Chapter 71. Extracorporeal Membrane Oxygenation

• Meconium aspiration syndrome.

• Congenital diaphragmatic hernia.

• Idiopathic pulmonary hypertension.

• Severe, reversible respiratory failure.

• Cardiac disease.

• 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).

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

• • Large vascular catheters.

  • Servo-regulated pump.

  • Silicone membrane artificial lung.

  • Heat exchanger.

• 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.

• 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.

• 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.

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