eCPR (standard resuscitation/care without ECMO cannulation). Primary outcome: Survival to hospital discharge (SHD) (OR 1.1, 95% CI 0.5-2.4).

Q: What does this research mean for the field?

Extracorporeal cardiopulmonary resuscitation achieves a 27% survival rate to hospital discharge in refractory out-of-hospital cardiac arrest but is not associated with improved outcomes compared to non-cannulated routed patients. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Nichole Bosson; Juliana Tolles; Clayton Kazan; Stephen Sanko; Tiffany M. Abramson; Marc K. Eckstein; Joel Martin Geiderman; Walid Ghurabi; Vadim Gudzenko; Anil Mehra; Sam S. Torbati; Atilla Üner; Amir Abolhoda; Marianne Gausche‐Hill; David M. Shavelle; Ali Nsair; Gene Yong Sung

doi:10.1016/j.resplu.2025.101177

November 25, 2025Resuscitation PlusOpen Access

Implementation of a regional extracorporeal membrane oxygenation program for out-of-hospital cardiac arrest: results of the prospective observational study

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Key result

Extracorporeal cardiopulmonary resuscitation achieved 27% survival to hospital discharge in refractory out-of-hospital cardiac arrest, with no significant survival difference vs non-cannulated routed patients.

Why the study?

This study assessed time-to-cannulation, survival, and neurologic outcomes for patients with OHCA routed by EMS to eCPR-capable centres following the implementation of a regional multi-centre eCPR program.

Does extracorporeal cardiopulmonary resuscitation (eCPR) improve survival to hospital discharge and neurologic outcomes in patients with refractory out-of-hospital cardiac arrest routed to eCPR-capable centres?

Key Points

To assess time-to-cannulation, survival to hospital discharge, and neurologic outcomes following regional implementation of an extracorporeal cardiopulmonary resuscitation (eCPR) protocol for out-of-hospital cardiac arrest.
Prospective observational cohort study of N=233 patients with out-of-hospital cardiac arrest transported by six EMS agencies to four eCPR-capable centres between July 2020 and September 2024.
Inclusion criteria for EMS routing were age 15-75 years, refractory or recurrent shockable arrest, application of a mechanical compression device, and an estimated transport time of 30 minutes or less.
Evaluated the association between eCPR and survival or neurologic status at discharge using multivariable logistic regression with inverse-probability weighting.
A total of 58 (27 %) patients were cannulated for eCPR, with a median arrest-to-cannulation time of 66 min (IQR 58-78).
Survival to hospital discharge was 27 % both overall and among cannulated patients, with 21 % achieving favourable neurologic recovery (cerebral performance category 1 or 2).
In the inverse-probability weighted logistic regression analysis, treatment with eCPR was not associated with improved outcomes.

Study Design

Type

Cohort (n=233)

Multicenter

Yes

Structured PICO

Does extracorporeal cardiopulmonary resuscitation (eCPR) improve survival to hospital discharge and neurologic outcomes in patients with refractory out-of-hospital cardiac arrest routed to eCPR-capable centres?

P

Population

233 patients (median age 58 years, 22% female) with refractory or recurrent shockable out-of-hospital cardiac arrest routed by EMS to eCPR-capable centers in Los Angeles County and followed through 90 days post-discharge.

E

Exposure

Regional extracorporeal cardiopulmonary resuscitation (eCPR) program protocol involving rapid EMS transport with a mechanical compression device (MCD), advanced airway with capnography, vascular access, and consideration for emergent veno-arterial ECMO cannulation in the emergency department or cardiac catheterization laboratory at an eCPR-capable centre (63 patients [27%] were cannulated for eCPR).

C

Comparator

Routed OHCA patients who did not receive eCPR cannulation (n=170, due to sustained ROSC in 22%, contraindications, poor prognostic indicators, or other reasons) managed with standard resuscitation and post-arrest care.

