Pediatric ECMO: Update Course 2018
With Dr. Doctor Herschel · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about H1N1 influenza
same diagnosisOnly a few other public items share this diagnosis — nothing to add yet.
Only a few other public items share this expert — go deeper there →
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
Centrifugal pumps are now magnetically levitated (maglev), eliminating bearings and reducing heat generation and hemolysis compared to older bearing-based designs.
Hollow fiber oxygenators now have coatings that prevent plasma leakage, allowing long-term support (previously limited to ~40 hours).
Centrifugal pumps are non-occlusive: clamping the outlet does not cause circuit rupture, and clamping the inlet does not cause significant hemolysis.
Some centers now have nurses manage both patient care and ECMO circuit management, with one respiratory therapist covering all ECMO patients in the unit.
Adult ECMO case volume is two- to threefold higher than neonatal or pediatric, driven by H1N1 and technological advances.
Neonatal ECMO volume has decreased approximately 5% due to the introduction of nitric oxide.
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.
VV ECMO provides normal left ventricular afterload and eliminates risk of systemic emboli from the circuit, as blood returns to the venous system.
VV ECMO avoids arterial cannulation, eliminating limb ischemia and carotid-related stroke risk.
Registry data show VV ECMO use in pediatrics has increased substantially in recent years compared to historical cumulative data.
Reducing ventilator settings on ECMO may allow weaning of pressors, so VV may be adequate even in patients initially requiring significant vasopressor support.
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.
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.
Timing of VV-to-VA conversion requires clinical judgment; observing the patient for 1–2 days often clarifies the need rather than converting prematurely.
Central (transthoracic) cannulation for VA ECMO carries risks of bleeding and mediastinitis and is impractical for patients who may require ECMO for months.
Echocardiography aids in deciding between VV and VA by assessing ventricular function.
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.
Some adult centers use bivalirudin as first-line anticoagulation in hundreds of ECMO cases; experience is concentrated in select institutions rather than widespread.
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.
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.
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).
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.
Carotid-related stroke can occur ipsilateral or contralateral to the cannulated side and may be embolic or ischemic in mechanism.
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.
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.
Alternative strategies to prevent leg ischemia include sewing a Gore-Tex side graft to the femoral or subclavian artery for ECMO cannulation ('stovepipe' technique).
For VV ECMO, draining from the femoral vein and reinfusing into the right atrium (via IJ) minimizes recirculation compared to the reverse configuration.
The Avalon double-lumen catheter is the preferred VV access method nationally and internationally due to single-site cannulation and improved patient mobility.
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.
In neonates, right atrial perforation with Avalon catheters increased from 0.1% to 3.2% in one series and reached 6.9% in another (Leicester, England).
Avalon catheters <19 French are no longer used at the speaker's institution due to perforation risk and difficulty maintaining IVC position; the Origin catheter (which sits in the right atrium) is used instead for smaller neonates.
Fluoroscopy is mandatory for Avalon placement at the speaker's institution; echocardiography alone is insufficient because wires can loop within the heart chambers, leading to perforation during catheter advancement.
Extracorporeal CPR (ECPR) achieves 30–40% survival in select in-hospital cardiac arrest cases, particularly in cardiac patients with correctable lesions.
Out-of-hospital ECPR programs are expanding in the United States, Japan, and elsewhere, with patients cannulated in the emergency department and often taken directly to the catheterization lab; early data suggest improved survival compared to standard resuscitation.
Femoral artery and vein cannulation is the typical approach for ECPR due to ease of ultrasound-guided access and minimal interference with CPR.
Small pneumothoraces in anticoagulated ECMO patients should be observed rather than drained unless causing physiologic compromise; chest tube placement leads to thoracotomy for bleeding in approximately 50% of cases.
ARDS net guidelines recommend peak inspiratory pressures <30 cm H2O and tidal volumes around 6 mL/kg.