Pediatric Respiratory Extra Corporeal Membrane Oxygenation (ECMO): A Review of Clinical Indications and Barriers to Efficacy within Acute Care Inpatient Pediatric   Luke Schulte Dr. Elizabeth Aquino Introduction Materials & Methods Results Heart disease and Chronic lower respiratory diseases are the 6th and 11th leading causes of mortality for individuals age 0-14 in the United States, respectively. Accounting for 2.7% of all death in this population. Extracorporeal Membrane Oxygenation (ECMO) is a form of cardiopulmonary life-support therapy to treat patients with severe acute respiratory failure or cardiac failure During ECMO therapy, two cannulas are placed within the vascular system either venous-venous (VV) or venous-arterial (VA). Blood is then circulated outside the body by a mechanical pump. While outside the body an oxygenator saturates hemoglobin with oxygen (O2), and removes carbon dioxide (CO2) through adjustable countercurrent gas flow. After which the blood is returned into circulation. VV ECMO supports gas exchange but does not bypass any organs, thus requires a functional heart to maintain tissue perfusion VA ECMO bypasses the heart and lungs, and thus supports these organs in the case of organ dysfunction While ECMO has been around since 1954, 36.5% (n=21,907) of all cases have being performed since 2009. As such this increased utilization warrants investigation into efficacy and barriers to use. Methods Clinical Efficacy Clinical Complications of ECMO Therapy VV ECMO has shown effectiveness supporting respiratory patients with the following disease conditions: acute respiratory distress syndrome (ARDS) bacterial or viral pneumonia aspiration syndromes alveolar proteinosis airway obstruction pulmonary contusion smoke inhalation primary graft failure after lung transplant bridge to lung transplant intraoperative ECMO status asthmaticus pulmonary hemorrhage congenital diaphragmatic hernia meconium aspiration VA ECMO has shown effectiveness supporting cardiac conditions such as the following: cardiogenic shock acute coronary syndrome cardiac arrhythmic storm sepsis with profound cardiac depression drug overdose myocarditis pulmonary embolism cardiac trauma anaphylaxis post cardiotomy post heart transplant bridge to longer term VAD support periprocedural support for high risk cardiac interventions bridge to heart transplant. Mechanical and patient related complications with respiratory ECLS, 2009–2015 Research Design Integrative Literature Review Inclusion Criterion Peer Reviewed Published after 2008 Written in English Acute Care Pediatric Populations (0-18 yr.) Exclusion Criterion Case Studies w/ low population size (Anecdotal Cases) Key Words extracorporeal membrane oxygenation, ECMO, extracorporeal life support, ECLS, pediatric, adolescent, infant, neonate, barrier, limitation, finance, adverse effect.   Neonatal Respiratory Pediatric Respiratory Complications N (%) After complication survival N (%) Mechanical     Oxygenator Failure 280 (5) 147 (53) 251 (8) 106 (42)     Pump Malfunction 84 (1) 46 (55) 47 (1) 24 (51)     Cannula Problem 696 (12) 400 (57) 515 (15) 305 (59)     Air in Circuit 209 (4) 119 (57) 181 (5) 90 (50) Patient     Seizure by EEG 158 (3) 77 (49) 111 (3) 39 (35)     Cerebral Infarct 180 (3) 79 (44) 158 (7) 54 (34)     ICH 643 (11) 255 (40) 243 (5) 52 (21)     Brain Death 23 (0.4) 117 (4)     Cardiac Tamponade 13 (0.2) 5 (38) 84 (3) 38 (45)     Surgical Site Bleeding 386 (7) 134 (35) 332 (10) 168 (51)     GI Hemorrhage 89 (2) 29 (33) 135 (4) 53 (39)     Amputation 0 (0) - 5 (0.1) 4 (80) CINAHL   N = 303 160 Number of studies found using keywords Number of studies meeting inclusion criteria Number of studies after excluding duplicates 138 Number of studies after using exclusion criteria PubMed N = 42 42 25 22 DePaul University Libraries Worldwide N = 970 145 111 98 Number of studies selected based on total content Mechanical and patient related complications with cardiac ECLS, 2009–2015   Neonatal Cardiac Pediatric Cardiac Complications N (%) After complication survival N (%) Mechanical     Oxygenator Failure 123 (4) 36 (29) 205 (5) 94 (46)     Pump Malfunction 37 (1) 12 (32) 49 (1) 22 (45)     Cannula Problem 156 (5) 52 (33) 194 (5) 92 (47)     Air in Circuit 101 (3) 33 (33) 105 (3) 49 (47) Patient     Seizure by EEG 100 (4) 41 (41) 42 (42)     Cerebral Infarct 93 (3) 31 (33) 231 (6) 83 (36)     ICH 326 (11) 91 (28) 251 (6) 65 (26)     Brain Death 21 (1) 107 (3)     Cardiac Tamponade 148 (5) 62 (42) 171 (4) 66 (39)     Surgical Site Bleeding 739 (26) 257 (35) 974 (25) 496 (51)     GI Hemorrhage 35 (1) 7 (20) 79 (2) 18 (23)     Amputation 3 (0.1) 2 (67) 4 (0.1) 3 (75) ECLS cases and survival to discharge, 1989–2017   Number of Cases Survived ECLS N (%) Neonatal     Respiratory 30,062 25,297 (84)     Cardiac 7,243 4,697 (65)     ECPR 1,554 1,048 (67) Pediatric 8,162 5,487(67) 9,479 6,482 (68) 3,469 1,995 (58)     Total 59,969 45,006 (75%)     Conventional Respiratory 45%     Conventional Cardiac 37%     Conventional CPR w/ AED Shocks 32.9% Institutional Barriers of ECMO Therapy In addition to the physiologic complications listed in the results, additional complications can be found with ECMO therapy in the forms of frequency of use and cost: Frequency of Utilization Low Volume Centers (< 20 ECMO’s per year) = 46% Mortality Rate High Volume Centers (> 50 ECMO’s per year) = 43% Mortality Rate P-Value: 0.015 Total Annual Hospital Expenditure Bedside Nurse + Perfusionist: $600,264 Beside Specialized Nurse: $234,000 Discussion ECMO is rapidly becoming a standard therapeutic option for children who are refractory to conventional medical interventions. Through this integrative literature review, it has been established that ECMO has varying levels of clinical efficacy determined by the initiating diagnosis for therapy use (cardiac, pulmonary, or ECPR). Four major adverse effects were identified for pediatric patients undergoing ECMO therapy. Those complications included: Inadequate flow and oxygen delivery Hemolysis Infection Neurological complications. In addition, institutional policies of volume of utilization and cost were assessed for their implication in therapy usage. Each of these factors had a significant impact upon the wellbeing of patients in terms of the short-term health status and long-term developmental status. While ECMO is not a solution to all problems and has significant adverse effects in terms of neurological complications it provides better predicted outcomes in critically ill pediatric patients who are acutely ill, with diminished cost of utilization through specialized nursing providers. This coupled with increased utilization across the globe should facilitate increased efficacy and standardization of ECMO therapy. Limitations Acknowledgements Overall, the major limitations within this research was the small sample size of research articles included. Larger sample sizes may be able to provide a more accurate indication of the clinical efficacy and adverse effects of ECMO therapy on pediatric populations. To achieve this larger sample size a meta-analysis could be conducted which would provide statistical analysis of the literature available. I would like to express my very great appreciation to Dr. Aquino for her valuable and constructive suggestions during the planning and development of this research work