The success of extracorporeal support in providing cardiopulmonary support for a variety of patients has led to the use of Extracorporeal Life Support, also known as ECLS, as a rescue for patients failing conventional resuscitation. The use of Extracorporeal Life Support in circumstances of cardiac arrest has come to be termed “Extracorporeal Life Support during Cardiopulmonary Resuscitation” or “ECPR”.Reference Dalton, Siewers and Fuhrman1, Reference Fiser and Morris2 Although Extracorporeal Life Support during Cardiopulmonary Resuscitation was originally described in patients following repair of congenital cardiac defects who suffered a sudden arrest, it has now been used in a variety of circumstances for patients both with and without primary cardiac disease.Reference del Nido, Dalton, Thompson and Siewers3–Reference Morris, Wernovsky and Nadkarni5 Multiple centres have reported successful use of Extracorporeal Life Support during Cardiopulmonary Resuscitation in adults and children.Reference Thiagarajan, Laussen, Rycus, Bartlett and Bratton6 However, because of the cost, the complexity of the technique, and the resources required, Extracorporeal Life Support during Cardiopulmonary Resuscitation is not offered in all centres for paediatric patients with refractory cardiac arrest. The increasing role of Extracorporeal Life Support during Cardiopulmonary Resuscitation in resuscitation, however, is highlighted by recommendations from groups such as that of the American Heart Association, which state:
…To consider extracorporeal CPR for in-hospital cardiac arrest refractory to initial resuscitation attempts if the condition leading to cardiac arrest is reversible or amenable to heart transplantation, if excellent conventional CPR has been performed after no more than several minutes of no-flow cardiac arrest, and if the institution is able to rapidly perform extracorporeal membrane oxygenation.Reference Kleinman, de Caen and Chameides7
Table 1 shows a summary of published literature regarding paediatric extracorporeal cardiopulmonary resuscitation. Most of the patients in these series were cardiac patients with rates of survival to discharge of 30–70%. Duration of cardiopulmonary resuscitation before Extracorporeal Life Support ranged from 4 to 127 minutes. One large paediatric study has shown that good outcome can be achieved when extracorporeal cardiopulmonary resuscitation is started after 30–90 minutes of refractory standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital.Reference Morris, Wernovsky and Nadkarni5
Table 1 Selected outcomes from Extracorporeal Life Support during Cardiopulmonary Resuscitation.
ELSO = Extracorporeal Life Support Organisation; NRCPR = National Registry Cardiopulmonary Resuscitation; ICU = intensive care unit
The success of Extracorporeal Life Support in patients who suffer cardiac arrest following congenital cardiac surgery has led to expansion of this technology to patients who were previously considered poor candidates. Patients who have undergone the Norwood (Stage 1) operation fall into this category. Although there are a few reports of Extracorporeal Life Support being applied routinely following the Norwood (Stage 1) operation to prevent the sudden cardiac deterioration often noted in these patients, this strategy has not become an accepted practice in most centres.Reference Underleider, Shen and Yeh8, Reference Hoskote, Bohn and Gruenwald9 Conversely, many early reports of Extracorporeal Life Support applied to patients with functionally univentricular hearts had poor survival, which led to exclusion of Extracorporeal Life Support in these patients in some centres. However, the increasing success and availability of Extracorporeal Life Support during Cardiopulmonary Resuscitation in post-operative cardiac patients, coupled with the fact that patients undergoing the Norwood (Stage 1) operation can have rapid, unpredictable cardiac deterioration and arrest, has led to a steady increase in the use of Extracorporeal Life Support during Cardiopulmonary Resuscitation in this population. Although the goal of applying Extracorporeal Life Support is to initiate support before arrest, correct identification of patients likely to suffer a cardiac arrest has proven difficult. Once the decision to place a patient with a functionally univentricular heart on Extracorporeal Life Support is made, these patients pose special considerations for care and management.
