Extracorporeal Membrane Oxygenation for Pediatric Cardiac Arrest

Abstract

It is only fitting that the first neonate to be supported by extracorporeal membrane oxygenation (ECMO) was named Esperanza, which when translated from Spanish means hope.1 Indeed, to the more than 50 000 patients who have survived because of ECMO, this revolutionary treatment has provided hope where there was none before. 2 In the past 5 decades, the use of artificial oxygenation and perfusion has revolutionized the care of critically ill patients, both in the operating room and in the intensive care unit. Use of artificial oxygenation and perfusion has evolved from bypass during cardiac surgery to advanced life support, to complex extracorporeal cardiopulmonary resuscitation (ECPR). Within the past 20 years, ECPR has been initiated when traditional resuscitation methods have failed and has proven its effectiveness with a survival to discharge rate of approximately 40%.3-13 However, the appropriate use of this therapy and delineated criteria for initiating and withdrawing this therapy have yet to be defined. Furthermore, implementation of this Pediatric CareExtracorporeal cardiopulmonary resuscitation (ECPR) remains a promising treatment for pediatric patients in cardiac arrest unresponsive to traditional cardiopulmonary resuscitation. With veno-arterial extracorporeal support, blood is drained from the right atrium, oxygenated through the extracorporeal circuit, and transfused back to the body, bypassing the heart and lungs. The use of artificial oxygenation and perfusion thus provides the body a period of hemodynamic stability, while allowing resolution of underlying disease processes. Survival rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation (CPR), although neurological outcomes require further investigation. The impact of duration of CPR and length of treatment with extracorporeal membrane oxygenation vary in published reports. Furthermore, current guidelines for the initiation and use of ECPR are limited and may lead to confusion about appropriate use of this support. Many ethical concerns arise with this advanced form of life support. More often than not, the dilemma is not whether to withhold ECPR, but rather when to withdraw it. Although clinicians must decide if ECPR is appropriate and when further intervention is futile, the ultimate burden of choice is left to the patient's caregivers. Offering support and guidance to the patient's family as well as the patient is essential. (Critical Care Nurse. 2015;35[1]:60-70) This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:1. Determine the difference between venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) 2. Describe the benefits of extracorporeal cardiopulmonary resuscitation 3. Discuss the ethical considerations related to management of patients undergoing ECMO CNE Continuing Nursing Education

Survival and Long-Term Functional Outcomes for Children With Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation

“…Extracorporeal Cardiopulmonary Resuscitation (ECPR), defined by the initiation of extracorporeal life support during active chest compressions, has the potential to offer survival and favorable neurological recovery (2). In the early 1990’s extracorporeal membrane oxygenation (ECMO) support instituted as rescue therapy during CPR promoted survival in children with cardiac disease who had cardiopulmonary arrest and failed to respond to conventional CPR (3).…”

Ethical Considerations for Care of the Child Undergoing Extracorporeal Membrane Oxygenation

“…Hospitals have their own individual policies, procedures, and guidelines for using resources to support the patient on ECMO. Recognizing that hospital resources are limited and that these resources should be distributed thoughtfully, however, is also a societal concern 19 . In 2015, Ryan 19 estimated the median patient charge for a course of emergent ECMO, not including hospital charges, to be $310,824.…”

“…Recognizing that hospital resources are limited and that these resources should be distributed thoughtfully, however, is also a societal concern 19 . In 2015, Ryan 19 estimated the median patient charge for a course of emergent ECMO, not including hospital charges, to be $310,824. Total hospital costs for a survivor of ECMO are approximately $519,450, which are higher than those for other intensive treatments such as bone marrow transplantation ($207,212), liver transplantation ($231,755), or kidney transplantation ($482,000) 7 .…”

Extracorporeal Membrane Oxygenation System and Usage Areas: Review

“…Konuyla ilgili kaynaklarda, en az bir yıl kritik hasta bakımı deneyimi olan ve ECMO ile ilgili eğitim alan hemşirelerin, ECMO sistemine bağlı hasta ile çalışabileceği bildirilmektedir. [24][25][26] ECMO desteği, özellikle solunum yetmezliğinin ön planda olduğu durumlarda, zamanında ve iyi bir hemşirelik bakımı ile hastanın yaşamını kurtarabilmektedir. Bu nedenle, ECMO sistemine bağlı hastanın hemşirelik bakımı, hem fiziksel hem de ruhsal olarak titizlik gerektirmektedir.…”

“…13,25 Tedavi ve bakımı yoğun bakım koşullarında sürdürülen ECMO sistemine bağlı hastaya uygulanacak hemşirelik bakım girişimleri aşağıdaki uygulamaları içermektedir. 13,[24][25][26][27][28] Ventilasyonun monitörizasyonu sırasında akciğerin iyileşmesini değerlendirmede kullanılan ve barotravmada yükselen plato basıncı (plato basıncı <28 cmH 2 O olmalı) sürekli izlenmeli ve yükseldi-ğinde hekime bildirilmelidir.…”