LAUSR

Introduction/Hypothesis: Emergent deployment of Extracorporeal Membrane Oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has become increasingly utilized as rescue therapy for critically ill infants and children. In our program, this process has been well established and is increasingly offered to patients who have already survived at least one prior ECMO run. We hypothesized that ECPR for patients who have survived a prior ECMO run would be offered primarily to cardiac patients and would result in lower survival to hospital discharge compared to ECPR as the first ECMO run. Methods: We performed a retrospective study of ECPR cases between January 2006 and October 2018 in a large tertiary care referral center. Patients with ECPR as the first ECMO run (ECPR-1) were compared to those who survived at least one prior ECMO run prior to ECPR (ECPR+). Demographics and ECMO related data were collected. The primary outcome measure was survival to hospital discharge after ECPR. Results: A total of 316 ECPR events in 295 patients occurred during the study period with an overall survival to hospital discharge of 41.8%. There were 274 ECPR-1 runs and 42 ECPR+ runs in 38 patients (representing 2nd to 4th ECMO run). ECPR+ patients were younger (median 84, IQR 14, 952 days vs median 122, IQR 8,1176 days), more likely to be a cardiac patient (98% vs 83%, p=0.01), were cannulated more often in the CICU rather than other locations (91% vs 72%, p=0.01), and had longer ECMO runs (median 110, IQR 57,202 hours vs median 93, IQR 40, 147 hours). ECPR+ and ECPR-1 events occurred with similar frequency in neonates (38% vs 37%, p=0.84) and on weekdays (74% vs 79%, p=0.5), and there was no difference in the rate of complications (p=0.36) or need for procedures (p=0.49) while on ECMO. Survival to hospital discharge was significantly worse in the ECPR+ group compared to the ECPR-1 group (17% [7/42] vs 46% [125/274], p=<0.01) with an odds ratio of death of 4.2 in the ECPR+ group. Conclusions: ECPR is a rescue therapy for the most critically ill children with low overall survival to hospital discharge. Chances of survival to discharge are even lower in patients with at least 1 prior ECMO run. Given poor outcomes and high resource utilization, there should be careful consideration in selecting candidates for ECPR+.