Indications for initiating Extracorporeal Life Support
The decision to initiate Extracorporeal Life Support varies by institutional practice for patients with functionally univentricular hearts. The presence of low cardiac output, systolic or diastolic dysfunction, uncontrolled arrhythmia, and/or cardiac arrest are common aetiologies.Reference Phelps, Mahle and Kim10, Reference Kumar, Zurakowski and Dalton11 Often, in patients with functionally univentricular hearts, an increased ratio of the flow of blood in the pulmonary circulation in comparison with the systemic circulation – Qp/Qs ratio – is a common cause for low cardiac output and manifests as elevated level of lactate in the serum and increased arteriovenous oxygen saturation difference.Reference Tweddell, Ghanayem and Mussatto12 Serial elevation of levels of lactate in the serum despite maximal medical therapies has been suggested as an indication for elective institution of Extracorporeal Life Support.Reference Hannan, Ybarra, White, Ojito, Rossi and Burke13 Other clinicians have noted that dosage of vasoactive agents, such as epinephrine, may be triggers for initiating Extracorporeal Life Support, although no specific dose has been identified. In a similar vein, the “vasoactive inotrope score” has also been suggested as related to both the need for Extracorporeal Life Support and the outcome after such support:Reference Polimenakos, Wojtyla and Smith14–Reference Grist, Whittaker and Merrigan16
![\[--><$$> \eqalign{ {\rm{(VIS}}\, )\,{\rm{ = }}\, & {\rm{dopamine}}\, {\rm{ + }}\, {\rm{dobutamine}}\, {\rm{ + }}\, {\rm{(epinephrine}} \times {\rm{100)}} \cr & {\rm{ + }}\, {\rm{(milrinone}} \times {\rm{10)}}\, {\rm{ + }}\, {\rm{(vasopressin}} \times {\rm{10,000)}}{\rm{.}} \cr} \eqno<$$><!--\]](https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20160115082707377-0530:S1047951111001673_eqnU1.gif?pub-status=live){kind=small}
In the above equation dosage as micrograms per kilogram per minute except vasopressin is expressed as units per kilogram per minute.
After failed attempts to improve cardiac output and maintain balance of transport of oxygen, Extracorporeal Life Support may be initiated.Reference Allan, Thiagarajan, del Nido, Roth, Almodovar and Laussen17 The fact that clinical examination and vital signs also give information that can be important must not be overlooked. Capillary refill time, urine output, mental awareness, activity, and respiratory examination can give important clues. Persistent tachycardia or bradycardia, temperature – especially the difference between core and peripheral temperature, and systemic arterial pressure are all important parameters when assessing the cardiac output and overall condition of the patient. Patients with functionally univentricular hearts, especially those who have undergone the Norwood (Stage 1) operation with a modified Blalock–Taussig shunt, may have low diastolic systemic arterial pressure from run-off into the aortopulmonary shunt and the pulmonary circulation. Extremely low diastolic pressures can lead to coronary arterial ischaemia and poor myocardial perfusion. Assurance of optimal balance of transport of oxygen includes continual balancing of two parallel circulations. Goals should be aimed to maintain normal arteriovenous oxygen saturation difference with systemic oxygenation levels appropriate for a patient dependent on an aortopulmonary shunt, usually greater than 70% arterial saturation.
Care of patients with a functionally univentricular heart on Extracorporeal Life Support
The majority of patients receiving Extracorporeal Life Support after the Norwood (Stage 1) operation are cannulated via the venoarterial route, often through a reopened mediastinum with cannulas placed directly into the right atrium and aorta. Although there is some logic to venovenous Extracorporeal Life Support being sufficient in cases of hypoxia, with improved systemic oxygenation allowing improvement in cardiac and respiratory function sufficient to support the patient, this strategy is not a common practice. In patients with venoarterial cannulation who have an aortopulmonary shunt, most institutions favour leaving the shunt open during Extracorporeal Life Support, as several early reports found poor survival when the shunt was closed, and more recent studies demonstrated improved survival when the shunt is left open.Reference Jaggers, Forbess and Shah18 Patients with open aortopulmonary shunts frequently require increased flow of blood to support both the pulmonary and the systemic circulations, often greater than 150–200 millilitres per kilogram per minute, secondary to the significant run-off into the aortopulmonary shunt and the pulmonary circulation. Excessive flow of blood into the pulmonary circulation can lead to pulmonary oedema and elevated pulmonary pressures, and thus some patients – estimates are as high as 40% – may require restriction of flow into the shunt via a clip or suture ligature during Extracorporeal Life Support. Manoeuvres to maintain elevated pulmonary vascular resistance to limit flow of blood into the pulmonary circulation have also been described. Patients who receive a right ventricular to pulmonary arterial conduit – Sano modification – require rates of flow similar to patients with biventricular circulation. Owing to the fact that many patients after the Norwood (Stage 1) operation suffer only problems with cardiac output and have good pulmonary exchange of gases, elimination of the oxygenator from the Extracorporeal Life Support circuit has been done to provide ventricular support without supporting exchange of gases.Reference Darling, Kaemmer, Lawson, Jaggers and Underleider19 This