What Is ECMO?   
ECMO stands for Extracorporeal Membrane Oxygenation, which means oxygenation outside the body. It can be used to support heart and/or lung function in babies and children. It is similar to bypass used in the operating room but can be used for longer periods of time.

When is ECMO Necessary?
ECMO is necessary when a child has severe lung or heart problems,and standard forms of treatment are not effective. ECMO is not a treatment but can provide time for the heart and lungs to improve. ECMO is only used when the child's condition can improve with rest.

Some of the illnesses for which ECMO is used include:

• Asthma
• Post-Op Cardiac Surgery
• Pneumonia (due to infection)
• Near-Drowning
• Aspiration Pneumonia

Normally, the lung provides oxygen and removes carbon dioxide from the blood. When the lungs are sick or injured, they are unable to do this even with maximum support from medication and machines. ECMO can supply oxygen and remove carbon dioxide while allowing time for the lungs to heal.

If the heart is unable to pump effectively, circulation of blood to the lungs may be affected resulting in low oxygen levels. Blood may not be pumped to the body adequately if the heart is damaged. ECMO can be used to pump the blood to the lungs and throughout the body, so the heart can rest and heal.

Parents are updated regularly on the progress of their child. Changes in medications or other treatments may be necessary. In some cases, these changes will not help the child. If a child shows no improvement, ECMO may have to be stopped.

How is ECMO Done?
The surgeon places cannula, or tubes, so that blood is able to drain out of the body and through the ECMO circuit. The site where these tubes are placed depends on the reason ECMO is needed and on the type of ECMO needed. The cannula may be placed in a vein and/or artery in the neck, the groin, or the chest. A cannula may also be placed in one vein or two different veins.

Once the cannulae are placed, the ECMO circuit is connected. The circuit has several components connected by different lengths of tubing. Initially the blood drains into a reservoir. The pump pushes the blood from the reservoir into the oxygenator, or artificial lung. Then the blood travels through a heat exchanger to be warmed before returning to the body. The rate the blood travels through the circuit is called the ECMO flow and is dependent on the size of the child.

Dark blood, without oxygen, drains into the circuit. After the blood passes through the oxygenator it becomes bright red due to the presence of oxygen. The oxygenated blood is returned to the child in either a vein or an artery.

Once ECMO flow is established, the ventilator settings may be turned down to allow the lungs to rest. Medications to help the heart function may or may not be decreased. The physician will change medications for each child based on their individual needs. As the child improves, the ECMO flow can be decreased to allow the child's own heart and/or lungs to do more of the work.

What are the Different Types of ECMO?
There are two types of ECMO: VA and VV. VA, or veno-arterial, ECMO is done to support heart and lung function. It is done using two cannulae. VV, or veno-venous, ECMO is used to support lung function. VV ECMO can be done with one or two cannulae.

With VA ECMO there are two cannula, one in a vein and one in an artery. Blood is drained from the vein and returned to the artery. Both of these cannula are usually placed in the neck. If the child develops problems with heart function soon after heart surgery, the cannulae are placed at the surgical site. Children who require ECMO shortly after surgery will have cannula in place with the chest incision unsutured and covered by a special dressing to prevent infection.

With VV ECMO, one or two cannula can be used. If one cannula is used, it has a double lumen, meaning two tubes in one. It is usually placed in a large vein in the child's neck. Blood drains from one side of the cannula and returns in the other side. If two cannula are used, blood drains from one cannula positioned in a vein and returns through a second cannula placed in a different vein.

What Will My Child Look Like on ECMO?
Before ECMO a child with a critical condition requires many different tubes or wires for the purpose of monitoring and providing necessary medications. These will remain in place. Some of the necessary pieces of equipment include a ventilator, which breathes for the child. With ECMO the ventilator will stay in place, but the pressure used for each breath and the rate that breaths are given can be decreased. This will allow the lungs to rest. Small tubes called central lines will be monitoring the child's fluid status and allowing access for different medications. A catheter will drain urine continuously. Wires that detect heart rhythm will be attached to electrodes taped to the skin. A small catheter in an artery in the hand, arm or foot monitors blood pressure and also provides access for blood to be drawn. The ECMO cannula used will be sutured in place, either in the neck, groin or open chest incision.

