Remaining vigilant for the child with a subtle presentation of a severe illness is part of our job in the Ped ED; however, sometimes, the illness is not subtle and the child requires critical actions (ex, Damage Control Resuscitation, Mechanical Ventilation, Optimize Chest Compressions) . Often, it is best to consider these critical actions prior to needing to do them so there is no delay. One such, potentially life-saving, critical action is Extracorporeal Membrane Oxygenation (ECMO). Recently there was a nice review of Pediatric ECMO [Gehrmann, 2015] that deserves further contemplation. Below are some highlights from that article:
ECMO: Basics
ECMO utilizes an external circuit to oxygenate blood and remove carbon dioxide.
It has been successfully used in the NICU for respiratory failure since 1970’s.
ECMO is not a therapy to correct a medical condition; it is used to support a patient while definitive strategies are able to correct the problem, or “time heals the wounds.”
ECMO essentially buys a patient some time.
Used for patients who have reversible cardiac or respiratory failure.
In the NICU that includes:
Meconium aspiration
Persistent fetal circulation
Congenital diaphragmatic hernia
Pulmonary hypertension of the newborn
Basic circuit has:
Vascular cannulas for access – one to extract blood and one to replace it.
Pump and Tubing
Gas-exchanger – to add the oxygen and extract the carbon dioxide.
Heat exchanger – to ensure that the blood returns to the patient at safe temperature.
ECMO: VA vs VV
The circuit can be completed through two modes: Venoarterial (VA) or Venovenous (VV).
Venoarterial
Accesses major vein (ex, IJ, Femoral Vein) and major artery (ex, Carotid)
Able to provide circulatory support as well as oxygenation.
Can be used for patients with primary heart failure.
Venovenous
Access two major veins (ex, IJ, Femoral Vein) or uses a double-lumen catheter to access one major vein (ex, IJ).
Advantage over VA is the lack of needing to access and repair major artery.
Less risk for ischemic injury or thromboembolic complications.
Provides oxygenation, but because oxygenated blood returns to venous side, the oxygenation level will be lower compared to VA.
Does not provide circulatory support and cannot be used for heart failure.
Well suited for reversible acute respiratory failure.
ECMO: in the Ped ED
ECMO is the last option when standard management has failed and:
the condition causing cardiopulmonary failure is reversible or
the organ transplantation is an option.
While it is the last option, considering it at the last minute will not help, as it requires time to coordinate with the teams and time to gain access and set up the system.
Common conditions ECMO is used for:
Newborns and infants:
Sepsis
Bronchiolitis
Congenital Heart Disease
Children and Adolescents
Pneumonia
Status asthmaticus
ARDS
Submersion injury
Acute chest syndrome
Traumatic pulmonary contusion
Myocarditis
Intractable dysrhythmias
Beta blocker / calcium channel blocker poisoning
Hypothermia – as a means to rewarm
Cardiac arrest
E-CPR (Extracorporeal Cardiopulmonary Resuscitation)
ECMO as a rescue therapy for cardiac arrest.
American Heart Association lists it as an option for In-Hospital Cardiac Arrest if condition is thought to be reversible or amenable to heart transplantation.
Effectiveness is higher when started within 30 min after cardiac arrest. [Tajik, 2008]
Proper patient selection is important, although there are no clear guidelines.
Moral of the Morsel
ECMO is not commonly needed in the ED, but on the rare occasion that it will be helpful, the means to initiate it need to already been known, as time is critical.
Having a protocol in place (hopefully, never to be needed) to help with patient selection and streamline the activation of the “ECMO Team” may literally save a child’s life.
References
Gehrmann LP1, Hafner JW2, Montgomery DL3, Buckley KW4, Fortuna RS5. Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians. J Emerg Med. 2015 Oct;49(4):552-60. PMID: 25980372. [PubMed] [Read by QxMD]
Extracorporeal membrane oxygenation (ECMO) therapy has supported critically ill pediatric patients in the intensive care unit setting with cardiac and respiratory failure. This therapy is beginning to transition to the emergency department setting. […]
Tajik M1, Cardarelli MG. Extracorporeal membrane oxygenation after cardiac arrest in children: what do we know? Eur J Cardiothorac Surg. 2008 Mar;33(3):409-17. PMID: 18206379. [PubMed] [Read by QxMD]
The use of extracorporeal membrane oxygenation (ECMO) as a resuscitative measure during or after manual cardiopulmonary resuscitation (CPR) shows sharply contrasting results. To assess the added value of ECMO in this situation and looking for predictors of mortality we performed a meta-analysis of individual patients collected from observational studies. An electronic Pubmed search restricted to English language publications between 1990 and 2007 […]
Posner JC1, Osterhoudt KC, Mollen CJ, Jacobstein CR, Nicolson SC, Gaynor JW. Extracorporeal membrane oxygenation as a resuscitative measure in the pediatric emergency department. Pediatr Emerg Care. 2000 Dec;16(6):413-5. PMID: 11138884. [PubMed] [Read by QxMD]
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