approach is colloquially termed “ECMO-lite” or “NOMO” – no-oxygenator membrane oxygenation. This adaptation may reduce the amount of heparin necessary, as heparin is not required to prevent the oxygenator from thrombosing, although there are no studies that have shown great benefit or risk from elimination of the oxygenator. It is likely that newer “hollow-fibre devices” may require less heparin than the “silicone membrane lung” and thus decrease the complications related to bleeding often seen in these post-operative patients, but these reports are small and few.Reference McMullan, Emmert and Permut20 Along with new technology in oxygenators, new centrifugal pumps are also now available for Extracorporeal Life Support. These systems often are more compact, require less priming volume, and can be implemented within several minutes. Their active venous “suction” action decreases the need for drainage dependent on gravity and allows reduction in the length of the circuit, which may also lessen the need for heparin, induce less inflammatory response, and diminish exposure to blood used for priming. Despite the fact that use of centrifugal pumps with “hollow-fibre oxygenators” is currently popular and seems to offer some advantages, they are dependent on adequate preload and sensitive to afterload for forward flow. Understanding differences between systems using the traditional roller-pump and systems using the centrifugal pump is paramount to providing optimal care for the patient. Another aspect of care for patients after the Norwood (Stage 1) operation is to remember that the large intra-atrial communications present leave them at excessively high risk for neurological or cardiac – coronary – injury from emboli of air. Prevention of entrainment of air into the Extracorporeal Life Support circuit and prevention of air reaching the patient is crucial. Owing to the fact that centrifugal pumps, as well as roller head devices, can generate extremely high negative pressures on the venous side of the circuit, most centres have monitoring and alarm limits set for decreasing flow or stopping the pump if the limit for negative pressure is reached. Maintaining some type of venous reservoir is also helpful to avoid large swings of negative pressure and associated haemolysis. Ventilatory strategies include placing patients on “resting” ventilatory support with
• a low rate, that is, less than 10 breaths per minute,
• high positive end expiratory pressure to maintain some lung inflation, that is, 8–15 centimetres of water, and
• 21% inspired oxygen.
“Sweep flow” and adjustment of delivery of inspired oxygen (FiO2) are used for normalising parameters on the blood gas. Owing to the fact that the lungs of these patients are often healthy, reducing mechanical ventilatory support to the level of extubation is physiologically possible but is rarely done in practice. Having control of the airway in the event of malfunction of the circuit and need for emergent separation from the Extracorporeal Life Support circuit is seen as worth the associated risks of continued intubation.
A few practical points regarding care of cardiac patients are to pay close attention to normalisation of the function of organs and the acid–base balance once Extracorporeal Life Support has begun. Several reports have outlined the fact that failure to normalise levels of lactate, acidosis, or renal or hepatic insufficiency by 24 hours after institution of support are all associated with poor outcome.Reference Raymond, Cunnyngham, Thompson, Thomas, Dalton and Nadkarni4, Reference Polimenakos, Wojtyla and Smith14 The amount of blood products consumed has also been linked to outcome.Reference Kumar, Zurakowski and Dalton11 In hypothermic patients, following clinical examination for adequacy of support is difficult, as these patients are often peripherally vasoconstricted and with poor colour of the skin. Following adjunct measures such as those discussed above, as well as other parameters such as mixed venous saturations and urine output, are all helpful during Extracorporeal Life Support. It is of paramount importance to assess neurological function following arrest. This assessment may best be accomplished by clinical examination, eliminating sedation or neuromuscular blockade until neurological activity such as movement of the patient can be assessed. Other measures such as electroencephalographic monitoring, computerised axial tomography scan, cranial ultrasonography, and evoked potentials are additional methods to monitor the condition and function of the brain non-invasively. Although monitoring with near-infrared regional spectroscopy is currently used in many centres, the true reliability of these monitors in assessing cerebral and somatic flow of blood and long-term neurological outcome is unknown.Reference Nelson, Andropoulos and Fraser21, Reference Knirsch, Stutz and Kretschmar22
Although there are no paediatric studies that demonstrate the effectiveness of hypothermia after cardiac arrest in improving outcome, the current trend is to maintain the core body temperature of the patient between 33 and 35 degrees centigrade for 24–48 hours. A randomised trial of hypothermia versus normothermia after cardiac arrest is in progress, and the results of this trial are eagerly awaited. Unfortunately, this trial will not be completed for several years, and thus conventional wisdom will have to guide decisions about the care of the patient in the meantime. One issue, on which clinicians agree even now, however, is that preventing fever following arrest is optimal, and this goal can be easily obtained with temperature control by the Extracorporeal Life Support circuit.
