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NICU guideline identifier

ECMO - guidelines for consideration in newborn

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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  or PaO2
<6.7-8.0kPa (50-60mmHg) for 2-12 hours 
Despite maximal ventilatory support
3. Acidosis and Shock  pH <7.25 due to metabolic acidosis
Raised lactate
Intractable hypotension

Contraindications to ECMO

Absolute

  • Grade 3 or 4 IVH
  • 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

  • Gestational age <34 weeks
  • Birth weight <2kg
  • > 14 days of mechanical ventilation
  • IVH Grade 1-2
  • Disease states with a high probability of a poor prognosis
  • Congenital Diaphragmatic Hernia if pre-ductal PaO2 never > 9.3kPa (70mmHg) or PaCO2 never < 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
Peripheral arterial line NICU Ideally, this should be pre-ductal (right radial or brachial) but if unsuccessful a functioning UAC is satisfactory.
Double lumen umbilical venous catheter NICU  
Double lumen femoral venous catheter PICU May be inserted by PICU team if time before cannulation.
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.

Discuss all infants who are potential ECMO candidates early with the PICU Consultant on call.

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

If a decision is made to transfer to PICU:

  1. Ensure that 2 adult units of red cells have been cross matched
  2. The transfer will be performed by either a Consultant Neonatologist or Senior Fellow
  3. PICU nursing staff will liaise with NICU nursing staff to determine current drug infusions and doses
  4. If a child is too unstable to be transferred safely to PICU, the child can be placed on ECMO in NICU and then transferred afterward.

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Document Control

  • Date last published: 29 October 2013
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years