Objectives: International guidelines on cardiopulmonary resuscitation, CPR, contain a universal algorithm, suggesting a “one size fits all” approach. Its simplicity aims at the highest possible transferrability and feasibility across systems. In contrast, patient centered, individualized resuscitation concepts form an emerging paradigm. These are known as “targeted”, “tailored”, “goal-directed” or “physiology guided” CPR, with some mentions in the guideline texts. These principles are increasingly being applied to all parts of the “chain of survival”, including advanced resuscitation measures such as eCPR. Therefore we described and developed the principle of “controlled automated repefusion of the whole body” (CARL), in the context of this evolution in patient centricity during CPR during the past 15 years.
Methods: Current guidelines on cardiopulmonary resuscitation are reviewed with respect to the concept of individalized CPR. Key features of a goal-directed approach to CPR, eCPR and finally, CARL therapy, are highlighted and discussed, respectively. Furthermore, extensive experience in chronic animal experiments and patient treatment are incorporated within this systematics. This review is then presented in a synopsis.
Results: Conventional CPR forms the basis of all resuscitative efforts, but is uncontrolled. Targeting endtidal carbon dioxide levels or diastolic blood pressure intra-arrest represents a more goal-directed approach. eCPR is a highly invasive, sophisticated technological intervention, but in its classic form only an untargeted external cardio-respiratory support, at least during the initial phase of reperfusion. Applying eCPR in a goal-directed way has little been described. It mainly refers to titration of oxygenation, ventilation, and temperature management. CARL is a therapy bundle based on extracorporeal circulation, aimed at organoprotection and the limitation of ischemia-reperfusion injury.
Conclusion
Advanced monitoring during CARL therapy facilitates a highly individualized, targeted therapy following refractory cardiac arrest, combining key features from eCPR as well as goal-directed CPR.

8 - From CPR to Targeted CPR to Targeted eCPR to CARL: A paradigm shift in advanced cardiopulmonary resuscitation