Extracorporeal membrane oxygenation in the pediatric population – who should go on, and who should not

Abstract

Purpose of review The role of extracorporeal membrane oxygenation (ECMO), a method of providing cardiorespiratory support in instances of cardiac or respiratory failure, in neonates and children continues to expand and evolve. This review details the current landscape of ECMO as it applies to neonates and children. Recent findings Specifically, this review provides the most recent evidence for which patients should be considered for the various forms of ECMO including venovenous ECMO, venoarterial-ECMO, and extracorporeal cardiopulmonary resuscitation. Specific topics to be discussed include indications and contraindications for the different types of ECMO in neonates and children, anticoagulation strategies and ways to monitor end-organ function, outcomes specific to the different types and populations with a focus on meaningful survival to discharge and neurologic outcomes, and consideration of special populations such as low birth weight infants, traumatically injured patients, and children who received recent bone marrow transplants. This review also discusses still unanswered questions surrounding the most appropriate use of ECMO as its role and applications continue to evolve. Summary With rapidly increasing utilization of ECMO, neonatologists and pediatricians should be aware of the most recent evidence guiding its indications, applications, and limitations.

Extracorporeal membrane oxygenation in children receiving haematopoietic cell transplantation and immune effector cell therapy: an international and multidisciplinary consensus statement

“…ECMO indications have increased in the past 10 years and vary according to the patient's age and the centre's experience; 17,20 however, indications are largely determined by the inability to provide adequate gas exchange and adequate end-organ perfusion.…”

“…The use of ECMO for neonatal respiratory failure has decreased over the past decade with the advent of highfrequency oscillatory ventilation, surfactant therapy, and inhaled nitric oxide. 17 Yet, its use in paediatric patients has rapidly increased over time. 19 In children, parenchymal lung diseases (eg, viral and bacterial pneumonia, and aspiration) are the most common respiratory diseases, whereas congenital heart diseases are the most common cardiac indications, followed by septic shock, myocarditis, cardiomyopathies, and cardiac arrest.…”

“…Improvements in ECMO technology have made it safer and more easily available at the bedside. [17][18][19] There are reports of the successful use of this technology among other populations previously considered to have relative contraindications (eg, premature infants, patients infected by Bordetella pertussis, and patients who received solid organ trans plantation). 16,17,20,21 There are also increasing reports of improvements in ECMO survival among paedi atric patients who have received HCT.…”

“…[17][18][19] There are reports of the successful use of this technology among other populations previously considered to have relative contraindications (eg, premature infants, patients infected by Bordetella pertussis, and patients who received solid organ trans plantation). 16,17,20,21 There are also increasing reports of improvements in ECMO survival among paedi atric patients who have received HCT. [22][23][24][25][26][27] Randomised trials to determine the efficacy of potentially life-saving interventions such as ECMO are complex to develop and the small number of cases available pose a statistical and ethical challenge around randomisation of these therapies.…”

Mechanical circulatory support in paediatric population

“…There are two predominant types of extra-corporeal membrane oxygenation, distinguishable by their unique circuity. 1,2 Veno-arterial extra-corporeal membrane oxygenation allows blood to be drained from a central vein and oxygenated blood to be returned to the arterial system, enabling both respiratory and circulatory support. As a result, a variation of venoarterial extra-corporeal membrane oxygenation, termed extra-corporeal cardiopulmonary resuscitation, can be used to support patients in cardiac arrest when other resuscitation measures are futile.…”