Extra Corporeal membrane oxygenation (ECMO) is one of the most advanced forms of life support therapy in the Intensive Care Unit. It relies on the principle where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) within which blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. The goal of ECMO is to provide a physiologic milieu for recovery in refractory cardiac/respiratory failure. The technology is not a definitive treatment for a disease, but provides valuable time for the body to recover. In that way it can be compared to a bridge, where patients are initiated on ECMO as a bridge to recovery, bridge to decision making, bridge to transplant or bridge to diagnosis. The use of this modality in children is not backed by a lot of randomized controlled trials, but the use has increased dramatically in our country in last 10 years. This article is not intended to provide an in-depth overview of ECMO, but outlines the basic principles that a pediatric intensive care physician should know in order to manage a kid on ECMO support.
ELSO guidelines: general guidelines for all ECLS cases. Version 1.4, 2017.
2.
GibbonJHJr.Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med1954; 37(3): 171–185.
3.
HillJDO’BrienTGMurrayJJ, et al. Prolonged extracorporeal oxygenation for acute posttraumatic respiratory failure (shock-lung syndrome): use of the Bramson membrane lung. N Engl J Med1972; 286(12): 629–634.
4.
BartlettRH.Esperanza. Trans ASAIO1985; 31: 723–735.
PeekGJMugfordMTiruvoipatiR, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet2009; 374(9698): 1330.
7.
BembeaMHoskoteAGuerguerianA.Pediatric ECMO research: the case for collaboration. Front Pediatr2018; 6: 240.
8.
BarbaroRPadenMGunerY, et al. Pediatric extracorporeal life support organization registry international report 2016. ASAIO J2017; 63(4): 456–463.
DaltonHJ.Extracorporeal life support: moving at the speed of light. Respir Care2011; 56(9): 1445–1453; discussion 1453–1456.
11.
LinJC.Extracorporeal membrane oxygenation for severe pediatric respiratory failure. Respir Care2017; 62(6): 732–750.
12.
BrownGDeatrickK. Guidelines for pediatric cardiac failure, extracorporeal life support organization ECLS guidelines. Elso.org, http://www.elso.org/resources/guidelines.aspx (2017).
13.
KaneDAThiagarajanRRWypijD, et al. Rapid-response extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in children with cardiac disease. Circulation2010; 122(11_suppl_1): S241–S248.
14.
ErdilTLemmeFKonetzkaA, et al. Extracorporeal membrane oxygenation support in pediatrics. Ann Cardiothorac Surg2019; 8(1): 109–115.
15.
RoeleveldPMendoncaM.Neonatal cardiac ECMO in 2019 and beyond. Front Pediatr2019; 7: 327.
16.
MontoyaJPMerzSIBartlettRH.A standardized system for describing flow/pressure relationships in vascular access devices. ASAIO Trans1991; 37(1): 4–8.
17.
HarveyC.Cannulation for neonatal and pediatric extracorporeal membrane oxygenation for cardiac support. Front Pediatr2018; 6: 17.
MacLarenGButtWBestD, et al. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med2011; 12(2): 133–136.
20.
GarciaAVJeyarajuMLaddMR, et al. Survey of the American Pediatric Surgical Association on cannulation practices in pediatric ECMO. J Pediatr Surg2018; 53(9): 1843–1848.
21.
KurkluogluMHynesCFAlfaresFA, et al. Choice of peripheral venoarterial extracorporeal membrane oxygenation cannulation site in patients above 15 kilograms. J Card Surg2015; 30: 461–465.
22.
JohnsonKJarboeMDMychaliskaGB, et al. Is there a best approach for extracorporeal life support cannulation: a review of the extracorporeal life support organization. J Pediatr Surg2018; 53(7): 1301–1304.
23.
GanderJWFisherJCReichsteinAR, et al. Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem. J Pediatr Surg2010; 45(11): 2136–2140.
24.
DaltonHJ.Management of veno-arterial ECMO in infants and children. Qatar Med J2017; 2017(1): 35.
25.
BaruteauAEBarnetcheTMorinL, et al. Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression. Eur Heart J Acute Cardiovasc Care2018; 7(1): 70–79.
26.
NappLCKühnCHoeperMM, et al. Cannulation strategies for percutaneous extracorporeal membrane oxygenation in adults. Clin Res Cardiol2016; 105(4): 283–296.
27.
ThompsonAFLuanJAl AklabiMM, et al. Pediatric extracorporeal membrane oxygenation (ECMO): a guide for radiologists. Pediatr Radiol2018; 48(10): 1488–1502.
28.
BroganTLequierLLorussoR, et al. Extracorporeal life support: the ELSO Red book. 5th ed.Ann Arbor, MI: ELSO, 2017.
29.
BembeaMMAnnichGRycusP, et al. Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey. Pediatr Crit Care Med2013; 14: e77–e84.
30.
