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Cucchi M, Mariani S, Kawczynski MJ, Shkurka E, Ius F, Comentale G, Hoskote A, Lorusso R. Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy. Perfusion 2024:2676591241240377. [PMID: 38652693 DOI: 10.1177/02676591241240377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. METHODS PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. RESULTS Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65). CONCLUSION Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.
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Affiliation(s)
- Marta Cucchi
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Pediatric Intensive Care Unit, Queensland Children Hospital, Brisbane, QLD, Australia
| | - Silvia Mariani
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michal J Kawczynski
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Emma Shkurka
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Giuseppe Comentale
- IRCCS Policlinico Universitario Sant'Orsola-Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Aparna Hoskote
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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2
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Shkurka E, Child H, Balls J, Melkhuln E, Carter L, Compton V, Marscheider R, McConnell R, Meenaghan S, Milburn N, Nugent G, Peabody G, Rimmer L. Early rehabilitation and mobilisation of neonatal and paediatric extracorporeal membrane oxygenation patients: A UK and Ireland consensus document. Perfusion 2024; 39:174-181. [PMID: 36240012 DOI: 10.1177/02676591221132676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite increasing early rehabilitation and mobilisation (ERM) in paediatric intensive care, current evidence for ERM of neonatal and paediatric patients receiving extracorporeal membrane oxygenation (ECMO) is limited. The proposed benefits of ERM in neonatal and paediatric ECMO patients are multifaceted, including reduced immobility related issues and maintenance of functional ability. However, ECMO presents additional safety and logistical challenges, and currently there are no published neonatal or paediatric guidelines. A consensus document was developed to provide guidance for ERM with neonatal and paediatric ECMO patients. The document was developed by specialist physiotherapists from nine ECMO centres within the UK and Ireland, together with the UK Paediatric Critical Care Society ECMO group and members of the multidisciplinary team. The document covers key considerations and practicalities for completing ERM in this population including, acuity level measurement, activity level guidance, safety and risk assessment, and goal setting. Risk assessment and safety checklist bedside tools are also included and designed to be adapted as required to meet specific unit policies and protocols.
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Affiliation(s)
- Emma Shkurka
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Hannah Child
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jennie Balls
- Royal Brompton and Harefield NHS Trust, London, UK
| | - Ellie Melkhuln
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lee Carter
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Rachel McConnell
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Natalie Milburn
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Gemma Peabody
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Laura Rimmer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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3
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Zens T, Ochoa B, Eldredge RS, Molitor M. Pediatric venoarterial and venovenous ECMO. Semin Pediatr Surg 2023; 32:151327. [PMID: 37956593 DOI: 10.1016/j.sempedsurg.2023.151327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure. To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology. This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques. Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation. Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.
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Affiliation(s)
- Tiffany Zens
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Brielle Ochoa
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - R Scott Eldredge
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Mark Molitor
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States.
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Jack T, Carlens J, Diekmann F, Hasan H, Chouvarine P, Schwerk N, Müller C, Wieland I, Tudorache I, Warnecke G, Avsar M, Horke A, Ius F, Bobylev D, Hansmann G. Bilateral lung transplantation for pediatric pulmonary arterial hypertension: perioperative management and one-year follow-up. Front Cardiovasc Med 2023; 10:1193326. [PMID: 37441704 PMCID: PMC10333590 DOI: 10.3389/fcvm.2023.1193326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/02/2023] [Indexed: 07/15/2023] Open
Abstract
Background Bilateral lung transplantation (LuTx) remains the only established treatment for children with end-stage pulmonary arterial hypertension (PAH). Although PAH is the second most common indication for LuTx, little is known about optimal perioperative management and midterm clinical outcomes. Methods Prospective observational study on consecutive children with PAH who underwent LuTx with scheduled postoperative VA-ECMO support at Hannover Medical School from December 2013 to June 2020. Results Twelve patients with PAH underwent LuTx (mean age 11.9 years; age range 1.9-17.8). Underlying diagnoses included idiopathic (n = 4) or heritable PAH (n = 4), PAH associated with congenital heart disease (n = 2), pulmonary veno-occlusive disease (n = 1), and pulmonary capillary hemangiomatosis (n = 1). The mean waiting time was 58.5 days (range 1-220d). Three patients were bridged to LuTx on VA-ECMO. Intraoperative VA-ECMO/cardiopulmonary bypass was applied and VA-ECMO was continued postoperatively in all patients (mean ECMO-duration 185 h; range 73-363 h; early extubation). The median postoperative ventilation time was 28 h (range 17-145 h). Echocardiographic conventional and strain analysis showed that 12 months after LuTx, all patients had normal biventricular systolic function. All PAH patients are alive 2 years after LuTx (median follow-up 53 months, range 26-104 months). Conclusion LuTx in children with end-stage PAH resulted in excellent midterm outcomes (100% survival 2 years post-LuTx). Postoperative VA-ECMO facilitates early extubation with rapid gain of allograft function and sustained biventricular reverse-remodeling and systolic function after RV pressure unloading and LV volume loading.
