Pediatric extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: outcomes and clinical trajectories.
Abstract
Aims
To characterize management, outcomes, and donation trajectories of pediatric extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA), and to describe early features observed among survivors and non-survivors.
Methods
We conducted a retrospective single-centre observational cohort study including all consecutive children (<18 years) treated with ECPR for OHCA at a tertiary pediatric ECMO referral centre between 1 January 2013 and 31 December 2025. Survivors were compared with non-survivors, and among non-survivors, patients with brain death diagnosis were compared with those without brain death diagnosis.
Results
Among 155 pediatric OHCA patients managed at our institution during the study period, 42 (27.1%) underwent ECPR and were included in the present analysis. Median age was 9 years, median low-flow time 85 min, and median ECMO duration 55 h. Survival to hospital discharge was 19.0% (8/42). In exploratory comparisons, survivors more often received bystander CPR (100.0% vs 52.9%, p=0.016), had more frequent transient pre-hospital ROSC (62.5% vs 20.6%, p=0.031), and shorter low-flow duration (53 vs 90 min, p=0.006) than non-survivors. Survivors also had lower initial lactate (11.18 vs 18.00 mmol/L, p=0.003), lower 24-h vasoactive-inotropic score (5 vs 18, p=0.0053), and lower 24-h transfusion burden (12 vs 40 mL/kg, p=0.029). Non-survivors had more severe and persistent early organ injury. Of 34 deaths, 12 had a brain death diagnosis (35.3% of non-survivors; 28.6% of the total cohort), and 4 became effective organ donors. At last follow-up (median, 412 days), 7 of 8 hospital survivors were alive, and 6 of 7 had PCPC ≤2.
Conclusions
Pediatric OHCA-ECPR yielded limited but meaningful survival. Measures of early resuscitation quality, low-flow duration, and early metabolic and organ-injury profiles may help distinguish different clinical trajectories after pediatric OHCA-ECPR.