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Kim H, Yang JH, Cho YH, Jun TG, Sung K, Han W. Outcomes of Extracorporeal Membrane Oxygenation in Children: An 11-Year Single-Center Experience in Korea. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:317-325. [PMID: 29124022 PMCID: PMC5628958 DOI: 10.5090/kjtcs.2017.50.5.317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 12/05/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has become an important treatment modality in pediatric patients with cardiopulmonary failure, but few studies have been conducted in Korea. Methods We conducted a retrospective review of pediatric patients younger than 18 years who were placed on ECMO between January 2004 and December 2014 at Samsung Medical Center. Results We identified 116 children on ECMO support. The overall rate of successful weaning was 51.7%, and the survival to discharge rate was 37.1%. There were 39, 61, and 16 patients on ECMO for respiratory, cardiac, and extracorporeal cardiopulmonary resuscitation, respectively. The weaning rate in each group was 48.7%, 55.7%, and 43.8%, respectively. The survival rate was 43.6%, 36.1%, and 25.0%, respectively. Sixteen patients on ECMO had functional single ventricle physiology; in this group, the weaning rate was 43.8% and the survival rate was 31.3%. Ten patients were on ECMO as a bridge to transplantation (8 for heart and 2 for lung). In patients with heart transplantation, the rate of survival to transplantation was 50.0%, and the overall rate of survival to discharge was 37.5%. Conclusion An increasing trend in pediatric ECMO utilization was observed. The outcomes were favorable considering the early experiences that were included in this study and the limited supply of specialized equipment for pediatric patients.
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Affiliation(s)
- Hongsun Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Tae-Gook Jun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Woosik Han
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Dalton HJ, Reeder R, Garcia-Filion P, Holubkov R, Berg RA, Zuppa A, Moler FW, Shanley T, Pollack MM, Newth C, Berger J, Wessel D, Carcillo J, Bell M, Heidemann S, Meert KL, Harrison R, Doctor A, Tamburro RF, Dean JM, Jenkins T, Nicholson C. Factors Associated with Bleeding and Thrombosis in Children Receiving Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2017; 196:762-771. [PMID: 28328243 DOI: 10.1164/rccm.201609-1945oc] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. OBJECTIVES (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. METHODS This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. MEASUREMENTS AND MAIN RESULTS ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. CONCLUSIONS The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.
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Affiliation(s)
- Heidi J Dalton
- 1 Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona
| | - Ron Reeder
- 2 Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Richard Holubkov
- 2 Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Robert A Berg
- 3 Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- 3 Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Frank W Moler
- 4 Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Thomas Shanley
- 4 Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Murray M Pollack
- 1 Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona
| | - Christopher Newth
- 5 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, Los Angeles, California
| | - John Berger
- 6 Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - David Wessel
- 6 Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Joseph Carcillo
- 7 Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Bell
- 7 Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sabrina Heidemann
- 8 Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Kathleen L Meert
- 8 Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Richard Harrison
- 9 Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, California
| | - Allan Doctor
- 10 Department of Pediatrics, Washington University, St. Louis, Missouri; and
| | - Robert F Tamburro
- 11 Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - J Michael Dean
- 2 Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Tammara Jenkins
- 11 Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Carol Nicholson
- 11 Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Jean S, Chardot C, Oualha M, Capito C, Bustarret O, Pouard P, Renolleau S, Lacaille F, Dupic L. Extracorporeal Membrane Oxygenation Can Save Lives in Children With Heart or Lung Failure After Liver Transplantation. Artif Organs 2017; 41:862-865. [DOI: 10.1111/aor.12975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/20/2017] [Accepted: 04/26/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Sandrine Jean
- Pediatric Intensive Care Unit; Hôpital Armand-Trousseau; Paris France
| | - Christophe Chardot
- Department of Surgery; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Carmen Capito
- Department of Surgery; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Olivier Bustarret
- Pediatric Intensive Care Unit; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Philippe Pouard
- Cardiac Surgery Intensive Care; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Florence Lacaille
- Department of Gastroenterology, Hepatology and Nutrition; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
| | - Laurent Dupic
- Pediatric Intensive Care Unit; Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France; France
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Okan Y, Sertac H, Erkut O, Taner K, Selen OI, Firat AH, Nihat C, Pelin A, Halime E, Alper G. Initial Clinical Experiences With Novel Diagonal ECLS System in Pediatric Cardiac Patients. Artif Organs 2017; 41:717-726. [DOI: 10.1111/aor.12977] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/03/2017] [Accepted: 05/10/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Yildiz Okan
- Department of Pediatric Cardiovascular Surgery; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Haydin Sertac
- Department of Pediatric Cardiovascular Surgery; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Ozturk Erkut
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Kasar Taner
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Onan I. Selen
- Department of Pediatric Cardiovascular Surgery; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Altin H. Firat
- Department of Pediatric Cardiovascular Surgery; Siyami Ersek Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Cine Nihat
- Department of Pediatric Cardiovascular Surgery; Kartal Koşuyolu Yüksek İhtisas Education and Research Hospital; Istanbul Turkey
| | - Ayyildiz Pelin
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Erkan Halime
- Pediatric Perfusion; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Guzeltas Alper
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
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Rilinger JF, Smith CM, deRegnier RAO, Goldstein JL, Mills MG, Reynolds M, Backer CL, Burrowes DM, Mehta P, Piantino J, Wainwright MS. Transcranial Doppler Identification of Neurologic Injury during Pediatric Extracorporeal Membrane Oxygenation Therapy. J Stroke Cerebrovasc Dis 2017; 26:2336-2345. [PMID: 28583819 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 04/07/2017] [Accepted: 05/17/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND We used transcranial Doppler to examine changes in cerebral blood flow velocity in children treated with extracorporeal membrane oxygenation. We examined the association between those changes and radiologic, electroencephalographic, and clinical evidence of neurologic injury. METHODS This was a retrospective review and prospective observational study of patients 18 years old and younger at a single university children's hospital. Transcranial Doppler studies were obtained every other day during the first 7 days of extracorporeal membrane oxygenation, and 1 additional study following decannulation, in conjunction with serial neurologic examinations, brain imaging, and 6- to 12-month follow-up. RESULTS The study included 27 patients, the majority (26) receiving veno-arterial extracorporeal membrane oxygenation. Transcranial Doppler velocities during extracorporeal membrane oxygenation were significantly lower than published values for age-matched healthy and critically ill children across different cerebral arteries. Neonates younger than 10 days had higher velocities than expected. Blood flow velocity increased after extracorporeal membrane oxygenation decannulation and was comparable with age-matched critically ill children. There was no significant association between velocity measurements of individual arteries and acute neurologic injury as defined by either abnormal neurologic examination, seizures during admission, or poor pediatric cerebral performance category. However, case analysis identified several patients with regional and global increases in velocities that corresponded to neurologic injury including stroke and seizures. CONCLUSIONS Cerebral blood flow velocities during extracorporeal membrane oxygenation deviate from age-specific normal values in all major cerebral vessels and across different age groups. Global or regional elevations and asymmetries in flow velocity may suggest impending neurologic injury.