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Affiliation(s)
- Thomas Jack
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Julia Carlens
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Franziska Diekmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Hosan Hasan
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Philippe Chouvarine
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Nicolaus Schwerk
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Ivonne Wieland
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Gregor Warnecke
- Department of Cardiac Surgery, Ruprecht-Karls-University, Heidelberg, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
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5
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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Abstract
Neonatal and pediatric extracorporeal membrane oxygenation (ECMO) has evolved over the past 50 years. Advances in technology, expertise, and application have increased the number of centers providing ECMO with expanded indications for use. However, increasing the use of ECMO in recent years to more medically complex critically ill children has not changed overall survival despite increased experience and improvements in technology. This review focuses on ECMO history, circuits, indications and contraindications, management, complications, and outcome data. The authors highlight important areas of progress, including unintubated and awake patients on ECMO, application during the COVID-19 pandemic, and future directions.
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Affiliation(s)
- Katherine Cashen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC, USA; Duke University Medical Center, 2301 Erwin Road, Suite 5260Y, DUMC 3046, Durham, NC 27710, USA.
| | - Katherine Regling
- Division of Pediatric Hematology Oncology, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, USA; Central Michigan University, Mt. Pleasant, MI, USA
| | - Arun Saini
- Division of Pediatric Critical Care Medicine, Texas Children's Hospital, 6651 Main Street, Suite 1411, Houston, TX 77030, USA; Baylor University School of Medicine, Houston, TX, USA
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Impact of the inspiratory oxygen fraction on the cardiac output during jugulo-femoral venoarterial extracorporeal membrane oxygenation in the rat. BMC Cardiovasc Disord 2022; 22:174. [PMID: 35428203 PMCID: PMC9013166 DOI: 10.1186/s12872-022-02613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) with femoral access has gained wide acceptance in the treatment of critically ill patients. Since the patient´s cardiac output (CO) can compete with the retrograde aortic ECMO-flow, the aim of this study was to examine the impact of the inspiratory oxygen fraction on the cardiac function during V-A ECMO therapy.
Methods
Eighteen male Lewis rats (350–400 g) received V-A ECMO therapy. The inspiratory oxygen fraction on the ventilator was randomly set to 0.5 (group A), 0.21 (group B), or 0 in order to simulate apnea (group C), respectively. Each group consisted of six animals. Arterial blood pressure, central venous saturation (ScvO2), CO, stroke volume, left ventricular ejection fraction (LVEF), end diastolic volume, and pressure were measured. Cardiac injury was determined by analyzing the amount of lactate dehydrogenase (LDH).
Results
During anoxic ventilation the systolic, mean and diastolic arterial pressure, CO, stroke volume, LVEF and ScvO2 were significantly impaired compared to group A and B. The course of LDH values revealed no significant differences between the groups.
Conclusion
Anoxic ventilation during V-A ECMO with femoral cannulation leads to cardiogenic shock in rats. Therefore, awake V-A ECMO patients might be at risk for hypoxia-induced complications.
