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Extracorporeal CPR for Inhospital Cardiac Arrest

Question Type:
Intervention
Full Question:
In infants and children with IHCA

 (P), does does the use of ECMO for resuscitation, also called ECPR



 (I), compared with when compared with conventional resuscitative treatment (CPR without the use of ECMO)

 (C), change survival to 180 days with good neurological outcome, survival to hospital discharge, survival to intensive care discharge (O)?
Consensus on Science:
For the critical outcome of survival at 180 days with favorable neurologic outcome, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 pediatric observational study of IHCA(Wu 2009, 443-448) showing no benefit to the use of ECPR when compared with CPR without the use of ECMO (RR, 1.21; 95% CI, 0.67–2.17).For the critical outcome of survival to hospital discharge, we identified very-low-quality evidence from 4 pediatric observational studies of IHCA(de Mos 2006, 1209-1215; Wu 2009, 443-448; Lowry 2013, 1422-1430; Odegard 2014, 175-182) (downgraded for indirectness, inconsistency, and residual confounding) and very-low-quality evidence from 1 unpublished analysis of a study’s public dataset(Moler 2009, 2259-2267) (downgraded for serious risk of residual confounding) showing no benefit to the use of ECPR when compared with CPR without the use of ECMO (RR range, 0.64–1.63). We also identified low-quality evidence (downgraded for indirectness, inconsistency, and residual confounding) from a single pediatric study of IHCA(Ortmann 2011, 2329-2337) that showed benefit to ECPR when compared with CPR without the use of ECMO (OR, 2.5; 95% CI, 1.3–4.5; P=0.007 in surgical cardiac diagnoses; OR, 3.8; 95% CI, 1.4–5.8; P=0.011 in medical cardiac diagnoses).
Treatment Recommendation:
We suggest that ECMO with resuscitation (ECPR) may be considered for infants and children with cardiac diagnoses who have IHCA in settings that allow expertise, resources, and systems to optimize the use of ECMO during and after resuscitation (weak recommendation, very-low-quality evidence). The confidence in effect estimates is so low that that there is insufficient evidence to suggest for or against the routine use of ECMO with conventional resuscitation (ECPR) in infants and children without cardiac diagnoses who have IHCA (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force Insights In making this recommendation, we value the improved survival of a select patient population (cardiac) over the expense incurred and intensity of resources necessary for universal deployment of ECMO for pediatric IHCA. All of the reports to date are heavily influenced by selection bias of ECPR candidates. Significant expertise and resource implications exist in order for this treatment strategy to be appropriately applied. These should be taken into account before extending the implementation to more in-patient settings, including the risk-benefit analysis for patients without cardiac diagnoses as well as those with cardiac conditions, whether or not related to the cause of the cardiac arrest. The task force acknowledged that selection of patients and local practice is highly variable and that further controlled studies are indicated.
CoSTR Attachments:
407_PedsECMO_Feb12015_n.docx    

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