Collection
Extracorporeal Membrane Oxygenation
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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In-depth Review
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ECMO Podcast
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This episode is a review of pediatric ECMO with Dr. Samir Gadepalli, Dr. Alejandra Casar Berazaluce, and Dr. Todd Ponsky. Intro and outro tracks are adapted from "I dunno" by grapes, featuring J Lang, Morusque. Artist URL: ccmixter.org/file
podcast · Dec 2020
Work-up and Treatment
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Updates
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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
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
Central Line Placement at ECMO Decannulation: A Missed Opportunity
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AbstractIntroductionECMO is a support modality for refractory critical illness. This study reviews the incidence and utility of central venous line (CVL) placement at pediatric ECMO decannulation.MethodsA single-institution retrospective st
article · Feb 2021
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For patients & families
ECMO is a life-support machine that takes over the work of the heart and lungs when they need time to heal. Doctors now use newer pumps that are gentler on blood and special coatings that let the machine run safely for weeks or even months. There are two main types: VV ECMO helps only the lungs, while VA ECMO helps both the heart and lungs. Most patients can use the gentler VV type, which avoids some risks like blood clots traveling to the brain. The tubes (cannulas) can be placed in the neck or groin, and doctors choose the safest spot based on the child's size and condition. Placing tubes in the leg can sometimes reduce blood flow to that limb, so surgeons often add a small extra tube to keep the leg healthy. A newer single tube that goes in the neck makes it easier for patients to move around. ECMO has also been used during CPR to save children whose hearts have stopped, with about 30–40% surviving when the problem can be fixed. Your medical team will monitor your child closely and adjust the machine as their heart and lungs recover.
ECMO is a life-support machine that takes over the work of the heart and lungs when they need time to heal. Doctors now use newer pumps that are gentler on blood and special coatings that let the machine run safely for weeks or even months. There are two main types: VV ECMO helps only the lungs, while VA ECMO helps both the heart and lungs. Most patients can use the gentler VV type, which avoids some risks like blood clots traveling to the brain. The tubes (cannulas) can be placed in the neck or groin, and doctors choose the safest spot based on the child's size and condition. Placing tubes in the leg can sometimes reduce blood flow to that limb, so surgeons often add a small extra tube to keep the leg healthy. A newer single tube that goes in the neck makes it easier for patients to move around. ECMO has also been used during CPR to save children whose hearts have stopped, with about 30–40% surviving when the problem can be fixed. Your medical team will monitor your child closely and adjust the machine as their heart and lungs recover.
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
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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