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8
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Georges G, Kalavrouziotis D, Mohammadi S. Commentary: Walking wounded: Role of ambulatory femoral venovenous extracorporeal membrane oxygenation. JTCVS Tech 2021; 9:204-205. [PMID: 34647104 PMCID: PMC8501209 DOI: 10.1016/j.xjtc.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Gabriel Georges
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Québec City, Québec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Québec City, Québec, Canada
| | - Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Québec City, Québec, Canada
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9
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Sommer W, Warnecke G. Lung transplantation for pediatric pulmonary arterial hypertension-quo vadis? Cardiovasc Diagn Ther 2021; 11:1178-1189. [PMID: 34527542 DOI: 10.21037/cdt-21-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/23/2021] [Indexed: 11/06/2022]
Abstract
In children with pulmonary arterial hypertension, lung transplantation illustrates a feasible treatment option once pharmacological therapy is exhausted. Timing of listing for lung transplantation in children remains difficult since hemodynamic deterioration often occurs abruptly and the time on the waiting list is usually hard to predict. Clear contraindications for lung transplantation are recent history of malignancies as well as irreversible end-organ failure. Generally, patients with pulmonary arterial hypertension in the absence of structural cardiac defects can safely undergo bilateral lung transplantation, combined heart-lung transplantation remains a procedure with a higher perioperative risk and should only be performed in selected cases with irreversible structural defects. Donor selection in recent years shows donors with extended criteria as well as lobar transplantation with good outcome, having the positive effect of broadening of the donor pool. Bridging to lung transplantation with veno-arterial ECMO treatment is feasible and has a good outcome in experienced transplant centers. Surgical considerations should include the risk of hemodynamic decompensation upon anesthesia induction and the need for extracorporeal support pre-, intra- and postoperative. Lung transplantation should be performed on veno-arterial ECMO support with either peripheral (>20 kg) or central cannulation (<20 kg). The surgical transplantation procedure includes the bronchial anastomosis as well as anastomoses of the pulmonary artery and the left atrium. Postoperative prolonged veno-arterial ECMO treatment for the immediate postoperative period allows for left ventricular remodeling given the new hemodynamic circumstances with lower pulmonary vascular resistance. Standard triple immunosuppression in most lung transplant programs currently includes steroids, mycophenolate mofetil and tacrolimus. Survival after pediatric lung transplantation for IPAH is comparable to pediatric lung transplants for other underlying diseases with a 1-year survival of approx. 80% and a 5-year survival of 64-65%. Therefore, evolving techniques in the field of lung transplantation led to overall improved survival prospects in children with end-stage pulmonary vascular disease.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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Montero S, Huang F, Rivas-Lasarte M, Chommeloux J, Demondion P, Bréchot N, Hékimian G, Franchineau G, Persichini R, Luyt CÉ, Garcia-Garcia C, Bayes-Genis A, Lebreton G, Cinca J, Leprince P, Combes A, Alvarez-Garcia J, Schmidt M. Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:585-594. [PMID: 33822901 DOI: 10.1093/ehjacc/zuab018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/08/2021] [Accepted: 03/11/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is currently one of the first-line therapies for refractory cardiogenic shock (CS), but its applicability is undermined by the high morbidity associated with its complications, especially those related to mechanical ventilation (MV). We aimed to assess the prognostic impact of keeping patients in refractory CS awake at cannulation and during the VA-ECMO run. METHODS A 7-year database of patients given peripheral VA-ECMO support was used to conduct a propensity-score (PS)-matched analysis to balance their clinical profiles. Patients were classified as 'awake ECMO' or 'non-awake ECMO', respectively, if invasive MV was used during ≤50% or >50% of the VA-ECMO run. Primary outcomes included ventilator-associated pneumonia and ECMO-related complication rates, and secondary outcomes were 60-day and 1-year mortality. A multivariate logistic-regression analysis was used to identify whether MV at cannulation was independently associated with 60-day mortality. RESULTS Among 231 patients included, 91 (39%) were 'awake' and 140 (61%) 'non-awake'. After PS-matching adjustment, the 'awake ECMO' group had significantly lower rates of pneumonia (35% vs. 59%, P = 0.017), tracheostomy, renal replacement therapy, and less antibiotic and sedative consumption. This strategy was also associated with reduced 60-day (20% vs. 41%, P = 0.018) and 1-year mortality rates (31% vs. 54%, P = 0.021) compared to the 'non-awake' group, respectively. Lastly, MV at ECMO cannulation was independently associated with 60-day mortality. CONCLUSION An 'awake ECMO' management in VA-ECMO-supported CS patients is feasible, safe, and associated with improved short- and long-term outcomes.
