Is age at initiation of extracorporeal life support associated with mortality and intraventricular hemorrhage in neonates with respiratory failure?

COVID-19-related coagulopathy is a known complication of SARS-CoV-2 infection and can lead to intracranial hemorrhage (ICH), one of the most feared complications of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence and etiology of ICH in patients with COVID-19 requiring ECMO. Patients at two academic medical centers with COVID-19 who required venovenous-ECMO support for acute respiratory distress syndrome (ARDS) were evaluated retrospectively. During the study period, 33 patients required ECMO support; 16 (48.5%) were discharged alive, 13 died (39.4%), and 4 (12.1%) had ongoing care. Eleven patients had ICH (33.3%). All ICH events occurred in patients who received intravenous anticoagulation. The ICH group had higher C-reactive protein (P = 0.04), procalcitonin levels (P = 0.02), and IL-6 levels (P = 0.05), lower blood pH before and after ECMO (P < 0.01), and higher activated partial thromboplastin times throughout the hospital stay (P < 0.0001). ICH-free survival was lower in COVID-19 patients than in patients on ECMO for ARDS caused by other viruses (49% vs. 79%, P = 0.02). In conclusion, patients with COVID-19 can be successfully bridged to recovery using ECMO but may suffer higher rates of ICH compared to those with other viral respiratory infections.

What is New in ECMO for COVID-19?

It has been suggested that venovenous (VV) extracorporeal life support (ECLS) confers a survival advantage over venoarterial (VA) ECLS. These results have been confounded by differences in patient populations. In this study, a matched pairs comparison of survival and complication rates in neonatal respiratory failure patients managed with VA or VV ECLS was performed. Retrospective matching of 643 VA and VV patient pairs from the Extracorporeal Life Support Organization Registry was performed. Pairs were matched by same year, same diagnosis, gestational age +/- 1 week, birth weight +/- 0.3 kg, and oxygenation index +/- 5. Further matching for hemodynamic status was possible for 272 pairs and included pre ECLS CPR, use of epinephrine, and arterial pH +/- 0.1. Statistical significance was defined for outcome and selected complication rates using McNemar's chi-square analysis with correction for multiple comparisons. A survival advantage for VV was significant when matching for respiratory failure (83.8% VA versus 91.5% VV), but was not significant when matching for hemodynamic failure (90.4% VA versus 94.5% VV). In the latter match, hemolysis (10.7% VA versus 23.5% VV) and cannula kinking (0.4% VA versus 10.6% VV) were more common with VV ECLS. The incidence of intracranial hemorrhage did not significantly differ between groups (6.3% VA versus 7.4% VV). Survival is not significantly greater with VV ECLS when patients are matched for degree of respiratory and hemodynamic failure. Hemolysis and cannula kinking are more common with VV ECLS. There is no identified difference in the incidence of intracranial hemorrhage.

Intracranial hemorrhage in premature neonates treated with extracorporeal membrane oxygenation correlates with conceptional age

Hybrid and parallel extracorporeal membrane oxygenation circuits

Identify the incidence and risk factors for development of acute, severe central nervous system (CNS) complications of pediatric extracorporeal life support (ECLS). Retrospective review of Extracorporeal Life Support Organization (ELSO) registry database. Pediatric intensive care units of 115 tertiary centers internationally. Pediatric patients, 1 month to 18 yrs of age, who had ECLS between the years 1981-2002. Data concerning 4,942 patients who underwent one run of ECLS were analyzed. Six hundred thirty-six patients (12.9%) developed acute, severe CNS complications. Patients who required ECLS during extracorporeal cardiopulmonary resuscitation (n = 161; 3.3%) were more likely to develop CNS complications (n = 42; 26.1%) than patients who did not have extracorporeal cardiopulmonary resuscitation (p < .001; odds ratio [OR], 2.48; 95% confidence interval [CI], 1.73-3.57). Stepwise logistic regression analysis of therapies patients received before initiation of ECLS showed that the use of a left ventricular assist device (p = .001; OR, 3.45; 95% CI, 1.64-7.22), bicarbonate (p < .001; OR, 1.61; 95% CI, 1.26-2.05), and vasopressor/inotropic medications (p = .035; OR, 1.22; 95% CI, 1.01-1.48) were significant independent predictors of development of CNS complications. Among patients who had pulmonary failure as an indication for ECLS, the CNS complication rate was significantly higher for those treated with venoarterial ECLS than those who had venovenous ECLS (13.5% vs. 5.7%; p < .001; OR, 0.43; 95% CI, 0.34-0.67). Multiple logistic regression analysis of the complications other than CNS complications associated with the use of ECLS showed that pH <7.20, creatinine concentration >3.0 mg/dL, use of inotropes, presence of myocardial stun, and requirement of cardiopulmonary resuscitation during ECLS independently predicted development of CNS complications. Patients who have metabolic acidosis, a bicarbonate or inotrope/vasopressor requirement, cardiopulmonary resuscitation, or a left ventricular assist device before initiation of ECLS are at greater risk for development of CNS complications. After initiation of ECLS, patients who develop renal failure or metabolic acidosis or undergo venoarterial ECLS should be closely monitored for development of CNS complications.

This study was conducted to determine the timing of intracranial hemorrhage (ICH) in patients on extracorporeal life support (ECLS) to improve the use of the head ultrasound in the detection of ICH. A review was conducted of all neonatal ECLS patients at the neonatal intensive care nursery at Kosair Children's Hospital in Louisville, Kentucky, from May, 1985 through November, 1994 to establish a study group of infants in whom an ICH developed while on ECLS. Thirty infants who had an ICH (excluding subarachnoid hemorrhage and infarction) on ECLS were included in the study. Data were collected that included patients demographics, age at initiation of ECLS, duration of ECLS, type of ECLS support (venoarterial or venovenous), oxygenation index and last arterial blood gas before ECLS, hours of ECLS before ICH, and grade of ICH. ICH occurred in 9.9% of the neonatal patients requiring ECLS. These included 8 infants with a Grade I bleed, 1 infant with a Grade II, 4 infants with a Grade III, and 17 infants with a Grade IV. Ten of the 30 patients had sepsis as their primary diagnosis, and these infants were more likely to have an ICH while on ECLS compared to nonseptic infants (p < 0.02). The Kaplan-Meier curve showed that 50% of ICHs occurred in the first 24 hours of ECLS, 75% by 48 hours, and that 85% of ICHs occurred within 72 hours of initiation of bypass. There was no difference in timing of ICH in the septic infants compared to the nonseptic infants. The late occurring bleeds (> 72 hours) were all associated with significant neurologic changes or with multiorgan failure. It is concluded that daily head ultrasounds should be performed during the first 3 days of ECLS because most ICHs (85%) occur in the first 72 hours of cardiopulmonary bypass. In this era of cost containment, subsequent head ultrasounds should be obtained with changes in the infant's neurologic status or with the development of multiorgan failure.

Idiopathic inflammatory myopathies (IIM), including dermatomyositis (DM) and polymyositis (PM), have a reported mortality rate of 28.6% despite immunosuppressive therapies.1 IIMs are complicated by interstitial lung disease (ILD) in 41% of cases.2 ILD can be chronic or rapidly progressive (RP-ILD) and worsens outcomes with excess mortality of 40%.3 Intubated patients with IIM-ILD have mortality rates up to 90%, decompensating despite mechanical ventilation.4 Extracorporeal membrane oxygenation (ECMO) is a supportive therapy for cardiorespiratory failure refractory to invasive mechanical ventilation or vasoactive support. ECMO is initiated as a bridge to recovery (BTR) or bridge to transplantation (BTT). Literature regarding ECMO in IIM-ILD is sparse, but there have been successful outcomes with ECMO as both BTR and BTT, prompting our investigation of ECMO in patients with IIM-ILD.3 Methods This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry from 2000 to 2020 including patients with DM (which included dermatopolymyositis and juvenile DM), and PM, who was supported on ECMO. The Baylor College of Medicine IRB waived the need for consent given the use of de-identified data. Our primary outcome was survival to hospital discharge. For analysis, categorical and dichotomous variables were expressed as exact numbers with percentages, and continuous variables were expressed as median with interquartile ranges. Pearson's χ2 and Fisher's exact test were used for categorical variables. Continuous variables were analyzed using the Student's t-test or the Wilcoxon-Mann-Whitney U test. Significant associations were reported in odds ratios with 95% confidence intervals. The data were analyzed using JMP software (version 16, SAS, Cary, NC). Results We identified 118 patients with IIM-ILD supported on ECMO (Table 1). There were 102 adults and 16 pediatric patients (≤18 years old) with a survival of 32% in adults and 31% in the pediatric population. The median age was 44 [31.8–52.4] years old. Most patients were supported on ECMO for respiratory indications (92%). The median length of pre-ECMO mechanical ventilation was 42 [12.0–167.5] hours. The median ECMO duration was 456 [204.5–836.0] hours. Overall, 38 (32%) of patients survived to discharge. Table 1. - Characteristics of Patients With IIM-ILD Supported on ECMO All patientsN = 118 ECMO as BTRN = 93 (79%) ECMO as BTTN = 25 (21%) Survival 38 (32%) 27 (29%) 11 (44%) Lung transplant received 10 (9%) 4 (4%) 6 (24%) Characteristics Age (years) 44.1 [31.8–52.4] 42.8 [29.7–52.6] 47.4 [36.7–51.6] Weight (kg) n = 113 75.0 [58.0–88.5] 76.0 [56.6–91.0] 69.0 [59.4–86.3] Female n = 116 68 (59%) 54 (59%) 14 (56%) Pediatric 16 (14%) 15 (16%) 1 (4%) Race/ethnicity White 48 (41%) 35 (38%) 13 (52%) Black 24 (20%) 21 (23%) 3 (12%) Asian 22 (19%) 20 (22%) 2 (8%) Hispanic 9 (8%) 7 (8%) 2 (8%) Inflammatory myopathy† Dermatomyositis 92 (78%) 75 (81%) 17 (68%) Polymyositis 28 (24%) 75 (81%) 15 (60%) Comorbidities Prior lung transplant 4 (3%) 4 (4%) 0 Pneumonia 26 (22%) 24 (26%) 2 (8%) Pulmonary fibrosis 17 (14%) 9 (10%) 8 (32%)* Pneumothorax or air leak 14 (12%) 13 (14%) 1 (4%) Pulmonary hypertension 5 (4%) 3 (3%) 2 (8%) Pulmonary embolism 4 (3%) 4 (4%) 0 Acute kidney injury 18 (15%) 16 (17%) 2 (8%) CKD or ESRD‡ 2 (2%) 2 (2%) 0 Opportunistic infections§ 20 (17%) 19 (20%) 1 (4%) Pre-ECMO cardiac arrest 6 (5%) 5 (5%) 1 (4%) Pre-ECMO ventilator support Extubated on ECMO 5 (4%) 0 5 (20%)* MV before ECMO (hours) n = 105 42.0 [12.0–167.5] 67.0 [14.5–173.0] 17.5 [1.5–60.0]* PEEPn = 82 10.0 [8.0–14.0] 10.0 [8.0–14.0] 12.0 [7.3–17.5] Mean airway pressure n = 61 20.0 [17.0–27.5] 20.0 [17.0–27.5] 23.5 [15.2–29.3] Fraction of inspired oxygen n = 98 1.0 [0.81–1.0] 1.0 [0.8–1.0] 1.0 [0.84–1.0] Pre-ECMO support Vasoactive 54 (46%) 45 (48%) 9 (36%) Pulmonary vasodilators 26 (22%) 24 (26%) 2 (8%) Neuromuscular blockade 53 (45%) 49 (53%) 4 (16%)* Proning 11 (9%) 11 (12%) 0 Steroids 37 (31%) 32 (34%) 5 (20%) ECMO ECMO mode VV 98 (83%) 80 (86%) 18 (72%) VA 20 (17%) 13 (14%) 7 (28%) ECMO indication Respiratory 109 (92%) 86 (93%) 23 (92%) Cardiac 6 (5%) 5 (5%) 1 (4%) ECPR 3 (3%) 2 (2%) 1 (4%) ECMO hours n = 117 456.0 [204.5–836.0] 460.0 [227.5–836.0] 321.0 [156.5–831.8] ECMO cannulation technique Peripheral 117 (99%) 92 (99%) 25 (100%) Dual lumen cannula 34 (29%) 26 (28%) 8 (32%) Procedures¶ Lung transplantation 10 (8%) 4 (4%) 6 (24%)* Renal replacement therapy 8 (7%) 8 (9%) 0 Plasmapheresis 10 (8%) 8 (9%) 2 (8%) Tracheostomy 23 (19%) 19 (20%) 4 (16%) Thoracostomy (±chest tube) 19 (16%) 18 (19%) 1 (4%) ECMO-related complications Cardiovascular 42 (36%) 34 (36%) 8 (32%) Hemorrhagic 44 (37%) 35 (38%) 9 (36%) Infectious 22 (19%) 16 (17%) 6 (24%) Limb 2 (2%) 1 (1%) 1 (4%) Mechanical 41 (35%) 33 (35%) 8 (32%) Metabolic 23 (19%) 19 (20%) 4 (16%) Neurologic 14 (12%) 13 (14%) 1 (4%) Pulmonary 12 (10%) 11 (12%) 1 (4%) Renal 40 (34%) 30 (32%) 10 (40%) Co-infections∥ Viral 4 (3%) 3 (3%) 1 (4%) Bacterial 40 (34%) 32 (34%) 8 (32%) Fungal 19 (16%) 15 (16%) 4 (16%) *Statistically significant finding, P < 0.05.†Two patients were diagnosed both with dermatomyositis and polymyositis.Number of patients with data in each category is indicated with (n = x) if there is missing data.‡CKD or ESRD is determined by the following international classification of diseases codes: 585, N18.§Opportunistic pulmonary infection includes: aspergillosis, cytomegalovirus, invasive pulmonary aspergillosis, mucormycosis, mycobacterium, pneumocystis jiroveci pneumonia, pulmonary candidiasis, pulmonary mucormycosis, tuberculosis.¶Procedure occurred before or while on ECMO, unless otherwise indicated.∥Infections were sustained before or while on ECMO.BTR, bridge to recovery; BTT, bridge to transplant; CKD, chronic kidney disease; ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation; ESRD, end-stage renal disease; IIM-ILD, idiopathic inflammatory myopathy interstitial lung disease; MV, mechanical ventilation; PEEP, positive end-expiratory pressure; VV, veno-venous; VA, veno-arterial. In 25 patients (21%), ECMO was initiated as BTT (Table 1). Ninety-three patients (79%) were placed on ECMO as BTR, including 15 (94%) pediatric patients. Eleven (44%) BTT patients survived to discharge, compared with 27 (29%) BTR patients. Pulmonary fibrosis was more prevalent in the BTT population (32% vs. 10%, OR 4.4 [CI, 1.48–13.01]). BTT patients were less likely to be paralyzed (16% vs. 53%, OR 0.17 [CI, 0.05–0.54]), had shorter mechanical ventilation (17.5 vs. 67 hours, p = 0.0228), and were more likely to be extubated on ECMO (20% vs. 0%, OR 50.17 [CI, 2.67–943.63]). Ten patients (8%) underwent lung transplantation (Table 2). Six of the transplanted patients were initially supported as BTT and 4 as BTR. Survival in the 10 patients who received transplantation was 80%, compared with 30 patients (28%) who were not transplanted (OR 10.4 [CI, 2.09–51.81]). Transplant recipients had more pulmonary fibrosis (50% vs. 11%, OR 8.0 [CI, 2.02–31.71]), were more likely to be extubated on ECMO (30% vs. 2%, OR 22.71 [CI, 3.25–158.99]), and had less pre-ECMO mechanical ventilation (1 vs. 52.3 hours, p = 0.02). No transplanted patients received steroids. There were no significant differences in ECMO-related complications between patients who received transplants and those who did not. Table 2. - IIM-ILD Patients Supported on ECMO Who Received Lung Transplants Compared With Those Who did not Lung Transplant RecipientN = 10 (8%) No TransplantN = 108 (92%) Survival 8 (80%) 30 (28%)* Characteristics Age (years) 42.5 [35.5–53.3] 44.6 [31.6–52.5] Weight (kg)n = 113 65.1 [55.0–76.5] 75.5 [58.0–90.0] Female n = 116 4 (40%) 64 (60%) Pediatric 1 (10%) 15 (14%) Race/ethnicity White 6 (60%) 42 (39%) Black 1 (10%) 23 (21%) Asian 2 (20%) 20 (19%) Hispanic 1 (10%) 8 (7%) Inflammatory myopathy† Dermatomyositis 9 (90%) 83 (77%) Polymyositis 2 (20%) 26 (24%) Comorbidities Prior lung transplant 2 (20%) 2 (92%)* Pneumonia 1 (10%) 25 (23%) Pulmonary fibrosis 5 (50%) 12 (11%)* Pneumothorax or air leak 1 (10%) 13 (12%) Pulmonary hypertension 2 (20%) 3 (3%) Pulmonary embolism 1 (10%) 3 (3%) Acute kidney injury 2 (20%) 16 (15%) CKD or ESRD‡ 0 2 (2%) Opportunistic infections§ 0 20 (19%) Pre-ECMO cardiac arrest 0 6 (6%) Pre-ECMO ventilator support Extubated on ECMO 3 (30%) 2 (2%)* MV before ECMO (hours)n = 105 1.0 [0–93.5] 52.5 [13.3–170.0]* PEEPn = 82 7.5 [3.3–9.5] 11.0 [8.0–14.3] Mean airway pressure n = 61 14.0 [10.0–30.0] 20.5 [17.0–27.3] Fraction of inspired oxygen n = 98 0.9 [0.6–1.0] 1.0 [0.9–1.0] Pre-ECMO support Vasoactive 3 (30%) 51 (47%) Pulmonary vasodilators 1 (10%) 25 (23%) Neuromuscular blockade 3 (30%) 50 (46%) Proning 0 11 (10%) Steroids 0 37 (34%)* ECMO ECMO mode VV 9 (90%) 89 (82%) VA 1 (10%) 19 (18%) ECMO indication Respiratory 10 (100%) 99 (92%) Cardiac 0 6 (6%) ECPR 0 3 (3%) ECMO as BTT 6 (60%) 19 (18%)* ECMO as BTR 4 (40%) 89 (82%)* ECMO hours n = 117 452.0 [175.5–774.3] 456.0 [214.0–836.0] ECMO cannulation technique Peripheral 10 (100%) 107 (99%) Dual lumen cannula 8 (80%) 26 (24%)* Procedures¶ Lung transplantation 10 (100%) 0 Renal replacement therapy 0 8 (7%) Plasmapheresis 1 (10%) 9 (8%) Tracheostomy 1 (10%) 22 (20%) Thoracostomy (±chest tube) 2 (20%) 17 (16%) ECMO-related complications Cardiovascular 3 (30%) 39 (36%) Hemorrhagic 4 (40%) 40 (37%) Infectious 3 (30%) 19 (18%) Limb 1 (10%) 1 (1%) Mechanical 3 (30%) 38 (35%) Metabolic 3 (30%) 20 (19%) Neurologic 1 (10%) 13 (12%) Pulmonary 0 12 (11%) Renal 3 (30%) 37 (34%) Co-infections∥ Viral 0 4 (4%) Bacterial 3 (30%) 37 (34%) Fungal 1 (10%) 18 (17%) *Statistically significant finding, p < 0.05.†Two patients diagnosed both with dermatomyositis and polymyositis.Number of patients with data in each category is indicated with (n = x) if there is missing data.‡CKD or ESRD determined by the following international classification of diseases codes: 585, N18.§Opportunistic pulmonary infection includes: aspergillosis, cytomegalovirus, invasive pulmonary aspergillosis, mucormycosis, mycobacterium, pneumocystis jiroveci pneumonia, pulmonary candidiasis, pulmonary mucormycosis, tuberculosis.¶Procedure occurred before or while on ECMO, unless otherwise indicated.∥Infections were sustained before or while on ECMO.BTR, bridge to recovery; BTT, bridge to transplant; CKD, chronic kidney disease; ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation; ESRD, end-stage renal disease; IIM-ILD, idiopathic inflammatory myopathy interstitial lung disease; MV, mechanical ventilation; PEEP, positive end-expiratory pressure; VV, veno-venous; VA, veno-arterial. Discussion We aimed to investigate the utility of ECMO in IIM-ILD. Overall, survival is poor in this population. Patients with IIM-ILD supported on ECMO as BTT had improved survival compared with those placed on ECMO as BTR. Patients with IIM-ILD who receive transplants have even higher survival and had less mechanical ventilation, reinforcing the use of awake ECMO in the pretransplant population. The BTR patients in our study had poor survival, as previously demonstrated.4 In the literature, ECMO as BTR has been beneficial for RP-ILD with early ECMO use.5 ECMO as BTR may be more suitable for RP-ILD because acutely ill lung parenchyma may be more responsive to pharmacotherapies than in chronic ILD, although further investigation is needed. Similar to Trudzinski et al, survival in our study improved with ECMO as BTT.4 However, survival in this population is still lower than patients supported as BTT for all-cause lung transplantation.6 Pulmonary fibrosis was common in our BTT group, indicating these patients may have had end-stage lung disease and were previously listed for transplant before offering ECMO support. In addition, transplanted patients did not receive steroids, had no opportunistic infections, and had decreased ventilatory times. Avoidance of steroids may reflect steroid-refractory disease or an effort to minimize steroid side effects pretransplant, including opportunistic infections and poor wound healing.7 ECMO also allowed for less mechanical ventilation, which is pivotal as pretransplant mechanical ventilation is an independent risk factor for post-transplant mortality.8 When compared with the BTR group, the BTT group had fewer ventilation hours and decreased neuromuscular blockade. The BTT group was also more likely to be extubated while on ECMO, known as awake ECMO.9 Proposed benefits of awake ECMO include decreased ventilator-induced lung injury, decreased sedation, and increased mobility pretransplant.9,10 One study demonstrated 80% 6 months survival for pretransplant patients supported with awake ECMO compared with 50% survival in mechanically ventilated patients.10 Awake ECMO is promising for improving transplant outcomes. Our study used ELSO registry data, which lacks the granularity to distinguish between RP-ILD and chronic ILD. Clinically relevant laboratory data is limited and amyopathic DM, a severe form of RP-ILD, cannot be identified in the registry. The ELSO registry does not report non-steroidal immunotherapies or detail the specific intensive care management these patients received, which likely contributed to the improved survival of the BTT patients. Lastly, our results may be impacted by the rarity of IIM-ILD and even rarer use of ECMO in this population. Conclusions Patients with IIM-ILD supported with ECMO have high mortality. Patients supported on ECMO as BTT have improved survival, and outcomes improve further with successful lung transplantation. Further studies are needed to better elucidate ECMO candidacy and the impact of specific treatment strategies in patients with IIM-ILD supported on ECMO.

