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ECMO in newborns and children
ECMO temporarily replaces the lungs (VV) or the lungs and heart (VA) to buy time for recovery; in newborns the decision is based mainly on the oxygenation index (OI), and the main contraindications are prematurity, low weight and intracranial haemorrhage.
Why it matters in the exam
In newborns the common indications are CDH, meconium aspiration, persistent pulmonary hypertension (PPHN) and sepsis. The oxygenation index (OI) is calculated as mean airway pressure times FiO2 times 100, divided by PaO2; an OI above 40 is an accepted indication for ECMO, and an OI between 25 and 40 calls for consideration and transfer to an ECMO centre. Accepted relative contraindications: gestational age below 34 weeks, weight below 2 kg, significant intracranial haemorrhage, a lethal anomaly or irreversible lung damage, and prolonged aggressive ventilation beyond 10–14 days.
In neonatal VA ECMO a cannula is placed in the right internal jugular vein (drainage) and the right common carotid artery (return), and the carotid is sometimes ligated; VA also supports the heart. VV ECMO uses a double-lumen cannula in the jugular vein and supports only oxygenation — the patient's heart must work. In adults and larger children on femoral VA, if the lungs do not oxygenate and the heart recovers, the deoxygenated blood ejected by the heart reaches the upper body ("harlequin", north–south difference); a venous return cannula is added (VVA) or the position is changed to improve oxygenation of the upper body and brain.
Oxygen delivery to tissues (DO2) is cardiac output times arterial oxygen content, and the content depends mainly on haemoglobin and saturation (1.34 times haemoglobin times saturation, plus a small dissolved part); so to improve DO2 haemoglobin or cardiac output is raised, and raising PaO2 beyond full saturation adds little. Anticoagulation (usually a heparin infusion, monitored by ACT or anti-Xa) is essential, so the main complications are bleeding — especially intracranial — and circuit clots. In CDH, ECMO is used for stabilisation, and repair is done on ECMO or after it.
Key points
- OI above 40 — indication for ECMO in a newborn.
- VA supports heart and lungs; VV only the lungs.
- Relative contraindications: below 34 weeks, below 2 kg, intracranial haemorrhage.
- Harlequin on femoral VA — VVA.
- Bleeding is the main complication.
Summary table
| Topic | VA ECMO | VV ECMO |
|---|---|---|
| Support | Heart and lungs | Lungs only |
| Neonatal cannulae | Right internal jugular vein and right common carotid artery | Double-lumen cannula in the jugular vein |
| When | Respiratory failure with cardiac failure, severe PPHN, CDH | Respiratory failure with a normal heart |
| Special complication | Carotid injury; systemic embolism | Recirculation reduces efficiency |
| Relative contraindications | Below 34 weeks, below 2 kg, intracranial haemorrhage | As for VA |
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Sources
- ELSO Guidelines for Neonatal Respiratory Failure, 2022 — Indications, contraindications and cannulation
- ELSO General Guidelines for all ECLS cases, 2017 — Physiology, anticoagulation and complications
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.