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Affiliation(s)
- Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Florent Huang
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Mercedes Rivas-Lasarte
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juliette Chommeloux
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Pierre Demondion
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Guillaume Franchineau
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Romain Persichini
- Medical-Surgical Intensive Care Unit, CHU de La Réunion, Felix-Guyon Hospital, Saint Denis, La Réunion, France
| | - Charles-Édouard Luyt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Cosme Garcia-Garcia
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Antoni Bayes-Genis
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Guillaume Lebreton
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Juan Cinca
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pascal Leprince
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Alain Combes
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France.,Sorbonne Université, GRC 30, RESPIRE, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Jesus Alvarez-Garcia
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France.,Sorbonne Université, GRC 30, RESPIRE, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
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11
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Fallon BP, Gadepalli SK, Hirschl RB. Pediatric and neonatal extracorporeal life support: current state and continuing evolution. Pediatr Surg Int 2021; 37:17-35. [PMID: 33386443 PMCID: PMC7775668 DOI: 10.1007/s00383-020-04800-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 12/24/2022]
Abstract
The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, ECLS Laboratory, B560 MSRB II/SPC 5686, Michigan Medicine, University of Michigan, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ronald B Hirschl
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
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12
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Abstract
Extracorporeal membrane oxygenation (ECMO) is used in patients with acute respiratory failure that is not responsive to conventional management. The practice of awake ECMO has become an area of interest but with limited data and experience. Most reported experience comes from adult and pediatric populations. Traditional management of these patients still includes mechanical ventilator support and often requires the use of sedatives for provision of safe care. We present a series of eight neonates who were electively extubated while on ECMO, with expanded discussion of two representative cases. We discuss the rationale for extubation and outcomes. The greatest benefit of this management was seen in patients with significant air leak, and in no reported case did we experience any adverse effects or complications as a direct result of extubation while on ECMO. In conclusion, in our experience, awake neonatal ECMO appears safe and effective and may offer significant advantages over traditional management in certain clinical scenarios. Prospective comparison trials are warranted to further investigate the clinical benefits and risks of awake neonatal ECMO.
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Deng L, Xia Q, Chi C, Hu G. Awake veno-arterial extracorporeal membrane oxygenation in patients with perioperative period acute heart failure in cardiac surgery. J Thorac Dis 2020; 12:2179-2187. [PMID: 32642123 PMCID: PMC7330313 DOI: 10.21037/jtd.2020.04.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective extracorporeal life support technology that has been applied to treat cardiorespiratory failure patients. Some medical centers have started using ECMO on awake, non-intubated, spontaneously breathing patients, as this strategy offers several benefits over mechanical ventilation. However, most awake-ECMO methods focus on venovenous ECMO, and few cases of awake veno-arterial ECMO (V-A ECMO) have been reported, especially in perioperative acute heart failure. Therefore, our study aimed to examine awake—V-A ECMO cases that were not given continuous sedation or invasive mechanical ventilation (IMV) during perioperative heart failure. Method In total, 40 ECMO patients from December 2013 to November 2019 were divided into 2 groups (the awake-ECMO group and the asleep-ECMO group) according to the ventilation use. The demographics, patient outcomes, and ECMO parameters were collected and retrospectively analyzed. Results We identified 12 cases of awake ECMO without continuous ventilation, and 28 cases of simultaneous IMV and ECMO (asleep ECMO). Awake-ECMO patients showed fewer complications and better outcomes compared to ventilation patients. All patients in the awake group were successfully weaned off ECMO, while only 5 (18%) patients were weaned off ECMO in the asleep group. Furthermore, 9 (75%) patients survived until discharge in the awake group vs. 3 (11%) in the asleep group; 3 patients died of septic shock after weaning in the awake group, while 25 patients died of septic shock, hemodynamic disorder, bleeding, cerebral hemorrhage, etc., in the asleep group. These complications, including bleeding, pneumonia, hemolysis, and abdominal distension, etc., occurred less frequently in the asleep group compared to the awake group (P<0.05). Conclusions Awake V-A ECMO is an effective, feasible, and safe strategy in patients with perioperatively acute heart failure and can be applied as a bridge to cardiac function recovery or transplantation.