Failure of cardiac function to return within 72 hours of cannulation has been associated with poor outcome in post-cardiotomy patients.Reference Prodhan, Fiser and Dyamenahalli23–Reference Huang, Wu and Chen25 Although function may not have returned to a level to allow separation from the Extracorporeal Life Support circuit, a continuous improvement in cardiac function and the function of the other organs should be observed after successful Extracorporeal Life Support during Cardiopulmonary Resuscitation. Cardiac catheterisation should be strongly considered if cardiac function does not return quickly to identify any residual lesions, which can be repaired either surgically or with transcatheter interventions. “Myocardial stunning”, which is the term given for asystole or minimal contractility noted following initiation of Extracorporeal Life Support, is often seen in the first few hours following initiation of venoarterial extracorporeal membrane oxygenation for Extracorporeal Life Support during Cardiopulmonary Resuscitation. Although the exact aetiology of this myocardial stunning is unknown, it may relate to changes in the cellular concentration of calcium, and thus maintaining normal levels of ionised calcium is important, or from the sudden increased ventricular afterload and decreased ventricular preload that occurs with venoarterial extracorporeal membrane oxygenation. Although this condition seems to be self-limited in many patients, others respond to cardiac pacing and/or vasoactive manipulations including reduction of afterload with milrinone or nitroprusside. Although not necessary in patients with functionally univentricular hearts with open atrial communications, emergent left atrial decompression by septostomy or left atrial cannulation may be required in patients with biventricular circulation with acute left heart failure on Extracorporeal Life Support. The inability for the aortic valve to open and eject blood may lead to left atrial hypertension, pulmonary venous congestion, and pulmonary haemorrhage. Maintaining the intra-cardiac filling pressures at low levels to augment endocardial flow of blood is also an important component of cardiac recovery.
Although renal insufficiency or renal failure requiring renal replacement therapy or filtration to maintain balance of fluids is frequent in patients who undergo Extracorporeal Life Support during Cardiopulmonary Resuscitation, it should be remembered that renal failure and use of dialysis has been associated with worse outcome in most reports.Reference Chen, Tsai and Chang26 The lack of pulsatility during venoarterial Extracorporeal Life Support may be one factor that contributes to the development of renal insufficiency, although again no specific aetiology other than a proposed period of poor perfusion to the kidneys has been identified as the ultimate cause of renal disease during Extracorporeal Life Support.
Prognostic features and outcome
Predictive markers are important to identify appropriate candidates for Extracorporeal Life Support during Cardiopulmonary Resuscitation and provide prognostic information. Common independent factors reported in the literature associated with failure to wean off Extracorporeal Life Support are
• prolonged duration of Extracorporeal Life Support,
• elevated levels of lactate in the serum,
• renal failure,
• multi-organ failure, and
• functionally single ventricle.
Importantly, findings are often variable between published reports, and thus no concrete recommendations for candidacy or outcome can be determined. A recent reportReference Kumar, Zurakowski and Dalton11 identified specific factors associated with failure to wean off Extracorporeal Life Support as
• duration of greater than 10 days of support with Extracorporeal Life Support,
• urine output less than 2 millilitres per kilogram per hour in the first 24 hours of initiation of Extracorporeal Life Support,
• renal failure, and
• pH less than 7.35 after 24 hours of Extracorporeal Life Support.
Poor outcomes are also associated with low regional cerebral oxygen saturations by near-infrared regional spectroscopy in the first 48 hours after the Norwood (Stage 1) operation.Reference Tweddell, Ghanayem and Mussatto12 A recent reportReference Grist, Whittaker, Merrigan, Fenton, Pallotto and Lofland27 described an institution that developed specific cut-points where mortality greatly increased. Patients with the following findings had a higher mortality than patients with lower scores:
• adjusted anion gap (AGc) value greater than 23 milliequivalents per litre,
• a first venoarterial carbon dioxide gradient (p[v-a]CO2) value greater than 16, and
• a first viability index (AGc + p[v-a]CO2) greater than 28.
Following the variables discussed above and paying careful attention to optimising care while on Extracorporeal Life Support to reverse findings such as acidosis, serial elevations of lactate, and others, may have a beneficial effect on ultimate outcome.
