Extracorporeal cardiopulmonary resuscitation, or ECPR, is relatively new to UF Health’s Shands Hospital in Gainesville, FL, but as with the model for ECPR that has been deployed in San Diego, emergency medicine is playing an integral role in making the technology available to area residents.
At UF Health, the ECPR program is housed within the Division of Critical Care Medicine in the Department of Emergency Medicine; all of the faculty in the division are dually trained in emergency medicine and critical care medicine, explains Torben Becker, MD, PhD, MBA, RDMS, FAWM, FAEMS, FCCM, an associate professor in the Department of Emergency Medicine at the University of Florida College of Medicine and executive director of the UF Critical Care Organization. “It cannot be overstated that ECMO (extracorporeal membrane oxygenation) is a very interdisciplinary undertaking in any case, whether it is for the purposes of ECPR or not,” he says, “and so we have people on our team from other departments as well.”
The impetus for developing an ECPR program at Shands Hospital was the reality that the needle has barely moved in recent decades with respect to outcomes for patients in cardiac arrest. “We’ve seen very little progress in terms of overall survival without severe neurologic injury,” observes Becker. “The use of ECPR offers significant promise to help save patients who previously would have had a very low, if not nonexistent, chance of survival.”
Interestingly, unlike the model for ECPR being deployed by hospitals in San Diego, where dozens of emergency physicians are being trained in the technique, developers of the ECPR program at UF Health have decided that it is important to restrict the number of emergency physicians that perform ECPR.
“One of the keys with an ECPR program is to keep the pool of cannulators — meaning the physicians who place the cannulas [in patients’ veins and arteries] and then connect them to the [ECMO] machine — small because it is a relatively rare procedure,” states Becker. “This way, those physicians performing ECPR are well-versed in it and are accustomed to the unique aspects of doing such a cannulation while a patient is in full cardiac arrest.”
Becker notes that UF Health currently has a team of four physicians that do ECPR, and each of these physicians rotates through the position of being on call so that someone is always prepared to respond in the event that a patient in cardiac arrest who is eligible to receive ECPR is en route to the ED. However, the tradeoff for keeping the pool of physicians that perform ECPR small is that a high level of personal commitment is required from the clinicians involved, acknowledges Becker. “Being on call for a quarter of the year is not an insignificant commitment, so it does take people who are very committed to helping victims of cardiac arrest, pushing this technology further, and expanding its use,” he says.
At most centers where ECPR is performed, people learn and start to do ECMO on non-cardiac arrest-related cases first, shares Becker. “This is because ECPR is, without question, the most difficult form of deploying the ECMO technology for patients,” he says. “So, typically physicians — and that includes our physicians — gain training in ECMO in the non-cardiac patient population first before then transitioning the skill to patients in full cardiac arrest.”
However, Becker stresses that training is required for the allied staff involved with performing ECPR as well, including the nursing staff and the specialists (or what some call perfusionists, depending on the institution). “This is because when we use ECMO for the purpose of ECPR, time is most certainly of the essence — even more so than when ECMO is used for a non-cardiac arrest [purpose],” he says.
While allied staff receive individual training on the nuts and bolts of the ECPR technique, one way Shands keeps their skills sharp is by holding regular drills. “The teams don’t know it is happening beforehand,” states Becker. “We simulate where EMS (emergency medical services) comes in with a mannequin on a stretcher to where they hand off the stretcher to be cannulated.”
Then clinicians insert the cannulas into the mannequin and actually place the mannequin on an ECMO pump, describes Becker. “We simulate the whole process — all the way from EMS bringing the patient into the ED to the handover to the intensive care unit — to identify any performance or communication issues, and to have the whole team practice together,” he says.
Although the ECPR program at UF Health began in spring 2023, clinicians did not handle their first case until several months later. “That did not surprise us because there was a lot of education that needed to be done,” states Becker. “For example, we needed to make EMS aware that such a program exists, because for it to work really well, it is important for all parts of the chain of survival to work together — and for EMS to alert us when they have a potential candidate [for ECPR].”
The way the process is set up to work at Shands is there is a dedicated 24/7 phone line that is staffed by the emergency physician who is on call for ECMO/ECPR cannulation, explains Becker. “That number can be called by anyone — by staff from the ED, by EMS, and so on,” he says. “That’s how we get pre-arrival notification [that a potential ECPR patient is en route].”
Developers of the program concluded that this early, direct communication with the physician was important because determining whether a patient is a good candidate for ECPR rarely is clear-cut with respect to the inclusion criteria because there often are several unknown factors, explains Becker. For example, he notes that EMS may not have a clear idea of how long the patient was in cardiac arrest or how quickly bystanders began CPR.
“What we found is by having an approach where people can communicate directly with the physician — rather than having to go up to the level of paging something out hospital-wide — helps to lower the threshold for people to call and say they may have a case,” shares Becker. “If the on-call physician says yes, this sounds like the patient is a good candidate, then we’re going to activate the whole process with something called an ECPR alert, which gets paged out hospital-wide.”
The alert then prompts staff to prepare all the required resources for the incoming patient, including making sure a bed is available in the ICU for the patient to be cared for following ECPR in the ED, explains Becker.
The first patient to receive ECPR at Shands was a 63-year-old man who received CPR from his 26-year-old daughter when he went into cardiac arrest in late November 2023. The ED at Shands was alerted to the case by EMS, and then mobilized the ECPR team, which included Becker. It was a highly successful first case, since the patient survived with no lasting neurological or physical damage.
As of mid-April 2024, the hospital has treated a total of four patients with ECPR, states Becker. “The outcomes are pretty much in line with what other high-performing [ECPR] centers report, which is about a 50% survival rate,” he says.
Eventually, Becker and his team would like to develop the capability to bring ECPR to the patient in the prehospital environment — a move that could trim precious minutes off the time between cardiac arrest and ECPR, potentially saving more lives. “There are a number of prehospital [ECPR] programs, especially in Europe, where, generally, physicians are on ambulances in addition to paramedics … making ECPR a lot easier to implement [in the prehospital environment],” he says.
Becker also refers to the “very high resource” ECPR program at the University of Minnesota Medical School in Minneapolis, where cardiac specialists can travel in a large, well-equipped mobile unit to connect with ambulances in the field to perform ECPR on patients in cardiac arrest before they are taken to the hospital. (https://med.umn.edu/dom/research/programs-centers/center-resuscitation-medicine)
“The sooner we can stop the no- or low-flow state to the brain and other organs, the better for the immediate and long-term survival,” states Becker. “So the idea of bringing the ECMO/ECPR and the team to the patient so that we can remove another 15 or 20 minutes from the whole process — it definitely has an immediate kind of appeal because we know time is of the essence.”
Putting such a program in place would be expensive and complicated, but it is something that Becker and his team would eventually like to build. “At this moment in time, though, my primary focus is to continue to build the program we have currently and make sure that we keep up with the training and the high quality of our staff preparedness,” he says.
Becker acknowledges that other ECPR centers are working to train dozens of emergency physicians in the procedure, but he reiterates that the drawback to that approach is that it potentially makes performing the delicate cannulation procedure a very low-frequency event for each individual physician.
“The jury is out on what model will ultimately prevail as ECPR is becoming more and more common,” he says. “It is very likely to move more into the medical mainstream, including being more frequently employed in smaller hospitals.”
Becker’s advice to colleagues intrigued by the potential of offering ECPR to patients is to carefully consider the challenge. “This is not a side-project sort of thing. It requires a fair amount of resources and human capital to be involved in this,” he says.
However, given the fact there are multiple components involved in the development of an ECPR program, he urges colleagues determined to press forward with a program to keep their eyes on the ultimate outcome. “Try not to get stuck in the political or administrative minutia,” he says. “Focus on the fact that you currently have patients in the community with refractory cardiac arrest [who] do not survive, [but] with this technique, such patients can go back to live normal lives.”
Extracorporeal cardiopulmonary resuscitation, or ECPR, is relatively new to UF Health’s Shands Hospital in Gainesville, FL. Interestingly, unlike the model for ECPR being deployed by hospitals in San Diego, where dozens of emergency physicians are being trained in the technique, developers of the ECPR program at UF Health have decided that it is important to restrict the number of emergency physicians who perform ECPR.
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