Extracorporeal Membrane Oxygenation in Pediatric Severe Aplastic Anemia: A Case Report Highlighting Risk-Benefit and Ethical Considerations

Severe aplastic anemia (SAA) is a rare pediatric bone marrow failure disorder marked by profound pancytopenia and high risk of infection, bleeding, and organ dysfunction. Despite advances in definitive therapy, children with SAA remain vulnerable to rapid deterioration during neutropenic sepsis. The role of extracorporeal membrane oxygenation (ECMO) in this population is poorly defined due to substantial hemorrhagic, thrombotic, and infection risks, thus necessitating careful risk-benefit assessment. A four-year-old child presented with febrile neutropenia and profound pancytopenia and was diagnosed with idiopathic severe aplastic anemia based on bone marrow biopsy demonstrating marked hypocellularity. Her course was complicated by persistent marrow failure and recurrent infections despite supportive care. Four months later, she developed refractory septic shock requiring ECMO, which was complicated by severe bleeding, disseminated intravascular coagulation, venous thrombosis, and progressive multi-organ failure, resulting in death. This case highlights the narrow therapeutic window of ECMO in pediatric SAA, in which profound cytopenias and immunosuppression markedly increase morbidity. While ECMO may provide temporary cardiopulmonary stabilization, its benefit depends on the likelihood of hematologic recovery and a clear pathway to definitive therapy. The use of ECMO in pediatric severe aplastic anemia, therefore, requires cautious patient selection, early multidisciplinary collaboration, and proactive goals-of-care discussions to ensure alignment with prognosis and family-centered values.