Venoarterial extracorporeal membrane oxygenation for chemotherapy-induced neutropenic septic shock in children: a single-center experience

Background Venoarterial extracorporeal membrane oxygenation (VA ECMO) in pediatric septic shock patients remains controversial, particularly in children with neutropenia, because of concerns about bleeding, infection, and poor prognosis. Chemotherapy-induced neutropenia, however, is often transient and potentially reversible. Evidence about the feasibility of VA ECMO in this high-risk population remains insufficient. Methods We conducted a retrospective single-center study of pediatric patients with chemotherapy-induced neutropenic septic shock who required VA ECMO between March 2023 and December 2025. Patients were selected based on refractory septic shock, anticipated potential for hematologic recovery, and absence of uncontrolled malignancy or prior hematopoietic stem cell transplantation. Clinical characteristics, ECMO strategies, complications, and outcomes are reported. Results Four pediatric patients (median age, 13.0 years) underwent peripheral VA ECMO for refractory septic shock. Neutrophil recovery occurred before, during, or shortly after ECMO support in all cases. All patients were successfully weaned from ECMO after a median support duration of 5.0 days and survived to hospital discharge with intact neurologic outcomes. One patient, in whom placement of a distal perfusion catheter was attempted but was not technically feasible because of severe vasoconstriction and small-caliber vessels, developed severe limb ischemia that required amputation. No life-threatening hemorrhagic or neurologic complications were observed. Conclusion VA ECMO may be a viable rescue therapy for carefully selected pediatric patients with chemotherapy-induced neutropenic septic shock in whom hematologic recovery is anticipated. Strict patient selection, timely multidisciplinary decision-making, peripheral cannulation, and a restrictive anticoagulation strategy can contribute to favorable outcomes in this high-risk population.