Extracorporeal Membrane Oxygenation (ECMO)

The Wolfson Children’s Hospital Extra-Corporeal Membrane Oxygenation (ECMO) team has created this parent information packet in order to provide you with some helpful information to better understand ECMO and the role it will play in your child’s care. The packet explains what ECMO is, identifies the key people caring for your child while on ECMO, some of the benefits and risks and how the ECMO machine works.

We encourage you to ask questions and share your concerns with the staff at any time. This packet is intended to provide you with additional information to make the discussions you have with the ECMO team members helpful and more meaningful.

ECMO is a special means of support that allows for your child’s heart and lungs to rest when your child has a condition that prevents the heart and lungs from functioning properly. This means of support involves a machine that will take over the work of the lungs and heart until your child gets better and is able to do the work on his/her own.

Children are placed on ECMO when they have a reversible heart or lung problem that has not improved with other forms of less invasive treatment.

There are two types: VA (Veno-Arterial) and VV (Veno-Venous).

• VA ECMO supports the heart and lungs.
• VV ECMO supports the lungs.

Some children may be placed on VV ECMO and need to be changed to VA ECMO. If this need arises, the ECMO team and your child's doctor will discuss this with you.

Your child will have surgery to place the ECMO cannulas. This procedure is most often done at the child's bedside by the ECMO surgeon and his or her team. Your child will first be given some medication through an IV to prevent pain during the procedure. Your child will also be given a medication to keep him/her from moving. Your child's nurse or doctor may refer to this as a "paralytic." The medicine will wear off shortly after the procedure is complete.

A numbing medication is injected into the area where the cannulas will be placed (in the neck and/or groin). The cannulas are then placed into the blood vessels and pointed towards the heart. The ECMO circuit will then be connected to the cannulas. After surgery is complete, an X-ray will be taken to be sure the cannulas are in the correct position. Your child will remain on a breathing machine, also referred to as a ventilator, to help keep the lungs inflated and allow the team to remove secretions from the lungs.

Blood is removed from the body through the cannula in the neck and/or groin. The blood moves through the ECMO circuit and through an artificial lung, called an oxygenator. The artificial lung provides the blood with oxygen and removes carbon dioxide. This oxygenated blood is then returned to your child through the same cannula (VV ECMO) or a separate cannula (VA ECMO). The pump is adjusted based on your child’s needs.

• Your child will receive many different types of medications and blood products while on ECMO. One of the medications your child will remain on while he/she is on ECMO is a medication that prevents the blood from clotting in the ECMO circuit.
• Frequent blood samples will be drawn from your child and the ECMO circuit. Adjustments may be made based on the results of these blood samples.
• Your child will have a daily chest X-ray to visualize signs that your child's lungs are improving.
• Infants will receive an ultrasound of the head to look for any signs of bleeding in the brain.
• Your child will get a cardiac ECHO (echocardiogram) to see how well the heart is pumping.
• Your child's head and body may look swollen or puffy at the beginning of treatment. This should improve after the first few days.

Several individuals will be caring for your child while on ECMO. Each person plays an important role in providing the best care for your child. Every morning during "patient rounds" your child's care team will come together to discuss with you how your child is doing and the plan of care. We encourage you to participate in rounds and discuss any concerns or questions you may have. Some ECMO team members you will see at your child's bedside include:

• The ECMO Primer: A pediatric intensive care nurse or respiratory therapist that oversees the daily care of your child and the ECMO equipment
• The ECMO Specialist: A pediatric intensive care nurse or respiratory therapist who monitors your child and operates the ECMO circuit

Your child will be provided the nutrition he or she needs through IV therapy. If you are breastfeeding or plan to breastfeed, a breast pump can be provided for you to pump while at your child’s bedside. We can store the milk at the hospital for when your child is ready to eat.

Some children may have complications that arise from treatment as a result of the ECMO process. As parents, you will be involved in decisions that are made about the care of your child. Below are some of the risks and complications the ECMO surgeon has already discussed with you. The ECMO team also welcomes any questions you have, including those about:

• Bleeding
• Stroke
• Infection
• Blood clots
• ECMO circuit issues
• Skin breakdown

In the event your child needs to be temporarily removed from the ECMO circuit, your child will be placed on higher settings on the ventilator until your child can be safely placed back onto ECMO. The ECMO team has had both training and experience to respond to these situations.

Your child will be asleep the majority of the time while on ECMO; however, he or she can still hear you. Talking to them, playing music or reading to them may be comforting. You won't be able to hold your child while on ECMO but we encourage you to hold their hand. There are several ways you may be able to participate in their care including:

• Helping with baths
• Providing special toys or blankets
• Bringing in pictures or drawings from siblings to hang at the bedside
• Taking care of yourself by eating and getting enough rest. We need you to stay well so you can be there for your child. We know you would like to always be at your child's bedside, but it is important to take time for your own self-care.
• You can call at any time of the day or night while you are away from the bedside to get an update on your child.

Each Intensive Care Unit (ICU) has different visitation guidelines. Please ask your nurse for the visitation hours and number of family members who are allowed at the bedside at one time. Parents are free to visit any time, although we may ask parents and family to step out during certain procedures. If you or a family member is sick, it is vital that you refrain from visiting the ICU.

The length of your child’s ECMO treatment will depend on his or her condition. As your child’s heart and lungs begin to improve, the ECMO support will be decreased. Your child will be taken off the ECMO circuit and the cannulas will be removed after careful evaluation of your child’s heart and lungs.

Upon discharge from the hospital, your child will be scheduled for a follow-up visit with the ECMO surgeon, as well as a doctor who specializes in child development. In addition to routine visits with your pediatrician, this child development specialist will continue to see your child to be sure he or she is developing as expected.