Duration of cardiopulmonary resuscitation before extracorporeal rescue: how long is not long enough?

Despite the extensive resources required, extracorporeal cardiopulmonary resuscitation (ECPR) has been recognized as an extension of traditional CPR. The reported duration of CPR before ECPR initiation is similar between survivors and nonsurvivors, but the duration of CPR that results in futility of care is unknown. We report two cases of prolonged CPR followed by ECPR resulting in acceptable neurologic outcomes. Ventricular tachycardia developed in a 4-year-old with myocarditis, resulting in a cardiac arrest requiring CPR for 176 minutes before initiation of extracorporeal membrane oxygenation (ECMO). The patient required ECMO for 9 days. He survived neurologically normal. A ventricular arrhythmia developed in a newborn after an arterial switch procedure, leading to cardiac arrest requiring CPR for 97 minutes before ECMO, which lasted for 11 days. Hydrocephalus developed, but the patient is progressing developmentally. The upper limit of CPR duration before ECPR resulting in acceptable neurological outcomes is unknown. Many clinical and biochemical factors are potential predictors of appropriate ECPR utility. The Extracorporeal Life Support Organization registry is a plausible forum to collect data regarding ECPR. We suggest that possible predictive variables be collected. Until then, practitioners must rely on experience and judgment regarding the value of ECPR in children.