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Extracorporeal Membrane Oxygenation (ECMO): Initiation and Management– Pediatric/Neonatal – Inpatient

Extracorporeal Membrane Oxygenation (ECMO): Initiation and Management– Pediatric/Neonatal – Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Respiratory


Extracorporeal Membrane Oxygenation (ECMO) – Pediatric/Neonatal
Guideline Summary
Target Population: Neonatal and pediatric patients with a reversible and (potentially) survivable disease, disorder or
injury who meet criteria for ECMO
Full Guideline: Extracorporeal Membrane Oxygenation (ECMO): Initiation and Management - Pediatric/Neonatal - Inpatient
Extracorporeal Cardiopulmonary Resuscitation (ECPR)
Indications for ECPR Contraindications for ECPR
• Monitored/witnessed in-hospital cardiac arrest w/prompt
and effective CPR
• No recovery of cardiac function within 20 mins of CPR
initiation
• Parental refusal for use of mechanical support
• Do not resuscitate (DNR) order
• All other general contraindications for ECMO use
For Emergent ECMO, page 4844 with following Patient MRN, location (PICU/OR/Cath lab), weight, call back #
ECMO Initiation
VA ECMO Once cannulated for VA ECMO, flow is gradually increased slowly over 1-10 minutes depending on patient condition
and age. The younger the patient is, the slower the rate of increase. This rate is increased to a calculated flow
of 100 – 120 mL/kg/min
VV ECMO Prior to initiating VV ECMO, inotropic support may be increased until an increase in blood pressure is seen. Careful
attention must be made that the ECMO circuit prime has a normalized ionized calcium and potassium level given the
limited ability in VV ECMO to support hemodynamics. Pump flow is initiated at 50 mL/kg/min in a neonatal or pediatric
patient and increased SLOWLY by 10-15 mL/kg/min and increased over 5-15 minutes to a flow of 120 -150
mL/kg/min.
For VA- and
VV-ECMO
It is recommended that the FiO2 of the ECMO blender be set at 1.0 and the sweep gas rate equal to the blood flow rate
(1:1 ratio) when starting ECMO.
During the initial phase of full support, small changes in flow rate may be required to optimize flow to achieve general
patient management targets. Ventilator settings may be reduced to “rest settings” during this time as well. As
hemodynamic stability ensues, cardiovascular drugs may be weaned and discontinued as tolerated.
ECMO Patient Management Parameters
VA VV Notes
HCT > 25 >30
14
Goal to minimize transfusion unless bleeding
Can adjust targets if bleeding or inadequate oxygen delivery
Plts >75 K/µL >75 K/µL Goal to minimize transfusions unless bleeding
Sats >90 >80
Flows 100-120 mL/kg/min 100-150 mL/kg/min Adequate flow to be determined by SVO2 and NIRS values;
lactate
pH 7.35 – 7.45 7.30 -7.40 Adjust per patient condition
PaO2 < 300 <120 Goal is to avoid hyperoxia
pCO2 35 – 45 mm Hg 40 – 50 mm Hg
ECMO Circuit Blood Gas Management
Premembrane (Venous) Postmembrane
pH 7.30 –7.40 7.40 – 7.50
PCO
2
45 – 55 30 – 40
PO2 35 – 45 mm Hg
15
> 200 mm Hg
Saturation > 65% 100%
Ventilator “Rest” Settings
Setting Notes
Fi02 0.21- 0.30
Intermittent mandatory ventilation (IMV) 4 – 10 breaths per
minute
Peak inspiratory pressure (PIP) 20 – 30 cm Limit PIP to avoid alveolar overdistention
Positive End-expiratory Pressure (PEEP) 5-12 cm H
2
O CPAP/High PEEP 10-12 cm to maintain functional residual
capacity (FRC) can often shorten bypass time.
If ECMO circuit fails, treat as code situation. Call for help and be prepared to perform CPR if necessary and support patient
with emergency code drugs and ventilator settings (e.g., shift patient back to pre-ECMO vent settings.)
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Hand crank pump only if: ALL electrical sources for pump exhausted (i.e., hospital generator, batteries), catastrophic pump
failure, or decoupling of pump head (typically when running very high flows.)

