Beating the Odds: Survival After Extracorporeal Membrane Oxygenation Decannulation Due to Poor Prognosis in Children—An Extracorporeal Life Support Organization Registry Study

Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for critically ill children. However, decisions regarding discontinuation due to poor prognosis remain ethically complex. While outcomes after successful weaning are well described, survival following decannulation for perceived futility is poorly understood. We conducted a retrospective cohort study using the Extracorporeal Life Support Organization (ELSO) registry, including pediatric ECMO runs from 2013 to 2023. Among 6,662 cases decannulated for poor prognosis, we identified patients who survived until hospital discharge. Patient characteristics, ECMO parameters, complications, and outcomes were compared between survivors and nonsurvivors. Of 6,662 cases, 18 patients (0.3%) survived to discharge. Baseline characteristics were similar between groups. Survivors more often had pulmonary indications (44% vs . 27%, p = 0.2) and significantly lower pre-ECMO lactate levels (median 2.7 vs . 6.2 mmol/L, p = 0.031). They also experienced fewer on-ECMO complications (median 1 vs . 2, p = 0.11) and longer ECMO duration (8 vs . 4 days, p = 0.07). Venoarterial support was less frequent among survivors (61% vs . 80%). Survival after ECMO decannulation for poor prognosis is rare but possible (1/370 cases). Lower pre-ECMO lactate levels and pulmonary indications may indicate potential for unexpected recovery, highlighting uncertainty in prognostication and the importance of individualized, multidisciplinary decision-making.