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Jucker JA, Cannizzaro V, Kirsch RE, Streuli JC, De Clercq E. Between hope and disillusionment: ECMO seen through the lens of nurses working in a neonatal and paediatric intensive care unit. Nurs Crit Care 2024; 29:765-776. [PMID: 38511290 DOI: 10.1111/nicc.13051] [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] [Received: 02/24/2023] [Revised: 12/06/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Using extracorporeal membrane oxygenation (ECMO) in paediatric and neonatal intensive care units (PICU/NICU) creates ethical challenges and carries a high risk for moral distress, burn out and team conflicts. AIM The study aimed to gain a more comprehensive understanding of the underlying factors affecting moral distress when using ECMO for infants and children by examining the attitudes of ECMO nurses. METHODS Four focus groups discussions were conducted with 21 critical care nurses working in a Swiss University Children's Hospital. Purposive sampling was adopted to identify research participants. The data were analysed using reflexive thematic analysis. RESULTS Unlike "miracle machine" stories in online media reports, specialized nurses working in PICU/NICU expressed both their hopes and fears towards this technology. Their accounts also contained references to events and factors that triggered experiences of moral distress: the unspeakable nature of the death of a child or infant; the seemingly lack of honest and transparent communication with parents; the apparent loss of situational awareness among doctors; the perceived lack of recognition for the role of nurses and the variability in end-of-life decision-making; the length of time it takes doctors to take important treatment decisions; and the resource intensity of an ECMO treatment. CONCLUSION The creation of a multidisciplinary moral community with transparent information among all involved health care professionals and the definition of clear treatment goals as well as the implementation of paediatric palliative care for all paediatric ECMO patients should become a priority if we want to alleviate situations of moral distress. RELEVANCE FOR CLINICAL PRACTICE The creation of a multidisciplinary moral community, clear treatment goals and the implementation of palliative care for all paediatric ECMO patients are crucial to alleviate situations of moral distress for nurses, and thus to improve provider well-being and the quality of patient care in PICU/NICU.
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Affiliation(s)
- Jovana A Jucker
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zürich, Switzerland
- Department of Neonatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Roxanne E Kirsch
- Department of Bioethics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jürg C Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, Zürich, Switzerland
- Stiftung Dialog Ethik, Zürich, Switzerland
| | - Eva De Clercq
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
- Stiftung Dialog Ethik, Zürich, Switzerland
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2
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Alizadeh F, Gauvreau K, Mayourian J, Brown E, Barreto JA, Blossom J, Bucholz E, Newburger JW, Kheir J, Vitali S, Thiagarajan RR, Moynihan K. Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes. Pediatrics 2023; 152:e2023061305. [PMID: 37933403 DOI: 10.1542/peds.2023-061305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.
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Affiliation(s)
| | | | | | | | | | - Jeff Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | | | | | - John Kheir
- Departments of Cardiology
- Departments of Pediatrics
| | - Sally Vitali
- Anesthesia, Critical Care, Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | | - Katie Moynihan
- Departments of Cardiology
- Departments of Pediatrics
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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3
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Fallon BP, Thompson AJ, Prater AR, Buchan S, Alberts T, Hoenerhoff M, Rojas-Pena A, Bartlett RH, Hirschl RB. Seven-day in vivo testing of a novel, low-resistance, pumpless pediatric artificial lung for long-term support. J Pediatr Surg 2022; 57:614-623. [PMID: 35953340 PMCID: PMC10112847 DOI: 10.1016/j.jpedsurg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/31/2022] [Accepted: 07/06/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION For children with end-stage lung disease that cannot wean from extracorporeal life support (ECLS), a wearable artificial lung would permit extubation and provide a bridge to recovery or transplantation. We evaluate the function of the novel Pediatric MLung-a low-resistance, pumpless artificial lung developed specifically for children-in healthy animal subjects. METHODS Adolescent "mini sheep" weighing 12-20 kg underwent left thoracotomy, cannulation of the main pulmonary artery (PA; inflow) and left atrium (outflow), and connection to the MLung. RESULTS Thirteen sheep were studied; 6 were supported for 7 days. Mean PA pressure was 23.9 ± 6.9 mmHg. MLung blood flow was 633±258 mL/min or 30.0 ± 16.0% of CO. MLung pressure drop was 4.4 ± 3.4 mmHg. Resistance was 7.2 ± 5.2 mmHg/L/min. Device outlet oxygen saturation was 99.0 ± 3.3% with inlet saturation 53.8 ± 7.3%. Oxygen delivery was 41.1 ± 18.4 mL O2/min (maximum 84.9 mL/min) or 2.8 ± 1.5 mL O2/min/kg. Platelet count significantly decreased; no platelet transfusions were required. Plasma free hemoglobin significantly increased only on day 7, at which point 2 of the animals had plasma free hemoglobin levels above 50 mg/dL. CONCLUSION The MLung provides adequate gas exchange at appropriate blood flows for the pediatric population in a PA-to-LA configuration. Further work remains to improve the biocompatibility of the device. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Alex J Thompson
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Aaron R Prater
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Skylar Buchan
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Trevor Alberts
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Mark Hoenerhoff
- In Vivo Animal Core, Unit for Laboratory Animal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Pena
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA; Department of Surgery, Section of Transplant Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Robert H Bartlett
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ronald B Hirschl
- Department of Surgery, Extracorporeal Life Support Laboratory, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA; Department of Surgery, Section of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, USA
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4
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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5
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Casar Berazaluce AM, Frischer JS. Hospital and Professional Charges and Reimbursement Patterns in Pediatric Extracorporeal Membrane Oxygenation. Am Surg 2022; 88:2612-2618. [PMID: 35574635 DOI: 10.1177/00031348221091968] [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: 11/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an expensive therapeutic modality. We sought to identify the main charge contributors to patient bills and analyze their patterns of reimbursement. We additionally sought to evaluate the impact of 2015 Current Procedural Terminology (CPT) code changes in professional billing for pediatric surgeons. METHODS A retrospective review of ECMO cases at a standalone quaternary children's hospital between 2008-2017 was performed. Itemized hospital and professional bills were analyzed. RESULTS Top charges included room rates, nitric oxide, medications, invasive support and monitoring, and laboratory testing. Average reimbursement was ∼60% for hospital and ∼36% for professional bills. CPT code changes in 2015 represented a 65% reduction in RVUs and 46% reduction in professional charges. Medicaid reimbursement for professional billing remained stable at 9%, and commercial reimbursement fell from 70% to 59% during the study period. CONCLUSIONS The main drivers of ECMO charges are unrelated to ECMO supplies or surgery. Evidence-based guidelines for ECMO management could make a difference in healthcare expenditure. Modern CPT codes depreciate RVUs and professional charges, compromising revenue. As the infrastructure required to provide this service is costly, diminishing returns may limit access to this therapy.
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Affiliation(s)
- Alejandra M Casar Berazaluce
- Division of Pediatric General and Thoracic Surgery, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Surgery, 14742University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jason S Frischer
- Division of Pediatric General and Thoracic Surgery, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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6
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Williamson CG, Tran Z, Rudasill S, Hadaya J, Verma A, Bridges AW, Satou G, Biniwale RM, Benharash P. Race-based disparities in access to surgical palliation for hypoplastic left heart syndrome. Surgery 2022; 172:500-505. [PMID: 35450745 DOI: 10.1016/j.surg.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome. METHODS The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center. RESULTS Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization. CONCLUSION We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sarah Rudasill
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Alexander W Bridges
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Gary Satou
- Division of Pediatric Cardiology, Mattel Children's Hospital, University of California, Los Angeles, CA
| | - Reshma M Biniwale
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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7
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Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States. J Trauma Acute Care Surg 2022; 93:e17-e29. [PMID: 35358106 DOI: 10.1097/ta.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
LEVEL OF EVIDENCE V.
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8
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Zheng H, Gong C, Chapman R, Yieh L, Friedlich P, Hay JW. Cost-effectiveness analysis of extended extracorporeal membrane oxygenation duration in newborns with congenital diaphragmatic hernia in the United States. Pediatr Neonatol 2022; 63:139-145. [PMID: 34742677 DOI: 10.1016/j.pedneo.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The duration of extracorporeal membrane oxygenation (ECMO) has been historically confined in many centers to two weeks. We evaluated the cost-effectiveness of additional weeks on ECMO beyond two weeks for newborns with congenital diaphragmatic hernia (CDH) who may require longer stays to maximize survival potential. METHODS We modeled lifetime outcomes using a decision tree from the US societal perspective. Survival at discharge, probability of long-term sequelae, direct medical costs, indirect costs, and quality-adjusted life years (QALY) for long-term disability were considered. Considering the nature of severity of CDH, we used $200,000 per QALY as the willingness-to-pay threshold in the base case. RESULTS The lifetime costs per CDH infant generated from staying on ECMO for ≤2 weeks, 2-3 weeks, and >3 weeks are $473,334, $654,771, $1,007,476, respectively (2018 USD), and the total QALYs gained from each treatment arm are 1.83, 3.6, and 5.05. In the base case, the net monetary benefits are -$108,034 for ECMO ≤2 weeks, $64,258 for 2-3 weeks, and $2955 for >3 weeks. In probabilistic simulations, a duration of ≤2 weeks is dominated by a duration of 2-3 weeks in 65.3% of cases and dominated by > 3 weeks in 60.2% of cases. A duration of 2-3 weeks is more cost-effective than >3 weeks in 68.6% of simulations. CONCLUSION Our findings suggest that 2-3 weeks of ECMO may be the most cost-effective for CDH infants that are unable to wean off at 2 weeks from the US societal perspective. Regardless of ECMO duration, ECMO use generates positive incremental NMB at WTP of $200,000 if the survival probability is greater than 0.3. Future research must be conducted to evaluate the long-term outcomes and sequelae of CDH patients post-discharge to better inform the clinical decision-making in neonatal intensive care unit.
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Affiliation(s)
- Hanke Zheng
- USC Leonard D. Schaeffer Center for Health Policy and Economics, 635 Downey Way, Verna & Peter Dauterive Hall (VPD), Los Angeles, CA, United States; Department of Pharmaceutical and Health Economics, USC School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, United States.
| | - Cynthia Gong
- USC Leonard D. Schaeffer Center for Health Policy and Economics, 635 Downey Way, Verna & Peter Dauterive Hall (VPD), Los Angeles, CA, United States; Fetal & Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, USC Keck School of Medicine, 4650 Sunset Blvd., Los Angeles, CA, United States
| | - Rachel Chapman
- Fetal & Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, USC Keck School of Medicine, 4650 Sunset Blvd., Los Angeles, CA, United States
| | - Leah Yieh
- Fetal & Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, USC Keck School of Medicine, 4650 Sunset Blvd., Los Angeles, CA, United States
| | - Philippe Friedlich
- Fetal & Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, USC Keck School of Medicine, 4650 Sunset Blvd., Los Angeles, CA, United States
| | - Joel W Hay
- USC Leonard D. Schaeffer Center for Health Policy and Economics, 635 Downey Way, Verna & Peter Dauterive Hall (VPD), Los Angeles, CA, United States; Department of Pharmaceutical and Health Economics, USC School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, United States
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9
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Extracorporeal Membrane Oxygenation for Pediatric Burn Patients: Is Management Improving Over Time? ASAIO J 2022; 68:426-431. [DOI: 10.1097/mat.0000000000001474] [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] Open
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10
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Fallon BP, Lautner-Csorba O, Thompson AJ, Lautner G, Kayden A, Johnson MD, Harvey SL, Langley MW, Peña AR, Bartlett RH, Hirschl RB. A pumpless artificial lung without systemic anticoagulation: The Nitric Oxide Surface Anticoagulation system. J Pediatr Surg 2022; 57:26-33. [PMID: 34649727 PMCID: PMC8810669 DOI: 10.1016/j.jpedsurg.2021.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/08/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Artificial lungs have the potential to serve as a bridge to transplantation or recovery for children with end-stage lung disease dependent on extracorporeal life support, but such devices currently require systemic anticoagulation. We describe our experience using the novel Nitric Oxide (NO) Surface Anticoagulation (NOSA) system-an NO-releasing circuit with NO in the sweep gas-with the Pediatric MLung-a low-resistance, pumpless artificial lung. METHODS NO flux testing: MLungs (n = 4) were tested using veno-venous extracorporeal life support in a sheep under anesthesia with blood flow set to 0.5 and 1 L/min and sweep gas blended with 100 ppm NO at 1, 2, and 4 L/min. NO and NO2 were measured in the sweep and exhaust gas to calculate NO flux across the MLung membrane. Pumpless implants: Sheep (20-100 kg, n = 3) underwent thoracotomy and cannulation via the pulmonary artery (device inflow) and left atrium (device outflow) using cannulae and circuit components coated with an NO donor (diazeniumdiolated dibutylhexanediamine; DBHD-N2O2) and argatroban. Animals were connected to the MLung with 100 ppm NO in the sweep gas under anesthesia for 24 h with no systemic anticoagulation after cannulation. RESULTS NO flux testing: NO flux averaged 3.4 ± 1.0 flux units (x10-10 mol/cm2/min) (human vascular endothelium: 0.5-4 flux units). Pumpless implants: 3 sheep survived 24 h with patent circuits. MLung blood flow was 716 ± 227 mL/min. Outlet oxygen saturation was 98.3 ± 2.6%. Activated clotting time was 151±24 s. Platelet count declined from 334,333 ± 112,225 to 123,667 ± 7,637 over 24 h. Plasma free hemoglobin and leukocyte and platelet activation did not significantly change. CONCLUSIONS The NOSA system provides NO flux across a gas-exchange membrane of a pumpless artificial lung at a similar rate as native vascular endothelium and achieves effective local anticoagulation of an artificial lung circuit for 24 h.
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Affiliation(s)
- Brian P Fallon
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, B560 MSRB II/SPC 5686, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Orsolya Lautner-Csorba
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Alex J Thompson
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Gergely Lautner
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Adrianna Kayden
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Matthew D Johnson
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Stephen L Harvey
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Mark W Langley
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Alvaro Rojas Peña
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Robert H Bartlett
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Ronald B Hirschl
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA,Department of Surgery, Section of Pediatric Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
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11
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Surgical Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation Cannulation: Early Repair Improves Survival. Ann Surg 2021; 274:186-194. [PMID: 31425289 DOI: 10.1097/sla.0000000000003386] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the optimal timing of congenital diaphragmatic hernia (CDH) repair after extracorporeal membrane oxygenation (ECMO) cannulation. SUMMARY BACKGROUND DATA The timing of CDH repair after ECMO cannulation remains a controversial topic due to studies with low power or strong selection bias. METHODS This is a 2-aim retrospective cohort study based on the CDH Study Group registry for the period of 2007-2017. Aim 1-Compare On versus After ECMO repair. Aim 2-Compare Early versus Late repair on ECMO. In order to minimize selection bias and account for non-repairs, subjects in each aim were stratified into study groups based on their treatment center's characteristics. In each aim, the study groups were matched based on propensity score (PS). The main outcomes included mortality rate and incidence of non-repair. RESULTS In aim 1, 136 patients remained in each group after PS matching. Compared to the After ECMO group, patients in the On ECMO group demonstrated a lower mortality rate, hazard ratio (HR) 0.54 (0.38, 0.77) (P < 0.001), and lower incidence of non-repair, 5.9% versus 33.8% (P < 0.001). In aim 2, 77 patients remained in each group after PS matching. Compared to the Late group, Early repair of CDH on ECMO was associated with a lower mortality rate, HR 0.51 (0.33, 0.77) (P = 0.002), and lower incidence of non-repair, 9.1% versus 44.2% (P < 0.001). CONCLUSIONS The approach of early repair after ECMO cannulation is associated with improved survival compared to delayed surgical correction.
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Fetal liver and lung volume index of neonatal survival with congenital diaphragmatic hernia. Pediatr Radiol 2021; 51:1637-1644. [PMID: 33779798 DOI: 10.1007/s00247-021-05049-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/28/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) assesses pulmonary hypoplasia in fetal congenital diaphragmatic hernia (CDH). Neonatal mortality may occur with CDH. OBJECTIVE To quantify MRI parameters associated with neonatal survival in fetuses with isolated CDH. MATERIALS AND METHODS Fetal MRI for assessing CDH included region of interest (ROI) measurements for total lung volume (TLV), herniated liver volume, herniated other organ volume and predicted lung volume. Ratios of observed lung volume and liver up volume to predicted lung volume (observed to predicted TLV, percentage of the thorax occupied by liver) were calculated and compared to neonatal outcomes. Analyses included Wilcoxon rank sum test, multivariate logistic regression and receiver operating characteristic (ROC) curves. RESULTS Of 61 studies, the median observed to predicted TLV was 0.25 in survivors and 0.16 in non-survivors (P=0.001) with CDH. The median percentage of the thorax occupied by liver was 0.02 in survivors and 0.22 in non-survivors (P<0.001). The association of observed to predicted TLV and percentage of the thorax occupied by liver with survival for gestational age (GA) >28 weeks was greater compared to GA ≤28 weeks. The ROC analysis demonstrated an area under the curve of 0.96 (95% confidence interval 0.91-1.00) for the combined observed to predicted TLV, percentage of the thorax occupied by liver and GA. CONCLUSION The percentage of the thorax occupied by liver and observed to predicted TLV was predictive of neonatal survival in fetuses with CDH.
