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Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is a technique of life support for neonates in
cardiac or respiratory failure not responding to conventional therapy.


Conduct of Extracorporeal Membrane Oxygenation:
For venoarterial ECMO, the system consists of a venous pressure control module, a roller pump, a
countercurrent membrane oxygenator, and a heat exchanger, connected in series and primed with
heparinized buffered blood
A catheter(14 F) is inserted in the right internal jugular vein with its tip in the right atrium, and another
catheter (8 to 12 F) is inserted in the right common carotid artery with its tip in the arch of the aorta.
The venous control module regulates the operation of the pump, ensuring that the venous drainage
from the patient and the pump output to the patient are balanced.
The heart and lungs, to a variable extent, are bypassed.
Over 30 minutes, the flow is slowly increased to about 120 to 150 mL/kg/minute, after which the
mechanical ventilator can be reduced to benign settings, 25% to 30% oxygen, 15 to 20 cm H2O peak
pressure, 5 cm H2O PEEP, and a rate of 10 breaths/minute.
The ECMO flow can usually be decreased gradually to about 90 to 100 mL/kg/minute after the first
day.


The arterial oxygen pressure can be maintained between 50 and 70 mm Hg by adjusting the ECMO
flow
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The venous oxygen saturation may be used to assess the overall level of oxygenation; values below
70% suggest that the cardiac output may not be sufficient
Heparinization is continued by an adjustable infusion, to maintain the activated clotting time at 180 to
220 seconds, up to two times longer than normal.

packed red blood cells are transfused to maintain the hematocrit above 40%, platelets are transfused
to maintain the platelet count above 100,000/mm3, and fresh frozen plasma is transfused to maintain
the fibrinogen level above 200 mg/dL.

An improvement in lung function may be recognized by increased lung compliance with the use of
periodic bag tube ventilation and increased pulse oximeter saturation.


After 4 to 5 days, the ECMO flow is further reduced, and the ventilator settings are again increased to
assume responsibility for gas exchange

After brief period at a low ECMO flow (30 mL/kg/minute), to ensure adequate pulmonary function, the
infant can be decannulated and the vessels ligated.

INDICATIONS( Patient Selection):

1. Respiratory failure:

a. reversible respiratory failure
b. a predicted mortality with conventional therapy great enough to warrant the risks of ECMO.
c. life-threatening air leaks not manageable with optimal ventilatory support and chest
drainage
d. Many centers prefer to use the oxygenation index before use of ECMO
i. The product of three factors:
(1) the percent oxygen,
(2) the mean airway pressure,
(3) the reciprocal of arterial PO2
OI = mean arterial blood pressure(MAP) Fio
2
/Pao
2
100
e. Failure to respond to iNO at 40 ppm for 2 to 3 hours is considered a reliable indication for
ECMO.
f. Patients with meconium aspiration pneumonia, RDS,neonatal pneumonia, congenital
diaphragmatic hernia,and PPHN are prime candidates
2. Cardiac failure:
a. ECMO provides biventricular support for neonates with cardiac failure.
b. ECMO for congenital heart defects (hypoplastic left heart syndrome, coarctation of the
aorta, pulmonary atresia, total anomalous venous return) is offered as a bridge to definitive
treatment until the neonate's condition has stabilized
c. failure to wean from cardiopulmonary bypass, cardiomyopathy, and pulmonary
hypertension
3. Rapid-response ECMO (ECMO-cardiopulmonary resuscitation [CPR]):
a. ECMO in the setting of a witnessed cardiorespiratory arrest is offered in centers with a rapid
response team
b. Effective CPR before cannulation is essential for a favorable outcome during rapid-response
ECMO.
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4. Ex utero intrapartum treatment (EXIT) procedure:
a. The vessels are cannulated during a cesarean section while the neonate remains on
placental support
b. Indications include severe congenital diaphragmatic hernia, lung tumors, and airway
obstructing lesions such as large neck masses and mediastinal tumors.

Contraindications.:
Because of need of systemic heparinization, infants weighing less than 2000 g and less than 34
weeks of gestation at birth have a high incidence of cerebral hemorrhage
lethal congenital abnormality
continuous CPR for more than an hour before ECMO support


TYPES: 2 types
Veno Arterial (V-A) ECMO:
o V-A ECMO supports the cardiac and the respiratory systems
o Indicated for primary cardiac failure or respiratory failure combined with secondary
cardiac failure
o In V-A ECMO, the blood is drained from a vein (internal jugular vein, femoral vein) and
returned into the arterial system (internal carotid artery).
o The patient's total cardiac output (CO) is the sum of the native CO and the pump flow
generated by the circuit: CO
total
= CO
native
+ CO
circuit

Venovenous (V-V) ECMO:
o V-V ECMO supports only the respiratory system and is indicated for isolated respiratory
failure.
o In V-V ECMO, the blood is drained as well as returned to the jugular vein through a
double-lumen cannula.
o As a requirement for V-V ECMO, the internal jugular vein has to be large enough for a
14-French double-lumen cannula
o Converting to V-A ECMO is considered in the presence of additional hypotension,
cardiac failure, or metabolic acidosis.


