Extracorporeal Membrane Oxygenation (ECMO)

Indications & Inclusion Criteria

• Reversible, profound respiratory or cardiac failure utterly unresponsive to maximal medical management (HFOV, iNO, Inotropes).
• Oxygenation Index (OI) > 40 on two blood gases strictly > 30 minutes apart.
• Severe Hypoxia: PaO2 < 40 mmHg for > 2 hours despite FiO2 1.0.
• Severe persistent pulmonary hypertension of the newborn (PPHN), CDH, severe Meconium Aspiration, or crashing cardiogenic shock/myocarditis.
• Gestational age > 34 weeks and Birth weight > 2000 grams (due exclusively to vessel size required for cannulation).

Absolute Contraindications

• Gestational age < 34 weeks (extreme risk of fatal IVH universally approaching 100% due to systemic heparinization).
• Lethal chromosomal abnormalities (Trisomy 13, 18).
• Pre-existing severe and irreversible brain injury (Grade III/IV IVH, profound cystic PVL).
• Uncontrollable absolute systemic bleeding diathesis.

Veno-Arterial (VA) vs Veno-Venous (VV) ECMO Management

• VA ECMO: Cannulation of Right Internal Jugular (drainage) and Right Common Carotid Artery (return). Completely bypasses heart and lungs. Mandated for cardiac failure.
• VV ECMO: Double-lumen catheter strictly in Right Internal Jugular. Only bypasses lungs (relies on native cardiac output).
• Anticoagulation: Systemic unfractionated Heparin infusion. Target ACT roughly 180-220 seconds, closely monitor Anti-Xa levels.
• Rest settings: Ventilator is turned down severely to 'rest' settings (e.g., PIP 20, PEEP 10, Rate 10, FiO2 30%) to prevent barotrauma and absolutely minimize oxygen toxicity while the circuit operates.

Diagnostic & Management Algorithm

• ECMO Deployment Criteria: [START] Severe hypoxemic failure (OI > 40) -> [DECISION] Reversible condition? -> [YES] Cannulate VA or VV ECMO -> [NO] Palliative Care

References

1. Di Nardo M, MacLaren G, Marano M, et al. Extracorporeal membrane oxygenation in neonates. Ann Transl Med.