Since 1988, more than 100 neonates have been treated at MUSC using extracorporeal mem- brane oxygenation (ECMO). In more recent years, using ECMO with pediatric patients has steadily become a reliable, successful treatment option.

“ECMO has been used on children age 6 months to 14 years for the last several years at MUSC,” said Joel Cochran, D.O., assistant professor of pediatrics in MUSC’s Pediatric Critical Care Division.

A total of 21 pediatric patients who had life-threatening pulmonary or lung problems have been treated using ECMO in the Pediatric Intensive Care Unit at MUSC Children’s Hospital. Several others who have had cardiac conditions also have been on ECMO. The shortest time a surviving child has been on ECMO is five to six days. The longest was just more than three weeks.

ECMO is essentially a lung bypass technique that’s mainly used to oxygenate blood so that injured or diseased lungs can rest. (ECMO also was used at MUSC in 1992 to treat pediatric cardiotoxic poisoning in a 16-month-old patient, setting a new national standard for ECMO usage.)

Referrals come mainly from other pediatric intensive care units in the state. When ICU physicians do not see progress with conventional treatments, ECMO is considered. “The children who go onto ECMO have a 90 to 100 percent chance of dying without it,” said Cochran. “At MUSC, the survival rate for pediatric patients on ECMO is between 65 and 70 percent, while the national average is about 50 percent.”

Guidelines, new techniques aid treatment decisions

While ECMO has proven to be useful in treating children, it remains a procedure with many potential complications. “We learn something new every time we use it,” said Cochran.

In 1993, Fred Tecklenburg, M.D., director of the Pediatric Critical Care Division, asked Cochran to learn as much as he could about treating pediatric patients with ECMO. Cochran attended national conferences and visited other medical centers to find out how others are using the procedure. Division members then developed guidelines for when ECMO can safely be used for pediatric patients.

Neonates who develop persistent fetal circulation or persistent pulmonary hypertension, commonly caused by infection, aspiration of meconium or diaphragmatic hernia, are routinely put onto ECMO. As long as they are old enough and big enough and have no evidence of bleeding, nearly all neonates can safely go on ECMO, Cochran said.

In children age 6 months and older, the criteria are more problematic. The decision of whether a child can be treated with ECMO depends a great deal on how long he has been on a ventilator.

“If a 6-month-old has been on ventilation for a week or 10 days, he probably can still go on ECMO, but if a 10-year-old has been on that long, using ECMO is more difficult,” said Cochran. Decisions also are based on whether a child has a potentially recoverable disease. “If a child has cancer and may not survive it, he may not be a good candidate. Or if the child has had cardiac arrest and we don’t know his neurological condition we may not take the chance of using ECMO,” said Cochran.

The procedure is expensive, requires 24-hour monitoring by specially trained ICU staff members and is not without risks. Bleeding is the biggest risk, followed by infection. Plus when a neonate or a child is placed on ECMO, it’s necessary to sacrifice the carotid artery and jugular vein on one side of the neck so that the bypass cannulas can be inserted into the heart.

Fortunately, recent advances in the field have allowed pediatric surgeons to repair such vessels. According to Andre Hebra, M.D., MUSC pediatric surgeon, reconstruction of the cartoid artery has become almost routine at MUSC for most pediatric patients who require ECMO.

“The concept of cartoid artery reconstruction is very appealing because it allows the re-establishment of maximal blood flow to the brain after discontinuation of ECMO,” said Hebra. The procedure is technically challenging due to the very small size of the vessels. Using microsurgical techniques, pediatric surgeons at MUSC have been able to offer carotid reconstruction to many patients who require ECMO, particularly if they were on bypass for less than two weeks. For consultation or referrals, call MUSC Health Connection at 792-1414.

Editor’s note: The article is reprinted from MDialogue newsletter, a physician liaison program publication.