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ARDS
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Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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High stroke rates in ECMO patients may be due to patient illness severity rather than specifically carotid cannulation — Ron Herschel, Update Course Rewind: ECMO 2018 · 5:58
Update Course Rewind: ECMO 2018
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Today, we hear from Dr. Ron Herschl about pediatric ECMO from an Update Course session back in 2018.
podcast12:32 · Aug 2021
Reducing ventilator settings on ECMO may allow weaning of pressors, so VV may be adequate even in patients initially requiring significant vasopressor support. Pediatric ECMO: Update Course 2018 · 9:46
Pediatric ECMO: Update Course 2018
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At the 6th Annual Pediatric Surgery Update Course, Dr. Ronald Hirschl and Alejandra Casar Berazaluce discuss novel approaches in the management of respiratory failure, focusing on thetechnical aspects of ECMO and cannulation, including disc
video42:58 · Sep 2018
AI image recognition could be applied live during surgery to implement CT scan data and provide warnings such as proximity to the hepatic artery — Todd Ponsky, AI applications in pediatric surgery and clinical transformation with Dr. Todd Ponsky · 6:40
AI applications in pediatric surgery and clinical transformation with Dr. Todd Ponsky
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AIMed Talks with Dr Todd Ponsky
Dr Anthony Chang, Founder, AIMed speaks with Dr Todd Ponsky, Professor of Surgery, Director of Clinical Growth and Transformation, Cincinnati Children’s Hospital University of Cincinnati.
video7:41 · Oct 2026
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Pediatric ECMO: Update Course 2018
ARDS net guidelines recommend peak inspiratory pressures <30 cm H2O and tidal volumes around 6 mL/kg.
Host summaryThe host summarizing the discussion — not the host's own clinical position2:00 ↗
Centrifugal pumps are now magnetically levitated (maglev), eliminating bearings and reducing heat generation and hemolysis compared to older bearing-based designs.
clinicalHerschel3:39 ↗
Hollow fiber oxygenators now have coatings that prevent plasma leakage, allowing long-term support (previously limited to ~40 hours).
clinicalHerschel3:39 ↗
Centrifugal pumps are non-occlusive: clamping the outlet does not cause circuit rupture, and clamping the inlet does not cause significant hemolysis.
clinicalHerschel3:39 ↗
Some centers now have nurses manage both patient care and ECMO circuit management, with one respiratory therapist covering all ECMO patients in the unit.
clinicalHerschel3:39 ↗
Adult ECMO case volume is two- to threefold higher than neonatal or pediatric, driven by H1N1 and technological advances.
epidemiologicalHerschel5:58 ↗
Neonatal ECMO volume has decreased approximately 5% due to the introduction of nitric oxide.
epidemiologicalHerschel5:58 ↗
VA ECMO increases left ventricular afterload, which can lead to transient cardiac standstill (electrical activity without ejection) for 1–2 days in severely compromised patients; function typically recovers.
clinicalHerschel7:20 ↗
VV ECMO provides normal left ventricular afterload and eliminates risk of systemic emboli from the circuit, as blood returns to the venous system.
clinicalHerschel7:20 ↗
VV ECMO avoids arterial cannulation, eliminating limb ischemia and carotid-related stroke risk.
clinicalHerschel7:20 ↗
Registry data show VV ECMO use in pediatrics has increased substantially in recent years compared to historical cumulative data.
epidemiologicalHerschel7:20 ↗
Reducing ventilator settings on ECMO may allow weaning of pressors, so VV may be adequate even in patients initially requiring significant vasopressor support.
opinion9:46 ↗
On VV ECMO, oxygen saturations typically run in the low-to-mid 80s and mixed venous saturation around 60%, which is adequate for tissue oxygen delivery.
clinical9:46 ↗
Converting from VV to VA involves adding arterial return while maintaining venous drainage; if using a double-lumen catheter, both venous limbs can drain to the new arterial cannula.
clinicalHerschel10:42 ↗
Timing of VV-to-VA conversion requires clinical judgment; observing the patient for 1–2 days often clarifies the need rather than converting prematurely.
opinionHerschel10:42 ↗
Echocardiography aids in deciding between VV and VA by assessing ventricular function.
clinicalHerschel13:03 ↗
Bivalirudin is easier to manage than heparin for ECMO anticoagulation and may reduce bleeding in some patient populations (e.g., congenital diaphragmatic hernia post-repair), though data are mixed.
clinicalHerschel13:25 ↗
Some adult centers use bivalirudin as first-line anticoagulation in hundreds of ECMO cases; experience is concentrated in select institutions rather than widespread.
epidemiologicalHerschel13:25 ↗
Central (transthoracic) cannulation for VA ECMO carries risks of bleeding and mediastinitis and is impractical for patients who may require ECMO for months.
clinicalHerschel10:45 ↗
Registry analysis of 30,000 patients shows stroke rate is ~5% with carotid cannulation versus ~4% without, indicating some stroke risk is inherent to the disease process.
epidemiologicalHerschel14:55 ↗
Carotid-related stroke can occur ipsilateral or contralateral to the cannulated side and may be embolic or ischemic in mechanism.
clinicalHerschel21:37 ↗
North-South syndrome occurs with femoral VA ECMO: deoxygenated blood from the native heart perfuses the upper body (brain, heart, arms) while oxygenated ECMO blood perfuses the lower body.
clinicalHerschel14:55 ↗
North-South syndrome can be mitigated by adding an IJ cannula to infuse oxygenated blood into the right atrium; a Hoffman clamp adjusts flow distribution between the IJ (for oxygenation) and femoral artery (for blood pressure support).
clinicalHerschel14:55 ↗
At the speaker's institution, VA ECMO in children <35 kg uses carotid-IJ cannulation; in those >35 kg, femoral or carotid-IJ is chosen based on clinical context, with preference for VV whenever possible.
clinicalHerschel14:55 ↗
In one series of femoral arterial cannulation (ages 2–22 years), 50% developed limb ischemia; even with distal perfusion cannulas, 9 of 11 had ischemia, and at least one required below-knee amputation.
epidemiologicalHerschel22:31 ↗
Prophylactic posterior tibial artery cannulation (via cut-down) for distal perfusion is now routine at the speaker's institution; 58% cannulated <6 hours had no ischemia, versus 42% cannulated >6 hours who had complications.
clinicalHerschel22:31 ↗
Alternative strategies to prevent leg ischemia include sewing a Gore-Tex side graft to the femoral or subclavian artery for ECMO cannulation ('stovepipe' technique).
clinicalHerschel22:31 ↗
For VV ECMO, draining from the femoral vein and reinfusing into the right atrium (via IJ) minimizes recirculation compared to the reverse configuration.
clinicalHerschel27:49 ↗
The Avalon double-lumen catheter is the preferred VV access method nationally and internationally due to single-site cannulation and improved patient mobility.
clinicalHerschel27:49 ↗
Avalon catheter placement requires the distal tip to be positioned in the IVC, which is technically challenging and requires fluoroscopic and/or wire-guided techniques.
clinicalHerschel27:49 ↗
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