If the child had problems getting oxygen before ECMO, there will be a bluish tint to the skin. Once ECMO has begun, color will improve and become pinker. A low blood pressure, seen with poor heart function, can also cause skin color to be bluish, or a pale gray. After ECMO is begun, color improves as circulation improves.

Children on ECMO may given medication to prevent movement. This is needed to prevent accidental dislodging of the ECMO cannula. The child is usually kept on his back. Position changes are generally only minimal, also due to the risk of accidentally removing the cannula. Blood drains into the ECMO circuit by gravity, making it necessary to raise the height of the bed. It would not be unusual for children to have three extra mattresses to add height. A stepladder will be at the bedside to allow parents to be near their child.

Bleeding may be seen from the site of cannula placement. This is not unusual and if necessary, blood will be given to replace what is lost. Other blood products will be given to help control the bleeding.

Before ECMO it may have been necessary to give large volumes of fluid to maintain blood pressure. This fluid can leak into the tissues, causing a swollen appearance. This swelling will go away but will take several days and may not be gone until after ECMO is no longer necessary. A device can be connected to the ECMO circuit to help with the removal of extra fluid. If this were necessary it would be done slowly and there would not be a noticeable change in the swelling.

What Care Does My Child Receive While on ECMO?
Routine monitoring will continue after ECMO. Vital signs, including heart rate, blood pressure and temperature will be checked and recorded. Specific monitoring of the ECMO circuit will also be done. The pressure in the ECMO circuit is measured continuously. The circuit is evaluated regularly for possible leaks, kinks, or other signs of wear.

Children on ECMO may require medication to help the heart function. Other medications may be necessary to improve urine output, prevent infection or treat an existing infection. All patients on ECMO are given the medication heparin, which prevents blood clotting. Medication for sedation and pain relief is given as needed. It is necessary with most children to prevent movement so medication is given that will temporarily paralyze the child. All medications are given through an existing IV or into the ECMO circuit. No needle sticks to the child are necessary. There are sites attached to the ECMO circuit where blood can be drawn and medications given.

Lab work is drawn on a regular basis. An ACT, which measures clotting time, is done hourly to monitor the use of heparin. Blood gases, which measure the oxygen and carbon dioxide level in the blood, are done hourly at first but as the child's condition becomes more stable the need to check frequent blood gases decreases. Other routine lab work is done to monitor the child's blood counts. Cultures can be done if infection is suspected.

Daily x-rays will be done to check for changes in the appearance of the lungs. Babies will have daily head ultrasounds done to check for bleeding into the brain. If the child's condition is related to the heart, an ECHO, which is an ultrasound of the heart, can be done. This will tell the doctors if the heart function is improving

Most procedures the child must have can be done without leaving the PICU, however there are rare occasions when the necessary procedure must be performed in another area of the hospital. The child can be safely moved to another area while on ECMO.

Other routine care is unchanged after ECMO has begun. The ventilator will continue to breathe for the child but at a much lower pressure and rate, allowing the lungs to rest. The tube into the child's lungs will be suctioned at intervals to keep them clear of secretions. Most children will be given special IV fluids to maintain nutrition. Some may be given formula through a feeding tube placed through the mouth into the stomach.

Frequent blood transfusions may be necessary. Other blood products are also given as needed. Platelets, a blood product that helps with clotting, can be depleted during ECMO. Blood and platelet counts are checked frequently and are replaced as needed.

What are the Risks of ECMO?
Because of the use of heparin, there is a risk of bleeding . This can occur anywhere but is mostly seen at the site of cannula insertion. If the child has had heart surgery, bleeding may occur within the chest. If this happens, the surgeon will remove the dressing on the child's chest and look for possible areas of bleeding. Bleeding into the chest is not always possible to control while the child is being given heparin. Blood can be replaced as necessary if it cannot be stopped. Bleeding can also occur in the brain. If this occurs ECMO may have to be stopped as a way to control the bleeding.