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Affiliation(s)
- Jay F Rilinger
- Department of Pediatrics, Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig M Smith
- Department of Pediatrics, Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raye Ann O deRegnier
- Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joshua L Goldstein
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michele G Mills
- Department of Pediatrics, Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marleta Reynolds
- Divisions of General Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carl L Backer
- Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Delilah M Burrowes
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Priya Mehta
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juan Piantino
- Section in Child Neurology, Oregon Health and Science University, Portland, Oregon
| | - Mark S Wainwright
- Department of Pediatrics, Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Sánchez Pérez R, Rey-Lois J, Polo-López L, González-Rocafort Á, Builes-Cardona LM, Uceda-Galiano A, Labrandero-de Lera C, Marín-Huarte N, Sanabria-Carretero P, Verdú-Sánchez C, Menéndez-Suso JJ, Villar-Sánchez-Real MA, Segura-Escobar J, Aroca Peinado Á. ¿Es necesario disponer de ECMO para reparar cardiopatías congénitas de complejidad elevada? Nuestra experiencia en los últimos 6 años. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) remains a promising treatment for pediatric patients in cardiac arrest unresponsive to traditional cardiopulmonary resuscitation. With venoarterial extracorporeal support, blood is drained from the right atrium, oxygenated through the extracorporeal circuit, and transfused back to the body, bypassing the heart and lungs. The use of artificial oxygenation and perfusion thus provides the body a period of hemodynamic stability, while allowing resolution of underlying disease processes. Survival rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation (CPR), although neurological outcomes require further investigation. The impact of duration of CPR and length of treatment with extracorporeal membrane oxygenation vary in published reports. Furthermore, current guidelines for the initiation and use of ECPR are limited and may lead to confusion about appropriate use of this support. Many ethical concerns arise with this advanced form of life support. More often than not, the dilemma is not whether to withhold ECPR, but rather when to withdraw it. Although clinicians must decide if ECPR is appropriate and when further intervention is futile, the ultimate burden of choice is left to the patient's caregivers. Offering support and guidance to the patient's family as well as the patient is essential.
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Affiliation(s)
- Jennie Ryan
- Jennie Ryan in a nurse practitioner in the intensive care unit at Nemours Cardiac Center. She is also a per diem faculty member in the Helene Fuld Pavillion Simulation Lab at the University of Pennsylvania, School of Nursing, in Philadelphia.
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58
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Cashen K, Hollis TK, Delius RE, Meert KL. Extracorporeal membrane oxygenation for pediatric cardiac failure: Review with a focus on unique subgroups. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Chandler HK, Kirsch R. Management of the Low Cardiac Output Syndrome Following Surgery for Congenital Heart Disease. Curr Cardiol Rev 2016; 12:107-11. [PMID: 26585039 PMCID: PMC4861938 DOI: 10.2174/1573403x12666151119164647] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/15/2015] [Indexed: 12/16/2022] Open
Abstract
The purpose of this review is to discuss the management of the low cardiac output syndrome (LCOS) following surgery for congenital heart disease. The LCOS is a well-recognized, frequent post-operative complication with an accepted collection of hemodynamic and physiologic aberrations. Approximately 25% of children experience a decrease in cardiac index of less than 2 L/min/m2 within 6-18 hours after cardiac surgery. Post-operative strategies that may be used to manage patients as risk for or in a state of low cardiac output include the use of hemodynamic monitoring, enabling a timely and accurate assessment of cardiovascular function and tissue oxygenation; optimization of ventricular loading conditions; the judicious use of inotropic agents; an appreciation of and the utilization of positive pressure ventilation for circulatory support; and, in some circumstances, mechanical circulatory support. All interventions and strategies should culminate in improving the relationship between oxygen supply and demand, ensuring adequate tissue oxygenation.
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Affiliation(s)
- Heather K Chandler
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin st. W6006, Houston, Texas, 77030, USA.
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Long-term neurologic outcomes following paediatric out-of-hospital cardiac arrest. Resuscitation 2016; 102:122-6. [DOI: 10.1016/j.resuscitation.2016.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 11/25/2015] [Accepted: 01/06/2016] [Indexed: 11/22/2022]
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Identifying Prognostic Criteria for Survival after Resuscitation Assisted by Extracorporeal Membrane Oxygenation. Crit Care Res Pract 2016; 2016:9521091. [PMID: 27006826 PMCID: PMC4781941 DOI: 10.1155/2016/9521091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/30/2016] [Accepted: 02/07/2016] [Indexed: 11/18/2022] Open
Abstract
To improve survival rates during CPR, some patients are put on extracorporeal membrane oxygenation (ECMO). Among children who have undergone ECMO cardiopulmonary resuscitation (ECPR), the overall rate of survival to discharge is close to 40%. However, despite its wide acceptance and use, the appropriate indications and organizational requirements for ECPR have yet to be defined. Our objective was to assess the clinical outcomes of children after ECPR and to determine pre-ECPR prognostic factors for survival to guide its indication. Among the 19 patients who underwent ECPR between 2008 and 2014 in our center, 16 patients (84%, 95% confidence interval: 62-95%) died during their hospital stay, including nine (47%) who were on ECMO and seven (37%) after successful weaning from ECMO. All three survivors had normal cognitive status, but one child suffered from spastic quadriplegia. Survivors tended to have lower lactate, higher bicarbonate, and higher pH levels before ECMO initiation, as well as shorter length of resuscitation. In conclusion, in our center, ECPR has a poorer outcome than expected. Therefore, it might be important to identify, a priori, patients who might benefit from this treatment.
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Mitchell EA, Gomez D, Joy BF, Fernandez RP, Cheatham JP, Galantowicz M, Cua CL. ECMO: Incidence and Outcomes of Patients Undergoing the Hybrid Procedure. CONGENIT HEART DIS 2016; 11:169-74. [PMID: 27037636 DOI: 10.1111/chd.12311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To document the extracorporeal membrane oxygenation (ECMO) incidence and outcome in patients undergoing the hybrid procedure at an institution that routinely performs this procedure. DESIGN A retrospective chart review on all patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. Patients were excluded if they underwent the hybrid procedure after 60 days of birth or subsequently underwent a biventricular repair. SETTING A single center, tertiary pediatric hospital. PATIENTS One hundred eighty-one patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We studied a total of 181 patients (105 males: 76 females). Gestational age was 37.8 ± 2.0 weeks and birth weight was 3.0 ± 0.7 kg. Underlying diagnosis was hypoplastic left heart syndrome in 149 patients and other in 32 patients. Age at surgery was 7.8 ± 6.8 days and weight at surgery was 3.1 ± 0.6 kg. Two patients underwent ECMO support after the hybrid procedure. One patient had aortic atresia/mitral atresia and weighed 2.3 kg and the other patient had aortic atresia/mitral stenosis and weighed 2.1 kg at time of surgery. Both patients died. Incidence of ECMO support after hybrid procedure was 1.3% (2/149) for the hypoplastic left heart syndrome patients and 1.1% (2/181) for the entire cohort. CONCLUSION Mortality in patients who underwent ECMO after the hybrid procedure was higher than reported for the Norwood procedure, however, the incidence of ECMO after hybrid procedure was also significantly lower than reported for the Norwood procedure. Future studies are needed to determine how to improve outcomes in this complex patient population.
