In 1988, the Pediatric Intensive Care Unit at Nicklaus Children's Hospital broke new medical ground, opening Florida's first Extracorporeal Life Support (ECLS) program to provide life-saving intervention for the region's most critically ill infants and children. Since those pioneering beginnings, the Extracorporeal Life Support program at Nicklaus Children's Hospital is proud to have given new life to hundreds of youngsters, while maintaining one of the best outcome records in the field.
The ECLS program includes Extracorporeal Membrane Oxygenation (ECMO) Therapy and is one of only three in the nation to perform emergency pediatric therapeutic apheresis, a safe and effective way of treating serious blood infections and diseases. ECMO Therapy is the use of a machine that acts like an artificial heart and lungs for a child delivering the oxygen to the blood they require to stay alive. Although a child’s heart continues to beat while undergoing this treatment, this machine makes it easier as it does much of the pumping for them. ECMO therapy is used for infants and children who suffer from respiratory and/or heart failure due to birth defects, trauma or serious infection.
Extracorporeal Life Support services are provided through the Pediatric Intensive Care Unit at Nicklaus Children's Hospital the leading pediatric care facility in the state of Florida.
What is Apheresis Therapy?
Apheresis therapy is used for treating serious blood infections and diseases. This involves removing the blood from the body, processing out key components and returning the remaining blood to the patient.
Three forms of apheresis therapy are offered, depending on patient diagnosis:
- Therapeutic Plasma Exchange: This method of apheresis therapy is used to remove plasma from the blood of children with diseases and disorders that leave poisons and other damaging substances in the blood supply. Therapeutic plasma exchange is often used for children with meningitis, Guillain Barre, Hemolyitc Uremic Syndrome and Lupus Erythematosus. After removal of the damaged plasma, the child receives new plasma.
- Red Cell Exchange: Commonly used to treat patients with Sickle Cell Disease, malaria and other diseases that attack the red blood cells, this treatment involves removal of the damaged red cells, after which the patient receives healthy red cells.
- Leukopheresis: This apheresis therapy procedure is used for cancer patients. One type —used for children with cancer diseases such as lymphoma— involves removal of the abnormally large number of white cells associated with the disease. The second type of leukopheresis allows for collection of stem cells from the blood, which are later returned to a cancer patient during a bone marrow transplant.
What is Extracorporeal Membrane Oxygenation (ECMO) for Children?
ECMO stands for Extracorporeal Membrane Oxygenation. Extracorporeal means outside of the body. A membrane oxygenator is a piece of equipment which acts as a lung to deliver oxygen into the child's blood. The ECMO circuit acts as an artificial heart and lung for the patient during ECMO therapy.
ECMO is a life-saving technique that mimics the natural function of the heart and lungs, allowing an infant or child to rest while natural healing of the affected organs takes place. Candidates for ECMO include newborns and children suffering respiratory and/or cardiac failure as a result of birth defects, trauma or severe infection.
Throughout extracorporeal membrane oxygenation treatment, the child is the center of a highly coordinated team medical effort and receives around-the-clock care while on this "heart lung machine". The ECMO procedure involves channeling the patient's blood into a roller pump that serves as the child's "heart" throughout treatment. The pump sends the blood through an oxygenator, which serves as an artificial lung, infusing the blood with oxygen and removing carbon dioxide and returning it to the patient.
During extracorporeal membrane oxygenation treatment, the child's heart continues to beat, but its work is made easier because the ECMO machine does much of the pumping. The length of time a child remains on therapy depends on the diagnosis and the child's individual response
Candidates for ECMO
ECMO is used to help babies with a wide variety of medical challenges, including:
ECMO is also used for older children suffering from the following conditions:
- Post-op cardiac repair
- Aspiration pneumonia
- Near drowning
- Hydrocarbon ingestion (lighter fluid, turpentine)
In adults, ECMO may be indicated for:
- Underlying disease with reasonable likelihood of reversal
- Septic shock
- Pulmonary failure
Different Types of ECMO
- Venous Arterial (VA) ECMO — In VA ECMO, a catheter is placed in the vein on the right side of the neck which removes un-oxygenated blood from the body. A second catheter is placed in the artery on the right side of the neck which returns oxygenated blood from the ECMO circuit to the body.
