Extracorporeal membrane oxygenation for pediatric respiratory failure: History, development and current status

Diverse Morbidity and Mortality Among Infants Treated with Venoarterial Extracorporeal Membrane Oxygenation

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized for cardiopulmonary failure. We aimed to qualify and quantify the predictors of morbidity and mortality in infants requiring VA-ECMO.

Methods: Data was collected from 170 centers participating in the extracorporeal life support organization (ELSO) registry. Relationships between in-hospital mortality and risk factors were assessed using logistic regression. Survival was defined as being discharged from the hospital.

Results: Six hundred and sixty-two eligible records were reviewed. Mortality occurred in 303 (46%) infants. Congenital diaphragmatic hernia patients (OR=3.83, 95% CI 1.96-7.49, p<0.001), cardiac failure with associated shock (OR= 2.90, 95% CI 1.46-5.77, p=0.002), and pulmonary failure including respiratory distress syndrome (OR=4.06, 95% CI 1.72-9.58, p=0.001) had the highest odds of mortality in this cohort. Birth weight (BW) < 3 kg (OR=1.83, 95% CI 1.21-2.78, p=0.004), E-CPR (OR=3.35, 95% CI 1.57-7.15, p=0.002), hemofiltration (OR=2.04, 95% CI 1.32-3.16, p=0.001), and dialysis (OR=6.13, 95% CI 1.70-22.1, p<0.001) were all independent predictors of mortality.

Conclusion: Infants requiring VA-ECMO experience diverse sequelae and their mortality are high.

Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists: a retrospective single-institution case series

OBJECTIVE

Extracorporeal membrane oxygenation provides support for patients with severe acute cardiopulmonary failure, allowing the application of lung or myocardial rest in anticipation of organ recovery, or as a bridge to long-term support. Advances in technology have improved the safety and ease of application of extracorporeal membrane oxygenation. Percutaneous cannulation is one of these advances and is now preferred over surgical cannulation in most cases. Percutaneous cannulation is increasingly performed by intensivists, cardiologists, interventional radiologists, and related specialties. The objective of this study is to review the experience of percutaneous cannulation by intensivists at a single institution.

DESIGN

A retrospective review of 100 subjects undergoing percutaneous cannulation for extracorporeal membrane oxygenation.

SETTING

Adult ICUs and PICUs at a tertiary academic medical institution.

PATIENTS

Critically ill neonatal, pediatric, and adult subjects with severe respiratory and/or cardiac failure undergoing percutaneous cannulation for extracorporeal membrane oxygenation. Modes of support included venoarterial, venovenous, venovenoarterial, and arteriovenous.

INTERVENTIONS

Percutaneous extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

Case reports submitted to the Extracorporeal Life Support Organization and hospital records of the subjects were retrospectively reviewed. Subject demographics, type of support, cannulation configuration, types of cannulas, use of imaging modalities, and complications were recorded and summarized. One hundred ninety cannulations with cannula sizes from size 12 to 31F were performed by four intensivists in 100 subjects. Twenty-three were arterial (12-16F) and 167 were venous (12-31F). Preinsertion ultrasound was performed in 93 subjects (93%), fluoroscopic guidance in 79 subjects (85% of nonarteriovenous subjects), and ultrasound-guided insertion was performed in 65 subjects (65%). Two major complications occurred, each associated with mortality. Cannulation was successful in all other subjects (98% of subjects and 99% of cannulations). There were no cases of cannula-related bloodstream infection.

CONCLUSIONS

Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists can be performed with a high rate of success and a low rate of complications when accompanied by imaging support.

Acute respiratory distress syndrome in a child with severe epileptic disorder treated successfully by extracorporeal membrane oxygenation: a case report

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is now a candidate therapy for children with acute respiratory failure.

CASE PRESENTATION

We report our experience of using central ECMO therapy for acute respiratory distress syndrome followed by seizure in a 15-month-old girl with a severe epileptic disorder. Her respiratory distress was refractory to standard medical treatment and mechanical ventilatory support. Her condition was complicated by development of a pneumothorax. The patient was successfully weaned off ECMO and discharged without deterioration of her neurological status.

CONCLUSION

The successful outcome in this case resulted from the central ECMO, which enabled "lung rest" and adequate cerebral blood flow. In skilled ECMO facilities, early implementation of ECMO would give some advantages to patients such as the one presented here. Given the invasiveness and the ease of the procedure, introduction of dual-lumen catheters adequately sized for pediatric patients in Japan is required.

Respiratory failure

On the basis of research evidence, (1)(2) numerous diseases and conditions can impair gas exchange, resulting in failure to meet the body's metabolic demands and leading to respiratory failure. On the basis of consensus, (1)(2)(7)(8)(9)(10) the clinical presentations of respiratory failure depend on the underlying cause and the level of hypoxemia and hypercapnia. Early diagnosis, close monitoring, and timely intervention are of utmost importance. On the basis of research evidence, (5)(14)(25) interventions range from noninvasive methods, such as close monitoring and supplemental oxygen, to full respiratory support with mechanical ventilation and in extreme cases even the use of extracorporeal membrane oxygenation.

Imaging adults on extracorporeal membrane oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) is increasingly being used in adults following failure to wean from cardiopulmonary bypass, after cardiac surgery or in cases of severe respiratory failure. Knowledge of the different types of ECMO circuits, expected locations of cannulas and imaging appearance of complications is essential for accurate imaging interpretation and diagnosis. Commonly encountered complications are malposition of cannulas, adjacent or distal haemorrhage, stroke, stasis thrombus in access vessels, and distal emboli. This article will describe the imaging appearance of different ECMO circuits in adults as well as commonly encountered complications. If a CT (computed tomography) angiogram is being performed on these patients to evaluate for pulmonary embolism, the scan may be suboptimal from siphoning off of the contrast by the ECMO. In such cases, an optimal image can be obtained by lowering the flow rate of the ECMO circuit or by disabling the circuit for the duration of image acquisition.

Key Points

• Femoroatrial VV ECMO: femoral vein drainage cannula and right atrial return cannula.

• Femorofemoral VV ECMO: return and drainage cannulas placed in femoral veins.

• Dual-lumen single cannula VV ECMO: via the right IJ/Femoral vein with the tip in the IVC/SVC.

• Peripheral VA ECMO: peripheral venous drainage cannula and peripheral arterial return cannula.

• Central VA ECMO: direct right atrial drainage cannula and aortic return cannula.