Patient selection for neonatal extracorporeal membrane oxygenation: beyond severity of illness

Abstract

Objective: To explore how neonates with respiratory failure are selected for extracorporeal membrane oxygenation (ECMO) once severity of illness criteria are met, and to determine how conflicts between ECMO providers and parents over the initiation of ECMO are addressed.

Study design: A cross-sectional study was conducted using a data collection survey, which was sent to the directors of neonatal respiratory ECMO centers.

Result: The lowest birth weight and gestational age at which respondents would consider placing a neonate on ECMO were frequently below recommended thresholds. There was wide variability in respondents' willingness to place neonates on ECMO in the presence of conditions such as intraventricular hemorrhage and hypoxic ischemic encephalopathy. The number of respondents who would never seek to override parental refusal of ECMO was equal to the number who would always do so.

Conclusion: Significant variability exists in the selection criteria for neonatal ECMO and in how conflicts with parents over the provision of ECMO are resolved.

Figure 1

(a) Responses to the survey question, ‘What is the lowest gestational age that you would consider placing a neonate on ECMO?' Answer choices are identified with associated shading. Percentages of responses are shown in the pie-chart. (b) Responses to the survey question, ‘What is the lowest birth weight, assuming that the patient meets your minimum gestational age requirements, that you would consider placing a neonate on ECMO?' Answer choices are identified with associated shading. Percentages of responses are shown in the pie-chart.

Figure 2

Responses to the survey question, ‘Assuming a patient has failed conventional therapy, meets your criteria for ECMO, and has no other potential contraindications, how often would you offer ECMO if the following conditions were present?' Answer choices are ‘Never', ‘Rarely', ‘Sometimes', ‘Usually', or ‘Always'. Answer choices for each of four conditions are presented on the x axis, percentage of responses within each condition on the y axis.

Figure 3

Responses to the survey question, ‘How often would you seek to override parental refusal of ECMO for respiratory failure if you believe the neonate is likely to survive ECMO with a favorable neurodevelopmental outcome?' Answer choices are presented on the x axis, percentage of responses on the y axis.