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Extracorporeal Membrane Oxygenation (ECMO)

ECMO Indications
  • Hypoxic or hypercapnic respiratory failure
  • Circulatory failure
  • Acute clinical deterioration

ECMO may be possible, though considered HIGH RISK in the following circumstances

  • Recommend thorough discussion with care team and family about the utility of ECMO in severe cases

Hypoxic/hypercapnic respiratory failure
  • Conventional mechanical ventilation (CMV) requirements of peak inspiratory pressure (PIP) > 26 - 28 cmH2O, positive end-expiratory pressure (PEEP) > 6 cmH2O, or respiratory rate > 50 
  • High-frequency oscillatory ventilation of mean airway pressure (MAP) > 14 cmH2O, frequency of oscillation < 7 Hz, or amplitude > 40
  • Inability to maintain preductal saturations (SpO2) > 85%
  • Persistent severe respiratory acidosis (pCO2 > 70 mmHg) with pH < 7.20

Circulatory failure
  • Inadequate O2 delivery with metabolic acidosis
  • Inadequate end-organ perfusion, lactate > 3, and oliguria
  • Refractory systemic hypotension nonresponsive to fluid and vasoactive medications
  • Pulmonary hypertension, with or without right ventricular dysfunction
  • Left ventricular failure

Acute clinical deterioration
  • Preductal desaturation < 70% with inability to recover despite efforts to optimize ventilator management
  • Hemodynamic instability recalcitrant to inotrope and chronotrope initiation/titration

ECMO Contraindications
  • Severe pulmonary hypoplasia as evidenced by preductal saturations that never exceed 80% and severe hypercarbia despite optimal ventilator management (ensure the infant's caregivers have been provided adequate consultation regarding the parameters)
  • Multiple genetic differences due to non-reversible conditions
  • Significant cardiac defects
  • Intracranial hemorrhage that is grade 3 or higher
  • Significant coagulopathy/uncontrolled bleeding
  • Birth weight < 2 kg and gestational age < 34 weeks (relative contraindication)

Work-Up Prior to ECMO

Imaging
  • Head ultrasound
  • Echocardiogram

Laboratory Studies
  • Newborn screen
  • Labs per ECMO for Congenital Diaphragmatic Hernia Repair Powerplan

References

Guner, Y., Jancelewicz, T., Di Nardo, M., Yu, P., Brindle, M., Vogel, A. M., Gowda, S. H., Grover, T. R., Johnston, L., Mahmood, B., Gray, B., Chapman, R., Keene, S., Rintoul, N., Cleary, J., Ashrafi, A. H., and Harting, M. T. (2021). Management of congenital diaphragmatic hernia treated with extracorporeal life support: Interim guidelines consensus statement from the Extracorporeal Life Support Organization. American Society for Artificial Internal Organs Journal, 67(2), 113-120. https://doi.org/10.1097/MAT.0000000000001338

 

 

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.

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