22, 21, 17, 15
The ECPR textbook, which advises gradual rewarming and then states that commonly used rewarming rates are around 3 degrees per hour — an order of magnitude faster than conventional post-arrest practice. Both are printed in Chapter 22 and neither is corrected.
The operational backbone of Chapter 22. Two items are unusual and easily missed: the instruction to WAIT before cardioverting, and the placement of hypocarbia avoidance as a line inside the pulmonary oedema row rather than only in the gas row.
Minutes (Table 32-3): confirm cannula position by echo or fluoroscopy, secure and dress; drainage tip at the SVC-RA junction. Mean arterial pressure 60 to 80 mmHg from a right upper limb arterial line, anticipating that pressors may need rapid down-titration. Measure PaO2 from the right-sided line, avoid hyperoxia, and consider differential hypoxia if hypoxaemic. Titrate sweep gas and ventilation, aiming to avoid hypocarbia. Echocardiography and 12-lead ECG. Anticoagulation targets must consider the increased bleeding risk after arrest with or without percutaneous intervention. Hours (Table 32-4): coronary angiography unless an obvious non-cardiac cause, independent of age and presenting rhythm; CT pulmonary angiography with appropriate phasing; consider LV venting if distended; for post-arrest pulmonary oedema exclude LV distension, ensure adequate PEEP and avoid hypocarbia; target saturation 92 to 97%; targeted temperature management 33 to 36 degrees for the first 24 hours then gradual rewarming to 37, explicitly extrapolated from non-ECPR populations; distal perfusion cannula within 4 hours; CT brain and a neurological care bundle; cerebral and peripheral NIRS. Also: cardioversion is not emergent after initiation, and waiting a few minutes to establish perfusion appears to give more successful and sustained organised rhythm.
Post-ECPR management in the first minutes and the first hours