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Extracorporeal membrane oxygenation (ECMO) is a well-known means of advanced life support in patients with significant cardiorespiratory impairment refractory to conventional therapeutic interventions. It is a salvage rescue therapy that can result in negative consequences if utilized by unfamiliar personnel. Nevertheless, there is a niche of critically ill children that will benefit from ECMO, and it is vital to appropriately select candidates to avoid or overcome complications and ethical dilemmas. This activity outlines the use of ECMO in children and highlights the role of the interprofessional team in treating patients who undergo ECMO. Objectives: Describe the modes of support and indications for initiating ECMO in pediatric patients. Explain the equipment, personnel, preparation, and technique required for ECMO. Identify the clinical significance and potential complications commonly observed in children and neonates on ECMO. Review healthcare team strategies for improving care coordination and communication to improve clinical outcomes with the use of pediatric ECMO. Access free multiple choice questions on this topic.

Extracorporeal membrane oxygenation (ECMO), synonymous with extracorporeal life support (ECLS), is used as a lifesaving mechanical form of bypassing a patient’s cardiopulmonary system when in failure. Historically, it was adapted during the 1970s from perioperative cardiopulmonary bypass performed during cardiac surgery and was initially pioneered for children. As a result, much of the knowledge about ECMO today has been extrapolated from the pediatric and neonatal populations. ECMO is a highly specialized technology with limited availability in children’s hospitals but is associated with improved survival. ECMO use is increasing worldwide due to improved survival rates in children who have been placed on ECMO.[1] Optimal delivery of care remains challenging as substantial human and physical resource utilization is critical. To facilitate success, it is essential to have a comprehensive healthcare team that manages the pediatric patient using this artificial oxygenation machine, addresses any possible sequelae that may arise, and understands the implications of some technical challenges that may require a higher level of care.

Since ECMO was first successfully used, cumulative information regarding its use, including complications, has been collected by the Extracorporeal Life Support Organization (ELSO). The overall survival to hospital discharge for pediatric respiratory ECMO is 57%; for pediatric cardiac ECMO, it’s 50%.[7] Technical complications Inadvertent decannulation Membrane lung failure Tubing rupture Pump malfunction Medical complications Neurologic (most common): intracranial hemorrhage, seizures, brain death, ischemic infarction Hematologic: cannula site bleeding, surgical site bleeding, clots in the circuit, vessel injury from cannulation, pulmonary hemorrhage, gastrointestinal hemorrhage, hemolysis, disseminated intravascular coagulation, inadequate anticoagulation, limb ischemia End-organ hypoperfusion: renal failure, liver failure Cardiac tamponade Infection High-pressure system in neonates: increased hemolysis, hyperbilirubinemia, hypertension, end-organ damage with renal failure Long term: poor growth, neurodevelopmental deficits, organ damage (e.g., sensorineural hearing loss, lung injury, renal dysfunction)[10][11][12][13]

Over the years, paying special attention to the technical approach of ECMO has led to its refinement. As it is necessary to have a vast composition of interprofessional teams, every member needs to be on board and have direct lines of communication when involved in the day-to-day clinical course. Effective teamwork must involve every healthcare team member, including clinicians (MDs, DOs, NPs, PAs) of all specialties, nurses, pharmacists, perfusionists, respiratory therapists, technicians—plays an invaluable role. Each patient has their own individualized management when initiating and weaning ECMO. This interprofessional approach will drive improved patient results. [Level 5] Weaning trials should begin as soon as the patient has sufficiently recovered from their disease process and is hemodynamically stable. However, being prepared means that contingency plans are discussed beforehand and that all necessary personnel is accessible in case there is a need to go back onto full ECMO support. Being prepared also means acknowledging morbidity and mortality is inevitable. After all, ECMO is often utilized as a last resort to restore life in extremely sick children. Despite the delicacy and potential for adverse outcomes, there are decades of ongoing support for ECMO as a mainstream salvage therapy for neonatal and pediatric patients experiencing severe, medically refractory cardiorespiratory failure.[14][15][16] [Level I]