O

Outcome

Survival to hospital discharge (SHD)hard clinical

Main Result

Odds Ratio: 1.1 (95% CI 0.5–2.4)

Absolute Event Rate: 27% vs 26.5%

Limitations

Limited to a single urban-suburban EMS system with an established cardiac care system and readily available specialty resources
Observational design without randomization or a formal control group
Lower-than-expected cannulation rate (27%) with non-standardized clinical care and cannulation decisions across the four centers
Target arrest-to-cannulation time achieved in only 38% of patients
Lack of an a priori sample size calculation and underpowered to detect clinically meaningful differences between groups
Iterative protocol modifications during the study period (e.g., transport after two shocks instead of three) and COVID-19 pandemic disruptions
Non-randomized observational design lacking a true control group
Lower-than-expected cannulation rate (27%) with cannulation at the discretion of the ECMO team and non-standardized clinical care across the four centres
Unable to report total number of patients screened at the EMS clinician level and no a priori sample size calculation (not powered to detect clinically meaningful differences)
Iterative protocol modifications during the study period (changing transport initiation from after three shocks to after two shocks) and disruptions/pauses due to the COVID-19 pandemic

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Implication

Implementing a regional multi-centre eCPR program integrated with EMS for refractory out-of-hospital cardiac arrest is feasible and achieved a 27% survival to hospital discharge rate (21% with favorable neurologic outcome) among cannulated patients.

Abstract

Background: We implemented a multi-centre extracorporeal cardiopulmonary resuscitation (eCPR) program in a regional emergency medical services (EMS) system and assessed the time-to-cannulation, survival, and neurologic outcomes for patients routed by EMS to eCPR-capable centres. Methods: This was an observational study of patients with out-of-hospital cardiac arrest (OHCA) transported to eCPR-capable centres from July 2020 to September 2024. Patients were routed to an eCPR-capable centre if all applied: age 15-75, refractory/recurrent shockable arrest, a mechanical compression device (MCD) applied, and treatment by a participating EMS unit. Additional patients were routed on clinician judgment. Patients with traumatic arrest, do-not-resuscitate order, known terminal illness, baseline severe neurologic deficit, pregnancy, MCD contraindications, or estimated >30-min transport to an eCPR-capable centre were not routed. The outcomes were survival to hospital discharge (SHD) and neurologic status at discharge. We conducted a logistic regression with inverse-probability weighting to evaluate the association between eCPR and patient outcomes. Results: There were 233 patients routed for eCPR. Median age was 58 years (IQR 48-65), 51 (22 %) were female. Fifty-eight (27 %) were cannulated for eCPR; median time from arrest to cannulation was 66 min (IQR 58-78). Both for all routed patients and among those cannulated, SHD was 27 % and SHD with cerebral performance category (CPC) 1 or 2 was 21 %. In the regression analysis, eCPR was not associated with improved outcomes. Conclusion: In this regional eCPR program, survival among patients refractory to conventional therapy and treated with eCPR was 27%.

Discussion

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Cite This Study

Bosson et al. (2025) conducted a cohort in Out-of-hospital cardiac arrest (OHCA) (n=233). Extracorporeal cardiopulmonary resuscitation (eCPR) / ECMO cannulation vs. Routed OHCA patients who did not receive eCPR (standard resuscitation/care without ECMO cannulation) was evaluated on Survival to hospital discharge (SHD) (OR 1.1, 95% CI 0.5-2.4). Extracorporeal cardiopulmonary resuscitation achieved 27% survival to hospital discharge in refractory out-of-hospital cardiac arrest, with no significant survival difference vs non-cannulated routed patients.

synapsesocial.com/papers/6af79c308d04d13770931807 https://doi.org/10.1016/j.resplu.2025.101177

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Implementation of a regional extracorporeal membrane oxygenation program for out-of-hospital cardiac arrest: results of the prospective observational study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Implementation of a regional extracorporeal membrane oxygenation program for out-of-hospital cardiac arrest: results of the prospective observational study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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