Remaining vigilant for the child with a subtle presentation of a severe illness is part of our job in the Ped ED; however, sometimes, the illness is not subtle and the child requires critical actions (ex, Damage Control Resuscitation, Mechanical Ventilation, Optimize Chest Compressions)  .  Often, it is best to consider these critical actions prior to needing to do them so there is no delay. One such, potentially life-saving, critical action is Extracorporeal Membrane Oxygenation (ECMO).  Recently there was a nice review of Pediatric ECMO [Gehrmann, 2015] that deserves further contemplation. Below are some highlights from that article:

ECMO: Basics

• ECMO utilizes an external circuit to oxygenate blood and remove carbon dioxide.
• It has been successfully used in the NICU for respiratory failure since 1970’s.
• ECMO is not a therapy to correct a medical condition; it is used to support a patient while definitive strategies are able to correct the problem, or “time heals the wounds.”
• ECMO essentially buys a patient some time.

• Used for patients who have reversible cardiac or respiratory failure.
  • In the NICU that includes:
    • Meconium aspiration
    • Persistent fetal circulation
    • Congenital diaphragmatic hernia
    • Pulmonary hypertension of the newborn
• Basic circuit has:
  • Vascular cannulas for access – one to extract blood and one to replace it.
  • Pump and Tubing
  • Gas-exchanger – to add the oxygen and extract the carbon dioxide.
  • Heat exchanger – to ensure that the blood returns to the patient at safe temperature.

ECMO: VA vs VV

• The circuit can be completed through two modes: Venoarterial (VA) or Venovenous (VV).
• Venoarterial
  • Accesses major vein (ex, IJ, Femoral Vein) and major artery (ex, Carotid)
  • Able to provide circulatory support as well as oxygenation.
  • Can be used for patients with primary heart failure.
• Venovenous
  • Access two major veins (ex, IJ, Femoral Vein) or uses a double-lumen catheter to access one major vein (ex, IJ).
    • Advantage over VA is the lack of needing to access and repair major artery.
    • Less risk for ischemic injury or thromboembolic complications.
  • Provides oxygenation, but because oxygenated blood returns to venous side, the oxygenation level will be lower compared to VA.
  • Does not provide circulatory support and cannot be used for heart failure.
  • Well suited for reversible acute respiratory failure.

ECMO: in the Ped ED

• ECMO is the last option when standard management has failed and:
  • the condition causing cardiopulmonary failure is reversible or
  • the organ transplantation is an option.
• While it is the last option, considering it at the last minute will not help, as it requires time to coordinate with the teams and time to gain access and set up the system.

• Common conditions ECMO is used for:
  • Newborns and infants:
    • Sepsis
    • Bronchiolitis
    • Congenital Heart Disease
  • Children and Adolescents
    • Pneumonia
    • Status asthmaticus
    • ARDS
    • Submersion injury
    • Acute chest syndrome
    • Traumatic pulmonary contusion
    • Myocarditis
    • Intractable dysrhythmias
    • Beta blocker / calcium channel blocker poisoning
    • Hypothermia – as a means to rewarm
    • Cardiac arrest
      • E-CPR (Extracorporeal Cardiopulmonary Resuscitation)
        • ECMO as a rescue therapy for cardiac arrest.
        • American Heart Association lists it as an option for In-Hospital Cardiac Arrest if condition is thought to be reversible or amenable to heart transplantation.
        • Effectiveness is higher when started within 30 min after cardiac arrest. [Tajik, 2008]
        • Proper patient selection is important, although there are no clear guidelines.

Moral of the Morsel

• ECMO is not commonly needed in the ED, but on the rare occasion that it will be helpful, the means to initiate it need to already been known, as time is critical.
• Having a protocol in place (hopefully, never to be needed) to help with patient selection and streamline the activation of the “ECMO Team” may literally save a child’s life.

References

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