Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support for critically ill patients with severe cardio-respiratory failure, who are otherwise unresponsive to conventional intensive care therapies.
What is ECMO?
- The ECMO circuit provides temporary cardio-respiratory support to stabilise patients, and serves as a bridge to organ recovery, medical decision making, ventricular assist device implantation or transplantation.
- This life-saving intervention uses a simplified heart-lung machine, wherein the patient’s oxygen-poor blood is passed through an external circuit which removes carbon dioxide and enriches blood with oxygen, before it is returned to the patient via an artery or vein.
- The duration of ECMO support is determined by the patient’s medical condition and readiness to receive conventional treatment.
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Worldwide, the use of ECMO in neonatal and paediatric critical care settings is increasing. The Extracorporeal Life Support Organization (ELSO), the largest international registry of ECMO cases, reports that ECMO has been used to treat more than 81,000 neonatal and paediatric patients from 1990 to 20221. These patients present with a myriad of diseases including neonatal and paediatric cardiac and respiratory failure, and extracorporeal cardiopulmonary resuscitation (E-CPR).
Specialised ECMO programme for babies and children
The KKH Paediatric and Neonatal ECMO Programme supports newborns and children up to 18 years old. The first and largest of its kind locally, the programme has benefited more than 150 critically ill babies and children since its launch in 2012.
“ECMO was no ordinary machine – it was huge, it was loud and we could see his blood flowing through huge tubes from his tiny neck. When our son was on ECMO, we were torn between feeling helpless and feeling assured that ECMO was giving him a chance to recover.”
Click to read KKH patient Seshan’s story.
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The average number of ECMO runs in KK Women’s and Children’s Hospital (KKH) has increased steadily from 4.4 to 15 cases per year. It is also increasingly utilised in non-cardiac indications such as sepsis, respiratory failure and E-CPR. The most common conditions requiring ECMO at KKH include post-cardiotomy support, myocarditis and severe persistent pulmonary hypertension of the newborn.
ECMO was first instituted at KKH in 2002, for a child with post-cardiotomy syndrome, a condition where the patient had low cardiac output following heart surgery. In the decade that followed, it was initiated on an ad-hoc basis for patients with severe cardiac failure.
In 2011, KKH clinicians embarked on a Health Manpower Development Programme to established ECMO centres in North America, including Boston Children’s Hospital and The Hospital for Sick Children, Toronto, gaining proficiency and expertise to formally establish a dedicated programme at KKH.
A child on ECMO support at the KKH Children’s ICU
ECMO specialist nurse-led model of care
Key to the success of KKH’s ECMO programme is the establishment of a nurse-led, perfusionist-supported model of care, the only one of its kind in Singapore. In this paradigm shift, ECMO specialist nurses are the primary resource person in the neonatal and paediatric intensive care units (ICUs), providing continuous care of the ECMO circuit and coordinating care with multidisciplinary stakeholders.
“As a healthcare provider and mother of two, I am always extremely happy when a child’s condition improves. Witnessing the anxiety, fear and sadness that families experience in near-death situations, I share their joy when they finally see light at the end of the tunnel.”
Click to read ECMO specialist nurse Naw Myat Su Mon’s story.
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This was made possible through the development of a structured course comprising of didactic lectures, wet laboratory and simulation sessions followed by a clinical preceptorship to gain bedside skills.
A pioneer cohort of four ICU nurses was accredited as ECMO specialist nurses in 2012, doubling to eight in 2013. ECMO specialist nurses now provide 24-hour bedside coverage for patients, with the pool of trained specialists increasing steadily to 36 in 2022. This has enabled service expansion to match increasing clinical indications, whilst maintaining manpower and cost efficiency.
The ECMO specialist nurse-led model of care is unique to the KKH Paediatric and Neonatal ECMO Programme.
ECMO on-the-go
Transporting patients on ECMO is extremely high-risk. Working with the KKH Children’s Hospital Emergency Transport Service (CHETS), the KKH Paediatric and Neonatal ECMO Programme has successfully cannulated and safely transported critically ill children referred to KKH from other local medical facilities since 2014.
Together with CHETS, the programme team has streamlined ambulance services for patients on ECMO, equipped hospital ambulances with state-of-the-art mobile ECMO equipment and developed new workflows including transport timeout and equipment checklists.
KKH provides ECMO-enabled ambulance transport for critically ill neonates and children.
Adapting to evolving needs
To maintain high standards of care, regular ECMO simulation exercises and quarterly audit meetings are conducted to ensure team competency and improve processes. During the COVID-19 pandemic, a new workflow was developed in anticipation of infectious patients requiring ECMO. Team members were familiarised with a modified workflow involving personal protective equipment, isolation precautions and space constraints in the isolation ICU.
ECMO simulation exercises in the (A) Neonatal ICU (B) Children’s ICU, (C) Children’s Emergency and (D) a paediatric isolation ward
Helping patients to thrive
As we strive for excellence in care at KKH, ECMO patients up to eight years of age are offered follow-up for neurodevelopmental assessment with appropriate early intervention, to optimise their quality of life. The KKH Paediatric and Neonatal ECMO Programme team also closely tracks and reports patient- and team-related outcomes to the ELSO registry for international benchmarking.
The provision of ECMO to critically ill patients requires the commitment and dedication of a comprehensive, multidisciplinary team with a robust service delivery model. Behind every ECMO patient is a huge care team which includes ECMO specialist nurses, bedside ICU nurses, respiratory therapists, paediatric and neonatal intensivists, cardiologists, cardiothoracic surgeons, perfusionists, haematologists, anaesthetists as well as dieticians, physiotherapists, medical social workers and child life therapists.
More than a decade on, we celebrate the successes of our programme, one that we can be proud of and proves that patients are at the heart of all we do.
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Dr Anuradha P Menon, Consultant, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital
Following her training in general paediatrics and paediatric critical care in Singapore, Dr Anuradha underwent further specialist training fellowships in paediatric critical care and cardiac critical care at the Hospital for Sick Children in Toronto, Canada (SickKids).
Her areas of clinical expertise and interest include cardiac critical care, mechanical circulatory support and quality and safety in the ICU. She is actively involved in the growth of the paediatric ECMO and ventricular assist device (VAD) programmes at KKH.
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