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13
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Sanaiha Y, Khoubian JJ, Williamson CG, Aguayo E, Dobaria V, Srivastava N, Benharash P. Trends in Mortality and Costs of Pediatric Extracorporeal Life Support. Pediatrics 2020; 146:peds.2019-3564. [PMID: 32801159 DOI: 10.1542/peds.2019-3564] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations. METHODS We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008-2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs. RESULTS Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalizations increased 329%, from 11 to 46 cases per 100 000 pediatric hospitalizations, from 2008 to 2015 (P < .001). Overall mortality decreased from 50.3% to 34.6% (P < .001). Adjusted hospital costs increased significantly ($214 046 ± 11 822 to 324 841 ± 25 621; P = .002) during the study period despite a stable overall hospital LOS (46 ± 6 to 44 ± 4 days; P = .94). CONCLUSIONS Use of ECLS in pediatric patients has increased with substantially improved ECLS survival rates. Hospital costs have increased significantly despite a stable LOS in this group. Dissemination of this costly yet life-saving technology warrants ongoing analysis of use trends to identify areas for quality improvement.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
| | - Jonathan J Khoubian
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and.,Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
| | - Neeraj Srivastava
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
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Aiello SR, Flores S, Coughlin M, Villarreal EG, Loomba RS. Antithrombin use during pediatric cardiac extracorporeal membrane oxygenation admission: insights from a national database. Perfusion 2020; 36:138-145. [PMID: 32650697 DOI: 10.1177/0267659120939758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The frequency of extracorporeal membrane oxygenation in pediatric patients continues to increase, especially in patients with complex congenital heart disease. Providing adequate anticoagulation is necessary for patients on extracorporeal membrane oxygenation and is achieved with adequate heparin administration. Antithrombin is administered to potentiate heparin's effects. However, the efficacy of antithrombin supplementation is unclear and a clear clinical benefit has not been established. We present a large retrospective study examining the effects of antithrombin on pediatric patients receiving extracorporeal membrane oxygenation. METHODS Data for this study were obtained from the Pediatric Health Information System and Pediatric Health Information System+ databases from 2004 to 2015. Pediatric patients receiving extracorporeal membrane oxygenation with a congenital heart disease diagnosis were included and divided into groups that did or did not utilize antithrombin. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. RESULTS A total of 9,193 admissions were included and 865 (9.4%) utilized antithrombin. Between groups, there were significantly different frequencies of co-morbidities, cardiac lesion types and antithrombin usage over the study period. There were significantly lower odds in the antithrombin group of venous thrombosis. Antithrombin was not significantly associated with hemorrhage; however, antithrombin was associated with increased inpatient mortality and a decrease in length of stay and billed charges. CONCLUSION Antithrombin administration is associated with increased mortality, a shorter length of stay, and decreased billing cost. Recently, antithrombin usage has been decreasing-potentially due to the reported lack of clinical benefit. Together, these results reinforce that antithrombin may not be indicated for all pediatric extracorporeal membrane oxygenation patients.
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Affiliation(s)
- Salvatore R Aiello
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
| | - Saul Flores
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Megan Coughlin
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Enrique G Villarreal
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
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Gong CL, Song AY, Horak R, Friedlich PS, Lakshmanan A, Pruetz JD, Yieh L, Ram Kumar S, Williams RG. Impact of Confounding on Cost, Survival, and Length-of-Stay Outcomes for Neonates with Hypoplastic Left Heart Syndrome Undergoing Stage 1 Palliation Surgery. Pediatr Cardiol 2020; 41:996-1011. [PMID: 32337623 DOI: 10.1007/s00246-020-02348-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Abstract
The objective of this analysis was to update trends in LOS and costs by survivorship and ECMO use among neonates with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation surgery using 2016 data from the Healthcare Cost and Utilization Project Kids' Inpatient Database. We identified neonates ≤ 28 days old with HLHS undergoing Stage 1 surgery, defined as a Norwood procedure with modified Blalock-Taussig (BT) shunt, Sano modification, or both. Multivariable regression with year random effects was used to compare LOS and costs by hospital region, case volume, survivorship, and ECMO vs. no ECMO. An E-value analysis, an approach for conducting sensitivity analysis for unmeasured confounding, was performed to determine if unmeasured confounding contributed to the observed effects. Significant differences in total costs, LOS, and mortality were noted by hospital region, ECMO use, and sub-analyses of case volume. However, other than ECMO use and mortality, the maximum E-value confidence interval bound was 1.71, suggesting that these differences would disappear with an unmeasured confounder 1.71 times more associated with both the outcome and exposure (e.g., socioeconomic factors, environment, etc.) Our findings confirm previous literature demonstrating significant resource utilization among Norwood patients, particularly those undergoing ECMO use. Based on our E-value analysis, differences by hospital region and case volume can be explained by moderate unobserved confounding, rather than a reflection of the quality of care provided. Future analyses on surgical quality must account for unobserved factors to provide meaningful information for quality improvement.
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Affiliation(s)
- Cynthia L Gong
- Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA. .,Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, Los Angeles, USA. .,Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA.
| | - Ashley Y Song
- Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA.,Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Robin Horak
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA.,Department of Anesthesia and Critical Care, Children's Hospital Los Angeles, Los Angeles, USA
| | - Philippe S Friedlich
- Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA
| | - Ashwini Lakshmanan
- Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA.,Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, Los Angeles, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA.,Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jay D Pruetz
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA.,Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Los Angeles, Los Angeles, USA
| | - Leah Yieh
- Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA.,Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, Los Angeles, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA
| | - S Ram Kumar
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA.,Division of Cardiothoracic Surgery, Department of Surgery, Heart Institute, Children's Hospital Los Angeles, Los Angeles, USA
| | - Roberta G Williams
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA.,Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Los Angeles, Los Angeles, USA
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Fernando SM, Qureshi D, Tanuseputro P, Dhanani S, Guerguerian AM, Shemie SD, Talarico R, Fan E, Munshi L, Rochwerg B, Scales DC, Brodie D, Thavorn K, Kyeremanteng K. Long-term survival and costs following extracorporeal membrane oxygenation in critically ill children-a population-based cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:131. [PMID: 32252807 PMCID: PMC7137509 DOI: 10.1186/s13054-020-02844-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/21/2020] [Indexed: 12/16/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is used to provide temporary cardiorespiratory support to critically ill children. While short-term outcomes and costs have been evaluated in this population, less is known regarding long-term survival and costs. Methods Population-based cohort study from Ontario, Canada (October 1, 2009 to March 31, 2017), of pediatric patients (< 18 years of age) receiving ECMO, identified through the use of an ECMO procedural code. Outcomes were identified through linkage to provincial health databases. Primary outcome was survival, measured to hospital discharge, as well as at 1 year, 2 years, and 5 years following ECMO initiation. We evaluated total patient costs in the first year following ECMO. Results We analyzed 342 pediatric patients. Mean age at ECMO initiation was 2.9 years (standard deviation [SD] = 5.0). Median time from hospital admission to ECMO initiation was 5 days (interquartile range [IQR] = 1–13 days). Overall survival to hospital discharge was 56.4%. Survival at 1 year, 2 years, and 5 years was 51.5%, 50.0%, and 42.1%, respectively. Among survivors, 99.5% were discharged home. Median total costs among all patients in the year following hospital admission were $147,957 (IQR $70,571–$300,295). Of these costs, the large proportion were attributable to the inpatient cost from the index admission (median $119,197, IQR $57,839–$250,675). Conclusions Children requiring ECMO continue to have a significant in-hospital mortality, but reassuringly, there is little decrease in long-term survival at 1 year. Median costs among all patients were substantial, but largely reflect inpatient hospital costs, rather than post-discharge outpatient costs. This information provides value to providers and health systems, allowing for prognostication of short- and long-term outcomes, as well as long-term healthcare-related expenses for pediatric ECMO survivors.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Danial Qureshi
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sonny Dhanani
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.,Division of Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne-Marie Guerguerian
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sam D Shemie
- Department of Pediatrics, McGill University, Montreal, QC, Canada.,Division of Critical Care, Montreal Children's Hospital, Montreal, QC, Canada
| | - Robert Talarico
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Damon C Scales
- ICES, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
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17
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Kirby E, Keijzer R. Congenital diaphragmatic hernia: current management strategies from antenatal diagnosis to long-term follow-up. Pediatr Surg Int 2020; 36:415-429. [PMID: 32072236 DOI: 10.1007/s00383-020-04625-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/16/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental birth defect consisting of a diaphragmatic defect and abnormal lung development. CDH complicates 2.3-2.8 per 10,000 live births. Despite efforts to standardize clinical practice, management of CDH remains challenging. Frequent re-evaluation of clinical practices in CDH reveals that management of CDH is evolving from one of postnatal stabilization to prenatal optimization. Translational research reveals promising avenues for in utero therapeutic intervention, including fetoscopic endoluminal tracheal occlusion. These remain highly experimental and demand improved antenatal diagnostics. Timely diagnosis of CDH and identification of severely affected fetuses allow time for delivery planning or in utero therapeutics. Optimal perinatal care and surgical treatment strategies are highly debated. Improved CDH mortality rates have placed increased emphasis on identifying and monitoring the long-term sequelae of disease throughout childhood and into adulthood. We review the current management strategies for CDH, highlighting where progress has been made, and where future developments have the potential to revolutionize care in this vulnerable patient population.
