ECMO in Children: Challenges and Solutions in the Modern Era

ECMO in Children: Challenges and Solutions in the Modern EraECMO has its applications in all ages.The growth of ECMO started with its application in the neonatal age-group.Dr Robert Barlett's first case of neonatal ECMO in 1975 remains a milestone in the evolution of ECMO.The baby was named "Esperanza" which means hope in Spanish. 1 She remains "Hope" for the entire ECMO community.Despite efforts to spread the use of ECMO in the adult population, the initial adult ECMO trials in the US in 1970s and 80s were not successful.Though there was sporadic use of adult ECMO in the world, for the next 3 decades, ECMO flourished in the neonatal age-group, with extension to pediatrics using the same principles of management.No wonder, Extracorporeal Life Support Organization (ELSO) statistics in the initial 3 decades were dominated by neonatal data.The predominant indications for ECMO remain the same across all age-groups, with a few differences.The majority of the cases of failure of gas exchange in the neonatal period were due to reversible causes.Neonatal ECMO physicians are encouraged by the relatively short duration of ECMO, resulting in the resolution of the underlying disease process.The permanent irreversible conditions, such as surfactant protein B deficiency and alveolar capillary dysplasia, are scarce as they are stated as contraindications for ECMO support.Since the advances in neonatology, such as the development of high-frequency oscillation and inhaled nitric oxide therapy came into regular practice, the outcome of the cases with severe meconium aspiration syndrome resulting in failure of gas exchange became less severe.Management of severely affected neonates with persistent pulmonary hypertension has become less problematic, the neonatal cases have started getting better.It is possible that better perinatal practices had a greater impact on their survival, too.Neonatal and pediatric cardiac indications for ECMO remained similar with pro-procedural stabilization, refractory cardiac arrhythmias and postcardiac surgical ECMO.In India, prior to 2000, selective institutions were putting children on ECMO following prolonged cardiopulmonary bypass as extended cardiopulmonary support following prolonged cardiac surgery.ECMO for respiratory failure started after 2010.Though the adult ECMO picked up, for reasons not substantiated, less number of cases are supported on neonatal/pediatric ECMO.One of the main reasons could be the expertise needed for cannulation of blood vessels (especially for arterial cannulation) in this age-group. 2Pediatric cardiac surgeons, vascular surgeons, pediatric cardiac anesthesiologists and intensivists could fill this gap.As ECMO is possible as a team effort, motivation, developing the infrastructure, and expertise will go a long way in establishing pediatric ECMO centers.In general, pediatric cases needing ECMO would be fewer in number compared to adults or neonates.In any setup, ECMO program would be successful by being part of a combined ECMO program serving all age-groups.This combined setup involving interested and dedicated professionals from each age-group (neonatal, pediatric and adult) will help in building a robust service.Compared to the healthcare delivery in the Western countries, in India, ECMO is mostly self-sponsored.Hence, generating funds to bear the expenses for the ECMO run of unknown duration will add a high demand to any family.Health insurance coverage helps in some cases, but the families covered by health insurance need to increase further.Simultaneously, the cost factor for ECMO run should come down to make it affordable to an average-income family.Awareness of ECMO in the country has been on the rise.Compared to the situation a decade ago, we can see a vast difference in knowing the significance of ECMO.Utilization of ECMO at the appropriate time by avoiding undue delay in a center caring for critically ill patients with all requirements should go a long way in improving faith in ECMO, besides meeting parental expectations.