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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of Medicina Intensiva&#44; Mart&#237;nez-Mart&#237;nez et al&#46; present the most extensive series of cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation &#40;ECPR&#41; in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this retrospective single-center study&#44; 54 patients received ECPR over four years&#46; At the 180-day mark&#44; 16 patients &#40;29&#46;6&#37;&#41; were alive&#44; and 15 achieved good neurological performance&#46; Overall&#44; the results described by Mart&#237;nez-Mart&#237;nez et al&#46; are comparable with previously published experiences&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">According to the Extracorporeal Life Support Organization&#44; ECPR is defined as the application of rapid-deployment veno-arterial extracorporeal membrane oxygenation &#40;VA-ECMO&#41; to provide circulatory support in patients in whom conventional CPR is unsuccessful in obtaining a sustained return of spontaneous circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although international recommendations on CPR include ECPR in their algorithms&#44; there are still no universally agreed indications to start ECPR&#44; and even though inclusion criteria vary among studies&#44; the time between cardiac arrest identification&#44; the onset of resuscitation maneuvers&#44; and the start of ECPR are crucial&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As with any other aspect of CPR&#44; ECPR is very time-sensitive&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the performing arts world&#44; it is well known that practice makes perfect&#44; and we think that ECPR is no exception&#46; The existence of ECMO centers&#44; with highly skilled and well-trained ECMO teams&#44; is the cornerstone of an ECPR program&#46; This training should be simulation-based and should not only include in-hospital but also out-of-hospital healthcare professionals who need to implement scoop-and-run policies when managing cardiac arrest patients if an ECPR scenario is possible&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Particular attention should be paid to cannulation skills since&#44; as described by Mart&#237;nez-Mart&#237;nez et al&#46;&#44; cannulation complications can affect up to 25&#37; of the patients&#46; These ECMO centers should work on standard protocols for ECPR management to homogenize aspects like criteria for ECPR initiation&#46; They should also establish appropriate pathways for post-cardiac arrest care in the ECPR setting&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Although the available data does not support the broad use of ECPR&#44; the chances of seeing benefits will be scarce if we do not deploy adequate ECMO programs nationwide&#46; The INCEPTION trial&#44; performed in the Netherlands&#44; could be an example of this&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This study&#44; published in 2023&#44; failed to demonstrate any differences when comparing conventional CPR to ECPR &#40;16 &#37; vs 20&#37; survival for each group&#41;&#46; Still&#44; when analyzing the data&#44; patients were enrolled at ten different cardiosurgical centers served by 12 emergency medical services&#44; and eight out of those ten centers included less than 15 ECPR patients over four years&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Also&#44; due to the complexity of ECPR&#44; initial efforts might need to be directed towards in-hospital cardiac arrest &#40;IHCA&#41;&#46; Chico-Carballa et al&#46; reported the first experience of a Spanish IHCA ECPR program during the first year of its implementation at a tertiary care hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This retrospective analysis included seven patients&#46; In all cases&#44; bystander CPR was initiated in less than 1 min&#44; and the median time between bystander CPR and advanced ICU CPR was 5 min &#40;IQR 5&#8211;10 min&#41; with median low-flow times of 55 min &#40;IQR 36&#46;25&#8211;62&#46;5 min&#41;&#46; Overall hospital survival was 42&#46;9&#37; &#40;3 patients&#41;&#44; and all survivors achieved a good neurological recovery&#46; In Mart&#237;nez-Mart&#237;nez et al&#46;&#8217;s experience&#44; survival with good neurological outcomes in IHCA was 32&#37; &#40;8 out of 25&#41;&#44; whereas in OHCA&#44; 24&#46;1&#37; &#40;7 out of 29&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although ECPR programs are contributing to increased cardiac arrest survival with good neurological prognosis&#44; the number of patients that die after ECPR is still high&#44; with casualties reaching 70&#8211;85&#37; according to the different published data&#46; The most common causes of death described by Mart&#237;nez-Mart&#237;nez et al&#46; in this population were anoxic encephalopathy &#40;17 patients&#44; 51&#46;5&#37;&#41; followed by brain death &#40;10 patients&#44; 30&#46;3&#37;&#41;&#46; Ten deceased patients &#40;30&#46;3&#37;&#41; became organ donors after neuroprognostication in their study&#46; Even though this is an undesired outcome&#44; the potential benefits of organ donation are undeniable&#46; ECPR might raise the number of potential donors&#44; either after the determination of death by neurological criteria &#40;brain death&#41; or by circulatory criteria &#40;both uncontrolled and controlled scenarios&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> For this reason&#44; ECPR teams and donor coordination units should all be part of a complex network led by intensivists&#44; with clearly defined roles at each point&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">While we wait for further data regarding ECPR results&#44; it seems reasonable to start training and organizing for what the future might bring&#46; Change takes time&#44; and time is something the cardiac arrest patient does not have&#46;</p></span>"
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Journal Information
Vol. 48. Issue 10.
Pages 563-564 (October 2024)
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Vol. 48. Issue 10.
Pages 563-564 (October 2024)
Editorial
ECPR … Ready for it?
ECMO-RCP… ¿Estamos listos?
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Sara Alcántara Carmona
Corresponding author
saralcanta@gmail.com

Corresponding author.
, Héctor Villanueva Fernández
Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
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