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  1. Introduction. Extracorporeal membrane oxygenation (ECMO) is a mechanical means of providing oxygen (O2) delivery and carbon dioxide (CO2) removal for patients who have cardiac and/or respiratory failure. It is accomplished by draining blood from the right atrium with the aid of a roller or centrifugal blood pump that propels blood through an oxygenator where gas exchange occurs. From there it is warmed in a heat exchanger and then transfused back to the patient into the aorta (venoarterial [VA]) or into the right atrium (venovenous [VV]) (Figures 13–1 and 13–2). Uniform guidelines have been established to describe essential equipment, procedures, personnel, and training required for neonatal ECMO.

  2. Indications. ECMO is used primarily for critically ill term and late preterm newborns with reversible respiratory and/or cardiac failure who have failed appropriate maximal medical management with ventilator support (conventional and/or high frequency), inhaled nitric oxide, volume expansion, as well as vasopressor and inotropic support. Neonatal conditions treated using ECMO support include meconium aspiration syndrome, congenital diaphragmatic hernia, persistent pulmonary hypertension of the newborn, respiratory distress syndrome, sepsis, pneumonia, and cardiac failure due to cardiomyopathies or severe rhythm disturbances. ECMO can also be used as a bridge to cardiac surgery or transplantation and after open heart surgery.

  3. Relative ECMO entrance criteria

      1. Weight ≥1.8 kg; gestational age ≥34 weeks. (The cannula size is limited by the infant's weight.)

      1. Respiratory criteria

          1. Oxygenation index (OI) >30–40 for 0.5–4 h

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            (FIO2, fraction of inspired O2; MAP, mean airway pressure; Pao2, partial pressure of oxygen, arterial)

          1. Acute deterioration with intractable hypoxemia. For example, a Pao2 <30–40 mm Hg or preductal SaO2 <70% not responding to conventional support.

          1. Barotrauma. Severe air leak not responsive to low tidal volume conventional ventilation and/or high-frequency oscillatory or jet ventilation.

      1. Cardiovascular/oxygen delivery criteria

        • Plasma lactate >45 mg/dL or 5 mmol/L with a metabolic acidosis that is not improving or escalating despite volume expansion and inotropic support.

        • Mixed venous saturation <55–60% for 0.5–1 h.

        • Cardiac arrest.

  4. Relative contraindications to ECMO

      1. Gestational age <32–34 weeks and/or a birthweight <1800 g due to the risk of intracranial hemorrhage and surgical difficulties with vessel cannulation. Lower birthweight is associated with increased mortality and morbidity.

      1. Mechanical ventilation >10–14 days due to likely irreversible lung disease.

      1. Intracranial hemorrhage greater than grade I due to higher risk of bleeding. Patients with an intracranial hemorrhage greater than grade I may be considered a candidate for ECMO, but these decisions are institutionally and individually based.

      1. Coagulopathy unlikely to resolve with transfusion therapy.

      1. Severe congenital anomalies incompatible with long life.

      1. Cardiac lesions that cannot be corrected or palliated.

      1. Congenital diaphragmatic hernia patients whose best OI >45, or who never have a preductal saturation >85% (varies per institution).

      1. Marked perinatal asphyxia

        • Severe neurologic syndrome persisting after respiratory and metabolic resuscitation (stuporous, flaccid, and absent primitive reflexes) (varies per institution).

        • Plasma lactate >225 mg/dL (25 mmol/L)

            1. Lactate levels >225 mg/dL (25 mmol/L) are highly predictive of death.

            1. Lactate levels >135 mg/dL (15 mmol/L) are highly predictive of adverse neurologic outcome.

        • Base deficit >30 on two ABGs.

  5. Transfer of patients possibly ...

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