Pediatric and neonatal extracorporeal life support: current state and continuing evolution

Abstract

The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.

Keywords: Extracorporeal life support (ECLS); Extracorporeal membrane oxygenation (ECMO); Neonatal; Pediatric; Respiratory failure.

Fig. 1

a Schematic of the artificial placenta with V–V ECLS configuration; b Photo of an extremely premature sheep supported by the V–V ECLS artificial placenta. Ao: aorta; DV: ductus venosus; IJV: internal jugular vein; IVC: inferior vena cava; RA: right atrium; SVC: superior vena cava. a Reproduced with permission from Church et al. [46] (License number 4930520731885). b Original unpublished image

Fig. 2

a In veno-arterial (V–A) cannulation, drainage is from the superior vena cava (SVC) and right atrium (RA) via the right internal jugular vein (IJ) and reinfusion is to the right carotid artery (CA); b In veno-venous (V–V) cannulation with two cannulae, drainage is from the SVC and RA via the right IJ and reinfusion is to the inferior vena cava (IVC); c In V–V cannulation with a double-lumen cannula, drainage is from the SVC and IVC and reinfusion is into the RA. Reproduced with permission from Frischer et al. [176] (License number 4924341211861)

Fig. 3

The University of Michigan Pediatric MLung. a Computer-aided design (CAD) drawing of pediatric MLung, top view. Arrows depict the blood flow pattern; b Top view of the pediatric MLung. Red lines depict the blood flow pattern. Solid yellow lines depict concentric gates. Key features of the MLung include: (1) Blood inlets; (2) outer fiber bundle; (3) inner fiber bundle; (4) blood outlet; c Pediatric MLung empty housing (left) and housing with fiber bundle installed (right); d. MLung in vivo immediately after cannulation and connection. Key features of the circuit include: (1) inlet cannula (from PA); (2) MLung; (3) outlet cannula (to LA); (4) sweep gas inlet; (5) gas outlet with suction tubing. b Reproduced with permission from Thompson et al. [132] (License number 4924370285770)

Fig. 4

Patient ambulating on a treadmill while on V–V ECLS. Reproduced with permission from Hayes et al. [25] (License number 4930510559332