Extracorporeal Membrane Oxygenation (ECMO)

What is ECMO and What Are The Goals of ECMO?

Extracorporeal Membrane Oxygenation (ECMO) is a mechanical circulatory support device that routes blood from a patient’s body into a type of machine that is composed of different components that can perform the function of the lung (remove carbon dioxide and add oxygen) and of the heart (by pumping oxygenated blood to the body’s organs and tissues) and return that blood to the patient. ECMO is a type of life-support system that can help maintain a person’s heart and lung function while they are recovering from an illness or surgery, or awaiting another procedure or surgery. Although it can be life-saving, ECMO is a complex mechanical circulatory support device that requires its own team of providers and is associated with its own risks.

ECMO can be used to treat a variety of respiratory and cardiac conditions, as well as provide support for more global disease states. Patients requiring ECMO typically have breathing tubes and are on mechanical ventilators before ECMO, this is continued throughout their ECMO course. The goal of ECMO is to support the patient so that cardiac medications and ventilatory support can be decreased to allow for heart and lung recovery. Depending on the underlying disease that ECMO is treating, the hope is that patients can be given enteral nutrition and be as awake as they tolerate it and make movements that do not risk disruption of the ECMO circuit.

What Conditions Does ECMO Treat?

Common neonatal conditions include:

• Meconium Aspiration Syndrome
• Pulmonary Hypertension
• Congenital Diaphragmatic Hernia

Common pediatric conditions include:

• Severe Acute Respiratory Distress Syndrome
• Severe Sepsis
• Multi-organ Failure
• Acute Toxic Ingestions

Common cardiac conditions include:

• Myocarditis
• Cardiomyopathies
• Post-operative Cardiac Dysfunction
• Decompensated Heart Failure
• Intractable Arrhythmias
• Cardiac Ischemia

What are the risks of ECMO?

The most common risks of ECMO are severe bleeding, development of arterial and venous thrombosis (blood clots), and infection. The bleeding and thrombosis most significantly can affect the patient’s brain, and so there is increased risk of intra-cranial hemorrhage, seizures and stroke. Thrombosis may also affect the patient’s circulation to their hands and feet. Typically blood transfusions and systemic anticoagulation (blood thinners) are required. Patients are constantly monitored for bleeding and thrombosis with frequent medication adjustment and use of blood products. Patients are followed very closely for the development of any neurologic complications, including use of head ultrasounds in neonates/infants and continuous EEG monitoring. The requirement for catheters to attach the patient to the ECMO circuit also increases risk for infection, which is actively surveyed for and aggressively treated as needed. Typically, patients requiring ECMO need to lay flat and still, so tissue breakdown and wounds may result and patients are followed closely by the wound team. Also, muscle weakness can result due to the need for pain and sedating medications. These medications are frequently utilized, and may require a long weaning process following the discontinuation of ECMO. It is not uncommon that the patients may require support by physical therapy.

Where is ECMO done?

Critically ill neonates may be put on ECMO in the NICU. Once on ECMO they are transferred to the Pediatric Cardiac Care Center (PCCC) or Pediatric Intensive Care unit (PICU) for their ongoing management.

Neonatology consultation continues to be provided as needed. Critically ill neonates, infants and children may be put on ECMO in the PCCC or PICU and remain in that unit throughout their ICU stay. Neonates/infants and children with cardiac disease may be put on ECMO in the cardiac OR and then are transferred to the PCCC for their ICU stay. Infants and children put on ECMO at outside hospitals are often transferred to the PICU or PCCC for their ICU stay.

What is The Follow Up After ECMO?

• Patients are seen in follow up with Pediatric Neurology and require follow up brain MRI either before or after hospital discharge.
• Patients with cardiac disease are followed up with Pediatric Cardiology.
• Patients with evidence of ongoing lung disease are followed up with Pediatric Pulmonology.
• Patients will follow up with other specialists as determined by their clinical course during their hospitalization.

All patients require close follow up with their pediatrician including physical therapy and early intervention as needed.

Our ECMO Team

All our ECMO providers, nurses and specialists have received advanced ECMO training, in addition to their own certifications, in the care of children requiring ECMO support. We work collaboratively, as a team, to ensure the highest level of family-centered, developmentally appropriate, multidisciplinary care to our children who are managed with ECMO.

Perfusionists

• Ronald Angona – Chief Pediatric Perfusionist, Pediatric ECMO Coordinator
• Nathan Darrow, C.C.P., ECMO Educator, Pediatric Perfusionist
• Ashleigh Leblanc, C.C.P., F.P.P.

Pediatric ECMO Specialists

• Kasie Way
• Roy Way
• Brian O’Key

Pediatric Intensivists and Cardiac Intensivists and Neonatologists

Pediatric Advanced Practice Providers

Pediatric Critical Care and Neonatology Nurses

Pediatric Intensive Care and Cardiac Intensive Care Pharmacologists

Pediatric Sub-specialists and Surgical Sub-specialists

Pediatric Social Work and Discharge Coordinators

Pediatric Palliative Care

Pediatric Occupational Therapy, Physical Therapy

Child Life, Developmental Care Team

Awards

ELSO Award for Excellence in Life Support

UR Medicine’s Golisano Children’s Hospital (GCH) is a recipient of "Gold Level Center of Excellence" awards from ELSO. Extracorporeal Life Support Organization (ELSO) is a major global healthcare enterprise committed to establishing a consortium of clinicians, scientists, and health care administrators to study the new technology of ECMO.

• Read more about the Extracorporeal Life Support Organization (ELSO)

Research & Quality Improvement – GCH ECMO Program

At Golisano Children's Hospital, we constantly work to advance patient care and the science of pediatric medicine, including how we provide ECMO support. With a shared commitment to excellence, we employ a multidisciplinary team to analyze and optimize our processes through clinical research and quality improvement practices. GCH participates in several organizations that allow for benchmarking of our performance as compared to regional and national performance outcomes.  We utilize National Benchmarking data to allow for local practice appraisal and quality improvement activities.  GCH is part of Children’s Hospitals’ Solutions for Patient Safety (SPS), Virtual Pediatric Systems (VPS), Pediatric Cardiac Critical Care Consortium (PC4) and the Society of Thoracic Surgery (STS) and New York State Congenital Cardiac Surgery database.

We developed an evidence-based guideline for the use of anticoagulation on ECMO with the aim to reduce bleeding and clotting events, decrease administration of blood products, and optimize the use of antithrombin. Recently, we have shown that the adoption of a performance checklist at the initiation of ECMO, guides a more unified, focused team to a faster onset of therapy. We are also investigating how this may improve the neurologic outcomes of patients who require ECMO.

These are just a few examples, amongst many, of how we are dedicated to achieving the best results for each of our patients, now and into the future.

Patient and Family Support

The GCH ECMO program focuses on care of the patient and family. We understand that family centered care recognizes the vital role families play in ensuring the health and well-being of patients of all ages. Educational materials are provided to family members and families are encouraged to participate in their loved one’s care. ECMO care at GCH is family-centered and family is encouraged to be present at, and participate in, daily rounding. Developmentally appropriate care is always provided and each child is followed by the GCH Critical Care Developmental Care team who establishes and shares developmentally appropriate goals for each patient with nurses, providers and families. These goals are posted at the bedside and are documented as part of the nursing care plan in the medical record. Social work and discharge coordinators are essential partners in the care of these critically ill children and are available to provide support to families throughout their child’s hospitalization. The Palliative Care Team provides consultation and additional support to patients and families and can provide additional resources as needed.

• See more information at: ELSO Patient & Family Support Resources