MANAGEMENT:
Pre-ECMO:
In preparation for cannulation, the following should be available: central venous access to the
patient, postductal arterial catheter, cross-matched blood in the blood bank, complete blood
count, coagulation profile, head ultrasonographic examination.
Platelets should be transfused for a platelet count <50,000/mL. An echocardiogram should be
done before ECMO in order to rule out structural abnormalities

Membrane:
The appropriate membrane for a neonate is a 0.8 m
2
or 1.5 m
2
membrane oxygenator. The
resulting total volume of a neonatal ECMO circuit is 600 mL.
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Saline priming:

when Pt connected to ECMO urgently Instead of blood products, the circuit is primed with
normal saline.
The neonate's own blood volume is initially diluted with the normal saline from the ECMO circuit.
This causes a drop in hematocrit and a transient decrease in oxygen carrying capacity.
The hematocrit is later restored by using ultrafiltration and transfusing packed red blood cells
(PRBCs).

Blood priming.:

Patients who are placed on ECMO nonemergently are started on a blood-primed circuit.
Orders for the initial prime of a neonatal circuit are as follows: 500 mL of PRBC (cytomegalovirus
[CMV] negative, <7 days old), 200 mL of fresh frozen plasma, 2 units of cryoprecipitate, 2 units of
platelets (not concentrated).
Heparin and Tham (Tris-hydroxymethyl-aminomethane, also Tris) buffer, and calcium gluconate
are added to the circuit
Circuit pH, ionized calcium and potassium levels are checked before going on to ECMO.

Cannulation.:
Bed side
Surgical cut down preferred over transcutaneous canulation
sedated and paralyzed with fentanyl, midazolam, and pancuronium.
Heparin 30 units/kg is administered 3 minutes before cannulation
The vein is cannulated first
Once the patient is on ECMO, 2 units of platelets and 2 units of cryoprecipitate are administered
On initiation of ECMO, vasopressors rapidly weaned. The neonate may become markedly
hypertensive on initiation of ECMO therapy. Hydralazine 0.1 to 0.4 mg/kg/dose is administered to
treat hypertension

ECMO therapy:
ECMO pump flow rate is generally 100 to 120 mL/kg. Sweep gas flow rate is 1 to 2.5 L/minute for a
0.8 m2 membrane
A safety check is conducted every 4 hours.
This safety check includes searching for blood clots and circuit inspection for leaks
Elective circuit changes are made only if one of the following indications is met:
o excessive clotting in the circuit;
o elevation of the premembrane pressure (>350 mm Hg), indicating membrane clotting and
failure;
o membrane failure proved by inadequate change from pre- to postmembrane Pao
2
and
Paco
2
;
o excessive platelet consumption;
o 120 hours of therapy with Amicar
o an uncorrectable coagulopathy that is thought to be caused by the circuit/membrane.

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Anticoagulation:
Heparine is used to prevent clot formation
ACT is kept at 180 to 200 seconds

Amicar:
-Aminocaproic acid lowers the incidence of hemorrhagic complications associated with ECMO,
including intracranial and postoperative hemorrhage
Patients who are considered to be at high risk for bleeding complications are given Amicar. They
include:
i. are <37 weeks' gestational age,
ii. have sepsis,
iii. have prolonged hypoxia or acidosis (pH 7.1) before ECMO,
iv. have grade I or II intraventricular hemorrhage
Dose: Loading dose : 100mg/kg followed by 30mg/kg/hr infusion

Emperical antibiotics
Analgesia and sedation

COMPLICATIONS:
Neurologic: due to hypoxia/acidosis/intra cranial bleeds
Mechanical: poor venous return
o Causes for poor venous return include hypovolemia, pneumothorax, or tamponade
physiology.
Cardiovascular:
Hemodynamic instability during ECMO may be a result of hypovolemia, vasodilation during
septic inflammatory response, arrhythmias, and pulmonary embolism.
Volume overload, especially in the setting of capillary leak, may worsen chest wall compliance
and further compromise gas exchange.
OUTCOME
Survival.:good with ECMO compared to conventional