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Affiliation(s)
- Eimear Kirby
- Trinity College Dublin School of Medicine, Trinity Biomedical Sciences Institute, Dublin, Ireland
| | - Richard Keijzer
- Thorlakson Chair in Surgical Research, Division of Pediatric Surgery, Department of Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada. .,Department of Pediatrics and Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada. .,Department of Physiology and Pathophysiology and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada.
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18
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Wagner R, Montalva L, Zani A, Keijzer R. Basic and translational science advances in congenital diaphragmatic hernia. Semin Perinatol 2020; 44:151170. [PMID: 31427115 DOI: 10.1053/j.semperi.2019.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Congenital Diaphragmatic Hernia (CDH) is a birth defect that is characterized by lung hypoplasia, pulmonary hypertension and a diaphragmatic defect that allows herniation of abdominal organs into the thoracic cavity. Although widely unknown to the public, it occurs as frequently as cystic fibrosis (1:2500). There is no monogenetic cause, but different animal models revealed various biological processes and epigenetic factors involved in the pathogenesis. However, the pathobiology of CDH is not sufficiently understood and its mortality still ranges between 30 and 50%. Future collaborative initiatives are required to improve our basic knowledge and advance novel strategies to (prenatally) treat the abnormal lung development. This review focusses on the genetic, epigenetic and protein background and the latest advances in basic and translational aspects of CDH research.
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Affiliation(s)
- Richard Wagner
- Departments of Surgery, Division of Pediatric Surgery, Pediatrics & Child Health and Physiology & Pathophysiology (Adjunct), University of Manitoba and Children's Hospital Research Institute of Manitoba, Biology of Breathing Theme, Winnipeg, Manitoba, Canada; Department of Pediatric Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Louise Montalva
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada and Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada; Department of Pediatric Surgery, Hospital Robert Debré, Paris, France
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada and Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Richard Keijzer
- Departments of Surgery, Division of Pediatric Surgery, Pediatrics & Child Health and Physiology & Pathophysiology (Adjunct), University of Manitoba and Children's Hospital Research Institute of Manitoba, Biology of Breathing Theme, Winnipeg, Manitoba, Canada.
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19
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Sorce LR, Curley MAQ, Kleinpell R, Swanson B, Meier PP. Mother's Own Milk Feeding and Severity of Respiratory Illness in Acutely Ill Children: An Integrative Review. J Pediatr Nurs 2020; 50:5-13. [PMID: 31670137 DOI: 10.1016/j.pedn.2019.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 03/25/2019] [Accepted: 09/10/2019] [Indexed: 12/19/2022]
Abstract
PROBLEM Breastfed infants experience less severe infections while actively breastfeeding. However, little is known about whether a history of prior breastfeeding affects severity of illness. Therefore, the purpose of this integrative review was to examine the relationship between previous exposure to mother's own milk (MOM) feeding and severity of respiratory infectious illness in infants and children. ELIGIBILITY CRITERIA Studies meeting the following criteria were included: human subjects, term birth, ages 0-35 months at time of study, diagnosis of pneumonia, bronchiolitis or croup, MOM feeding, and statistical analyses reporting separate respiratory infectious illness outcomes when combined with other infections. SAMPLE Twelve articles met eligibility criteria. RESULTS Major findings were inconsistent definitions of both dose and exposure period of breastfeeding and the severity of illness. In particular, the severity of illness measure was limited by the use of proxy variables such as emergency room visits or hospitalizations that lacked reliability and validity. However, given this limitation, the data suggested that exclusive breastfeeding for four to six months was associated with reduced severity of illness as measured by frequency of visits to the primary care provider office, emergency department or hospitalization. CONCLUSIONS Future research in this area should incorporate reliable and valid measures of MOM dose and exposure period and severity of illness outcomes in the critically ill child. IMPLICATIONS Among many positive outcomes associated with breastfeeding, an additional talking point for encouragement of exclusive breastfeeding for four to six months may be protective against severe respiratory infectious illness after cessation of breastfeeding.
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Affiliation(s)
- Lauren R Sorce
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA.
| | - Martha A Q Curley
- Ruth M. Colket Endowed Chair in Pediatric Nursing, Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Anesthesia and Critical Care Medicine - Perelman School of Medicine, Philadelphia, PA USA.
| | - Ruth Kleinpell
- Rush University College of Nursing, Nashville, TN USA; Vanderbilt University School of Nursing, Nashville, TN USA.
| | - Barbara Swanson
- Adult Health & Gerontological Nursing, Nursing Science Studies, Journal of the Association of Nurses in AIDS Care, Rush University College of Nursing, Chicago, IL USA.
| | - Paula P Meier
- Neonatal Intensive Care, Pediatrics, Women, Children and Family Nursing, Rush University Medical Chicago, IL USA.
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20
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Kirby E, Tse WH, Patel D, Keijzer R. First steps in the development of a liquid biopsy in situ hybridization protocol to determine circular RNA biomarkers in rat biofluids. Pediatr Surg Int 2019; 35:1329-1338. [PMID: 31570973 DOI: 10.1007/s00383-019-04558-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Epigenetic factors are involved in the pathogenesis of congenital diaphragmatic hernia (CDH). Circular RNAs (circRNAs) are epigenetic regulators amenable to biomarker profiling. Here, we aimed to develop a liquid biopsy protocol to detect pathognomonic circRNA changes in biofluids. METHODS Our protocol is adapted from the existing BaseScope™ in situ hybridization technique. Rat biofluids were fixed in a gelatin-coated 96-well plate with formalin. Probes were designed to target circRNAs with significant fold change in nitrofen-induced CDH. FastRED fluorescence was assessed using a plate reader and confirmed with confocal microscopy. We tested maternal serum and amniotic fluid samples from control and nitrofen-treated rats. RESULTS We detected circRNAs in rat serum and amniotic fluid from control and CDH (nitrofen-treated) rats using fluorescent readout. CircRNA signal was observed in fixed biofluids as fluorescent punctate foci under confocal laser scanning microscopy. This was confirmed by comparison to BaseScope™ lung tissue sections. Signal was concentration dependent and DNase resistant. CONCLUSION We successfully adapted BaseScope™ to detect circRNAs in rat biofluids: serum and amniotic fluid. We detected signal from probes targeted to circRNAs that are dysregulated in rat CDH. This work establishes the preliminary feasibility of circRNA detection in prenatal diagnostics.
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Affiliation(s)
- Eimear Kirby
- Trinity Biomedical Sciences Institute, Trinity College Dublin School of Medicine, Dublin, Ireland
- Division of Pediatric Surgery, Departments of Surgery, Pediatrics & Child Health and Physiology & Pathophysiology, University of Manitoba, Winnipeg, MB, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Wai Hei Tse
- Division of Pediatric Surgery, Departments of Surgery, Pediatrics & Child Health and Physiology & Pathophysiology, University of Manitoba, Winnipeg, MB, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Daywin Patel
- Division of Pediatric Surgery, Departments of Surgery, Pediatrics & Child Health and Physiology & Pathophysiology, University of Manitoba, Winnipeg, MB, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Richard Keijzer
- Division of Pediatric Surgery, Departments of Surgery, Pediatrics & Child Health and Physiology & Pathophysiology, University of Manitoba, Winnipeg, MB, Canada.
