Outcomes in Pediatric ECPR for In-Hospital Cardiac Arrest: An ELSO Registry Analysis

Raysa Morales-Demori, Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Houston, TX, USA.
Taylor L. Olson, Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington DC, USA.
Alexander Alali, Pediatric Cardiac Intensive Care Unit, Cook Children's Hospital, Fort Worth, TX, USA.
Ryan P. Barbaro, Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA; Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan, USA.
Peter Rycus, Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan, USA.
Peta M. Alexander, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
Erika R. O'Neil, Department of Pediatrics, United States Air Force, Brooke Army Medical Center, San Antonio, Texas.
Duy D. Dinh, Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Houston, TX, USA.
Sukru Aras, Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA; Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, Texas 77030, USA; Epidemiology and Population Health, Baylor College of Medicine, Houston, Texas 77030, USA.
Matthew Friedman, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.
Marc Anders, Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Houston, TX, USA.

Document Type

Journal Article

Publication Date

8-30-2025

Journal

Resuscitation

DOI

10.1016/j.resuscitation.2025.110794

Keywords

CPR; ECMO; ECPR; Extracorporeal Membrane Oxygenation; Pediatric

Abstract

BACKGROUND: Utilization of in-hospital extracorporeal cardiopulmonary resuscitation (ECPR) in pediatrics has increased significantly, with concurrent improvements in survival. Despite these advances, there remains considerable variability in the criteria for pediatric ECPR candidacy. This study aims to identify the patient demographics as well as pre-, peri-, and post-arrest characteristics associated with ECPR outcome. METHODS: This is a retrospective study of patients up to 18 years old with witnessed in-hospital cardiac arrest and ECPR from January 2020 until October 2024 reported to the Extracorporeal Life Support Organization (ELSO) Registry. The primary outcome was a composite measure including survival to hospital discharge, heart transplantation, or placement of permanent ventricular assist device. Univariate and multivariate logistic regression, as well as Kaplan Meier and Joint-Model analysis were performed. RESULTS: A total of 1,903 patients were analyzed in the study, with 1,410 (74.1%) presenting with cardiac precipitating events, 358 (18.8%) with non-cardiac events, and 135 (7.1%) with unknown causes. Overall, 788 patients (41.4%) achieved a favorable composite outcome, including 641 (45.5%) in the cardiac group, 100 (27.9%) in the non-cardiac group and 47 (34.8%) in the unknown group. On univariate analysis, non-cardiac event (OR 0.46 [0.36-0.60]), longer cardiopulmonary resuscitation (CPR) duration (OR 0.98 [0.98-0.99]), non-shockable rhythm (OR 0.62 [0.49-0.79]), and higher lactate (OR 0.95 [0.93-0.97]) were associated with decreased odds of favorable outcome, whereas signs of life (OR 1.52 [1.22-1.89]) and higher pH (OR 3.26 [2.03-5.27]) were associated with increased odds of favorable outcome. Independent predictors of increased odds of favorable outcome on multivariate analysis included higher pH at 24 hours (OR 10.69 [1.46-78.36]), whereas variables associated with decreased odds of favorable outcome included history of prior ECMO run (OR 0.37 [0.22-0.62]), lung disease (OR 0.37 [0.16-0.85]), renal replacement therapy (OR 0.39 [0.16-0.94]), higher PaCO prior to ECMO (OR 0.99 [0.99-0.99]), higher lactate at 24 hours (OR 0.80 [0.75-0.85]), and longer CPR time (OR (0.99 [0.99-0.99]). Elevated lactate tertiles at all points (pre-ECPR, 6 hours, and 24 hours) were associated with lower rates of favorable outcome by Kaplan-Meier (p log-rank<0.0001) and Joint model analyses (p=0.018). CONCLUSION: Pediatric ECPR is a complex, resource-intensive intervention impacted by institutional expertise, patient selection, arrest characteristics, and post-ECPR management. We highlight several prognostic variables that may be useful in determining ECPR candidacy.

Department

Pediatrics

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