Cardiac recovery on Extracorporeal Life Support is assessed during reduction of flow from the Extracorporeal Life Support circuit. The following variables at low flow often indicate that the patient is ready for a trial off the Extracorporeal Life Support circuit:
• adequate haemodynamics with good perfusion,
• low levels of lactate,
• satisfactory near-infrared regional spectroscopy,
• satisfactory mixed venous levels of oxygen or mixed venous oxygen saturation (SVO2).
Echocardiographic assessment of cardiac performance is often helpful during this period to assess contractility and valvar integrity. If the patient is able to maintain adequate haemodynamics, often with need for some vasoactive support, and exchange of gases after a trial period off Extracorporeal Life Support, removal of the cannulas can be performed. The sternum is often left “open” and covered with a silastic patch for 24–48 hours following separation from Extracorporeal Life Support to ensure that stable cardiac recovery has occurred.
More detailed data about outcomes of cardiac patients who receive Extracorporeal Life Support are provided elsewhere in this Supplement to Cardiology in the Young. A few studies have focused specifically on outcomes of patients with functionally univentricular hearts requiring Extracorporeal Life Support during Cardiopulmonary Resuscitation. The most recent of these noted that 14 out of 20 patients with functional single ventricles received Extracorporeal Life Support during active Cardiopulmonary Resuscitation.Reference Polimenakos, Wojtyla and Smith14 Of these 14 patients, 79% were weaned off Extracorporeal Life Support and 57% survived to discharge. Interval follow-up, median 11 months, at 1, 3, 6, and 12 months found freedom from death or cardiac transplantation in 57%, 50%, 43%, and 36%, respectively. When risk factors for survival were assessed, no difference in duration of cardiopulmonary resuscitation between survivors and non-survivors was noted (39 versus 42 minutes, p = 0.12). Survivors had significantly shorter duration of Extracorporeal Life Support (4 versus 8 days, p = 0.002). Of variables assessed prior, during, and after Extracorporeal Life Support during Cardiopulmonary Resuscitation was initiated, peak levels of lactate in the serum within the first 24 hours of Extracorporeal Life Support (p = 0.03) and duration of Extracorporeal Life Support (p = 0.02) proved significant between survivors and non-survivors. Further analysis noted that a level of lactate at 24 hours of 8.9 millimoles per litre was the best predictor for survival, with the area under the receiver operating characteristic curve, also known as the C-index, of 0.87, sensitivity of 87%, and specificity of 99%. Other points of note from this review of data at a single centre found that equivalent numbers of patients required Extracorporeal Life Support during Cardiopulmonary Resuscitation during the day, defined as 7 am to 6 pm, during the weeknights, defined as 7 pm to 6 am, or weekends, with no difference in survival based on time of day. All but two patients received Extracorporeal Life Support during Cardiopulmonary Resuscitation after arrest in the cardiac intensive care unit, and transthoracic cannulation was performed in 13 out of 14 patients. Aetiologies for arrest were primary cardiac in 86% of patients and respiratory failure leading to cardiac arrest in 14% of patients. Complications and findings after Extracorporeal Life Support between survivors and non-survivors were not significantly different. Mortality was due to
• multi-organ failure (29%, n = 4),
• sepsis or necrotising enterocolitis (36%, n = 5),
• cerebral haemorrhage (14%, n = 2), and
• failure of myocardial recovery (7%, n = 1).
Type of repair (Norwood, Damus–Kaye–Stansel procedure; creation of AP anastomosis without arch reconstruction; Sano modification, Blalock–Taussig shunt) was not associated with outcome, although categorical numbers were small. Of the two patients with associated genetic or chromosomal anomalies, weaning off Extracorporeal Life Support was obtained but neither survived to discharge. Approximately 50% of non-survivors had no improvement in ventricular function after 48 hours of Extracorporeal Life Support, whereas 50% of survivors demonstrated echocardiographic evidence of ventricular improvement, although this was not a statistical factor in overall outcome. Specific neurological outcome was not evaluated, although it is stated that survivors were “neurologically intact” at follow-up. One intriguing editorial comment that accompanied this report was related to the impact of elevated lactate on survival. Of four patients with a Blalock–Taussig shunt, an “open-shunt” approach with larger venous cannulas for increased drainage and flow on Extracorporeal Life Support was practiced. Whether run-off into the aortopulmonary shunt and the pulmonary circulation led to excessive pulmonary blood flow and decreased systemic perfusion is not able to be assessed, but it is a factor to keep in mind. It is estimated by others that approximately 40% of patients with Blalock–Taussig shunts receive some type of restriction to flow during Extracorporeal Life Support because of this concern. Similar to other studies, the inability to achieve reduction of serial levels of lactate following initiation of Extracorporeal Life Support was associated with poor outcome. Whether this relates to the extent of hypoperfusion before Extracorporeal Life Support, inadequate cardiopulmonary resuscitation during initiation of Extracorporeal Life Support, or problems in delivery of oxygen during Extracorporeal Life Support has not been determined. It does, however, reflect the need for vigilance in care once Extracorporeal Life Support is deployed to achieve several related objectives:
• optimise delivery of oxygen,
• reduce production of lactate, and
• maximise clearance of lactate.