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada.
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21
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Erickson S. Extra-corporeal membrane oxygenation in paediatric acute respiratory distress syndrome: overrated or underutilized? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:512. [PMID: 31728365 DOI: 10.21037/atm.2019.09.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass which may provide support for severe cardiorespiratory failure including paediatric acute respiratory distress syndrome (PARDS). While ECMO was initially demonstrated to successfully support neonates with severe respiratory failure, the use of ECMO has expanded rapidly to support both paediatric and adult respiratory failure. Extracorporeal Life Support Organization (ELSO) registry data shows that the use of ECMO for paediatric respiratory failure has expanded rapidly over the past decades with increasing use of venovenous ECMO. Despite the increasing complexity of children supported by ECMO for ARDS, outcomes have remained consistent with survival to hospital discharge greater than 50%. ECMO complications are still common and potentially devastating, especially neurological complications. There is grade 1 evidence to support the use of ECMO in both neonatal and adult respiratory failure but evidence in paediatric respiratory failure is confined to case series and case-control studies. While there are no published guidelines for use of ECMO in PARDS, in particular no clearly defined inclusion and exclusion criteria, current evidence suggests that children with severe ARDS may benefit from ECMO support, with survival to hospital discharge equivalent or better than conventional management in children with severe ARDS.
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Affiliation(s)
- Simon Erickson
- Paediatric Critical Care, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Senior Lecturer, University of Western Australia, Hackett Drive, Nedlands, Western Australia, Australia
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Lorusso R, Raffa GM, Kowalewski M, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, Oreto L, D'Alessandro DA, Boeken U, Whitman G. Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients. J Heart Lung Transplant 2019; 38:1144-1161. [PMID: 31421976 DOI: 10.1016/j.healun.2019.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/19/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy.
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Khalid Alenizy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Niels Sluijpers
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maged Makhoul
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Brodie
- Division of Pulmonary & Critical Care Medicine, Columbia University, New York, New York
| | - Mike McMullan
- Cardiac Surgery Unit, Seattle Children Hospital, Seattle, Washington
| | - I-Wen Wang
- Cardiac Transplantation and Mechanical Circulatory Support Unit, Indiana University School of Medicine, Health Methodist Hospital, Indianapolis, Indiana
| | - Paolo Meani
- Heart & Vascular Centre, Cardiology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University of Singapore, Singapore
| | - Heidi Dalton
- INOVA Fairfax Medical Centre, Adult and Pediatric ECMO Service, Falls Church, Virginia
| | - Ryan Barbaro
- Division of Pediatric Critical Care and Child Health Evaluation and Research Unit, Ann Arbor, Michigan
| | - Xaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nicholas Cavarocchi
- Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Ped Cardiovascular Surgery, National Taiwan University Hospital, Taipei, China
| | - Ravi Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Peta Alexander
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lilia Oreto
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Pediatric Hospital, Taormina, Messina, Italy
| | - David A D'Alessandro
- Cardio-Thoracic Surgery Department, Massachusetts Medical Center, Boston, Massachusetts
| | - Udo Boeken
- Cardiovascular Surgery Unit, University of Düsseldorf, Düsseldorf, Germany
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit and Heart Transplant, Johns Hopkins Hospital, Baltimore, Maryland
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Robb K, Badheka A, Wang T, Rampa S, Allareddy V, Allareddy V. Use of extracorporeal membrane oxygenation and associated outcomes in children hospitalized for sepsis in the United States: A large population-based study. PLoS One 2019; 14:e0215730. [PMID: 31026292 PMCID: PMC6485643 DOI: 10.1371/journal.pone.0215730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 04/08/2019] [Indexed: 12/14/2022] Open
Abstract
Objective The American College of Critical Care Medicine recommends that children with persistent fluid, catecholamine, and hormone-resistant septic shock be considered for extracorporeal membrane oxygenation (ECMO) support. Current national estimates of ECMO use in hospitalized children with sepsis are unknown. We sought to examine the use of ECMO in these children and to examine the overall outcomes such as in-hospital mortality, length of stay (LOS), and hospitalization charges (HC). Methods A retrospective analysis of the National Inpatient Sample, which approximates a 20% stratified sample of all discharges from United States community hospitals, was performed. All children (≤ 17 years) who were hospitalized for sepsis between 2012 and 2014 were included. The associations between ECMO and outcomes were examined by multivariable linear and logistic regression models. Results A total of 62,310 children were included in the study. The mean age was 4.2 years. ECMO was provided to 415 of the children (0.67% of the cohort with sepsis). Comparative outcomes of sepsis in children who received ECMO versus those who did not included in-hospital mortality rate (41% vs 2.8%), mean HC ($749,370 vs $90,568) and mean LOS (28.8 vs 9.1 days). After adjusting for confounding factors, children receiving ECMO had higher odds of mortality (OR 11.15, 95% CI 6.57–18.92, p < 0.001), longer LOS (6.6 days longer, p = 0.0004), and higher HC ($510,523 higher, p < 0.0001). Conclusions Use of ECMO in children with sepsis is associated with considerable resource utilization but has 59% survival to discharge. Further studies are needed to examine the post discharge and neurocognitive outcomes in survivors.
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Affiliation(s)
- Katharine Robb
- Division of Critical Care, Department of Pediatrics, Stead Family Children’s Hospital, University of Iowa, Iowa City, Iowa, United States of America
| | - Aditya Badheka
- Division of Critical Care, Department of Pediatrics, Stead Family Children’s Hospital, University of Iowa, Iowa City, Iowa, United States of America
- * E-mail:
| | - Tong Wang
- Department of Management Sciences, Tippie College of Business, University of Iowa, Iowa City, Iowa, United States of America
| | - Sankeerth Rampa
- Management & Marketing Department, School of Business, Rhode Island College, Providence, Rhode Island, United States of America
| | - Veerasathpurush Allareddy
- Brodie Craniofacial Endowed Chair, Department of Orthodontics, College of Dentistry, University of Illinois at Chicago, Chicago, Illinois, United States of America
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Azizov F, Merkle J, Fatullayev J, Eghbalzadeh K, Djordjevic I, Weber C, Saenko S, Kroener A, Zeriouh M, Sabashnikov A, Bennink G, Wahlers T. Outcomes and factors associated with early mortality in pediatric and neonatal patients requiring extracorporeal membrane oxygenation for heart and lung failure. J Thorac Dis 2019; 11:S871-S888. [PMID: 31183167 PMCID: PMC6535479 DOI: 10.21037/jtd.2018.11.107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/20/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Mortality and morbidity after surgical repair for complex congenital heart defects and severe cardiopulmonary failure on extracorporeal membrane oxygenation (ECMO) support remain high despite significant advances in medical management and technological improvements. We report on outcomes and factors after using ECMO in our surgical pediatric population including short- and long-term survival. METHODS A total of 45 neonatal and pediatric patients were identified who needed ECMO in our department between January 2008 and December 2016. In 41 cases (91%) a vaECMO (ECLS) was implemented, whereas 4 patients (9%) received vvECMO treatment for respiratory failure. In 33 cases vaECMO was implanted following cardiac surgery for congenital heart disease (CHD), whereas in 8 patients ECMO was utilized by means of extracorporeal cardiopulmonary resuscitation (eCPR) following refractory cardiac arrest. The primary endpoint of the present study was survival to discharge and long-term survival free from neurological impairments. Univariate and bivariate analysis was performed to address predictors for outcome. Kaplan-Meier survival analysis was used to address mid- and long-term survival. RESULTS Median [IQR] duration of ECMO support was 3 [2, 5] days (range, 1-17 days). Median age at ECMO implantation was 128 [14, 1,813] days, median weight of patients was 5.4 [3.3, 12] kg. Totally 10 patients included in this study were diagnosed with concomitant genetic conditions. A total of 20 (44%) patients were successfully weaned off ECMO (survived >24 h after ECMO explantation), whereas 15 (33%) of them survived to discharge. Single ventricle (SV) repair was performed in 14, biventricular repair in 19 patients. Neonates (<30 days of age), female patients, patients with genetic conditions, SV repair patients, and eCPR patient cohort showed lower odds of survival on ECMO. Failed myocardial recovery (P=0.001), profound circulatory failure despite a high dose of catecholamines (P<0.001), neurological impairment pre-ECMO and post-ECMO (P=0.04 and P<0.001, respectively), and severe pulmonary failure despite high respiratory pressure settings were most common mortality reasons. CONCLUSIONS ECMO provides efficient therapy opportunities for life-threatening conditions. Nevertheless, neonates and pediatric patients who underwent ECMO were at high risk for cerebrovascular events and poor survival. Appropriate patient selection using predictors of outcome reducing complications might improve outcomes of this patient cohort.
