What is the role of Extracorporeal Membrane Oxygenation (ECMO) in pediatrics?

From the Guidelines

Extracorporeal Membrane Oxygenation (ECMO) plays a crucial role in pediatrics as a life-sustaining intervention for children with severe cardiac or respiratory failure, including those with progressive pulmonary hypertension despite optimal therapy, by providing cardiopulmonary support to facilitate recovery or bridging to transplantation. The decision to use ECMO in pediatrics is guided by the severity of the underlying condition, with the goal of optimizing medical therapy, palliative shunt creation, or transplantation 1.

Key Considerations

• ECMO can be used in either venovenous (VV) or venoarterial (VA) modes, depending on the need for cardiac, pulmonary, or cardiopulmonary support, with the approach dictated by factors such as the severity of right ventricular dysfunction 1.
• When used as a bridge to transplantation, it is essential to optimize pharmacotherapies for pulmonary hypertension, avoid prolonged endotracheal intubation, and focus on patient rehabilitation through physical therapy, minimizing sedatives and neuromuscular blockade, and improving nutrition status 1.
• The configuration and securement of ECMO cannulae can be challenging, particularly when attempting to facilitate rehabilitation and ambulation, often requiring unique configurations 1.

Clinical Application

• In pediatric patients with severe cardiac or respiratory failure, ECMO provides temporary support, allowing for the possibility of recovery or bridging to definitive therapies such as transplantation.
• The management of ECMO requires a multidisciplinary team approach, including careful monitoring of anticoagulation, ventilator settings, fluid balance, and nutritional support.
• While ECMO is a life-saving intervention, it is not without risks, including bleeding, thrombosis, infection, and neurological injury, highlighting the need for careful patient selection and management 1.

From the Research

Role of ECMO in Pediatrics

• Extracorporeal membrane oxygenation (ECMO) is a crucial device in managing children with severe refractory cardiac and pulmonary failure 2.
• ECMO provides support to critically ill patients with cardiac disease and is commonly used in various settings 2, 3.
• The main indications for ECMO include refractory respiratory failure and refractory circulatory failure, such as cardiogenic shock, septic shock, and refractory cardiac arrest 4.

ECMO Types and Contraindications

• Different types of ECMO can be used depending on the initial failure, including venoarterial (VA) and venovenous (VV) ECMO 5.
• Contraindications to ECMO have reduced in recent years, but still include gestational age under 34 weeks, birth weight under 2kg, severe underlying pulmonary disease, and severe immune deficiency 4.

Outcomes and Complications

• The overall survival rate of ECMO is approximately 60%, varying depending on the initial disease 4.
• Complications of ECMO include neurological impairment, nosocomial infections, and acute kidney injury 4, 6.
• ECMO can be effective in allowing time for recovery of cardiac dysfunction and acute hypoxic insult, with some patients requiring long-term ECMO support 6.

Advances and Future Directions

• The formation of the Extracorporeal Life Support Organization (ELSO) has facilitated the development of consensus guidelines for ECMO use in various populations 3.
• Improving ECMO technology and increasing experience with ECMO have resulted in significant improvements in ECMO utilization, morbidity, and mortality 3.