Evolution of Technology, Establishment of Program, and Clinical Outcomes in Pediatric Extracorporeal Membrane Oxygenation: The “SickKids” Experience

Abstract

Technological development has had a tremendous impact on the management of patients who require extracorporeal membrane oxygenation (ECMO). Team development and education are a vital component of a successful extracorporeal life support (ECLS) Program to reduce complications and subsequently improve clinical outcomes. We sought to review the evolution in technology, importance of team development and training, and report our experience at The Hospital for Sick Children, Toronto. There were a total of 576 ECMO runs in 534 patients (42 repeat ECMO runs) between January 1988 and June 2012. The use of ECMO for cardiac disease has increased in the last decade due to an expanded indication for ECMO in patients with single-ventricle physiology. Cardiac ECMO still remains a challenge in terms of survival (177/392, 45%). Although development of an ECLS program and team education facilitated extracorporeal cardiopulmonary resuscitation, clinical outcomes were not satisfactory (survival, 33%). The most common complications were hemorrhagic (13.8%), followed by renal (10.6%) and pulmonary dysfunction (6.9%). Advances in technology made management during ECMO safer, and the mechanical complications related to the ECMO system were 6.1%, including circuit changes due to thrombus formation, cannula repositioning, or optimization of size.

Postcardiotomy ECMO in pediatric cardiac surgery: Impact of team training and equipment in the results

“…The high cost of technological development and the training of intensive care teams seem to be the greatest obstacles to this progress. Recently, the Toronto Sick Kids group reported their experience with ECMO emphasizing the importance of technological developments and team structure to improve performance [ 6 ] . The same group have had published some disappointing results almost ten years earlier [ 12 ] with a high incidence of neurological impairment and poor survival, which have led them to work on team performance and on improving technology.…”

“…The same group have had published some disappointing results almost ten years earlier [ 12 ] with a high incidence of neurological impairment and poor survival, which have led them to work on team performance and on improving technology. These investments were eventually paid off as they showed in their recent publication [ 6 ] .…”

“…International authors have been reporting satisfactory results with post-cardiotomy ECMO since the late 80's [ 6 ] . In Brazil, ECMO has been applied consistently in a few centers, but the experience reported in the literature is still scarce [ 7 ] .…”

Impact of Pulsatility and Flow Rates on Hemodynamic Energy Transmission in an Adult Extracorporeal Life Support System

“…Extracorporeal life support (ECLS) has been used in children and adults for over 40 years, and has evolved into a more effective technique in supporting patients with cardiovascular and respiratory failure as new technological advances have been developed (1)(2)(3)(4). Improved techniques and equipment have made ECLS a more cost-effective and manageable procedure (4)(5)(6). A modern ECLS circuit is typically comprised of a centrifugal pump, poly-methyl pentene (PMP) oxygenator, coated tubing, and cannulae.…”

The journey of pediatric ECMO

“…18–20 Improving results will encompass highly complex patients, and those with single-ventricle physiology will not be denied support and, in fact, will contribute a large percentage of ECMO patients. 21 Smaller and more efficient cannulas 22 are increasingly available for effective and rapid peripheral cannulation, 23,24 and can potentially trigger an upsurge in ECMO-CPR in children. 18,25 …”