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Affiliation(s)
| | - Daniel Gomez
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brian F Joy
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - John P Cheatham
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark Galantowicz
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
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"Awake Veno-arterial Extracorporeal Membrane Oxygenation" in Pediatric Cardiogenic Shock: A Single-Center Experience. Pediatr Cardiol 2015; 36:1647-56. [PMID: 26049415 DOI: 10.1007/s00246-015-1211-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
In pediatric patients with acute refractory cardiogenic shock (CS), extracorporeal membrane oxygenation (ECMO) remains an established procedure to maintain adequate organ perfusion. In this context, ECMO can be used as a bridging procedure to recovery, VAD or transplantation. While being supported by ECMO, most centers tend to keep their patients well sedated and supported by invasive ventilation. This may be associated with an increased risk of therapy-related morbidity and mortality. In order to optimize clinical management in pediatric patients with ECMO therapy, we report our strategy of veno-arterial ECMO (VA-ECMO) in extubated awake and conscious patients. We therefore present data of six of our patients with CS, who were treated by ECMO being awake without continuous analgosedation and invasive ventilation. Of these six patients, four were <1 year and two >14 years of age. Median time on ECMO was 17.4 days (range 6.9-94.2 days). Median time extubated, while receiving ECMO support was 9.5 days. Mean time extubated was 78 % of the total time on ECMO. Three patients reached full recovery of cardiac function on "Awake-VA-ECMO," whereas the other three were successfully bridged to destination therapy (VAD, heart transplantation, withdrawal). Four out of our six patients are still alive. Complications related to ECMO therapy (i.e., severe bleeding, site infection or dislocation of cannulas) were not observed. We conclude that "Awake-VA-ECMO" in extubated, spontaneously breathing conscious pediatric patients is feasible and safe for the treatment of acute CS and can be used as a "bridging therapy" to recovery, VAD implantation or transplantation.
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Cardiopulmonary Resuscitation in Children With In-Hospital and Out-of-Hospital Cardiopulmonary Arrest: Multicenter Study From Turkey. Pediatr Emerg Care 2015; 31:748-52. [PMID: 26535496 DOI: 10.1097/pec.0000000000000337] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this study were to determine the causes, location of cardiopulmonary arrest (CPA) in children, and demographics of cardiopulmonary resuscitation (CPR) in Turkish pediatric emergency departments and pediatric intensive care units (PICUs) and to determine survival rates and morbidities for both in-hospital and out-of-hospital CPA. METHODS This multicenter descriptive study was conducted prospectively between January 15 and July 15, 2011, at 18 centers (15 PICUs, 3 pediatric emergency departments) in Turkey. RESULTS During the study period, 239 children had received CPR. Patients' average age was 42.4 (SD, 58.1) months. The most common cause of CPA was respiratory failure (119 patients [49.8%]). The location of CPA was the PICU in 168 (68.6%), hospital wards in 43 (18%), out-of-hospital in 24 (10%), and pediatric emergency department in 8 patients (3.3%). The CPR duration was 30.7 (SD, 23.6) minutes (range, 1-175 minutes) and return of spontaneous circulation was achieved in 107 patients (44.8%) after the first CPR. Finally, 58 patients (24.2%) were discharged from hospital; survival rates were 26% and 8% for in-hospital and out-of-hospital CPA, respectively (P = 0.001). Surviving patients' average length of hospital stay was 27.4 (SD, 39.2) days. In surviving patients, 19 (32.1%) had neurologic disability. CONCLUSION Pediatric CPA in both the in-hospital and out-of-hospital setting has a poor outcome.
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Garcia Guerra G, Zorzela L, Robertson CMT, Alton GY, Joffe AR, Moez EK, Dinu IA, Ross DB, Rebeyka IM, Lequier L. Survival and neurocognitive outcomes in pediatric extracorporeal-cardiopulmonary resuscitation. Resuscitation 2015; 96:208-13. [PMID: 26303570 DOI: 10.1016/j.resuscitation.2015.07.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Extracorporeal Cardiopulmonary Resuscitation (E-CPR) is the initiation of extracorporeal life support during active chest compressions. There are no studies describing detailed neurocognitive outcomes of this population. We aim to describe the survival and neurocognitive outcomes of children who received E-CPR. METHODS Prospective cohort study. Children who received E-CPR at the Stollery Children's Hospital between 2000 and 2010 were included. Neurocognitive follow-up, including Wechsler Preschool and Primary Scales of Intelligence, was completed at the age of 4.5 years, and at a minimum of 6 months after the E-CPR admission. RESULTS Fifty-five patients received E-CPR between 2000 and 2010. Children with cardiac disease had a 49% survival to hospital discharge and 43% survival at age 5-years, with no survivors (n=4) in those with non-cardiac disease. Pediatric E-CPR survivors had a mean (SD) Full Scale Intelligence quotient (FSIQ) score of 76.5 (15.9); with 4 children (24%) having intellectual disability (defined as FSIQ over 2 standard deviations below the population mean; i.e., <70). Multiple Cox regression analysis found that mechanical ventilation prior to E-CPR, open chest CPR, longer duration of CPR, low pH and more red blood cells given on the first day of ECMO, and longer time for lactate to normalize on ECMO were associated with higher mortality at age 5-years. CONCLUSION Pediatric patients with cardiac disease who required E-CPR had 43% survival at age 5 years. Of concern, the intelligence quotient in E-CPR survivors was significantly lower than the population mean, with 24% having intellectual disability.