- Venous Venous (VV) ECMO — In VV ECMO, a single catheter is placed in a vein. VV ECMO only provides support for the lungs, whereas VA provides support to the heart and the lung.
ECMO blood flow is maintained at a sufficient rate to adequately perfuse the patient and allow "rest" of the heart and lungs. In most infants, this can be achieved at flows of 80% of the required cardiac output.
ECMO is also maintained at a level such that adequate oxygen delivery is achieved for patient needs. These oxygenation needs may change from time to time, depending on the patient's condition.
Weaning Patients from ECMO
Initially, when the patient is placed on ECMO, the pump flow is kept high to allow the heart and lungs are allowed to rest. As the heart and lung function begins to improve, the ECMO flow will be decreased, allowing the heart and lungs to do more of the work.
The function of the heart and lungs are measured by blood samples, chest x-rays, chest movement and echocardiogram. Once the patient's condition has improved, the ECMO flow is decreased and the patient is tried off pump for a couple of hours.
If during this time, the patient remains stable, ECMO can be discontinued and the patient will require full ventilation which will also be reduced once the patient improves. Once ECMO is discontinued, the catheters will be removed from the neck and the vessels will be repaired.
There are numerous complications of ECMO that might occur:
- Internal bleeding may result since the blood must be kept from clotting. A drug called Heparin is given to thin the blood which can lead to bleeding problems.
- Whenever a tube is inserted in a blood vessel, there is an increased risk of infection, surgical complications and stroke, which may occur since the procedure involves tying off two major blood vessels, typically the carotid and the internal jugular vein.
- Blood clots are another complication of ECMO that can occur even though the circuit is monitored visually for any signs of clots or air.
- Transfusion-related infections may occur due to the fact that patients will be receiving blood and blood products transfusions.
- Technical failure or malfunction can occur just as any piece of equipment can.
History of Pediatric ECMO Surgery
Extracorporeal membrane oxygenation is the use of extracorporeal circulation and gas exchange to provide temporary life support to patients with cardiac or pulmonary failure. One key component of ECMO is the transport of oxygen into blood across a semi-permeable membrane. This phenomenon was first recognized in 1944 when Kolff and Berk noted that blood became oxygenated as it passed through the cellophane chambers of their artificial kidney.
The concept of cardiopulmonary bypass was developed in the early 1950's. Devices used at that time were bubble or disk oxygenators with a direct oxygen-blood interface. Hemolysis occurred after a few hours of bypass. This precluded its use for long-term support. The development of the first membrane oxygenator, by Clowes in 1956, enabled prolonged cardiopulmonary bypass to become feasible.
The 1960's and 1970's were noted for advances in techniques and research, for prolonged pulmonary support. A nine hospital collaborative study was organized by the National Heart, Lung, and Blood Institute to study ECMO therapy, in adults with pulmonary insufficiency. Unfortunately, survival was not improved. The study had several problems: (1) the patients varied greatly as to the type and complexity of their disease process; (2) patients were often entered when lung damage was predicted as irreversible; (3) intensive ventilatory support was continued, which perpetuated lung damage.
The early ECMO experience in children was similar to that in the adult. However, these studies suggested that in appropriate patients who were treated early and did not have irreversible lung damage, ECMO was technically feasible with the potential to reverse pulmonary failure.
The first newborn population chosen for ECMO was the premature infant with hyaline membrane disease. These infants suffered an unacceptably high risk of intracranial hemorrhage. The combination of Hypoxia, hypothermia, acidosis, systemic heparinization, and alterations of cerebral circulation resulted in a prohibitively high mortality. A milestone in the history of ECMO was reached when Bartlett and associates pioneered the treatment of term or near term infants in acute, reversible respiratory failure.
Because of the pioneering efforts of Dr.Bartlett and his associates, we are able to offer ECMO to this population successfully. There are currently over eighty-five centers, internationally, offering ECMO with over 20,000 infants treated to date. The average survival rate is 83% for newborns, whom previously had a predicted survival of 20% without ECMO.