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Affiliation(s)
| | | | - Javid Fatullayev
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Sergey Saenko
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Axel Kroener
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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Peng JC, Ding J, He ZY, Deng YX, Xing SP, Zhao XY, Li Z, Dai YL, Gao Y. The efficacy of extracorporeal membrane oxygenation in liver transplantation from non-heart-beating donors: A systemic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14722. [PMID: 30817617 PMCID: PMC6831268 DOI: 10.1097/md.0000000000014722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A systematic review and meta-analysis was made to see whether extracorporeal membrane oxygenation (ECMO) in liver transplantation could improve non-heart-beating donors (NHBDs) recipients' outcomes compared with donors after brain death (DBDs) recipients. METHODS We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for eligible studies. The study eligible criteria are cohort or case-control studies using ECMO in all NHBDs; studies involved a comparison group of DBDs; and studies evaluated 1-year graft and patient survival rate in NHBDs and DBDs groups. RESULTS Four studies with 704 patients fulfilled the inclusion criteria. The pooled odds ratio (OR) of 1-year patient survival rate in NHBDs recipients compared with DBDs recipients was 0.8 (95% confidence interval [CI], 0.41-1.55). The pooled OR of 1-year graft survival rate in NHBDs recipients compared with DBDs recipients was 0.46 (95% CI, 0.26-0.81). NHBDs recipients were at greater risks to the occurrence of primary nonfunction (PNF) (OR = 7.12, 95% CI, 1.84-27.52) and ischemic cholangiopathy (IC) (OR = 9.46, 95% CI, 2.76-32.4) than DBDs recipients. CONCLUSIONS ECMO makes 1-year patient survival acceptable in NHBDs recipients. One-year graft survival rate was lower in NHBDs recipients than in DBDs recipients. Compared with DBDs recipients, the risks to develop PNF and IC were increased among NHBDs recipients.
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Pandya S, Baser O, Wan GJ, Lovelace B, Potenziano J, Pham AT, Huang X, Wang L. The Burden of Hypoxic Respiratory Failure in Preterm and Term/Near-term Infants in the United States 2011-2015. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:130-141. [PMID: 32685586 PMCID: PMC7299458 DOI: 10.36469/9682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This study quantified the burden of hypoxic respiratory failure (HRF)/persistent pulmonary hypertension of newborn (PPHN) in preterm and term/near-term infants (T/NTs) by examining health care resource utilization (HRU) and charges in the United States. METHODS Preterms and T/NTs (≤34 and >34 weeks of gestation, respectively) having HRF/PPHN, with/without meconium aspiration in inpatient setting from January 1, 2011-October 31, 2015 were identified from the Vizient database (first hospitalization=index hospitalization). Comorbidities, treatments, HRU, and charges during index hospitalization were evaluated among preterms and T/NTs with HRF/PPHN. Logistic regression was performed to evaluate mortality-related factors. RESULTS This retrospective study included 504 preterms and 414 T/NTs with HRF/PPHN. Preterms were more likely to have respiratory distress syndrome, neonatal jaundice, and anemia of prematurity than T/NTs. Preterms had significantly longer inpatient stays (54.1 vs 29.0 days), time in a neonatal intensive care unit (34.1 vs 17.5 days), time on ventilation (4.7 vs 2.2 days), and higher total hospitalization charges ($613 350 vs $422 558) (all P<0.001). Similar rates were observed for use of antibiotics (96.2% vs 95.4%), sildenafil (9.5% vs 8.2%), or inhaled nitric oxide (93.8% vs 94.2%). Preterms had a significantly higher likelihood of mortality than T/NTs (odds ratio: 3.6, 95% confidence interval: 2.3-5.0). CONCLUSIONS The findings of more severe comorbidities, higher HRU, hospitalization charges, and mortality in preterms than in T/NTs underscore the significant clinical and economic burden of HRF/PPHN among infants. The results show significant unmet medical need; further research is warranted to determine new treatments and real-world evidence for improved patient outcomes.
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Affiliation(s)
| | - Onur Baser
- Department of Internal Medicine, the University of Michigan, Ann Arbor, MI
| | | | | | | | - An T Pham
- School of Pharmacy, University of California San Francisco, San Francisco, CA
| | | | - Li Wang
- STATinMED Research, Plano, TX
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National trends in neonatal extracorporeal membrane oxygenation in the United States. J Perinatol 2018; 38:1106-1113. [PMID: 29795325 DOI: 10.1038/s41372-018-0129-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine trends in neonatal extracorporeal membrane oxygenation (ECMO) utilization from 2002-2011. STUDY DESIGN Using the Nationwide inpatient sample (NIS), we conducted a population-based retrospective cohort study to identify ECMO utilization among neonates. Incidence of ECMO utilization, length of stay (LOS), cost and mortality were estimated. RESULT In all, 33,367,146 neonates were identified of which 7603 (18 per 100,000 live births) underwent ECMO. Neonatal ECMO increased from 12 to 23 runs per 100,000 live births. Mortality was 48.4%, decreasing from 47.5 to 41.9% between 2002 and 2011. On multivariate analysis, mortality was significantly higher for infectious indications (OR 4.1; CI 1.1-16.0), E-CPR (OR 3.8; CI 1.4-10.7) and cardiac indications (OR 2.0; CI 1.5-2.8). On hierarchical regression, LOS increased by 1.6 days each year (p = 0.02) and cost of hospitalization increased by $14,033 each year (p < 0.0001). CONCLUSION Neonatal ECMO utilization increased, while mortality decreased during the study period. These findings suggest an improvement in neonatal ECMO care.
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Islam S, Kaul P, Tran DT, Mackie AS. Health Care Resource Utilization Among Children With Congenital Heart Disease: A Population-Based Study. Can J Cardiol 2018; 34:1289-1297. [PMID: 30205987 DOI: 10.1016/j.cjca.2018.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Data regarding health care resource utilization (HRU) in early childhood among children with congenital heart disease (CHD) are scarce. Therefore, we sought to describe the extent of HRU incurred among children with CHD in the first 5 years of life. METHODS This population-based retrospective cohort study included all children born between January 2005 and March 2014 in Alberta, Canada. We linked inpatient, outpatient, practitioner claims, and drug dispensing databases with vital statistics (birth and death registries). RESULTS In the first year of life, the cumulative hospitalization rate per 100 children was 335 (95% confidence interval: 312-360) for single ventricle (SV) children, 200 (194-206) for moderate-complex CHD, and 152 (149-156) for simple CHD vs 109 (108-109) among children without CHD (P < 0.001). The ambulatory-care visit rate per 100 children was 4871 (4780-4963) for SV, 2278 (2258-2299) for moderate-complex, and 1416 (1405-1426) for simple CHD vs 246 (246-247) for children without CHD (P < 0.001). The rates of physician claims and drug dispensing also demonstrated similar patterns. The median total hospitalization length of stay during the first year of life was 54 days (interquartile range: 26-95) in SV, 15 (4-39) in moderate-complex, and 6 (2-26) in simple CHD compared with 2 (1-3) among children without CHD (P < 0.001). These differences remained throughout the first 5 years of life, with children with CHD having consistently higher hospitalization rates and emergency department visit rates in every year of age compared with children without CHD. CONCLUSIONS Cumulative HRU is high among children with CHD in the first 5 years of life and increases with increasing CHD severity. Improving survival of SV lesions will require increasing resource allocation to this group.
