ECMO in

Cardiac and
Respiratory
Support for
Children with
COVID-19
Jacqueline Ong
Paediatric Intensive Care Unit
National University Hospital
Singapore
Overview

• What do we know about COVID-19 in children?

• What about PIMS-TS/MIS-C?

• What is extra-corporeal membrane oxygenation (ECMO)?

• What are the indications for use in children with COVID-19?

• Important considerations for the use of ECMO

What do we know about COVID-19 in
children?
• Prevalence in children is low:
• 2.2% of a cohort of > 70000 patients from Wuhan, China < 19 years old (Wu and
McGoogan, 2020).

• 1.2% of 22512 cases in Italy in March 2020 (Livingstone and Bucher, 2020)
• In Australia, 1% of cases 0-10 years, 3% of cases 10-19 years as of April 2020
(COVID-19 National Incident Room Surveillance Team, 2020).

• Children often have very mild symptoms or are asymptomatic.

• Likely to get it from a household contact; unlikely to be the index case in a
household.
• Admission to an paediatric intensive care unit is rare.
• 1.2 - 8% of paediatric cases require intensive care.
• Majority have co-morbidities e.g. pre-existing cardiac, respiratory,
immunological, chromosomal diagnoses.
• Mortality is low.
• Use of ECMO is rare in most documented paediatric cohorts in the
US, UK, Europe, Australia
• Usually less than 1%.
 Centers for Disease
Control and Prevention
(CDC), USA
27 April 2020
Multi-system
Inflammatory
Syndrome in Children
(MIS-C) associated with
COVID-19

27 May 2020
Paediatric Inflammatory Multi-System
Syndrome temporally associated with SARS-
CoV-2 (PIMS-TS)
• Features of profound
systemic inflammation
• Gastrointestinal
symptoms prominent
• Myocardial dysfunction,
vasodilatory shock
Treatment for PIMTS-TS/MIS-C
78 patients from 23
PICUs from April 1 to
May 10, 2020

Anecdotally,
children who
require ECMO for
PIMS-TS appear to
recover quite
quickly.
Slide courtesy of KR Ramanathan, NUHS
What is ECMO?
What is ECMO?
• Extra-Corporeal Membrane Oxygenation
• A technique that provides mechanical cardiovascular and
pulmonary support.
• Analogous to cardiopulmonary bypass (CPB) during surgery.
• Used to support cardiovascular and respiratory function in
severe failure of either system.
• ECMO differs from CPB in that patients can be maintained for
days à weeks rather than hours.
Types of ECMO
• Veno-arterial ECMO (VA ECMO)
• Blood drained from a large central vein and returned to
the arterial circulation.
• Cardiac and respiratory support
• Veno-venous ECMO (VV ECMO)
• Blood drained from a large central vein and returned to
the venous circulation.
• Respiratory support.
Components
Neck
cannulation
for VA
ECMO
 Oxygenator

Centrifugal pump
Water bath
 Sweep gas &
Oxygen blender

Pump console
VV ECMO for
respiratory
support
Does ECMO work for COVID-19?
So far, only adult
data available
Patient selection AND timing of cannulation are critical to success.
 • Is this acute, reversible disease?
• Has the child been ventilated < 14 days prior to
General cannulation?
• Is there only single organ involvement or is
principles in there multi-organ failure?
ECMO patient • Is there evidence of profound hypoxia or has
the child required CPR?
selection • Are there irreversible disease states e.g.
advanced malignancy, severe neurological
injury, immunosuppression?
ECMO for respiratory support
• OI > 40 for 2 hours
• Barotrauma

ASAIO J, May 2020

ECMO for cardiac support
• Progressive cardiogenic shock
• Myocardial dysfunction as evidenced by rising lactate, falling SVO2,
poor urine output
• Rapidly rising inotropic requirements
• Ventricular arrhythmias
 • Young
• No significant co-morbidities
• Acute, reversible illness
“Ideal” ECMO • Single organ failure
patient • Unable to be kept alive despite less
invasive rescue strategies
• Decision to provide ECMO made before
extreme instability / prolonged hypoxia /
cardiac arrest
Extra considerations
with COVID-19
 Call centre Porters
Pharmacy
Blood bank
OT
Charge nurse RT
Perfusionist PICU
resident Intensivist
ECMO Surgeon
Nurse
Infection PPE
control
Slide courtesy of KR Ramanathan, NUHS
Successful ECMO requires a system of care – even
in peacetime

MacLaren, Fisher, Brodie, JAMA Feb 2020

ASAIO J, May 2020
 • When would you consider futility?
• 5-7 days of no cardiac improvement in function
• Harder to judge for lung recovery; evaluation on a
case by case basis recommended
Ethical • Resource allocation, especially in the context of
a pandemic
considerations • High risk of moral distress.
• Communication with family; reduced family
presence at bedside.
• Providing dignified end of life care.
In summary:
• Use of ECMO in children with COVID-19 is
rare.
• Successful ECMO is critically dependent
on patient selection and timing of
cannulation.
• Provision of an ECMO service requires a
complex system of care and should not be
something to be rushed into when all
resources are stretched during a
pandemic.
• Team training is vital – we want good and
safe ECMO runs for patients and staff!
Thank you!

@ongsoomay
@paccman_asia