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Pediatrics

Extracorporeal Membrane Oxygenation in Children

Extracorporeal membrane oxygenation (ECMO) is a well-known means of advanced life support in patients with significant cardiorespiratory impairment refractory to conventional therapeutic interventions. It is a salvage rescue therapy that can result in negative consequences if utilized by unfamiliar personnel. Nevertheless, there is a niche of critically ill children that will benefit from ECMO, and it is vital to appropriately select candidates to avoid or overcome complications and ethical dile

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • patients with significant cardiorespiratory impairment refractory to conventional therapeutic interventions.
  • critically ill children that will benefit from ECMO
  • Recommended threshold pH < 7.0
  • Recommended threshold OI > 40
  • Consider transfer to ECMO center when OI > 25
  • Impaired gas exchange as defined by oxygenation index (OI = mean airway pressure x FiO x 100/PaO) or respiratory acidosis
  • OI not improving by day 2 of illness.
  • The problem of recirculation is usually diagnosed when there are low patient oxygen saturation and high pre-oxygenator saturations and can be identified by the proximity of the drainage and the reinfusion cannulae on the X-ray.
  • Before administering ECMO, neonates or pediatric patients should undergo extensive evaluation, including thorough physical examination focusing on neurologic assessment, complete blood count, metabolic panel, lactate, arterial blood gas, chest x-ray, cranial ultrasound, or head CT scan, and echocardiography.
  • Echocardiography
Oxygenation Index (OI)
OI = mean airway pressure x FiO x 100/PaO
  • ECMO surfaces elicit a systemic inflammatory response when blood is exposed to the circuit, causing a hypercoagulable state.
  • Frequent monitoring of platelet and coagulation studies is important.
  • Therefore, anticoagulation plays a key role in ECMO therapy.
  • Unfractionated heparin remains the gold standard way to manage the body’s pro-thrombotic state, although there is a trend towards using direct thrombin inhibitors as alternative agents.
  • For ECMO in the neonatal setting, clinical guidelines proposed by the American Society for Parenteral Enteral Nutrition recommend starting nutritional support expeditiously and enteral nutrition as soon as the patient is clinically stable.
Unfractionated heparin
Not specified in source
Adult
Not specified in source
Renal
Not specified in source
Duration
Not specified in source
  • Lethal chromosomal abnormalities (e.g., Trisomy 13 or 18)
  • Severe neurologic compromise (e.g., irreversible brain damage, grade III or higher intraventricular hemorrhage, severe hypoxic-ischemic encephalopathy)
  • Uncontrollable bleeding
  • Incurable malignancy
  • Prematurity < 30 weeks gestation
  • Low birth weight < 1 kg
  • Duration > 2 weeks of mechanical ventilation before ECMO
  • Recent neurosurgical procedures or intracranial hemorrhage (< 7 days)
  • Preexisting chronic illness with poor long-term prognosis
  • Allogeneic bone marrow transplant recipients
  • Solid-organ tumors
  • Birth weight < 2 kg
  • Neurologic (most common): intracranial hemorrhage, seizures, brain death, ischemic infarction
  • Hematologic: cannula site bleeding, surgical site bleeding, clots in the circuit, vessel injury from cannulation, pulmonary hemorrhage, gastrointestinal hemorrhage, hemolysis, disseminated intravascular coagulation, inadequate anticoagulation, limb ischemia
  • End-organ hypoperfusion: renal failure, liver failure
  • Cardiac tamponade
  • Infection
  • High-pressure system in neonates: increased hemolysis, hyperbilirubinemia, hypertension, end-organ damage with renal failure
  • Long term: poor growth, neurodevelopmental deficits, organ damage (e.g., sensorineural hearing loss, lung injury, renal dysfunction)
  • Weaning trials should begin as soon as the patient has sufficiently recovered from their disease process and is hemodynamically stable.
  • review
    Extracorporeal Membrane Oxygenation in Children. StatPearls [Internet] — David Charles Rosario, Shashikanth Ambati — StatPearls Publishing, 2023

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov