Neonatal ECMO Patient Selection In Australia

Neonatal extracorporeal membrane oxygenation (ECMO) is a rescue therapy for newborns whose lungs or heart cannot provide adequate oxygen delivery, even with advanced ventilation and cardiovascular support. It can sustain gas exchange while an underlying, potentially reversible condition is treated, but the circuit is invasive, resource-intensive and associated with bleeding, clotting, infection and neurological complications.

Selecting an infant for ECMO therefore requires more than a critically low oxygen level. Teams must assess reversibility, gestational age, birthweight, neurological status, treatment response, comorbidities and the family’s goals. These decisions are especially significant in Australia, where specialist neonatal ECMO is concentrated in a small number of metropolitan tertiary hospitals and retrieval distances can be substantial.

What ECMO Offers Newborns

In venoarterial ECMO, blood is drained from the venous circulation, oxygenated outside the body and returned to the arterial system. This can support both the heart and lungs. Venovenous ECMO provides respiratory support while preserving native cardiac output, although its use depends on the infant’s size, anatomy and local expertise.

The therapy does not cure pulmonary hypertension, meconium aspiration, congenital diaphragmatic hernia or sepsis. Instead, it buys time for the lungs to recover, pulmonary vascular resistance to fall, infection to respond to treatment or a cardiac lesion to be stabilised. The ideal candidate has a serious but reversible illness and a reasonable prospect of meaningful survival after decannulation.

The thresholds used in practice vary by centre and diagnosis. Oxygenation index, blood gas trends, echocardiography, lactate, blood pressure and ventilation requirements are useful signals, yet no single number should determine eligibility. A neonatologist, paediatric intensivist, ECMO specialist, surgeon and retrieval team should interpret the whole clinical picture.

Assessing Reversible Respiratory Failure

Respiratory candidates commonly have persistent pulmonary hypertension of the newborn, severe meconium aspiration syndrome, pneumonia, sepsis-related lung injury or pulmonary hypoplasia. Before referral, clinicians usually optimise lung recruitment, ventilation, sedation, blood pressure, acid-base balance and pulmonary vasodilation where appropriate. Echocardiography helps distinguish primary lung disease from structural heart disease or severe right-to-left shunting.

A deteriorating infant may need ECMO when hypoxaemia remains profound despite maximal conventional care and the underlying disease still appears reversible. Repeated blood gases, rising lactate, worsening acidosis and increasing vasoactive support indicate loss of physiological reserve. Early discussion with an ECMO centre is valuable because transport, consent, imaging and cannulation planning take time.

Australian practice must account for geography. A baby in a regional hospital near Newcastle, Hobart or Darwin may require urgent transfer to a metropolitan service, often by specialised road or aircraft retrieval. Weather, crew availability and long distances can alter the practical window for intervention. Referral should occur before the infant becomes unstable during transport.

The FAOPS 2020 congress site reflects the region’s long-standing focus on perinatal and neonatal research, including the exchange of experience across Asian and Oceanian health systems. That regional perspective matters when evidence, staffing models and access to ECMO differ between major cities and smaller hospitals.

Cardiac Disease And Complex Comorbidity

Newborns with severe cardiac failure may be considered for VA-ECMO after surgery, during profound shock or while awaiting a definitive procedure. Selection depends on the cardiac anatomy, the likelihood of repair or palliation, ventricular recovery, neurological status and whether ECMO is being used as a bridge to a known next step. It is less defensible when there is no realistic surgical or transplant pathway.

Congenital diaphragmatic hernia requires particularly careful assessment. Severe pulmonary hypoplasia may coexist with pulmonary hypertension, and ECMO can support oxygenation while the lungs mature. However, liver position, intracranial findings, cardiac function and the severity of associated anomalies influence both technical feasibility and prognosis.

Sepsis, coagulopathy and kidney injury do not automatically rule out ECMO, but they can narrow the margin of safety. Teams consider whether organ dysfunction is likely to reverse and whether anticoagulation can be managed. Active uncontrolled bleeding, major irreversible brain injury, severe untreatable chromosomal or structural disease and prolonged cardiopulmonary arrest are often viewed as major contraindications.

Neurological assessment is central. Cranial ultrasound, amplitude-integrated EEG and, when feasible, MRI may identify haemorrhage, infarction or hypoxic-ischaemic injury. Findings must be interpreted in context, because an unstable infant may not yet have a complete neurological assessment when the ECMO decision is urgent.

Timing, Treatment Response And Eligibility

ECMO should follow a documented trial of appropriate intensive care, but waiting for complete collapse can make recovery less likely. Clinicians assess trends rather than relying on a single blood gas: oxygenation index, carbon dioxide clearance, lactate, urine output, blood pressure, echocardiographic function and the duration of high-pressure ventilation all contribute to timing.

