Extracorporeal Cardiopulmonary Resuscitation for Pediatric Out-of-Hospital Cardiac Arrest

Adult evidence for extracorporeal cardiopulmonary resuscitation (ECPR) is substantial, but to our knowledge, comparative studies for pediatric out-of-hospital cardiac arrest (OHCA) are lacking. We compared outcomes of pediatric OHCA with ECPR versus continued cardiopulmonary resuscitation (CPR).

We conducted a retrospective cohort study of patients <18 years from a multicenter Japanese OHCA registry (2014 to 2022) transported to pediatric ECPR-capable institutions. Exposure was ECPR initiation versus continued CPR among patients at risk for ECPR (no ECPR yet; could receive ECPR later). Outcomes were one-month survival and favorable neurologic outcome (Pediatric Cerebral Performance Category 1 to 3). We applied risk-set matching with time-dependent propensity scores, using full matching with up to 4 controls per case.

Of 799 patients, 27 received ECPR; 1:4 matching yielded 108 at-risk controls. ECPR patients were adolescents (median 14 years), witnessed arrest (70.4%), cardiogenic (74.1%); patient characteristics were similar after matching. In patients receiving ECPR versus controls, 1-month survival was 25.9% (7/27) versus 11.1% (12/108) (risk difference 17.3%; 95% confidence interval [CI], -0.9 to 35.6; risk ratio, 3.56; 95% CI, 1.37 to 9.28) and favorable neurologic outcome was 18.5% (5/27) versus 6.5% (7/108) (risk difference 13.9%; 95% CI, -2.9 to 30.8; risk ratio, 3.78; 95% CI; 1.19 to 11.99).

Compared with continued conventional CPR among at-risk patients, ECPR might be associated with improved patient outcomes after pediatric OHCA, but the precision of estimates was limited, with wide confidence intervals. Interpretation is limited by the residual confounding inherent to an observational design; our findings can inform randomized trials of pediatric ECPR.