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[The present state of ECMO for newborn infants and children]
1Department of Anestesia, National Children's Hospital, Tokyo.
Insights
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers lung and cardiac support. However, excessive lung rest can cause heart damage in infants without shunts, necessitating careful patient selection and strategy.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiovascular Physiology
- Respiratory Support
Context:
- Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is a vital treatment for neonates and children with acute cardiorespiratory failure.
- Current V-A ECMO strategies may inadvertently cause myocardial hypoxic damage in specific patient populations, particularly those without a patent ductus arteriosus (PDA) or left-to-right shunt.
- Advancements in ECMO technology and adjunctive therapies are evolving treatment paradigms.
Purpose:
- To highlight the critical importance of accurately assessing pulmonary vascular resistance and cardiac contractility.
- To emphasize that these assessments should be independent of preload, afterload, and heart rate for optimal V-A ECMO management.
- To underscore the need for tailored ECMO selection, vascular access, and weaning strategies.
Summary:
- V-A ECMO provides both pulmonary and cardiac support but carries a risk of myocardial injury due to "lung rest" strategies in infants without shunts.
- Accurate estimation of pulmonary vascular resistance and cardiac contractility, independent of hemodynamic variables, is crucial for safe and effective V-A ECMO implementation.
- New ECMO circuit technologies and concurrent therapies influence patient management approaches.
Impact:
- Informing the selection of appropriate V-A ECMO candidates and optimizing treatment protocols.
- Reducing the incidence of myocardial hypoxic damage in vulnerable pediatric patients undergoing V-A ECMO.
- Guiding the development of personalized V-A ECMO strategies in severe cardiorespiratory failure.
Abstract:
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is considered to provide not only lung support but also cardiac assist to acute cardiac or pulmonary failure of the newborn infants and children. However, an excessive "LUNG REST" strategy may lead to myocardial hypoxic damage in patients without PDA or any left-to-right cardiac shunt. The estimation of pulmonary vascular resistance and cardiac contractility, which is independent of preload, afterload and heart rate, is very important for the selection of ECMO, vascular access and weaning strategy from ECMO. Introduction of new ECMO techniques including heparin-coated or FUT-175 infused circuit, ECMO into double-lumen venous cannulas, the other therapies, such as artificial surfactant therapy, high frequency oscillation or inhaled nitric oxide can affect our approaches toward patients with severe cardiorespiratory failure.