Extracorporeal membrane oxygenation for pediatric respiratory failure: History, development and current status

Abstract

Extracorporeal membrane oxygenation (ECMO) is currently used to support patients of all ages with acute severe respiratory failure non-responsive to conventional treatments, and although initial use was almost exclusively in neonates, use for this age group is decreasing while use in older children remains stable (300-500 cases annually) and support for adults is increasing. Recent advances in technology include: refinement of double lumen veno-venous (VV) cannulas to support a large range of patient size, pumps with lower prime volumes, more efficient oxygenators, changes in circuit configuration to decrease turbulent flow and hemolysis. Veno-arterial (VA) mode of support remains the predominant type used; however, VV support has lower risk of central nervous injury and mortality. Key to successful survival is implementation of ECMO before irreversible organ injury develops, unless support with ECMO is used as a bridge to transplant. Among pediatric patients treated with ECMO mortality varies by pulmonary diagnosis, underlying condition, other non-pulmonary organ dysfunction as well as patient age, but has remained relatively unchanged overall (43%) over the past several decades. Additional risk factors associated with death include prolonged use of mechanical ventilation (> 2 wk) prior to ECMO, use of VA ECMO, older patient age, prolonged ECMO support as well as complications during ECMO. Medical evidence regarding daily patient management specifically related to ECMO is scant, it usually mirrors care recommended for similar patients treated without ECMO. Linkage of the Extracorporeal Life Support Organization dataset with other databases and collaborative research networks will be required to address this knowledge deficit as most centers treat only a few pediatric respiratory failure patients each year.

Percutaneous Cannulation for Extracorporeal Membrane Oxygenation by Intensivists

“…Conclusions: Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists can be performed with a high rate of success and a low rate of complications when accompanied by imaging support. (Crit Care Med 2015; 43:1010-1015) Key Words: acute cardiac failure; acute respiratory distress syndrome; extracorporeal life support; extracorporeal membrane oxygenation; intensivist E xtracorporeal life support (ECLS) is a therapeutic option in the management of severe acute respiratory failure when mechanical ventilation and adjunctive measures fail to provide adequate gas exchange or when lung rest cannot be achieved due to high ventilator requirements (1)(2)(3). It is also used for short-term support of acute cardiac failure and for extracorporeal cardiopulmonary resuscitation (ECPR) (4)(5)(6).…”

Respiratory Failure

“…Risk factors associated with death include older patient age, other nonpulmonary organ dysfunction, prolonged use of mechanical ventilation (>2 weeks) before ECMO, prolonged ECMO support, and complications during ECMO. (25) (26) A small group of severely compromised children may require prolonged mechanical ventilation. Overall, their prognosis is good compared with adults.…”

First In Vivo Results of a Novel Pediatric Oxygenator with an Integrated Pulsatile Pump

“…2,15,16 Arteriovenous or venovenous cannulae serve as vascular access. At first, silicone oxygenators with a large surface area were used but difficulties with the initial priming volumes and inflammatory responses caused by the large artificial surfaces occurred.…”