StockerCFHortonSB.Anticoagulation strategies and difficulties in neonatal and peadiatric extracorporeal membrane oxygenation. Perfusion2016; 31(2): 95–102.
31.
IrbyKSwearingenCByrnesJ, et al. Unfractionated heparin activity measured by anti-factor Xa levels is associated with the need for extracorporeal membrane oxygenation circuit/membrane oxygenator change. Pediatr Crit Care Med2014; 15(4): e175–e182.
32.
LiverisABelloRFriedmannP, et al. Anti-factor Xa assay is a superior correlate of heparin dose than activated partial thromboplastin time or activated clotting time in pediatric extracorporeal membrane oxygenation. Pediatr Crit Care Med2014; 15(2): e72–e79.
33.
NorthropMSidonioRPhillipsS, et al. The use of an extracorporeal membrane oxygenation anticoagulation laboratory protocol is associated with decreased blood product use, decreased hemorrhagic complications, and increased circuit life. Pediatr Crit Care Med2015; 16(1): 66–74.
34.
ChanABlackLIngC, et al. Utility of aPTT in monitoring unfractionated heparin in children. Thromb Res2008; 122(1): 135–136.
35.
KhajaWBilenOLuknerR, et al. Evaluation of heparin assay for coagulation management in newborns undergoing ECMO. Am J Clin Pathol2010; 134(6): 950–954.
36.
LawsonSEllisCButlerK, et al. Neonatal extracorporeal membrane oxygenation devices, techniques and team roles: 2011 survey results of the United States’ extracorporeal life support organization centers. J Extra Corpor Technol2011; 43: 236–244.
37.
RanucciMBallottaAKandilH, et al. Surgical and clinical outcome research group: bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation. Crit Care2011; 15: R275.
38.
PappalardoFMajGScandroglioA, et al. Bioline heparin-coated ECMO with bivalirudin anticoagulation in a patient with acute heparin-induced thrombocytopenia: the immune reaction appeared to continue unabated. Perfusion2009; 24: 135–137.
39.
NagleELDagerWEDubyJJ, et al. Bivalirudin in pediatric patients maintained on extracorporeal life support. Pediatr Crit Care Med2013; 14(4): e182–e188.
40.
PettignanoRFortenberryJDHeardML, et al. Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure. Pediatr Crit Care Med2003; 4(3): 291–298.
41.
CoveMEMacLarenGFederspielWJ, et al. Bench to bedside review: extracorporeal carbon dioxide removal, past present and future. Crit Care2012; 16(5): 232.
42.
NasrVGMeserveJPereiraLM, et al. Sedative and analgesic drug sequestration after a single bolus injection in an ex vivo extracorporeal membrane oxygenation infant circuit. ASAIO J2019; 65(2): 187–191.
43.
HarthanAABuckleyKWHegerML, et al. Medication adsorption into contemporary extracorporeal membrane oxygenator circuits. J Pediatr Pharmacol Ther2014; 19(4): 288–295.
44.
JenksCLTweedJGigliKH, et al. An international survey on ventilator practices among extracorporeal membrane oxygenation centers. ASAIO J2017; 63(6): 787–792.
45.
CamporotaLNicolettiEMalafronteM, et al. International survey on the management of mechanical ventilation during ECMO in adults with severe respiratory failure. Minerva Anestesiol2015; 81(11): 1170–1183.
46.
BiscottiMGannonWDAgerstrandC, et al. Awake extracorporeal membrane oxygenation as bridge to lung transplantation: a 9-year experience. Ann Thorac Surg2017; 104: 412–419.
47.
AbramsDGaranARBrodieD.Awake and fully mobile patients on cardiac extracorporeal life support. Ann Cardiothorac Surg2019; 8: 44–53.
48.
BrochardLSlutskyAPesentiA.Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med2017; 195: 438–442.
49.
Anton-MartinPThompsonMTSheeranPD, et al. Extubation during pediatric extracorporeal membrane oxygenation: a single-center experience. Pediatr Crit Care Med2014; 15(9): 861–869.
50.
UpadhyayGRaoSJoshiV, et al. Pediatric cardiac ECMO: a review. J Pediatr Crit Care2017; 4(2): 54–66.
51.
BrainMJButtWWMacLarenG. Physiology of extracorporeal life support (ECLS). In: Extracorporeal life support for adults. New York, NY: Humana Press, 2016, pp.1–60.
52.
EckmanPMKatzJNEl BanayosyA, et al. Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: an introduction for the busy clinician. Circulation2019; 140(24): 2019–2037.
53.
NarukeTInomataTImaiH, et al. End-tidal carbon dioxide concentration can estimate the appropriate timing for weaning off from extracorporeal membrane oxygenation for refractory circulatory failure. Int Heart J2010; 51(2): 116–120.
54.
AissaouiNLuytCELeprinceP, et al. Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock. Intensive Care Med2011; 37: 1738–1745.
55.
