Patrick Bouvier Kennedy, the infant son of President John F. Kennedy, was born five-and-half weeks early. As you know, the most difficult breath a human takes is their first, but little Patrick struggled for each breath he drew.
He was rushed to Boston Children’s Hospital and placed in a hyperbaric chamber, but he died less than 48 hours later. Respiratory Distress Syndrome was, in 1963, the most common cause of death among premature infants.
Patrick’s death drew much attention to the morbidity and mortality of premature birth. By the mid-1970’s, this emphasis led to innovations and neonatal applications such as extracorporeal membrane oxygenation (ECMO).
Technology like the Transonic Extracorporeal Life Support Assurance (ELSA) Monitor can help optimize care for patients on ECMO.
How to Optimize ECMO in Pediatric Patients
To facilitate successful pediatric ECMO, a comprehensive healthcare team is assembled to help manage the patient and any technical challenges that may arise.
The care team may be composed of:
- Pediatric intensivists
- Neonatologists
- ICU nurses
- Cardiothoracic, vascular, or trauma/acute care surgeons
- Anesthesiology team
- Critical care transfer team
- ECMO coordinator and technicians
- Perfusionist
- Radiology department
- Echocardiography technicians
- Respiratory therapists
- Rehabilitation specialists
When considering ECMO for a pediatric or neonatal patient, the decision is based on the patient’s disease state. ECMO is usually considered an option if the mortality risk is 50% and is strongly indicated if mortality is 80% with conventional therapies.
Veno-venous extracorporeal membrane oxygenation (VV ECMO) can be challenging in children because of the body’s smaller stature. This can make bicaval catheter placement difficult. In this case, venoarterial extracorporeal membrane oxygenation (VA ECMO) is more appropriate.
How Technology Plays a Role in Optimizing ECMO for Children: A Case Example
During VV ECMO, the fraction of ECMO blood flow (QEC) that recirculates directly into the drainage cannula does not support systemic oxygenation. Therefore, measurement of recirculation is critical in identifying effective ECMO blood flow (QEFF).
The Transonic ELSA Monitor measures this recirculation, giving clinicians the knowledge they need to optimize their patient’s treatment.
Case Report
A 10-year-old patient (44kgs, 132cm) was suffering from extrapulmonary acute respiratory distress syndrome (ARDS) caused by postoperative sepsis and massive transfusion. The child was placed on VV ECMO in the pediatric ICU at Charité – Universitätsmedizin Berlin.
After femoro-jugular cannulas were inserted and ECMO was initiated, pulmonary arterial oxygen levels only increased from 44 mmHg to 66 mmHg. The child was then transferred to Charité’s intensive care unit. There, recirculation was measured with the Extracorporeal Life Support Assurance (ELSA) Monitor using saline dilution ultrasound technique. The position of the two cannulas was also visualized by CT-scans.
Together, the high recirculation fraction (Rf = 78%, 65%) with corresponding low effective ECMO blood flows (QEFF = 680 mL/min, 1260 mL/min) resulted with the visualization of the cannulas. This led the clinicians to postulate that the depth of the drainage cannula’s insertion caused direct jetting of blood towards the inferior vena cava, which causes high recirculation.
In response, they pulled the cannula back approximately 2 cm in an attempt to reduce recirculation. Measurements were again taken with the ELSA Monitor. Recirculation dropped dramatically to 25%, and effective ECMO blood flow increased to 1800 mL/min.
In conclusion, when high flow VV ECMO did not sufficiently support the child’s systemic oxygenation, measurements of recirculation, imaging techniques and applied ECMO physiology led to optimization of systemic oxygenation and protective lung ventilation.
Learn more about the ELSA Monitor and ECMO.
