Mark Dennis

Extracorporeal cardiopulmonary resuscitation for refractory out‐of‐hospital cardiac arrest is increasingly used, with survival rates up to ≈30% reported in select highly organized systems, although outcomes vary widely across programs. However, outcomes are driven largely by system performance rather than the procedure itself. To date, most literature has focused on efficacy, patient selection, and cannulation techniques, with limited emphasis on system‐level design. This narrative review synthesizes the key components required to implement an effective extracorporeal cardiopulmonary resuscitation–enabled cardiac arrest system from optimizing the existing emergency medical services, understanding the expected number and distribution of potential patients undergoing extracorporeal cardiopulmonary resuscitation, using geographic information systems to optimize system design to the value of integrated structured identification pathways, streamlined intra‐arrest transport strategies, coordinated postresuscitation care within specialized cardiac arrest centers, and cost‐effectiveness considerations.

Background: The global adoption of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest is accelerating, reflecting its potential to improve outcomes in select patient populations. Although research has increasingly focused on patient selection criteria, there remains a critical lack of evidence to guide best practices in post‐ECPR resuscitation management. This study aimed to identify key knowledge gaps and develop consensus‐based recommendations to inform clinical decision‐making in the post‐ECPR setting. Methods: An international, multidisciplinary steering committee comprising 11 ECPR experts and 1 survivor conducted a targeted literature review to identify key domains and gaps in post‐ECPR care. Experts were recruited based on field impact and snowball sampling. A modified Delphi process was used, comprising 3 survey rounds. Consensus was defined a priori as ≥70% agreement or disagreement on Likert‐scale statements. Results: A total of 53 experts were recruited, representing diverse health care professions, gender, and levels of clinical experience. Of these, 52 (98%) completed all 3 rounds of the Delphi process. Consensus was reached on 126 individual statements, which were synthesized into 42 summary position statements. These recommendations span key domains of post‐ECPR care, including system‐level considerations, hemodynamic targets and management strategies, ventilation and oxygenation protocols, anticoagulation practices, temperature regulation, complication mitigation, weaning approaches, and neuroprognostication. Conclusions: This modified Delphi study, informed by a diverse international panel, resulted in 42 consensus‐based position statements addressing key aspects of post‐ECPR care. In the absence of robust empirical evidence, these expert‐derived recommendations offer a valuable framework to support clinical decision‐making and the development of standardized post‐ECPR resuscitation protocols. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06552312.

Introduction Bleeding events are common during the provision of Venoarterial ECMO (VA ECMO). Previous observational has suggested that these bleeding events are associated with an increased risk of in-hospital mortality however data on long term mortality and functional outcomes are lacking. Methods This multi-centre prospective observational study included patients enrolled in the EXCEL registry from February 2019 until June 2023. We collected baseline demographics, and details of ECMO support. The primary outcome was a composite of death or new disability (defined as an increase of ≥ 10%. in the world health organisation disability assessment schedule score) at 180 days after ECMO initiation. We used multivariable logistic and quantile regression adjusted for illness severity and patient characteristics and diagnosis to assess the association of bleeding with death and new disability and other functional and clinical outcomes. Results The final study cohort included 704 participants, median [interquartile range IQR] age 54.5 [42 to 64] years and 259 (36.8%) were female. Bleeding complications occurred in 312 (44.3%) participants and 154 (22.3%) had major bleeding. Patients with bleeding complications were more often receiving VA ECMO for peri-operative support [112 (36.4%) vs (73 (19.3%), p < 0.001). Patients who experienced bleeding complications were at significantly increased risk of the primary outcome at 6 months risk difference (RD) 8.95% (95% CI: 1.62 to 16.14). However, this finding was due to a significantly increased risk of new disability- adjusted RD 18.04% (95% CI: 6.22 to 29.55) rather than an increased risk of mortality in patients with bleeding compared to no bleeding [adjusted RD 5.71% (95% CI: -1.55 to 13.01)]. Patients with bleeding complications were also associated with an increased use of healthcare resources such as ICU length of stay and renal replacement therapy. Conclusion Bleeding increased the rate of death and disability at 6-months, but this was driven by increased disability rather mortality. Bleeding complications were associated with an increased use of healthcare resources. Prospective studies to address modifiable risk factors for bleeding complications are warranted.