Acute brain injury risk prediction models in venoarterial extracorporeal membrane oxygenation patients with tree-based machine learning: An Extracorporeal Life Support Organization Registry analysis

Predictors of intracranial hemorrhage during neonatal extracorporeal membrane oxygenation

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Every Week Matters

The efficacy of extracorporeal life support in premature and low birth weight newborns

Essential Topics in the Management of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Acute Respiratory Distress Syndrome

To evaluate the relationship between duration of mechanical ventilation before the initiation of extracorporeal life support and the survival rate in children with respiratory failure. Extracorporeal life support has been used as a rescue therapy for >30 yrs in children with severe respiratory failure. Previous studies suggest patients who received >7-10 days of mechanical ventilation were not acceptable extracorporeal life support candidates as a result of irreversible lung damage. A retrospective review encompassing the past 10 yrs of the International Extracorporeal Life Support Organization Registry (January 1, 1999, to December 31, 2008). Extracorporeal Life Support Organization Registry database. A total of 1325 children (≥ 30 days and ≤ 18 yrs) met inclusion criteria. None. The following pre-extracorporeal life support variables were identified as independently and significantly related to the chance of survival: 1) >14 days of ventilation vs. 0-7 days was adverse (odds ratio, 0.32; p < .001); 2) the presence of a cardiac arrest was adverse (odds ratio, 0.56; p = .001); 3) pH per 0.1-unit increase was protective (odds ratio, 1.15; p < .001); 4) oxygenation index, per 10-unit increase was adverse (odds ratio, 0.95; p = .002); and 5) any diagnosis other than sepsis was related to a more favorable outcome. Patients requiring >7-10 or >10-14 days of pre-extracorporeal life support ventilation did not have a statistically significant decrease in survival as compared with patients who received 0-7 days. There was a clear relationship between the number of mechanical ventilation days before the initiation of extracorporeal life support and survival. However; there was no statistically significant decrease in survival until >14 days of pre-extracorporeal life support ventilation was reached regardless of underlying diagnosis. We found no evidence to suggest that prolonged mechanical ventilation should be considered as a contraindication to extracorporeal life support in children with respiratory failure before 14 days.