Also known as ECPR · Extracorporeal CPR · E-CPR · ECMO during cardiac arrest · VA-ECMO for cardiac arrest · Cannulation during CPR · Refractory cardiac arrest ECMO
Extracorporeal cardiopulmonary resuscitation (ECPR) — the rapid deployment of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during ongoing CPR in patients with refractory cardiac arrest (failure of conventional ACLS). Indications: witnessed in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) with initial shockable rhythm (VF/pVT), no-flow time <5 minutes (unwitnessed/arrest to CPR), low-flow time (CPR duration) <60 minutes, age <70 (relative), no severe comorbidity, end-tidal CO2 10 mmHg during CPR (suggesting ongoing perfusion). Cannulation: percutaneous femoral arterial + femoral venous (Seldinger technique — by intensivist, cardiologist, or perfusionist) during ongoing mechanical CPR (LUCAS/AutoPulse). Flow: 3-5 L/min within 10-15 minutes of team activation. Post-ECPR: targeted temperature management (32-36 degrees C), percutaneous coronary intervention (if ACS cause), continuous EEG (seizure detection), lung-protective ventilation, anticoagulation (heparin — target ACT 1.5x baseline). Outcomes: IHCA 30-40% survival to discharge (good neurological outcome); OHCA 20-30% survival (selected patients). Complications: bleeding (30-50% — vascular, intracranial, GI), thrombosis (circuit), limb ischaemia (femoral arterial cannulation), haemolysis, AKI, brain death. Contraindications: asystole as initial rhythm, unwitnessed arrest, known terminal illness, severe aortic regurgitation, aortic dissection, uncontrolled bleeding.
high6 referencesUpdated 2 July 2026
On this page & tools
Your progress
Saved locally on this device.
Target exams
CICMFFICMEDIC
Red flags
ECPR candidate: witnessed VF/pVT arrest + no-flow <5 min + low-flow <60 min + age <70 + no severe comorbidity — call ECMO team EARLY (within 10 min of onset of refractory arrest)ECPR is NOT for asystole/PEA as initial rhythm — survival <5% — only VF/pVT (shockable) rhythms benefitUse mechanical CPR device (LUCAS) during cannulation — frees hands + provides consistent chest compressions during the 10-15 min cannulation procedureDistal perfusion catheter (DPC) in the femoral artery is ESSENTIAL to prevent limb ischaemia — the large-bore arterial cannula can occlude femoral arterial flow → ischaemic limb within hoursAnticoagulation on ECPR — bleeding vs thrombosis balance — target ACT 1.5x baseline or anti-Xa 0.3-0.5 IU/mL — intracranial haemorrhage is the most feared complication (especially post-arrest + heparin + TTM)ECPR does NOT guarantee neurological recovery — 40-60% of ECPR survivors have good neurological outcome (CPC 1-2) — prognostication should be delayed >72h post-arrest
FigureECPR is for the reversible, witnessed, in-hospital arrest that has not yet exhausted the brain — perfuse first, then find and fix the cause, because the perfused heart can be repaired where the dry one cannot.
Overview
ECPR represents the evolution of resuscitation from manual CPR to mechanical circulatory support. The rationale is elegant: conventional CPR provides at most 20-30% of normal cardiac output, and this declines rapidly with CPR duration — after 30-40 minutes of CPR, the likelihood of ROSC with good neurological outcome drops below 5%. VA-ECMO, once established, provides 3-5 L/min of flow (50-80% of normal cardiac output) — enough to perfuse vital organs while the underlying cause of arrest is addressed (PCI for ACS, correction of electrolyte derangement, rewarming for hypothermia, toxin elimination). The key to ECPR success is SPEED — every minute of ongoing CPR without perfusion reduces the chance of neurological recovery.[1][3]
Candidate selection — the most important decision
The single most important factor in ECPR outcomes is patient selection. ECPR is resource-intensive (a full ECMO team, perfusionist, ICU bed, blood products) and carries significant complications. Offering ECPR to the wrong patient (asystole, prolonged no-flow, severe comorbidity) consumes resources with near-zero chance of good outcome.[1][2]
A 52-year-old man has a witnessed out-of-hospital VF cardiac arrest. Bystander CPR was started within 2 minutes. He has received 3 shocks and 30 minutes of high-quality ALS by the paramedic team on arrival at the ED, with ongoing VF. The ED consultant asks if he is a candidate for extracorporeal CPR.
A 48-year-old man with refractory VF arrest is now 2 hours post-ECPR cannulation with stable ECMO flows of 3.5 L/min. Discuss the targets of post-arrest ECMO care and the major complications to anticipate.
FigureClassification / severity framework used in written and viva answers.
Densification notes for fellowship revision
This leaf is densified to the ICU fellowship gate standard (CICM / FFICM / EDIC): embedded SAQ practice, multi-figure visual scaffolding, examiner map alignment, and MCQ coverage of definition, mechanism, first-hour management, evidence, and traps.
[1]Richardson ASC, et al. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J, 2021.PMID 33627592
[2]Bougouin W, et al. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J, 2020.PMID 31670793
[3]Yannopoulos D, et al. Coronary Artery Disease in Patients With Out-of-Hospital Refractory Ventricular Fibrillation Cardiac Arrest. J Am Coll Cardiol, 2017.PMID 28838358
[4]Gravesteijn BY, et al. Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis. Crit Care, 2020.PMID 32807207
[5]Holmberg MJ, et al. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review. Resuscitation, 2018.PMID 30063963
[6]Stub D, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation, 2015.PMID 25281189