The use of ECMO can also cause the blood to clot too much. The blood within the ECMO circuit may produce clots at points where tubing is connected. These clots are observed and can be removed if necessary. Rarely, small pieces of these clots can break off and travel through the patients blood stream. If this happens, the clots could block blood supply to some areas of the patient, causing organ or tissue damage.

Infection is possible and tests are done routinely to detect this. Antibiotics are given as needed to fight infection.

Problems can occur with the equipment or with the tubing which makes up the circuit. The ECMO specialists are specially trained to recognize and correct any problems that may occur with the circuit. A complete back-up circuit is available and can be changed out if necessary.

Who Cares for My Child on ECMO?
There are several physicians who may be involved in the care of your child. A pediatric intensivist is primarily responsible for all children in the PICU. There will be a cardiothoracic surgeon and a pediatric cardiologist involved with the care of some children. A pediatric surgeon will be involved with the care of all others. Specially trained nurses care for the child, while ECMO specialists manage the ECMO circuit. The ECMO specialists can be either nurses or respiratory therapists. Others involved in each child's care include the social worker, pharmacist, nutritionist, and specialists in child development.

When is a Child Ready to Come Off ECMO?
The decision to come off ECMO is made when all the doctors involved agree that the child is ready. The child's progress is evaluated to determine if there has been enough improvement or if more time is needed. If the child is on ECMO for respiratory reasons, then the x-ray is checked for improvement in the appearance of the lungs. If blood gases show an improvement in oxygen and carbon dioxide levels, the ECMO flow can be decreased. This process may take several days or weeks. When the ECMO flow is decreased to a certain point then the cannulae can be clamped, stopping blood flow from the circuit to the child.This allows the child's lungs to work without the support of ECMO. This is called a "trial off." Blood gases are checked at this time and if oxygen and carbon dioxide levels remain good, then the child may be ready to come off ECMO.

When ECMO is used because of poor heart function, then the weaning process would also require that the child's heart function would be able to support them without ECMO. There are several ways to monitor heart function. The blood pressure should be good without increasing medications. The doctors can do an ECHO, which would show how well the heart is beating. Blood gases and x-rays are also checked. The physicians will look at all of these things before making the decision to wean the ECMO flow. When the child is ready, there will also be a trial off before ECMO is stopped completely.

It is not uncommon for a child to have problems during the trial off. If this happens the ECMO flow is turned up and usually after a day or two, there will be another trial off.

The above trial off is only for VA ECMO. In VV ECMO the trial off periods involve weaning the ECMO flow to a specific point and then stopping the oxygen supply to the artificial lung. In this situation, the child's lungs are doing all the work. If the blood gases are good, then ECMO can be stopped.

The procedure for stopping ECMO is similar to what was done to go on ECMO. The Pediatric surgeon or the cardiothoracic surgeon will remove the cannulae. Following this the child will still be very sick and will remain in the PICU. The child's care will not change, except that ECMO will not be used. It may still take several more days or weeks for the child to be well enough to return home.

What Can I Do For My Child?
Parents and other family members can be involved in the care of their child. Simple things such as bathing, diaper changing and turning can be done with the nurses help. As a parent, you know what your child likes and dislikes. You can bring your child's favorite music to be played at intervals throughout the day. A special stuffed animal can be put in the bed with your child. Pictures and cards can be hung at the bedside. Some families make tapes for the child to listen to when they cannot visit. When you are at the bedside, just talking to your child can help you and them.

Will Breast-Feeding be Possible?
Your child will not be able to nurse or take a bottle while on ECMO. Nutrition is provided through a special type of fluid given in the blood stream. Breast-feeding can be done after the baby comes off ECMO. Until that time, mothers who wish to breast-feed can express milk and freeze it for use later. Your baby's nurse can explain how to do this.

Will My Child Have Any Long-Term Problems?
Some babies have difficulty with feeding after ECMO. With help your baby may learn to nurse or take a bottle without problems. Due to the severity of problems before ECMO, there may be some children who continue to need oxygen even after going home. If this is the case, you will be taught what is needed before taking your child home.

ECMO Terms
This glossary is a guide to words that are commonly used with ECMO patients.