HolgrenSEFredeRTCrumleyJP, et al. Novel utilization of the bridge during weaning off venoarterial ECMO: the Hoffman clamp method. Innovations (Phila)2016; 11(3): 229–231.
56.
AgarwalHSHardisonDCSavilleBR, et al. Residual lesions in postoperative pediatric cardiac surgery patients receiving extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg2014; 147(1): 434–441.
57.
MarhongJDTelesnickiTMunshiL, et al. Mechanical ventilation during extracorporeal membrane oxygenation. An international survey. Ann Am Thorac Soc2014; 11(6): 956–961.
58.
FordMAGauvreauKMcMullanDM, et al. Factors associated with mortality in neonates requiring extracorporeal membrane oxygenation for cardiac indications: analysis of the extracorporeal life support organization registry data. Pediatr Crit Care Med2016; 17(9): 860–870.
59.
GeMPanTWangJX, et al. Outcomes of early versus delayed initiation of extracorporeal life support in cardiac surgery. J Cardiothorac Surg2019; 14(1): 129.
60.
GuptaPRobertsonMJRettigantiM, et al. Impact of timing of ECMO initiation on outcomes after pediatric heart surgery: a multi-institutional analysis. Pediatr Cardiol2016; 37(5): 971–978.
61.
DomicoMBRidoutDABronickiR, et al. The impact of mechanical ventilation time before initiation of extracorporeal life support on survival in pediatric respiratory failure: a review of the Extracorporeal Life Support Registry. Pediatr Crit Care Med2012; 13(1): 16–21.
62.
ChengYTWuMYChangYS, et al. Developing a simple preinterventional score to predict hospital mortality in adult venovenous extracorporeal membrane oxygenation: a pilot study. Medicine2016; 95(30): e4380.
63.
CrabbeSMaloJNattB, et al. 1061: duration of mechanical ventilation and patient outcomes for extracorporeal membrane oxygenation. Crit Care Med2018; 46(1): 514.
64.
BartlettRHGazzanigaABFongSW, et al. Extracorporeal membrane oxygenator support for cardiopulmonary failure. Experience in 28 cases. J Thorac Cardiovasc Surg1977; 73(3): 375–386.
65.
BartlettRHGazzanigaABHuxtableRF, et al. Extracorporeal circulation (ECMO) in neonatal respiratory failure. J Thorac Cardiovasc Surg1977; 74(6): 826–833.
FernandoSMQureshiDTanuseputroP, et al. Long-term survival and costs following extracorporeal membrane oxygenation in critically ill children-a population-based cohort study. Crit Care2020; 24(1): 131.
68.
HuiTTDanielsonPDAndersonKD, et al. The impact of changing neonatal respiratory management on extracorporeal membrane oxygenation utilization. J Pediatr Surg2002; 37(5): 703–705.
69.
SchaibleTHermleDLoerschF, et al. A 20-year experience on neonatal extracorporeal membrane oxygenation in a referral center. Intensive Care Med2010; 36(7): 1229–1234.
70.
MugfordMElbourneDFieldD.Extracorporeal membrane oxygenation for severe respiratory failure in newborn infants. Cochrane Database Syst Rev2008; 3: CD001340.
71.
DaltonHJMacraeDJPediatric Acute Lung Injury Consensus Conference Group. Extracorporeal support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med2015; 16(5Suppl 1): S111–S117.
72.
YamNMcmullanDM.Extracorporeal cardiopulmonary resuscitation. Ann Transl Med2017; 5: 1–7.
73.
StillerBBuchholzH.Extracorporeal membrane oxygenation. In: Da CruzEMIvyDJaggersJ (eds.) Pediatric and congenital cardiology, cardiac surgery and intensive care. 1st ed. New York, NY: Springer, 2014. pp.2723–2754.
74.
NagaoKHayashiNKanmatsuseK, et al. Cardio-pulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital. J Am Coll Cardiol2000; 36: 776–783.
75.
LasaLLRogersRSLocalioR, et al. Extracorporeal cardiopulmonary resuscitation (E-CPR) during pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge. Circulation2016; 133: 165–176.
76.
BembeaMMNgDKRizkallaN, et al. Outcomes after extracorporeal cardiopulmonary resuscitation of pediatric in-hospital cardiac arrest: a report from the get with the guidelines-resuscitation and the extracorporeal life support organization registries. Crit Care Med2019; 47(4): e278–e285.
77.
de CaenARBergMDChameidesL, et al. Part 12: pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics2015; 136(Suppl 2): S176–S195.
78.
HanekampMNMazerPvan der Cammen-van ZijpMH, et al. Follow-up of newborns treated with extracorporeal membrane oxygenation: a nationwide evaluation at 5 years of age. Crit Care2006; 10(5): R127.
79.
BoyleKFellingRYiuA, et al. Neurologic outcomes after extracorporeal membrane oxygenation: a systematic review. Pediatr Crit Care Med2018; 19(8): 760–766.