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Affiliation(s)
| | - Liliane Zorzela
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Gwen Y Alton
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, AB, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - David B Ross
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Ivan M Rebeyka
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Laurance Lequier
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Sidhu N, Joffe AR, Doughty P, Vatanpour S, Dinu I, Alton G, Acton B, Robertson CMT. Sepsis After Cardiac Surgery Early in Infancy and Adverse 4.5-Year Neurocognitive Outcomes. J Am Heart Assoc 2015; 4:e001954. [PMID: 26251282 PMCID: PMC4599458 DOI: 10.1161/jaha.115.001954] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background We aimed to determine whether sepsis is associated with neurocognitive outcomes 4.5 years after congenital heart disease surgery in early infancy. Methods and Results A secondary analysis from a prospective inception cohort included all children having congenital heart disease surgery done at ≤6 weeks of age with cardiopulmonary bypass at the Western Canadian referral center from 1996 to 2009. Follow-up at the referral center determined the primary outcomes at 4.5 years with full-scale, performance, and verbal intelligence quotients on the Wechsler Preschool and Primary Scale of Intelligence. Perioperative variables were collected prospectively, and confirmation of blood culture–positive sepsis was done retrospectively. Multiple linear regression models for neurocognitive outcomes and multiple Cox proportional hazards regression for mortality were determined. Sepsis occurred in 97 of 502 patients (19%) overall and in 76 of 396 survivors (19%) with 4.5-year follow-up. By 4.5 years, there were 91 (18%) deaths, and 396 of 411 survivors (96%) had follow-up completed. Extracorporeal membrane oxygenation was associated with worse scores on all neurocognitive outcomes on multivariable regression; the association between extracorporeal membrane oxygenation and full-scale intelligence quotient had a regression coefficient of −13.6 (95% CI −21.3 to −5.9; P =0.001). Sepsis perioperatively was associated with performance and verbal intelligence quotients, with a trend for full-scale intelligence quotient (P =0.058) on multivariable regression. The regression coefficient for sepsis was strongest for performance intelligence quotient (−5.31; 95% CI −9.84 to −0.78; P =0.022). Sepsis was not but extracorporeal membrane oxygenation was associated with mortality by 4.5 years. Conclusions Perioperative sepsis and extracorporeal membrane oxygenation were associated with adverse neurocognitive outcomes on multivariable regression. Quality improvement to prevent sepsis has the potential to improve long-term neurocognitive outcomes in infants after surgery for congenital heart disease.
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Affiliation(s)
- Naveen Sidhu
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada (N.S., A.R.J.)
| | - Ari R Joffe
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada (N.S., A.R.J.)
| | - Paul Doughty
- Division of Pediatric Critical Care, Department of Pediatrics, University of Calgary, Alberta, Canada (P.D.)
| | - Shabnam Vatanpour
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada (S.V., I.D.)
| | - Irina Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada (S.V., I.D.)
| | - Gwen Alton
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (G.A.)
| | - Bryan Acton
- Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada (B.A.)
| | - Charlene M T Robertson
- Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.T.R.)
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Li X, Yu X, Cheypesh A, Li J. Non-invasive Measurements of Energy Expenditure and Respiratory Quotient by Respiratory Mass Spectrometry in Children on Extracorporeal Membrane Oxygenation-A Pilot Study. Artif Organs 2015; 39:815-9. [PMID: 25940695 DOI: 10.1111/aor.12465] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary life-saving support for pediatric patients with severe cardiac failure, but causes metabolic disturbances and altered nutritional requirements. However, few studies have addressed the optimal energy supply to meet the demand of these children, largely due to technical difficulties with their invasive nature. We have adapted respiratory mass spectrometry to continuously measure O2 consumption and CO2 production in the gas exchange across the ECMO oxygenator, as well as that across the ventilator. This study aimed to assess energy expenditure (EE) and respiratory quotient (RQ) in children on ECMO. Five children (aged 0.3 to 36 months, median 20) were studied between Day 1 and Day 6 on ECMO. EE and RQ were measured in sequential fashion at the child's native lungs and ECMO oxygenator using respiratory mass spectrometry. Measurements were collected at 4-h intervals, with the means in 24 h representing the values of each day. Each child's caloric and protein intakes were recorded for each day. Between ECMO Days 1 and 6, there was a small but significant increase in EE from 40 to 46 kcal/kg/day (P = 0.03). In comparison, the caloric intake significantly increased by twice as much as EE from 30 to 61 kcal/kg/day (P = 0.017). As a result, RQ significantly increased from 0.6 to 1.0 (P < 0.0001). Protein intake significantly increased during ECMO Days 1 to 6 from 0.5 to 1.5 g/kg/day (P = 0.04). Respiratory mass spectrometry is feasible to provide a unique and safe technique to measure EE and RQ in patients on ECMO. Without this knowledge, inadequate feeding may occur. Further studies are warranted in a larger patient population to provide better information to guide clinical practice in this special group of critically ill children.
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Affiliation(s)
- Xiaohui Li
- Division of Pediatric Cardiology, Capital Institute of Pediatrics, Beijing, China
| | - Xiaoyang Yu
- Clinical Physiology Research Center, Capital Institute of Pediatrics, Beijing, China.,Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Andriy Cheypesh
- Clinical Physiology Research Center, Capital Institute of Pediatrics, Beijing, China.,Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jia Li
- Clinical Physiology Research Center, Capital Institute of Pediatrics, Beijing, China.,Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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VEIEN M, LINDBERG L, TYNKKYNEN P, RAVN HB. Paediatric ECMO at low-volume paediatric cardiac centres in the Nordic countries. Acta Anaesthesiol Scand 2015; 59:337-45. [PMID: 25582418 DOI: 10.1111/aas.12460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/02/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a life-saving resource-intensive technology for patients with respiratory and/or circulatory failure. We aimed to evaluate outcome data from three Nordic paediatric centres comparing with data from the International Registry of the Extracorporeal Life Support Organization (ELSO) and selected high-volume single-centre studies. METHODS One-hundred nineteen patients < 19 years from 2002 to 2012 were enrolled. Data on demographics and outcome were collected using a standardised registration form. Outcome data were compared with the ELSO registry and high-volume single-centre studies. RESULTS Demographics, indications and diagnosis were similar to the ELSO register. Survival after ECMO was similar to outcome data from the ELSO register, apart from paediatric cardiac ECMO, where a significantly better survival to discharge was seen in the Nordic centres (68% vs. 49%; P = 0.03). Comparison with high-volume centres in the period after 2005 demonstrated a significantly better survival after cardiac ECMO in a single high-volume centre study, whereas four studies had significantly lower survival after cardiac ECMO. No significant difference was seen in children receiving respiratory ECMO in the Nordic centres and high-volume centres. CONCLUSIONS Survival after ECMO in three low-volume Nordic centres demonstrated comparable outcome data with ELSO data and data from high-volume centres. We believe regular quality assurance surveys, as the present study, should be performed in order to maintain excellent therapy within the individual ECMO centres.
