**6. Considerations for using ECMO in asphyxiated newborns treated with hypothermia**

ECMO is an expensive and labor-intensive, life-sustaining modality. The ideal candidate for ECMO is a patient with a reversible disease condition for whom standard treatments have failed to reverse the disease process and for whom mortality risk is high. The most common contraindications for neonatal ECMO currently include a gestational age less than 34 weeks, weight of less than 2 kg, significant coagulopathy, significant intraventricular hemorrhage, and an underlying genetic condition with a poor prognosis [42]. Severe metabolic acidosis prior to ECMO also is considered a relative contraindication for ECMO, since this has been associated previously with higher mortality and brain injury [43]. However, the successful use of ECMO has been reported for a newborn with persistent pulmonary hypertension, presumed sepsis, and a pre-ECMO pH of less than 6.6 [44]. Thus, asphyxiated newborns treated with hypothermia—if they do not present with intraventricular hemorrhage or proven severe and irreversible brain injury at the time of cannulation—should be eligible for ECMO.

If started in an optimal timeframe, ECMO associated with hypothermia treatment may ensure adequate oxygenation, treat catecholamines-resistant hypotension, and minimize further brain injury in these newborns, without causing intracerebral hemorrhage if coagulopathy can be kept under control.
