1. 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 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