You may have heard of ECMO saving lives of aged people with failing organs, but the machine is also saving the lives of children in acute critical care.

ECMO baby
Friday, January 07, 2022 - 12:12

By Dr Rakshay Shetty

As a paediatric intensivist, my practice involves treating children who are seriously ill and need advanced care. Many of these children need respiratory or cardiac support, and there are thousands of children in India who die every year due to such illnesses. In many such cases, what defeats us is time – if we could keep the child alive for a few more days, then we may be able to treat the underlying illness better, and possibly save the life of the child.

In the past few years, one miracle machine of modern medicine has enabled us to do that, and it’s called ECMO. ECMO, which stands for Extracorporeal Membrane Oxygenation, is the most aggressive form of life support available. It pumps blood out of the body, gives oxygen using an artificial lung and returns it to the body, keeping a person alive for days, weeks or months, even when their heart or lungs don’t work.

Game-changer in critical care

The use of ECMO has skyrocketed in recent years, for it often saves people from the brink of death. At our practice in Rainbow Hospitals, it has been particularly game-changing because we have been able to save the lives of children whose lungs have been ravaged by the flu or whose heart has given up.

Though it can certainly save lives when used correctly for a right indication, there is a possibility that with its increasing availability, it might be used as a last-ditch attempt to buy more time for dying patients with poor chances of survival.

ECMO is not designed to be a destination, but a bridge to somewhere — recovery, transplantation or an implanted heart device. But when patients are too sick to reach those goals, ECMO can become a “bridge to nowhere,” leaving the patient in limbo, possibly even awake and alert, but with no chance of survival outside the intensive care unit. Medical teams and families can be fiercely divided over when to pull the plug.

ECMO is very expensive, mostly due to the labour involved: a person on ECMO cannot live outside the ICU and must be continuously monitored for complications such as blood clots, bleeding, infection and loss of blood to the limbs. Hence it is important to have a bit of basic knowledge about this modality.

Dr. Rakshay Shetty

Dr Rakshay Shetty, Pediatric Intensivist & General Pediatrician, Rainbow Children’s Hospital and Birthright by Rainbow Hospitals, Marathahalli, Bengaluru

ECMO needs a good team

In India, competition between hospitals is so intense that every hospital wants the ability to provide this level of care. However, there are still a lot of hospitals that don’t fully understand what it can do and how to use it.

Generally, many paediatric cardiac centres use ECMO in their post-operative ICU after cardiac surgery. This is called cardiac ECMO and essentially done to support the heart. This is the most commonly used mode and is done until heart recovery or heart transplant.

The outcome depends on the chances of underlying heart recovery since heart transplant is almost non-available for children. Usually there are uncorrected heart lesions which need to be repaired or the heart needs some time to recover from a prolonged operation. Hence it is preferable to get operated for heart diseases in hospitals with ECMO facility.

Use of ECMO for bad lung disease, called respiratory ECMO, is not very common. The outcome depends on the chances of the lung recovering. It can give fantastic results if used correctly, generally if the child has stayed on ventilator for less than 10 days and has normal immunity. However, expertise on management of ventilators and good ICU care are needed for these children to show a remarkable outcome. In our experience at Rainbow Children’s Hospital, ECMO can be life-saving if used wisely in flu illnesses where a child has significantly injured lung with air leaks.

The experience of using ECMO across the world for flu has shown good outcomes, but the same can’t be said about COVID pneumonia. Unfortunately with COVID, many other organs apart from lungs seem to be involved which determines the outcome.

Families need to be aware of this modality and consider this option early in children with very severe pneumonia when regular ventilator treatment doesn’t improve oxygen saturation. Allowing too much time on very high ventilator settings can be counterproductive. Hence, it is better to be in ICU with ECMO facility while caring for severe pneumonia.

When not used for correct indication, it can be an expensive way to die and become a very traumatic experience for the family. To ensure that outcomes are good with minimal complications, the experience of the unit performing the ECMO is critical. Generally, the team that performs ECMO would have a cardiac surgeon to place the cannula, perfusionists to manage the ECMO circuit and a good intensive care team to manage the ECMO, ventilator and the patient in general.

This article was published in association with Rainbow Children’s Hospital by Dr Rakshay Shetty, Pediatric Intensivist & General Pediatrician, Rainbow Children’s Hospital and Birthright by Rainbow Hospitals, Marathahalli, Bengaluru