ECMO Patient Monitoring
Monitoring Intervention General Frequency and Comments
Chest radiography Daily
Electrocardiogram Once post-cannulation (for cardiac patients)
Cranial ultrasonography Daily
Activated clotting time Every hour upon initiation; once stable, then as needed
Antifactor-Xa (anti-Xa) Check within 6 hours of heparin initiation then every 6 hours when stable
Pre-membrane blood gas

Every 8 hours for first 24-48 hours until stable and then daily or as needed
thereafter (with no changes in circuit FiO2 and sweep)
Post-membrane blood gas

Every 8 hours for first 24-48 hours until stable and then daily or as needed
thereafter (with no changes in circuit FiO2 and sweep)
Patient blood gas
(including hemoglobin, electrolytes, lactate, and ionized
calcium)
Every 4 hours
Glucose monitoring test Every 4 hours
Complete blood cell count (CBC) with platelets
Once daily and as needed
If blood product replaced, full blood (vs whole CBC) hemoglobin/hematocrit and
platelets redraw 1 hour after transfusion completion
Basic Metabolic Panel
(Sodium, potassium, chloride, total carbon dioxide, anion
gap, glucose, BUN, creatinine, calcium)
Every 12 hours (calcium, magnesium, phosphorus, re-check based on
replacement needs)
PT/INR and Fibrinogen
Every morning; if infusion of blood products (e.g., cryoprecipitate, fresh frozen
plasma) redraw 4 hours after infusion completion
Blood culture
(bacteria and yeast)
Daily (starting on Day 1 of ECMO)

* Pts not placed on ECMO emergently, yeast culture may be obtained starting
Day 3
It is recommended to draw blood from patient versus drawing from the heparinized circuit to avoid falsely
elevated anti-Xa or ACT levels.

Anticoagulation Management
Condition
Anti-Xa
Therapeutic Range 0.3-0.7
PT/INR
Fibrinogen
Hemoglobin/Platelets AT III TEG
Initiation
Obtain within 6 hours of
heparin initiation

Stable Q6H Every morning
Q8H for the first 24hours
then every morning
If UFH infusion
> 60 units/kg/hr
N/A
Bleeding or
Clotting
Q 4 to 6 hours or at discretion
of primary attending physician
Treat and redraw
after 4 hr
Treat and redraw after 1
hr
PRN PRN

Weaning from ECMO
VA ECMO VV ECMO
1. Add bridge and stopcocks and tubing near cannula sites
2. Remove or clamp the LA vent if present
3. Adjust inotropes to prepare for the wean
4. Adjust/optimize ventilator for wean (e.g., FiO2, ventilator rate)
5. Place pulse oximeter post-ductal for trending
6. Optimize fluid balance
7. For cardiac patients, attach pacing cables to the pacing wire. Connect patient to a
temporary pacemaker.
8. Discuss upcoming wean with Cardiologist on service and order bedside
echocardiogram (ECHO).
9. Decrease ECMO flows incrementally by 10-20 mL/kg/min to approximately 50
mL/kg/min.
10. When flows are decreased, clamp the lines between the 2 stopcocks in the arterial
and venous line of the circuit. Open the bridge.
11. Clamp trial (7-10 min at a time), “Flush” the cannulas with heparin solution and
continue clamp trial.
12. Turn off sweep gas and heparin drip.
13. Obtain ABG, lactate and SVO2 (if available) every 10-15 minutes for 1 hour then and
monitor NIRS every 15 mins for 1 hour and then as needed.
14. If trial is successful, discuss proceeding with decannulation plan with pediatric
surgeon.
1. Optimize ventilation
2. Decrease ECMO FiO2
incrementally while obtaining blood
gases from the patient
3. Decrease sweep gas as necessary
to maintain proper patient blood
gas values
4. When ready to trial off, turn off
sweep gas flow while maintaining
ECMO blood flow (at this point, the
patient is technically off ECMO.)
5. If tolerating the clamp trial, obtain
ECHO
6. Obtain ABG, lactate and SVO2 (if
available) every 10-15 minutes for
1 hour then and monitor NIRS
every 15 mins for 1 hour and then
as needed.
7. If trial is successful, discuss
proceeding with decannulation plan
with pediatric surgeon.

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org