Guidelines for Consideration of ECMO
(ExtraCorporeal Membrane Oxygenation)

Reviewed by John Beca (PICU) and Carl Kuschel

July
2002

Eligibility Criteria	Contraindications	Pre-ECMO Investigations
Optimal Pre-ECMO Tubes and Lines	Consideration of ECMO

ECMO is proven treatment for life-threatening respiratory and/or cardiac failure in neonates. Overall survival rates are approximately 80% in infants with a predicted survival of 20%.

Eligibility Criteria

ANY of the following AND underlying disease process which is likely to be reversible

1.	OI ≥30 - 60 for 0.5 - 6 hours	OI = (MAP x FiO₂ x 100) / PaO₂(mmHg) (click here to open the OI calculator) Standard criteria: OI ≥40 on conventional ventilation OI ≥50-60 for HFOV
2.	PaO₂ <5.3kPa (40mmHg) for >2 hours	Despite maximal ventilatory support
3.	Acidosis and Shock	pH <7.25 due to metabolic acidosis Raised lactate Intractable hypotension

Contraindications to ECMO

Absolute

Gestational age <34 weeks

Birth weight <2kg

>Grade 1 intracranial haemorrhage

Severe and irreversible brain injury (as best as can be judged by consultant neonatologist)

Lethal malformations or congenital anomalies

Significant non-treatable congenital heart disease

Severe and irreversible lung, liver or kidney disease

Relative

> 10-14 days of mechanical ventilation

Uncontrolled bleeding or coagulopathy

IVH Grade 1

Congenital Diaphragmatic Hernia if PaO₂ never > 9.3kPa (70mmHg) or PaCO₂never < 10.7–13.3kPa (80–100mmHg)

Pre ECMO Investigations

Investigation	Responsibility
CXR	NICU
FBC and Differential	NICU
INR, APPT, Fibrinogen	NICU
Electrolytes Urea and Creatinine LFTs	NICU
Head Ultrasound Scan	NICU
Cardiac Echo	NICU but should have repeat study performed by Paediatric Cardiologist prior to cannulation
Crossmatch (2 adult units)	NICU

Optimal Pre ECMO Tubes and Lines

Item	Responsibility	Comments
Nasal ETT	NICU	If very unstable, the risks of electively changing an oral ETT to a nasal ETT need to be considered carefully. Otherwise change to nasal ETT after cannulation
Peripheral arterial line	NICU	Ideally, this should be pre-ductal (right radial or brachial) but if unsuccessful a functioning UAC is satisfactory.
Double lumen femoral venous catheter	PICU
Urinary catheter	NICU

Consideration of ECMO

With the advent of HFOV and nitric oxide, patients being referred for ECMO will generally be sicker than previously with little or no reserve. As a treatment with a proven survival benefit, ECMO should be considered for any neonate with severe cardio-respiratory failure and discussed early to facilitate timely transfers.

As many as possible of the pre-ECMO investigations, tubes and lines should be done prior to transfer to allow for rapid initiation of ECMO if it is required.

Consider and discuss ECMO in any near-term neonate with:

PaO₂<6.7kPa (50 mmHg)
FiO₂ 1.0
PIP >35cm H₂O

OI >30 on conventional ventilation
OI >40 on HFOV
Failure to improve with HFOV over 2-12 hours is also a very poor prognostic sign

In the first instance discussion should be with either Dr John Beca or Dr David Buckley
- If neither is available, contact the PICU Specialist on call with the switchboard.

If a decision is made to transfer to PICU: