What Is Pediatric Extracorporeal Membrane Oxygenation?

An ECMO system works by drawing blood from the patient’s body to artificially oxygenate the red blood cells in the blood and removes carbon dioxide from the blood.

Extracorporeal membrane oxygenation (ECMO), also called extracorporeal life support (ECLS), is a technique of providing prolonged cardiac and respiratory support to patients whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life. The technology provides cardiac (heart) and pulmonary (lungs) bypass support outside the patient’s body by evading the damaged heart and lungs. ECMO provides short-term life support and arrests the patient’s own circulation. ECMO functions as an artificial cardiopulmonary system.

An ECMO system works by drawing blood from the patient’s body to artificially oxygenate the red blood cells in the blood and removes carbon dioxide from the blood. It is usually used in patients after cardiopulmonary bypass, in the late-stage treatment of a patient with profound heart and/or lung failure or cardiac arrest (heart attack). ECMO is also beneficial in providing life support to patients with severe acute viral pneumonia with serious complications, for example, in COVID-19 (novel Coronavirus disease) cases, where artificial ventilation is insufficient to sustain blood oxygenation levels.

Pediatric ECMO is a treatment system that functions in the same way as a regular ECMO does. The system uses a pump to circulate blood out of the body to oxygenate the blood, remove carbon dioxide, and pump it back into the blood vessels of a very sick child or baby. It can help provide support to a child (or adult) who is awaiting a heart or lung transplant.

The differences between extracorporeal membrane oxygenation (ECMO) and cardiopulmonary bypass include the following:

• ECMO can be performed under local anesthesia. Standard cardiopulmonary bypass is usually performed under general anesthesia.
• ECMO is used for long-term support ranging from 3 to 10 days. Standard cardiopulmonary bypass is used for short-term support usually for a few hours.
• The purpose of ECMO is to allow time for recovery of the lungs and heart. Standard cardiopulmonary bypass provides support during various types of cardiac surgical procedures.

Pediatric extracorporeal membrane oxygenation (ECMO) is used in infants who are sick because of breathing or have heart problems. The purpose of ECMO is to provide enough oxygen to the baby while allowing time for the lungs and heart to rest or heal.

The most common conditions that may require pediatric ECMO in babies and children are as follows:

• Congenital diaphragmatic hernia (CDH): In this condition, the diaphragm (the muscle that separates the chest and abdomen) fails to develop properly during development. Hence, abdominal contents move into the chest, affecting the development of the lungs.
• Birth defects of the heart
• Meconium aspiration syndrome (MAS): During the process of labor or delivery, the baby may pass stools (meconium) in the uterus into the amniotic fluid. The meconium mixes with the amniotic fluid, and the baby may inhale the mixture. This can then lead to decreased oxygenation, severe breathing problems, and even death.
• Severe pneumonia (infection of the lungs)
• Severe air leaks
• Primary pulmonary hypertension (PPHN): It is severe high blood pressure in the arteries of the lungs
• Respiratory distress syndrome: It is a collection of fluid in the lungs leading to decreased oxygenation in the body.
• Sepsis (widespread infection in the body)
• Asphyxiation (decreased oxygenation due to choking, trauma, drowning, inhalation of toxic gases or electric shock)

After heart surgery, during the recovery period

• Pediatric ECMO can act as a bridge to recovery in temporary cardiomyopathy (dilation of the heart) secondary to renal failure, myocarditis (inflammation of the heart), and severe burns.

Selection criteria for neonates include the following:

• Gestational age of over 34 weeks
• Birth weight of more than 2000 g
• No significant bleeding disorders
• No major intracranial hemorrhage (bleeding within the brain)
• Mechanical ventilation for less than 10-14 days 
• Reversible lung disease 
• No fatal birth malformations
• No major untreatable cardiac malformation
• Failure of maximal medical therapy

Failure to meet the criteria is a relative contradiction. It depends on the extent of the disease, general condition of the patient, and the doctor’s discretion because not using extracorporeal membrane oxygenation (ECMO) despite the contraindications can lead to fatal complications or even death. 

Starting pediatric extracorporeal membrane oxygenation (ECMO) requires a large team of caregivers to stabilize the baby and those training in handling patients of the pediatric age group. A fully equipped multidisciplinary setup is required. Although ECMO can be performed by the bedside under local anesthesia, children and babies may require sedation to be able to cooperate with the procedure. The ECMO pump is primed with fluid and blood. The procedure is performed by attaching the ECMO pump to the baby through catheters (a tube put into the body to remove body fluids) that are placed into large blood vessels in the baby/child’s neck or groin.

Babies and children who are considered for extracorporeal membrane oxygenation (ECMO) are already very sick. Hence, they are at high risk for long-term complications, including death due to their underlying disease and age. Once they are placed on ECMO, some risks of the procedure include

• Bleeding
• Blood clot formation
• Infection
• Need for blood transfusions, which carry risks
• The pump can have mechanical/technical problems (tube breaks, system dysfunction, etc.)