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  • • Meconium aspiration syndrome.

    • Congenital diaphragmatic hernia.

    • Idiopathic pulmonary hypertension.

    • Severe, reversible respiratory failure.

    • Cardiac disease.

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  • • Preterm infants (< 34 weeks).

    • Small infants(< 2 kg) because of the increased risk of hemorrhage during heparinization.

    • Significant intracranial hemorrhage.

    • Lethal anomalies (eg, trisomy 18).

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  • • Extracorporeal membrane oxygenation (ECMO) bypass circuit (Figure 71–1), which includes the following:

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    • • Large vascular catheters.

      • Servo-regulated pump.

      • Silicone membrane artificial lung.

      • Heat exchanger.

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  • • The UK Collaborative ECMO Trial Group demonstrated that ECMO decreased mortality (32% vs. 59%) and reduced severe disability at 1 year of age (33% vs. 62%).

    • There are no universally accepted criteria for referral and initiation of ECMO; rather each center develops its own criteria based on experience.

    • Infants are cannulated for ECMO when their mortality is predicted to be 80% or greater.

    • Most centers factor in the severity of hypoxemia, the level of respiratory support, and severity of cardiac failure into the decision-making process.

    • An important consideration is reversibility of lung disease.

    • Infants who have received prolonged mechanical ventilation and exposure to high oxygen concentrations (more than 10–14 days) may be excluded from consideration due to concerns about irreversible lung injury.

    • Therefore, discussion with an ECMO center should occur relatively early in the disease process.

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  • • ECMO is only provided at highly specialized centers, and most infants cannulated for ECMO must be transported from the hospital of birth to the ECMO center.

    • Therefore, the additional time and difficulty associated with the transport should be taken into account when considering a referral for ECMO.

    • Most often, the need for ECMO cannot be anticipated prior to birth, and families require a great deal of support to understand and cope with the unexpected severe illness of their infant.

    • However, prenatal diagnosis of congenital diaphragmatic hernia is often possible.

    • • Discussion of ECMO criteria and outcomes will ideally occur prior to birth.

      • Delivery plans can be made with the possible need for ECMO in mind.

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  • • Support is most often provided using a venoarterial (VA) technique, meaning that catheters are inserted into the right atrium and right common carotid artery.

    • VA ECMO bypasses both the heart and lungs, providing both pulmonary and cardiac support.

    • Some infants can be supported with venovenous (VV) ECMO, in which blood is removed and returned to the right atrium through a double-lumen catheter.

    • VV ECMO does not provide cardiac support but can effectively remove CO2 and deliver additional oxygen.

    • Because contact of blood with the ECMO circuit activates the clotting cascade, patients must receive systemic heparin.

    • ECMO is continued until the lungs and heart recover.

    • Care is provided by a specialized interdisciplinary team.

    • • Surgeons.

      • Medical specialists.

      • Bedside intensive care nurse.

      • ECMO specialist trained specifically ...

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