Definition
• Extracorporeal life support for lung &/or cardiac fxn
Pediatric Indications
• Death “imminent” with other treatment and
• Reversible lung disease (commonly PNA, burns/inhalation, acute chest, ARDS PPHN)
• High ventilator support >7 d: PIP > 35, PEEP > 10, MAP > 18, OI > 40, PaO2/FiO2 > 150
• No other significant organ dysfunction or
• Bridge for cardiac support (CHD postop, myocarditis, arrhythmias, bridge to transplant—must be at a transplant center, postresuscitation care for rapid cooling)
• Severe hypothermia, sepsis
Basic Management/Monitoring
• Lung rest: PEEP to keep lung open, FiO2 21–30
• Goals
• PaO2 > 60, PCO2 40–45
• pRBC 20 cc/kg for HCT < 35, FFP 10 mL/kg for PT > 17, ACT 180–220, Plt >100 (>150 if bleeding), cryo 1 U/kg for fibrinogen > 150
• MAP 45–65 (might need inotropic support, esp in VV)
• Sedation: Ativan, morphine, possibly intermittent midazolam; paralysis not routine
• Nutrition: Enteral feeds OK; frequent lyte repletion; Qwk LFTs; lipid <2 g/kg/d to avoid accumulation in circuit; total fluids 80–100 cc/kg/d
• ID: Antibiotic ppx (cannula)
• Neuro: Frequent assessment, screening U/S 24 hr post cannula, then ≥q48h
• Heme: Amicar avoided if possible (decreases life of ECMO circuit). Use if bleeding despite maintaining lower ACTs and adequate platelets
• Renal: Frequent volume overload, edema, may need diuretics/HD
• Pharmacokinetics/dynamics for many drugs altered on ECMO circuit: Hydralazine, nicardipine, furosemide, epinephrine, & dopamine can be used at regular doses, but esmolol, amiodarone, nesiritide, bumetanide, sildenafil, & prostaglandins require dose modification (J Cardiovasc Pharmacol 2011;58:126)
Prognosis/Course (Pediatr Rev 2009;30:470)
• Complications: Hemorrhage, hemolysis, clot in circuit, neuro (hemorrhage, szr, air emboli), renal dysfxn, infection, cardiac stunning (VA), equipment failure
• Prognosis: Survival rate for pediatric patients on ECMO for viral pneumonia ∼64%
• Neurologic: 72–91% no/mild disability, 6% cerebral infarction, 10% seizure
• Rare chronic pulm disease
• Post-ECMO monitoring: Head U/S, CT scan, carotid Dopplers, auditory brainstem-evoked response testing, eye exam, follow BPs