Extracorporeal CPR Performance Metrics in In-Hospital Cardiac Arrest: A Stepwise, Evidence-Based Appraisal of the VA-ECMO Implementation Process

Extracorporeal cardiopulmonary resuscitation (ECPR) is an established intervention for select patients experiencing refractory cardiac arrest. Among modifiable predictors of survival and neurologic recovery, timely restoration of circulation remains the most critical—particularly in cases of refractory in-hospital cardiac arrest (IHCA). Despite its increasing use, the literature remains limited regarding operational standards, quality improvement metrics, and performance evaluation for ECPR. We conducted a comprehensive literature review structured around the ELSO framework for ECPR implementation. At each step, we synthesized evidence-based best practices and identified operational factors that directly influence time-to-circulation. Our goal was to provide a stepwise evaluation of ECPR initiation in order to consolidate existing best practices and highlight process components with potential for further study and standardization. Patient-level variables—such as age, comorbidities, initial rhythm, and arrest location—have all been associated with clinical outcomes. However, the most consistently impactful factor across studies is the duration of CPR prior to ECMO initiation, also known as the low-flow interval. We further evaluated the literature surrounding key technical components of ECPR, including cannula selection, placement technique, and positioning. Ongoing research is needed to refine and standardize each stage of the ECPR workflow. Developing optimized, protocol-driven approaches to ensure rapid, high-quality deployment will be essential for improving outcomes with this life-saving but resource-intensive therapy.