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Affiliation(s)
- Li Deng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Qingping Xia
- Department of Medical Research Center, Mudanjiang Medical University, Mudanjiang 157011, China
| | - Chao Chi
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guang Hu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Ellouze O, Lamirel J, Perrot J, Missaoui A, Daily T, Aho S, Petrosyan A, Guinot PG, Bouchot O, Bouhemad B. Extubation of patients undergoing extracorporeal life support. A retrospective study. Perfusion 2018; 34:50-57. [DOI: 10.1177/0267659118791072] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: The use of extracorporeal life support (ECLS) is increasing worldwide, in particular for the management of refractory cardiac arrest, cardiogenic shock and post cardiopulmonary bypass ventricular failure. Extubation of patients under extracorporeal membrane oxygenation (ECMO) for respiratory failure is a growing practice for adult and pediatric patients, especially for lung transplantation candidates. Because of potential complications and, specifically, accidental arterial decannulation, extubation of patients under ECLS is not standard practice. Our goal was to evaluate the interest in patient extubation under ECLS. Materials and methods: We performed a monocentric, retrospective study of all ECLS cases between January 2014 and January 2016. We excluded patients who died within the first 48 hours of ECLS. Results: We analyzed 57 of the initial 109 patients included in the study. The initial SOFA score was higher in the non-extubated group under ECLS, without significant difference (8.6 ± 2.8 vs 7.2 ± 2.1, p=0.065). Patients who were not extubated had a higher rate of acquired ventilator pneumonia (61.9% vs 26.7%, p=0.03). Moreover, patients who were extubated under ECLS had better 30-day survival rates (73.3% vs 40.5%, p=0.04). In multivariate analyses, the independent factors associated with mortality were age, duration of ECLS and the lack of extubation under ECLS. Conclusion: Extubation of patients under ECLS is safe and feasible. Furthermore, in extubated patients, we observed fewer cases of ventilator-associated pneumonia and better 30-day survival rates.