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Affiliation(s)
- Sunjidatul Islam
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dat T Tran
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew S Mackie
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Barbaro RP, Xu Y, Borasino S, Truemper EJ, Watson RS, Thiagarajan RR, Wypij D. Does Extracorporeal Membrane Oxygenation Improve Survival in Pediatric Acute Respiratory Failure? Am J Respir Crit Care Med 2018; 197:1177-1186. [PMID: 29373797 PMCID: PMC6019927 DOI: 10.1164/rccm.201709-1893oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/26/2018] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) has supported gas exchange in children with severe respiratory failure for more than 40 years, without ECMO efficacy studies. OBJECTIVES To compare the mortality and functional status of children with severe acute respiratory failure supported with and without ECMO. METHODS This cohort study compared ECMO-supported children to pair-matched non-ECMO-supported control subjects with severe acute respiratory distress syndrome (ARDS). Both individual case matching and propensity score matching were used. The study sample was selected from children enrolled in the cluster-randomized RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) clinical trial. Detailed demographic and daily physiologic data were used to match patients. The primary endpoint was in-hospital mortality. Secondary outcomes included hospital-free days, ventilator-free days, and change in functional status at hospital discharge. MEASUREMENTS AND MAIN RESULTS Of 2,449 children in the RESTORE trial, 879 (35.9%) non-ECMO-supported patients with severe ARDS were eligible to match to 61 (2.5%) ECMO-supported children. When individual case matching was used (60 matched pairs), the in-hospital mortality rate at 90 days was 25% (15 of 60) for both the ECMO-supported and non-ECMO-supported children (P > 0.99). With propensity score matching (61 matched pairs), the ECMO-supported in-hospital mortality rate was 15 of 61 (25%), and the non-ECMO-supported hospital mortality rate was 18 of 61 (30%) (P = 0.70). There was no difference between ECMO-supported and non-ECMO-supported patients in any secondary outcomes. CONCLUSIONS In children with severe ARDS, our results do not demonstrate that ECMO-supported children have superior outcomes compared with non-ECMO-supported children. Definitive answers will require a rigorous multisite randomized controlled trial.
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Affiliation(s)
- Ryan P. Barbaro
- Department of Pediatrics and
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Yuejia Xu
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Santiago Borasino
- Department of Pediatrics, University of Alabama, Birmingham, Alabama
| | - Edward J. Truemper
- Department of Pediatrics, Children’s Hospital and Medical Center of Nebraska, Omaha, Nebraska
| | - R. Scott Watson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | | | - David Wypij
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - RESTORE Study Investigators*
- Department of Pediatrics and
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Pediatrics, University of Alabama, Birmingham, Alabama
- Department of Pediatrics, Children’s Hospital and Medical Center of Nebraska, Omaha, Nebraska
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- The Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; and
- Department of Family and Community Health, School of Nursing, and
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.
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Affiliation(s)
- Roxanne Kirsch
- Department of Critical Care, The Hospital for Sick Children, Toronto, Canada; Department of Bioethics, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada.
| | - David Munson
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
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Weiss EM, Fiester A. From "Longshot" to "Fantasy": Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:3-11. [PMID: 29313768 DOI: 10.1080/15265161.2017.1401157] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from "longshot" to "fantasy" is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.
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Lopez-Magallon AJ, Saenz L, Lara Gutierrez J, Florez CX, Althouse AD, Sharma MS, Duran A, Salazar L, Munoz R. Telemedicine in Pediatric Critical Care: A Retrospective Study in an International Extracorporeal Membrane Oxygenation Program. Telemed J E Health 2017; 24:489-496. [PMID: 29252119 DOI: 10.1089/tmj.2017.0223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an invaluable rescue technique for critically ill children with imminent or present cardiopulmonary collapse. However, medical team expertise to optimize results and decrease complications is scarce. Telemedicine can be used to enhance the delivery of quality interventions. MATERIALS AND METHODS This is a retrospective review of pediatric patients assisted with ECMO in the cardiac intensive care unit (CICU) at Fundación Cardiovascular de Colombia from July 2011 to June 2015 (telemedicine) compared with similar patients from a previous period (pretelemedicine). Collected information included demographic data, cardiac diagnosis, risk adjustment for congenital heart surgery (RACHS-1), hospital mortality, CICU and hospital length of stay (LOS), ECMO type, and ECMO run hours as well as specific telemedicine information. RESULTS Fifty-seven patients in the pretelemedicine and 109 in the telemedicine periods were included in the analysis. Forty-nine teleconsulted patients received 218 teleconsultations, with a recommendation for diagnostic or interventional catheterization in 38 patients (77.5%). A surgical procedure for significant residual lesions was recommended in 30 patients (61.2%). Patients in the telemedicine period were older (4.7 months vs. 1.6 months, p = 0.006), more likely to receive operating room ECMO (43.1% vs. 24.6%, p = 0.02), and had a higher proportion of patients with two-ventricle physiology (73.4% vs. 54.4%, p = 0.013). Hospital survival was higher during the telemedicine period (54.1% vs. 29.8%, p = 0.002), with a longer hospital LOS (67 days vs. 28 days, p < 0.001). CONCLUSION The implementation of telemedicine-assisted interventions in a pediatric ECMO program delivered valuable diagnostic and therapeutic advice, was associated with significant changes in selection criteria and model of care, and an increased hospital survival.
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Affiliation(s)
- Alejandro J Lopez-Magallon
- 1 Division of Cardiac Intensive Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Lucas Saenz
- 1 Division of Cardiac Intensive Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Jorge Lara Gutierrez
- 1 Division of Cardiac Intensive Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Claudia X Florez
- 2 Department of Pediatric Cardiology and Cardiovascular Surgery, Fundación Cardiovascular de Colombia , Bucaramanga, Colombia
| | | | - Mahesh S Sharma
- 4 Department of Cardiothoracic Surgery, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Alvaro Duran
- 2 Department of Pediatric Cardiology and Cardiovascular Surgery, Fundación Cardiovascular de Colombia , Bucaramanga, Colombia
| | - Leonardo Salazar
- 2 Department of Pediatric Cardiology and Cardiovascular Surgery, Fundación Cardiovascular de Colombia , Bucaramanga, Colombia
| | - Ricardo Munoz
- 1 Division of Cardiac Intensive Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
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Nandi D, Rossano JW, Wang Y, Jerrell JM. Risk Factors for Heart Failure and Its Costs Among Children with Complex Congenital Heart Disease in a Medicaid Cohort. Pediatr Cardiol 2017; 38:1672-1679. [PMID: 28852817 DOI: 10.1007/s00246-017-1712-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/09/2017] [Indexed: 01/05/2023]
Abstract
Little research attention has been paid to the occurrence of heart failure (HF) in children with complex congenital heart diseases (CHDs). Herein, we describe the prevalence, risk factors, and costs associated with HF in complex CHD. Patients aged ≤17 years and diagnosed with a complex CHD on multiple service visits over a 15-year period in the SC Medicaid dataset (1996-2010) were tracked and analyzed. The cohort included 2999 unduplicated patients; 51.0% were male; 34.4% were African American. HF was diagnosed in 7.6%. Single ventricle lesions, genetic syndromes, and ventricular arrhythmia were significantly associated with an increased likelihood of being diagnosed with HF, controlling for development of comorbid pulmonary hypertension. Patients with HF received significantly more subspecialty care, more surgeries, more hospitalizations, more total days of inpatient care, and more emergency department care than those without HF. Patients with significantly higher total care costs paid by Medicaid had HF, more cardiac surgeries, and more specialized mechanical or other support procedures, controlling for diagnosed single ventricle CHD, a genetic syndrome, and number of non-cardiac surgeries. Complex CHD patients with HF incur significantly higher care costs but require multifaceted, intensive supports for management of incident complications and comorbid conditions.
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Affiliation(s)
- Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph W Rossano
- The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yinding Wang
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Jeanette M Jerrell
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC, 29203, USA.
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Carter MA. Ethical Considerations for Care of the Child Undergoing Extracorporeal Membrane Oxygenation. AORN J 2017; 105:148-158. [PMID: 28159074 DOI: 10.1016/j.aorn.2016.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/24/2016] [Accepted: 12/01/2016] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a complex, highly technical surgical procedure that can offer hope for children born with congenital heart defects. The procedure may only briefly prolong a life, has limited potential for decreasing mortality, and may lead to serious complications, however. Perioperative nurses play an important role in caring for the child who requires ECMO. They are involved in assessing the child, implementing the plan of care, and facilitating communication between the child's family members and the health care team. Thus, perioperative nurses have a responsibility to consider the broad range of ethical issues associated with the procedure. By examining the ethical concepts of beneficence, nonmaleficence, autonomy, justice, and moral distress, the perioperative nurse can better understand the dilemmas that can affect the care and outcome of the critically ill child who requires ECMO.
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Thiagarajan RR, Barbaro RP, Rycus PT, Mcmullan DM, Conrad SA, Fortenberry JD, Paden ML. Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J 2017; 63:60-67. [PMID: 27984321 DOI: 10.1097/mat.0000000000000475] [Citation(s) in RCA: 613] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Data on extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization's data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.