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Affiliation(s)
- M. VEIEN
- Department of Anaesthesia and Intensive Care; University Hospital of Aarhus; Aarhus N Denmark
| | - L. LINDBERG
- Department of Clinical Sciences; Skane University Hospital of Lund; Lund Sweden
| | - P. TYNKKYNEN
- Department of Anaesthesiology and Intensive Care; University Hospital of Helsinki; Helsinki Finland
| | - H. B. RAVN
- Department of Anaesthesia and Intensive Care; University Hospital of Aarhus; Aarhus N Denmark
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69
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Outcomes of pediatric patients undergoing cardiac catheterization while on extracorporeal membrane oxygenation. Pediatr Cardiol 2015; 36:625-32. [PMID: 25381624 DOI: 10.1007/s00246-014-1057-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
Abstract
The aim of the study is to explore the indications for cardiac catheterization while on extracorporeal membrane oxygenation (ECMO) and the various catheter interventions performed as well as assess the safety profile and determine the short- and intermediate-term survival. ECMO is a lifesaving intervention for pediatric patients with respiratory and/or cardiovascular failure. There is limited recent literature discussing the survival and outcomes of patients undergoing cardiac catheterization while on ECMO. A retrospective review of consecutive patients undergoing catheterization while on ECMO from 2004 to 2013 was performed. Thirty-six patients who underwent 40 cardiac catheterizations were identified. Indications for catheterization included hemodynamic/anatomic assessment of postoperative (16) and non-operative patients (7), planned catheter interventions (CI) (12), and cardiomyopathy assessment (5). CI were performed during 18 (45 %) catheterizations, including stenting of vessels/surgical shunts (9), balloon atrial septostomy (4), device closure of septal defects/vessels (3), thrombolysis of vessels (2), endomyocardial biopsy (2), and temporary pacer wire placement (1). Unexpected diagnostic information was found in 21 (52 %), and 13 patients were referred for surgical intervention. Successful decannulation was achieved in 86 % of patients. Survival to discharge was 72 % and intermediate survival was 69 % (median = 29 months). Survival was 88 % (15/17) among patients who underwent CI. There were six procedural complications (15 %); five vascular and one non-vascular. There were no complications related to patient transport. Cardiac catheterization and interventions while on ECMO are safe, with a survival to discharge of 72 %. Diagnostic information obtained from catheterization leads to management decisions which may impact survival.
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70
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Ryerson LM, Guerra GG, Joffe AR, Robertson CMT, Alton GY, Dinu IA, Granoski D, Rebeyka IM, Ross DB, Lequier L. Survival and neurocognitive outcomes after cardiac extracorporeal life support in children less than 5 years of age: a ten-year cohort. Circ Heart Fail 2015; 8:312-21. [PMID: 25575579 DOI: 10.1161/circheartfailure.114.001503] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Survival after pediatric cardiac extracorporeal life support (ECLS) is guarded, and neurological morbidity varies widely. Our objective is to report our 10-year experience with cardiac ECLS, including survival and kindergarten entry neurocognitive outcomes; to identify predictors of mortality or adverse neurocognitive outcomes; and to compare 2 eras, before and after 2005. METHODS AND RESULTS From 2000 to 2009, 98 children had venoarterial cardiac ECLS. Sixty-four patients (65%) survived to hospital discharge, and 50 (51%) survived ≤5 years of age. Neurocognitive follow-up of survivors was completed at mean (SD) age of 52.9 (8) months using Wechsler Preschool and Primary Scale of Intelligence. Logistic regression analysis found the longer time (hours) for lactate to fall below 2 mmol/L on ECLS (hazard ratio, 1.39; 95% confidence interval, 1.05, 1.84; P=0.022), and the amount of platelets (mL/kg) given in the first 48 hours (hazard ratio, 1.18; 95% confidence interval, 1.06, 1.32; P=0.002) was independently associated with higher in-hospital mortality. Receiving ECLS after the year 2005 was independently associated with lower risk of in-hospital mortality (hazard ratio, 0.36; 95% confidence interval, 0.13, 0.99; P=0.048). Extracorporeal cardiopulmonary resuscitation was not independently associated with mortality or neurocognitive outcomes. Era was not independently associated with neurocognitive outcomes. The full-scale intelligence quotient of survivors without chromosomal abnormalities was 79.7 (16.6) with 25% below 2 SD of the population mean. CONCLUSIONS Mortality has improved over time; time for lactate to fall on ECLS and volume of platelets transfused are independent predictors of mortality. Extracorporeal cardiopulmonary resuscitation and era were not independently associated with neurocognitive outcomes.
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Affiliation(s)
- Lindsay M Ryerson
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.).
| | - Gonzalo Garcia Guerra
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Ari R Joffe
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Charlene M T Robertson
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Gwen Y Alton
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Irina A Dinu
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Don Granoski
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Ivan M Rebeyka
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - David B Ross
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
| | - Laurance Lequier
- From the Department of Pediatrics (L.M.R., G.G.G., A.R.J., C.M.T.R., L.L.), Department of Public Health Sciences (I.A.D.), and Department of Surgery (I.M.R., D.B.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (C.M.T.R., G.Y.A.); and Pediatric Critical Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada (D.G.)
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Hsu J, Wang CH, Huang SC, Yu HY, Chi NH, Wu IH, Chan CY, Chang CI, Wang SS, Chen YS. Clinical Applications of Extracorporeal Membranous Oxygenation: A Mini-Review. ACTA CARDIOLOGICA SINICA 2014; 30:507-13. [PMID: 27122828 DOI: 10.6515/acs20140821a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
UNLABELLED The clinical usage of extracorporeal membranous oxygenation began more than 40 years ago. Although the indications for its use have expanded over the years, it has been challenging to conduct randomized controlled trials to prove that extracorporeal membranous oxygenation is more effective than traditional approaches. Through a review of retrospective reports and data from registries, we attempted to evaluate the appropriateness of its application for acute respiratory distress syndrome, cardiopulmonary resuscitation, postcardiotomy cardiogenic shock, and sepsis. Our investigation revealed that using extracorporeal membranous oxygenation when readily available is appropriate for all patients with cardiopulmonary resuscitation or postcardiotomy cardiogenic shock, and for selected patients with acute respiratory distress syndrome or sepsis. KEY WORDS Acute respiratory distress syndrome; Cardiopulmonary resuscitation; Extracorporeal membranous oxygenation; Postcardiotomy cardiogenic shock; Sepsis.
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Affiliation(s)
- Jiun Hsu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Yunlin Branch, Douliou City, Yunlin County
| | - Chih-Hsien Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shu-Chien Huang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Hsi-Yu Yu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei; ; Department of Cardiovascular Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, Taiwan
| | - Nai-Hsin Chi
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - I-Hui Wu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Chih-Yang Chan
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Chung-I Chang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shoei-Shen Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Yih-Sharng Chen
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
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Abstract
OBJECTIVE To assess the health-related quality of life of children who received cardiac extracorporeal life support. We hypothesized that extracorporeal life support survivors have lower health-related quality-of-life scores when compared with a healthy sample, with children with chronic conditions, and with children who had surgery for congenital heart disease and did not receive extracorporeal life support. DESIGN Prospective cohort study. SETTING Stollery Children's Hospital and Complex Pediatric Therapies Follow-up Program clinics. PATIENTS Children less than or 5 years old with diagnosis of cardiac disease (congenital or acquired) who received extracorporeal life support at the Stollery Children's Hospital from 1999 to 2009. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Health-related quality of life was assessed using the PedsQL 4.0 Generic Core Scales completed by the children's parents at the time of follow-up. Forty-seven cardiac extracorporeal life support survivors had their health-related quality of life assessed at a median age of 4 years. Compared with a healthy sample, children who received venoarterial extracorporeal life support have significantly lower PedsQL (64.9 vs 82.2; p < 0.0001). The PedsQL scores of children who received extracorporeal life support were also significantly lower than those of children with chronic health conditions (64.9 vs 73.1; p = 0.007). Compared with children with congenital heart disease who underwent cardiac surgery early in infancy and who did not receive extracorporeal life support, extracorporeal life support survivors had significantly lower PedsQL scores (64.9 vs 81.1; p < 0.0001). Multiple linear regression analysis found an independent association between both higher inotrope score in the first 24 hours of extracorporeal life support and longer hospital length of stay, with lower PedsQL scores. CONCLUSIONS Pediatric cardiac extracorporeal life support survivors showed lower health-related quality of life than healthy children, children with chronic conditions, and children with congenital heart disease who did not receive extracorporeal life support.
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Extracorporeal membrane oxygenation-supported cardiopulmonary resuscitation following stage 1 palliation for hypoplastic left heart syndrome. Pediatr Crit Care Med 2014; 15:538-45. [PMID: 24797720 DOI: 10.1097/pcc.0000000000000159] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To report on survival from a large multicenter cohort of neonates with hypoplastic left heart syndrome requiring extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation after stage 1 palliation operation. DESIGN Retrospective analysis of data from the Extracorporeal Life Support Organization data registry (1998 through 2013). We computed the survival to hospital discharge for neonates (age < 30 d) who required extracorporeal membrane oxygenation after stage 1 palliation and evaluated factors associated with mortality using multivariate logistic regression analysis. SETTING Multicenter data reported to Extracorporeal Life Support Organization registry. PATIENTS Infants with hypoplastic left heart syndrome after stage 1 palliation who received extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 307 extracorporeal membrane oxygenation runs in the setting of extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation in 293 neonates with hypoplastic left heart syndrome following stage 1 palliation operation. The median age at cannulation was 9 days (interquartile range, 5-14 d). Survival to hospital discharge was 36%. In univariate analysis, gestational age, weight, extracorporeal membrane oxygenation duration, presence of air embolism, hemorrhagic complications, renal failure, and pulmonary complications (pulmonary hemorrhage and pneumothorax) were all associated with nonsurvival. In multivariate analysis, lower body weight at cannulation (odds ratio, 3.9; 95% CI, 1.9-8.3), duration of the extracorporeal membrane oxygenation (odds ratio, 3.4; 95% CI, 1.9-7.3), and renal failure while on extracorporeal membrane oxygenation (odds ratio, 2; 95% CI, 1.2-3.5) increased odds of mortality. CONCLUSIONS Mortality for neonates with hypoplastic left heart syndrome supported with extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation after stage 1 palliation is high. Lower body weight, increased duration of extracorporeal membrane oxygenation support, and renal failure increased mortality.
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Gournay V, Hauet Q. Mechanical circulatory support for infants and small children. Arch Cardiovasc Dis 2014; 107:398-405. [PMID: 24973112 DOI: 10.1016/j.acvd.2014.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/15/2014] [Accepted: 04/22/2014] [Indexed: 11/19/2022]
Abstract
The number of children in need of mechanical circulatory support has increased substantially over the last two decades, due to the technological progress made in surgery and intensive care, leading to improved survival of patients with congenital heart disease. In addition, primary myocardial dysfunction related to myocarditis or dilated cardiomyopathy may cause end-stage cardiac failure in children or infants, although not as frequently as in adults. The need for mechanical circulatory support may be either temporary until spontaneous myocardial recovery, as in postcardiotomy cardiac failure, or prolonged until heart transplantation in the absence of recovery. Two types of mechanical circulatory devices are suitable for the paediatric population: extracorporeal membrane oxygenation for short-term support; and ventricular assist devices for long-term support as a bridge to transplantation. The aim of this review is to describe the specific issues related to paediatric mechanical circulatory support and the different types of devices available, to report on their rapidly growing use worldwide and on the outcomes for each indication and type of device, and to provide a perspective on the future developments and remaining challenges in this field.
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Affiliation(s)
| | - Quentin Hauet
- CHU de Nantes, Service de Cardiologie Pédiatrique, Nantes, France
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75
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The association of carotid artery cannulation and neurologic injury in pediatric patients supported with venoarterial extracorporeal membrane oxygenation*. Pediatr Crit Care Med 2014; 15:355-61. [PMID: 24622166 DOI: 10.1097/pcc.0000000000000103] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the prevalence of neurologic injury in a recent cohort of patients 18 years old or younger cannulated for venoarterial extracorporeal membrane oxygenation. To evaluate the association of carotid artery cannulation with neurologic injury when compared with other cannulation sites. To determine if age impacts the association of carotid artery cannulation with neurologic injury. DESIGN Retrospective analysis of data from the Extracorporeal Life Support Organization registry. SETTING Neonatal and pediatric medical/surgical and cardiac ICUs of 118 international tertiary care centers worldwide. PATIENTS Pediatric patients 18 years old or younger cannulated for venoarterial extracorporeal membrane oxygenation and reported to the Extracorporeal Life Support Organization registry during 2007 and 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two thousand nine hundred seventy-seven patients underwent venoarterial extracorporeal membrane oxygenation during the study period. Indications for extracorporeal membrane oxygenation included pulmonary (n = 1,390, 47%), cardiac (n = 1,168, 39%), extracorporeal membrane oxygenation during cardiopulmonary resuscitation (n = 418, 14%), and unknown (n = 1). Arterial cannulation sites were aorta (n = 938, 32%), femoral artery (n = 118, 4%), and carotid artery (n = 1,921, 64%). Overall, 611 patients (21%) had evidence of neurologic injury defined as seizures, infarction, and/or hemorrhage. The occurrence of neurologic injury varied significantly by cannulation site: femoral artery (n = 18, 15%), aorta (n = 160, 17%), and carotid artery (n = 433, 23%); p equals 0.001. Neonates represented the largest group of patients cannulated for venoarterial extracorporeal membrane oxygenation (n = 1,807, 61%), the majority of patients cannulated via the carotid artery (n = 1,276, 66%), and had the highest burden of neurologic injury (n = 398, 22%). Age, preextracorporeal membrane oxygenation high-frequency oscillatory ventilation use, preextracorporeal membrane oxygenation arterial pH and serum bicarbonate level, and preextracorporeal membrane oxygenation cardiac arrest were independently associated with neurologic injury in a covariate model. Carotid artery cannulation site was added to this adjusted model and found to independently increase odds of neurologic injury (odds ratio, 1.4 [95% CI, 1.01-1.69]). An interaction term containing age and cannulation site was not associated with neurologic injury (odds ratio, 1.06 [95% CI, 0.84-1.34]). CONCLUSIONS Carotid artery cannulation for venoarterial extracorporeal membrane oxygenation in patients 18 years old or younger is associated with statistically significant increased odds of neurologic injury. These increased odds are present across all age groups.
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76
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Jolley M, Thiagarajan RR, Barrett CS, Salvin JW, Cooper DS, Rycus PT, Teele SA. Extracorporeal membrane oxygenation in patients undergoing superior cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2014; 148:1512-8. [PMID: 24951018 DOI: 10.1016/j.jtcvs.2014.04.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 04/04/2014] [Accepted: 04/11/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients who have undergone the superior cavopulmonary anastomosis (Glenn procedure) have unique cardiopulmonary-cerebral physiology that may limit the success of cardiopulmonary resuscitation and extracorporeal membrane oxygenation (ECMO). Limited data published to date suggest grim morbidity and mortality when ECMO is used. We utilized the Extracorporeal Life Support Organization registry database to more thoroughly assess outcomes in these patients. METHODS Data from the Extracorporeal Life Support Organization registry from 1999 to 2012 for children with Glenn physiology aged 3 months to 1 year were retrospectively analyzed. Demographics and ECMO characteristics were compared between survivors and nonsurvivors. Factors associated with mortality were evaluated using multivariate logistic regression. RESULTS Of 103 infants, 42 (41%) survived to hospital discharge. Neurologic complications (eg, seizure, hemorrhage, or embolic stroke) were documented in 23% of patients (24 of 103) and 14% of survivors (6 of 42). In univariate analysis, inotropic requirement before ECMO, duration of ECMO, mechanical complications with the ECMO circuit, renal failure, and pulmonary hemorrhage or pneumothorax were predictors of mortality. In multivariate logistic regression, inotrope requirement (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.3-9.8), longer duration of ECMO support (OR, 7.2; 95% CI, 1.8-28), combined cardiopulmonary indication for ECMO (OR, 3.7; 95% CI, 1.4-9.7), and renal failure (OR, 4.2; 95% CI, 1.5-12) were associated with mortality. CONCLUSIONS Mortality in infants with Glenn physiology supported with ECMO is lower than that previously reported, but the incidence of neurologic injury is high. These data support use of ECMO in patients with Glenn physiology with refractory cardiopulmonary failure.
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Affiliation(s)
- Matthew Jolley
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
| | | | - Cindy S Barrett
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colo
| | - Joshua W Salvin
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - David S Cooper
- The Heart Institute, Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter T Rycus
- Extracorporeal Life Support Organization, University of Michigan, Ann Arbor, Mich
| | - Sarah A Teele
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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77
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Schmidt M, Pellegrino V, Combes A, Scheinkestel C, Cooper DJ, Hodgson C. Mechanical ventilation during extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:203. [PMID: 24447458 PMCID: PMC4057516 DOI: 10.1186/cc13702] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes.
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78
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Jeong IS, Woo YJ, Kim DW, Kim NY, Cho HJ, Ma JS. Efficacy of Electroencephalographic Monitoring for the Evaluation of Intracranial Injury during Extracorporeal Membrane Oxygenation Support in Neonates and Infants. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.2.70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- In Seok Jeong
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Young Jong Woo
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Do Wan Kim
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Nan Yeol Kim
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Sook Ma
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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79
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Ratio of PICU to ward cardiac arrest is increasing: so what? Crit Care Med 2013; 41:2438-9. [PMID: 24060773 DOI: 10.1097/ccm.0b013e3182913699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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80
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Mehta A, Ibsen LM. Neurologic complications and neurodevelopmental outcome with extracorporeal life support. World J Crit Care Med 2013; 2:40-7. [PMID: 24701415 PMCID: PMC3953870 DOI: 10.5492/wjccm.v2.i4.40] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 07/27/2013] [Accepted: 08/04/2013] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal life support is used to support patients of all ages with refractory cardiac and/or respiratory failure. Extracorporeal membrane oxygenation (ECMO) has been used to rescue patients whose predicted mortality would have otherwise been high. It is associated with acute central nervous system (CNS) complications and with long- term neurologic morbidity. Many patients treated with ECMO have acute neurologic complications, including seizures, hemorrhage, infarction, and brain death. Various pre-ECMO and ECMO factors have been found to be associated with neurologic injury, including acidosis, renal failure, cardiopulmonary resuscitation, and modality of ECMO used. The risk of neurologic complication appears to vary by age of the patient, with neonates appearing to have the highest risk of acute central nervous system complications. Acute CNS injuries are associated with increased risk of death in a patient who has received ECMO support. ECMO is increasingly used during cardiopulmonary resuscitation when return of spontaneous circulation is not achieved rapidly and outcomes may be good in select populations. Economic analyses have shown that neonatal and adult respiratory ECMO are cost effective. There have been several intriguing reports of active physical rehabilitation of patients during ECMO support that is well tolerated and may improve recovery. Although there is evidence that some patients supported with ECMO appear to have very good outcomes, there is limited understanding of the long-term impact of ECMO on quality of life and long-term cognitive and physical functioning for many groups, especially the cardiac and pediatric populations. This deserves further study.
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Floerchinger B, Philipp A, Foltan M, Keyser A, Camboni D, Lubnow M, Lunz D, Hilker M, Schmid C. Neuron-specific enolase serum levels predict severe neuronal injury after extracorporeal life support in resuscitation. Eur J Cardiothorac Surg 2013; 45:496-501. [PMID: 23878016 DOI: 10.1093/ejcts/ezt370] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Extracorporeal life support (ECLS) is a rescue option in critically ill patients. Since fast available and appropriate for respiratory and circulatory failure, it is frequently applied in resuscitation scenarios. Neurological injury is a complication common in ECLS patients limiting outcome, particularly after resuscitation. In this study, the institutional ECLS database was used to correlate neuron-specific enolase (NSE) serum peak values with outcome of patients supported with venoarterial (VA) ECLS during cardiopulmonary resuscitation (CPR). METHODS From January 2011 to August 2012, 31 patients were provided with a VA ECLS during CPR (external cardiac massage). Serum NSE peaks were monitored and correlated with neurological outcome and hospital mortality. Patients were divided into two groups with mild-to-moderate and high NSE levels (cut-off value 100 μg/l). RESULTS High NSE levels were seen in 7 patients (mean 218 ± 155 μg/l) and mild-to-moderate levels in 24 patients (50 ± 23 μg/l, P = 0.0001). Duration of extracoporeal support was comparable in both groups (6.3 ± 7.5 vs 5.0 ± 4.5 days, P = n.s.). Patients with mild-to-moderate NSE levels were significantly older than those with high NSE levels (58 ± 16 vs 44 ± 15 years, P = 0.02). Six patients with high NSE levels (86%) developed severe neurological complications. Though 4 patients could be weaned from extracorporeal support, hospital mortality was 86% (6 patients). In contrast, patients with mild-to-moderate NSE levels had a hospital mortality of 46% (11 patients). Eighteen patients (75%) could be weaned from the device, and incidence of major neurological events was 29% (6 patients) only. Serum pH and lactate levels before ECLS implantation were significantly lower in patients with mild-to-moderate NSE values (pH: 7.23 ± 0.04 vs 6.93 ± 0.12, P = 0.039; lactate: 106 ± 11 vs 161 ± 16 mg/l, P = 0.023). CONCLUSIONS High NSE serum levels after ECLS correspond to poor neurological outcome and considerable mortality. Therefore, early neuroimaging is reasonable for determining therapeutic strategies in patients with high NSE peaks after resuscitation and extracorporeal support.
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Affiliation(s)
- Bernhard Floerchinger
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Deutsch MA, Cleuziou J, Noebauer C, Eicken A, Vogt M, Hoerer J, Lange R, Schreiber C. Successful management of neonatal myocardial infarction with ECMO and intracoronary r-tPA lysis. CONGENIT HEART DIS 2013; 9:E169-74. [PMID: 23809294 DOI: 10.1111/chd.12117] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2013] [Indexed: 11/30/2022]
Abstract
Acute myocardial infarction (MI) is a life-threatening condition rarely encountered in neonates. The patients usually present with sudden cardiogenic shock. Clinical management in neonates is extremely challenging. If treatment is delayed, the prognosis is dismal. We report on a 4-day-old full-term male newborn presenting with acute MI and cardiogenic shock secondary to proximal thromboembolic occlusion of the left descending coronary artery. Hemodynamic stabilization could only be achieved after extracorporeal membrane oxygenation (ECMO) support. Coronary artery patency restoration was performed by selective intracoronary lysis with recombinant tissue plasminogen activator (r-tPA). ECMO support could be discontinued and myocardial function recovered within 6 weeks. We discuss the potential etiologies of acute perinatal MI and the role of ECMO support in the immediate post-MI period. Prompt recognition, timely referral to a cardiac center with availability of specialized advanced treatment options, and management in an orchestrated interdisciplinary approach are crucial for achieving a good outcome.
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Affiliation(s)
- Marcus-André Deutsch
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany
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85
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Abstract
Setting up an extracorporeal life support program requires motivated experts, institutional commitment, and an interprofessional team of healthcare providers with dedicated time, space, and resources. This article provides guidance on the key steps involved in the process of developing a sustainable extracorporeal membrane oxygenation program, based on guidelines from the Extracorporeal Life Support Organization and from an international perspective.
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86
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Abstract
OBJECTIVES The purpose of this review was to provide a systematic review of the literature regarding the use of extracorporeal life support (ECLS) in various specialized conditions, as part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support. DATA SOURCES MEDLINE and PubMed. STUDY SELECTION Searches for published abstracts and articles were conducted using the following MeSH terms: extracorporeal life support, extracorporeal membrane oxygenation, or mechanical support, and pediatric or children. DATA EXTRACTION Abstracts of all articles including case reports were reviewed; the full article was reviewed if the abstract indicated that it focused on extracorporeal life support for conditions other than primary respiratory disease or persistent pulmonary hypertension of the newborn and described outcomes such as survival to hospital discharge. Studies with potential overlapping patients were highlighted in the review process and summary results. DATA SYNTHESIS Classification of recommendations and level of evidence are expressed in the American College of Cardiology Foundation/American Heart Association format. CONCLUSIONS The majority of specialized situations where extracorporeal life support is used fall into the category of class II-III evidence. Class I indications for extracorporeal life support in the pediatric population include myocarditis and in the context of acute interventions in the cardiac catheterization laboratory.
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Abstract
Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.
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MESH Headings
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/therapy
- Cardiac Catheterization/methods
- Cardiac Catheterization/standards
- Child
- Child, Preschool
- Critical Care/methods
- Critical Care/standards
- Extracorporeal Circulation/methods
- Extracorporeal Circulation/standards
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/surgery
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/therapy
- Infant
- Infant, Newborn
- Monitoring, Physiologic/methods
- Monitoring, Physiologic/standards
- Nitric Oxide/administration & dosage
- Nitric Oxide/therapeutic use
- Oxygen Inhalation Therapy/methods
- Oxygen Inhalation Therapy/standards
- Postoperative Care/methods
- Postoperative Care/standards
- Postoperative Complications/diagnosis
- Postoperative Complications/therapy
- Respiration, Artificial/methods
- Respiration, Artificial/standards
- Risk Factors
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Affiliation(s)
- George Ofori-Amanfo
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Duke University Medical Center, DUMC 3046, 2300 Erwin Road, Durham, NC 27710, USA.
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Priddy CMO, Kajimoto M, Ledee DR, Bouchard B, Isern N, Olson AK, Des Rosiers C, Portman MA. Myocardial oxidative metabolism and protein synthesis during mechanical circulatory support by extracorporeal membrane oxygenation. Am J Physiol Heart Circ Physiol 2012. [PMID: 23203964 DOI: 10.1152/ajpheart.00672.2012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides essential mechanical circulatory support necessary for survival in infants and children with acute cardiac decompensation. However, ECMO also causes metabolic disturbances, which contribute to total body wasting and protein loss. Cardiac stunning can also occur, which prevents ECMO weaning, and contributes to high mortality. The heart may specifically undergo metabolic impairments, which influence functional recovery. We tested the hypothesis that ECMO alters oxidative metabolism and protein synthesis. We focused on the amino acid leucine and integration with myocardial protein synthesis. We used a translational immature swine model in which we assessed in heart 1) the fractional contribution of leucine (FcLeucine) and pyruvate to mitochondrial acetyl-CoA formation by nuclear magnetic resonance and 2) global protein fractional synthesis (FSR) by gas chromatography-mass spectrometry. Immature mixed breed Yorkshire male piglets (n = 22) were divided into four groups based on loading status (8 h of normal circulation or ECMO) and intracoronary infusion [(13)C(6),(15)N]-L-leucine (3.7 mM) alone or with [2-(13)C]-pyruvate (7.4 mM). ECMO decreased pulse pressure and correspondingly lowered myocardial oxygen consumption (∼40%, n = 5), indicating decreased overall mitochondrial oxidative metabolism. However, FcLeucine was maintained and myocardial protein FSR was marginally increased. Pyruvate addition decreased tissue leucine enrichment, FcLeucine, and Fc for endogenous substrates as well as protein FSR. The heart under ECMO shows reduced oxidative metabolism of substrates, including amino acids, while maintaining 1) metabolic flexibility indicated by ability to respond to pyruvate and 2) a normal or increased capacity for global protein synthesis.
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