Antenatal consultation can improve preparation when severe pulmonary hypoplasia, congenital diaphragmatic hernia or a major cardiac lesion is diagnosed before birth. Families can learn about delivery planning, possible intubation, transfer, surgery, ECMO complications and longer-term outcomes. This supports informed consent before an emergency develops.

Gestational age and birthweight are important because cannulation, vascular access, anticoagulation and neurological risk become more difficult in very small infants. They are not always absolute exclusions. Some Australian and international centres have experience with carefully selected low-weight neonates, but outcomes depend heavily on local case volume, equipment and expertise.

The local health system also shapes access. Australia’s public hospitals provide much neonatal critical care through state and territory services, while specialist capacity is concentrated in major centres such as Melbourne, Sydney, Brisbane, Perth and Adelaide. Medicare supports the broader public health system, but it does not remove the practical limits created by retrieval logistics, bed availability or the need for a highly trained ECMO team.

Shared Decisions And Ethical Practice

Parents should receive a clear explanation of the proposed benefit, realistic survival estimates, major complications and possible outcomes for neurodevelopment and quality of life. Communication should avoid presenting ECMO as a guaranteed rescue. It is a time-limited support strategy, and the team should explain what evidence would show recovery, treatment failure or the need to reconsider goals.

Consent may be difficult when the infant is deteriorating rapidly. Australian clinicians work within state and territory laws, hospital policies and professional guidance concerning parental responsibility and the child’s best interests. The Privacy Act 1988 and local health-record rules also influence how information is shared during retrieval, multidisciplinary review and cross-hospital consultation.

Ethical analysis should consider the burdens of cannulation, anticoagulation, surgery and prolonged intensive care alongside the likelihood of survival without severe disability. The family’s cultural values, preferred decision-makers and communication needs deserve attention. Interpreters and Aboriginal and Torres Strait Islander liaison services may be important, particularly when families are transferred far from home.

Neonatal care also includes preventive and supportive measures that affect outcomes around critical illness. Evidence discussions may cover nutrition, human milk, infection prevention and the use of probiotics in selected preterm infants; a relevant neonatal evidence discussion illustrates how broader intensive-care decisions require careful interpretation of benefits and risks.

Practical Selection Checklist

A reliable selection process brings together bedside data, specialist review and a plan for what happens if the infant improves or fails to respond. The following clinical features generally support urgent ECMO-centre consultation:

• Severe hypoxaemia, acidosis or shock despite optimised intensive care
• A reversible pulmonary or cardiac diagnosis
• Acceptable neurological findings or no evidence of established catastrophic injury
• A realistic pathway to recovery, surgery or another definitive treatment

Factors that commonly require heightened caution include:

• Extreme prematurity, very low birthweight or technically unsuitable vascular access
• Prolonged high-pressure ventilation with progressive multisystem failure
• Major intracranial haemorrhage, irreversible brain injury or uncontrolled bleeding
• An underlying condition with no meaningful treatment or recovery pathway

These lists support discussion rather than replace clinical judgement. A centre may accept an infant another service considers unsuitable because its equipment, staff experience and surgical options differ. Conversely, a candidate who appears eligible on paper may not benefit if transfer is unsafe or the disease has advanced beyond reversibility.

Coordinating Referral And Follow-Up

Referral pathways should be established before an emergency occurs. Regional maternity and neonatal units need direct contact details for the ECMO centre, clear escalation criteria and access to retrieval advice. Simulation training can reveal delays involving imaging, blood products, consent, transport equipment and communication between the referring and receiving teams.

Once an infant is placed on ECMO, selection decisions continue. The team monitors lung compliance, pulmonary pressures, cardiac function, lactate, renal output, bleeding, clot formation and neurological status. A trial of reduced circuit support can help determine whether the native organs are recovering. If recovery does not occur, the team must revisit the agreed goals rather than continuing treatment without a plausible endpoint.

After discharge, survivors require structured follow-up for hearing, vision, growth, motor development, language, cognition and psychosocial wellbeing. Families may face months of travel from rural or interstate locations, so telehealth, local paediatric services and coordinated developmental clinics are valuable. Australian households may also need help with accommodation, time away from work and the cost of repeated trips to a capital city.

For clinicians and families, the most useful next step is early consultation with the nearest neonatal ECMO centre whenever severe, potentially reversible respiratory or cardiac failure is emerging. A timely referral allows specialists to review eligibility, organise retrieval and discuss realistic options before the infant reaches a point where ECMO is technically possible but unlikely to help.