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Affiliation(s)
- Omar Ellouze
- Service d’Anesthésie Réanimation, CHU de Dijon, Dijon, France
| | - Julie Lamirel
- Service d’Anesthésie Réanimation, CHU de Dijon, Dijon, France
| | - Justine Perrot
- Service d’Anesthésie Réanimation, CHU de Dijon, Dijon, France
| | - Anis Missaoui
- Service d’Anesthésie Réanimation, CHU de Dijon, Dijon, France
| | - Theresa Daily
- Service d’Anesthésie Réanimation, CHU de Dijon, Dijon, France
| | - Serge Aho
- Service d’Epidémiologie et d’Hygiène Hospitalières, CHU de Dijon, Dijon, France
| | - Andranik Petrosyan
- Service de Chirurgie Cardiaque, Vasculaire et Thoracique, CHU de Dijon, Dijon, France
| | | | - Oliver Bouchot
- Service de Chirurgie Cardiaque, Vasculaire et Thoracique, CHU de Dijon, Dijon, France
| | - Belaid Bouhemad
- Service d’Anesthésie Réanimation, CHU de Dijon, Dijon, France
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15
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Schmidt F, Jack T, Sasse M, Mueller C, Schwerk N, Bobylev D, Beerbaum P, Koeditz H. Back to the roots? Dual cannulation strategy for ambulatory ECMO in adolescent lung transplant candidates: An alternative? Pediatr Transplant 2017; 21. [PMID: 28247591 DOI: 10.1111/petr.12907] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 11/29/2022]
Abstract
Bridging critically ill pediatric patients to lung transplantation still remains a major challenge. Although still controversial, within the last 5 years, ECMO has been increasingly used as a bridge to lung transplantation concept in adult and pediatric patients with acceptable outcomes. The outstanding developments in the field of extracorporeal devices and the introduction of awake ECMO concepts with the avoidance of mechanical ventilation have led to a real paradigm shift in the ICU management of pretransplant candidates with severe respiratory failure. Therefore, ECMO is no longer seen as a contraindication for lung transplantation at least at our center. Nevertheless, how to bridge these patients on ECMO still remains controversial. Thus, we introduced an ambulatory ECMO approach in adolescent lung transplant candidates with acute respiratory failure using a dual cannulation strategy and hereby present first results from this procedure.
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Affiliation(s)
- F Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - T Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - M Sasse
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - C Mueller
- Department of Pediatric Pneumology and Neonatology, Medical School Hannover, Hannover, Germany
| | - N Schwerk
- Department of Pediatric Pneumology and Neonatology, Medical School Hannover, Hannover, Germany
| | - D Bobylev
- Department of Cardiothoracic Surgery, Transplantation and Vascular Surgery, Medical School Hannover, Hannover, Germany
| | - P Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - H Koeditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
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16
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ECMO and cytokine removal for bridging to surgery in a patient with ischemic ventricular septal defect - a case report. Int J Artif Organs 2017; 40:526-529. [PMID: 28574104 DOI: 10.5301/ijao.5000600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 11/20/2022]
Abstract
Even in the modern era of percutaneous coronary intervention, postinfarction ventricular septal defect (VSD) remains a serious and often lethal complication. Whether or not immediate surgical repair or delaying surgery a few days aided by intra-aortic counterpulsation provides the optimal strategy remains a matter of debate. An interdisciplinary approach of intensivists and cardiac surgeons in this setting is mandatory. We report the use of veno-arterial extracorporeal membrane oxygenation and extracorporeal blood purification therapy (CytoSorb®) as bridging to surgical closure in a patient with an ischemic VSD leading to protracted cardiogenic shock after posterior myocardial infarction.
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Costa J, Dirnberger D, Froehlich C, Beaty C, Priest M, Ogino M. Awake extracorporeal membrane oxygenation in a neonatal patient with respiratory failure. Qatar Med J 2017. [PMCID: PMC5474640 DOI: 10.5339/qmj.2017.swacelso.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Joanna Costa
- 1Nemours/Alfred I DuPont Hospital for Children, Neonatology, Wilmington, DE, USA
| | - Daniel Dirnberger
- 1Nemours/Alfred I DuPont Hospital for Children, Neonatology, Wilmington, DE, USA
- 2F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Curtis Froehlich
- 1Nemours/Alfred I DuPont Hospital for Children, Neonatology, Wilmington, DE, USA
| | - Christopher Beaty
- 1Nemours/Alfred I DuPont Hospital for Children, Neonatology, Wilmington, DE, USA
| | - Marc Priest
- 1Nemours/Alfred I DuPont Hospital for Children, Neonatology, Wilmington, DE, USA
| | - Mark Ogino
- 1Nemours/Alfred I DuPont Hospital for Children, Neonatology, Wilmington, DE, USA
- 3Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Efficacy of “Awake ECMO” for critical respiratory failure after pediatric open-heart surgery. J Artif Organs 2015; 19:196-9. [DOI: 10.1007/s10047-015-0876-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/28/2015] [Indexed: 10/22/2022]
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