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March 1, 2021

Bridging the Gap Between Intensivists and Primary Care Clinicians in Extracorporeal Membrane Oxygenation for Respiratory Failure in Children: A Review

Author Affiliations
  • 1Department of Pediatrics, University of Michigan, Ann Arbor
  • 2Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
  • 3NewYork-Presbyterian Hospital, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York
  • 4Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
  • 5Cardiothoracic Intensive Care Unit, National University Health System, Singapore
  • 6Paediatric Intensive Care Unit, Department of Paediatrics, The Royal Children’s Hospital, The University of Melbourne, Melbourne, Victoria, Australia
JAMA Pediatr. 2021;175(5):510-517. doi:10.1001/jamapediatrics.2020.5921

Importance  Extracorporeal membrane oxygenation (ECMO) is a form of advanced life support that may be used in children with refractory respiratory or cardiac failure. While it is required infrequently, in the US, ECMO is used to support childhood respiratory failure as often as children receive kidney or heart transplants. ECMO is complex, resource intensive, and potentially lifesaving, but it is also associated with risks of short-term complications and long-term adverse effects, most importantly with neurodevelopmental outcomes that are relevant to all pediatric clinicians, even those remote from the child’s critical illness.

Observations  The 2009 influenza A(H1N1) pandemic, along with randomized clinical trials of adult respiratory ECMO support and conventional management, have catalyzed sustained growth in the use of ECMO. The adult trials built on earlier neonatal ECMO randomized clinical trials that demonstrated improved survival in severe perinatal lung disease. For children outside of the neonatal period, there appear to have been no respiratory ECMO clinical trials. Applying evidence from adult respiratory failure or perinatal lung disease to children outside the neonatal period has important potential pitfalls. For these children, the underlying diseases and risks of ECMO are different. Despite these differences, both neonates and older children are at risk of neurologic complications, such as intracranial hemorrhage, ischemic stroke, and seizures, and those complications may contribute to adverse neurodevelopmental outcomes. Without specific screening, subtle neurodevelopmental impairments may be missed, but when they are identified, children have the opportunity to receive therapy to optimize long-term development.

Conclusions and Relevance  All pediatric clinicians should be aware not only of the potential benefits and complications of ECMO but also that survivors need effective screening, support, and follow-up.

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