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Affiliation(s)
- Ravi R Thiagarajan
- From the *Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; †Department of Pediatrics, C.S. Mott Children's Hospital, Ann Arbor, Michigan; ‡Extracorporeal Life Support Organization, Ann Arbor, Michigan; §Department of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington; ¶Departments of Medicine, Pediatrics and Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and ‖Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
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Song AY, Chen HHA, Chapman R, Govindarajan A, Upperman JS, Burke RV, Stein J, Friedlich PS, Lakshmanan A. Utilization patterns of extracorporeal membrane oxygenation in neonates in the United States 1997-2012. J Pediatr Surg 2017. [PMID: 28622971 DOI: 10.1016/j.jpedsurg.2017.05.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) remains one of the most intensive therapies for newborns in the United States. However, there is limited information on resource utilization for neonates receiving ECMO. METHODS We conducted a retrospective data analysis of the Kids' Inpatient Database from 1997 to 2012. Bivariate and multivariate analysis was completed to identify predictors of LOS, hospital costs and mortality. Cardiac and non-cardiac diagnoses of neonates receiving ECMO were also included in the bivariate and multivariable analysis. RESULTS Of the 5151 ECMO cases, survival to discharge was 62%. 22% had a principal cardiac diagnosis. After adjusting for covariates, increased mortality was associated with treatment in the midwest compared to the northeast region (aOR=2.0, p<0.01) and decreased among neonates with a non-cardiac diagnosis (aOR=0.4, p<0.01). Living in midwest was associated with longer LOS by 13days and increased hospital costs by 63,000 dollars (p<0.01). When stratified by non-cardiac diagnoses, infants with a diagnosis of congenital diaphragmatic hernia was associated with increased mortality (2.3, p<0.01) and longer LOS (25, p<0.01) and increased costs (11,100, p<0.01). CONCLUSION Neonates who received ECMO in certain regions of the United States were associated with poorer survival outcomes as well as increased LOS and hospital costs. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ashley Y Song
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Hsuan-Hsiu Annie Chen
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Rachel Chapman
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ameish Govindarajan
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California
| | - Rita V Burke
- Department of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California
| | - James Stein
- Department of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California
| | - Philippe S Friedlich
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ashwini Lakshmanan
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, United States.
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Lau CT, Chan SY, Rocha B, Tam PK, Wong KK. Use of extracorporeal membrane oxygenation support for congenital diaphragmatic hernia repair: Bridging therapy for successful outcomes. SURGICAL PRACTICE 2017. [DOI: 10.1111/1744-1633.12259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Chin Tung Lau
- Department of Surgery; The University of Hong Kong, Queen Mary Hospital; Hong Kong
| | - Shu-Yan Chan
- Department of Paediatrics and Adolescent Medicine; The University of Hong Kong, Queen Mary Hospital; Hong Kong
| | - Barnabe Rocha
- Department of Surgery; The University of Hong Kong, Queen Mary Hospital; Hong Kong
| | - Paul K.H. Tam
- Department of Surgery; The University of Hong Kong, Queen Mary Hospital; Hong Kong
| | - Kenneth K.Y. Wong
- Department of Surgery; The University of Hong Kong, Queen Mary Hospital; Hong Kong
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Cure P, Bembea M, Chou S, Doctor A, Eder A, Hendrickson J, Josephson CD, Mast AE, Savage W, Sola-Visner M, Spinella P, Stanworth S, Steiner M, Mondoro T, Zou S, Levy C, Waclawiw M, El Kassar N, Glynn S, Luban NLC. 2016 proceedings of the National Heart, Lung, and Blood Institute's scientific priorities in pediatric transfusion medicine. Transfusion 2017; 57:1568-1581. [PMID: 28369923 DOI: 10.1111/trf.14100] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/30/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Pablo Cure
- Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stella Chou
- Department of Hematology and the Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allan Doctor
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Anne Eder
- National Institutes of Health, Bethesda, Maryland
| | - Jeanne Hendrickson
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut
| | | | - Alan E Mast
- Blood Research Institute, Blood Center of Wisconsin, and the Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Martha Sola-Visner
- Department of Newborn Medicine, Children's Hospital, Boston, Massachusetts
| | | | - Simon Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, and Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Marie Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - Shimian Zou
- Division of Blood Diseases and Resources, NHLBI/NIH
| | | | - Myron Waclawiw
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Simone Glynn
- Division of Blood Diseases and Resources, NHLBI/NIH
| | - Naomi L C Luban
- Division of Laboratory Medicine, Children's National Health System, Washington, DC
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Barbaro RP, Boonstra PS, Moler FW, Davis MM, Prosser LA. Hospital-level variation in inpatient cost among children receiving extracorporeal membrane oxygenation. Perfusion 2017; 32:538-546. [PMID: 28466677 DOI: 10.1177/0267659117702709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Pediatric extracorporeal membrane oxygenation (ECMO) varies in the way care is provided from hospital to hospital. This variability in hospital ECMO care can be represented by the variation in ECMO costs. We hypothesized that hospitals will demonstrate large variations in case-mix-adjusted ECMO inpatient costs for children requiring ECMO and higher volume hospitals will have lower associated costs. METHODS We retrospectively analyzed the inpatient cost of children receiving ECMO in 2006, 2009 and 2012, using the Healthcare Cost and Utilization Project Kids' Inpatient Database. We used a hierarchical linear regression model and the intraclass correlation coefficient to quantify how much of the difference in ECMO inpatient costs was associated with the hospital where a child received care. To do this, we adjusted for patient factors, hospital factors and potentially modifiable factors such as complications, procedures and length of stay. RESULTS The median inflation-adjusted inpatient costs for children requiring ECMO were $183,000, $240,000 and $241,000 in years 2006, 2009 and 2012, respectively. The largest median cost for ECMO cases in a given hospital in a given year ($690,000) was more than 11 times that of the smallest median cost ($60,000). After case-mix adjustment, 27% of the variation in inpatient costs was associated with the hospital where ECMO care was provided. Average hospital costs were not associated with hospital ECMO volume. CONCLUSIONS The large variation in ECMO inpatient costs between hospitals suggests great variation in care between hospitals, which is important because hospitals have a co-existing variation in ECMO survival rates.
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Affiliation(s)
- Ryan P Barbaro
- 1 Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.,2 Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, Michigan, USA
| | - Philip S Boonstra
- 3 Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank W Moler
- 1 Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew M Davis
- 4 Department of Pediatrics, Northwestern University, Chicago, Illinois, USA
| | - Lisa A Prosser
- 5 Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA.,6 School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2016; 17:684-91. [PMID: 27099971 DOI: 10.1097/pcc.0000000000000723] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is increasingly utilized to provide cardiopulmonary support to critically ill children. Although life-saving in many instances, extracorporeal membrane oxygenation support is associated with considerable morbidity and mortality. This study evaluates the effect of extracorporeal membrane oxygenation complications and extracorporeal membrane oxygenation hospital characteristics on mortality in neonates and children supported with extracorporeal membrane oxygenation. DESIGN Retrospective analysis of administrative data. SETTING Data from 31 U.S. states included in 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. PATIENTS Children treated with extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Study subject were identified using International Classification of Diseases, 9th Edition Clinical Modification code 39.65 and classified into six diagnostic categories: 1) cardiac surgery, 2) non-surgical heart disease, 3) congenital diaphragmatic hernia, 4) neonatal respiratory failure, 5) pediatric respiratory failure, and 6) sepsis. Demographics, hospital characteristics, and outcome information were used in a multivariate logistic regression analysis to determine factors associated with mortality. We identified 1,465 children treated with extracorporeal membrane oxygenation. Overall mortality was 40% (591/1,465). Mortality was independently associated with diagnosis (heart disease: odds ratio, 1.7; p = 0.01; congenital diaphragmatic hernia: odds ratio, 5.1; p < 0.001; and sepsis odds ratio: 2.4; p = 0.003 compared with neonatal respiratory failure) time from hospital admission to extracorporeal membrane oxygenation of more than 10 days (odds ratio, 4.5; p < 0.001) and extracorporeal membrane oxygenation complications (renal [odds ratio: 5; p < 0.001] and neurologic [odds ratio, 1.4; p = 0.03] injury). In addition, hospitals with bed size less than 400 had higher mortality (odds ratio, 1.4; p = 0.02). In patients with any extracorporeal membrane oxygenation complication, probability of mortality was lower for extracorporeal membrane oxygenation patients in larger hospitals, 38% (95% CI, 37-39) versus 44% (95% CI, 43-46) with p value of less than 0.001. CONCLUSIONS Extracorporeal membrane oxygenation mortality was significantly associated with patient diagnosis, time to extracorporeal membrane oxygenation initiation, extracorporeal membrane oxygenation complications, and extracorporeal membrane oxygenation hospital bed size. Improved survival in larger hospitals supports centralization of extracorporeal membrane oxygenation services to larger centers.
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