Failure to achieve these goals may prove to be a useful marker and predictor of short- and long-term morbidity and mortality.
One final note regarding Extracorporeal Life Support during Cardiopulmonary Resuscitation relates to cost. Although data on this topic are scarce, one summary of 32 patients receiving Extracorporeal Life Support for arrest (n = 18) or post-operative cardiac failure (n = 14) examined the financial impact of these patients.Reference Mahle, Forbess, Kirshbom, Cuadrado, Simsic and Kanter28 Congenital cardiac disease was present in 84% of patients. Survival to discharge was 47% in this study, although 50% were successfully weaned off Extracorporeal Life Support. The average duration of Extracorporeal Life Support was 5.1 plus or minus 4 days. Approximately, 44% of patients had the physiology of a functionally univentricular heart. The majority of deaths were related to multi-organ failure and occurred while receiving Extracorporeal Life Support or within 72 hours of decannulation. Approximately 31% (7 out of 32) of patients had significant neurological events, with three survivors noted to have gross motor weakness on discharge and two with significant cognitive impairment. The median hospital cost for Extracorporeal Life Support per patient was $156,324.00 (United States of America dollars), although there was wide variation in costs even among survivors ($81,413–1,238,004). The mean cost of Extracorporeal Life Support per hour was estimated at $16,430.00 plus or minus $6901. Follow-up costs in terms of the predicted need for additional surgical procedures, medications, and follow-up by physicians were also included in the overall economic analysis. Parents were asked to complete a “Health Utilities Analysis” questionnaire, which ranges from 0.1 to 1.0 in scale, with 1.0 described as full health. The mean score for survivors of Extracorporeal Life Support was 0.75 plus or minus 0.19. Using standard survival scales for patients with congenital cardiac disease and patients and functionally univentricular hearts, estimation of quality life-year saved was calculated. Overall range of cost utility was between $20,687 and $32,220, with a median of $24,386 per quality life-year saved. Accepted cost efficacy is described as procedures that result in less than $50,000 per quality-adjusted life-year saved. Although this report is from a single centre, future collaborations may continue to give ongoing evaluation of the economic impact of extracorporeal support in patients with cardiac disease.
Summary
Extracorporeal Life Support during Cardiopulmonary Resuscitation has been successfully used to rescue many patients with refractory cardiac arrest with short-term good neurological outcomes, including patients with hypoplastic left heart syndrome. To truly have a system of Extracorporeal Life Support during Cardiopulmonary Resuscitation, all required personnel should be available in-house 24 hours per day, 7 days per week. However, if this is not possible, a system that gets required surgical and supportive personnel to the bedside in a matter of minutes is needed. For Extracorporeal Life Support during Cardiopulmonary Resuscitation to be most successful, it must be deployed rapidly while the patient is undergoing excellent cardiopulmonary resuscitation. Early activation of the team that will perform cannulation could possibly shorten the duration of cardiopulmonary resuscitation and might improve survival and outcome.Reference Sivarajan, Best, Brizard, Shekerdemian, d'Udekem and Butt29 More research needs to be done to refine the populations and circumstances that offer the best outcome with Extracorporeal Life Support during Cardiopulmonary Resuscitation, evaluate the ratios of cost to benefit, and establish the long-term neurodevelopmental outcomes in survivors. Variability in techniques of the care of patients from centre to centre, equipment used, and protocols followed also make it difficult to extrapolate the experience of one centre to others. By collaboration and even attempting to standardise how Extracorporeal Life Support during Cardiopulmonary Resuscitation is performed, needed information as to the optimal means of providing support will be obtained.
