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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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Alizadeh F, Gauvreau K, Barreto JA, Hall M, Bucholz E, Nathan M, Newburger JW, Vitali S, Thiagarajan RR, Chan T, Moynihan KM. Child Opportunity Index and Pediatric Extracorporeal Membrane Oxygenation Outcomes; the Role of Diagnostic Category. Crit Care Med 2024:00003246-990000000-00351. [PMID: 38920540 DOI: 10.1097/ccm.0000000000006358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES To study the impact of social determinants of health (SDoH) on pediatric extracorporeal membrane oxygenation (ECMO) outcomes. DESIGN, SETTING, AND PATIENTS Retrospective study of children (< 18 yr) supported on ECMO (October 1, 2015 to March 1, 2021) using Pediatric Health Information System (44 U.S. children's hospitals). Patients were divided into five diagnostic categories: neonatal cardiac, pediatric cardiac, neonatal respiratory, pediatric respiratory, and sepsis. SDoH included the Child Opportunity Index (COI; higher indicates social advantage), race, ethnicity, payer, and U.S. region. Children without COI were excluded. Diagnostic category-specific clinical variables related to baseline health and illness severity were collected. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children supported on ECMO experienced a 33% in-hospital mortality (2863/8710). Overall, children with lower COI, "other" race, Hispanic ethnicity, public insurance and from South or West regions had greater mortality. Associations between SDoH and ECMO outcomes differed between diagnostic cohorts. Bivariate analyses found that only pediatric cardiac patients had an association between COI or race and mortality. Multivariable logistic regression analyses examined relationships between SDoH, clinical variables and mortality within diagnostic categories. Pediatric cardiac patients had 5% increased odds of death (95% CI, 1.01-1.09) for every 10-point decrement in COI, while Hispanic ethnicity was associated with higher survival (adjusted odds ratio [aOR] 0.72 [0.57-0.89]). Children with heart disease from the highest COI quintile had less cardiac-surgical complexity and earlier cannulation. Independent associations with mortality were observed in sepsis for Black race (aOR 1.62 [1.06-2.47]) and other payer in pediatric respiratory patients (aOR 1.94 [1.23-3.06]). CONCLUSIONS SDoH are statistically associated with pediatric ECMO outcomes; however, associations differ between diagnostic categories. Influence of COI was observed only in cardiac patients while payer, race, and ethnicity results varied. Further research should investigate differences between diagnostic cohorts and age groups to understand drivers of inequitable outcomes.
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Affiliation(s)
- Faraz Alizadeh
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Emily Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sally Vitali
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Titus Chan
- The Heart Center, Seattle Children's Hospital, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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3
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Turner AD, Streb MM, Ouyang A, Leonard SS, Hall TA, Bosworth CC, Williams CN, Guerriero RM, Hartman ME, Said AS, Guilliams KP. Long-Term Neurobehavioral and Functional Outcomes of Pediatric Extracorporeal Membrane Oxygenation Survivors. ASAIO J 2024; 70:409-416. [PMID: 38207105 PMCID: PMC11062843 DOI: 10.1097/mat.0000000000002135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
There are limited reports of neurobehavioral outcomes of children supported on extracorporeal membrane oxygenation (ECMO). This observational study aims to characterize the long-term (≥1 year) neurobehavioral outcomes, identify risk factors associated with neurobehavioral impairment, and evaluate the trajectory of functional status in pediatric ECMO survivors. Pediatric ECMO survivors ≥1-year postdecannulation and ≥3 years of age at follow-up were prospectively enrolled and completed assessments of adaptive behavior (Vineland Adaptive Behavior Scales, Third Edition [Vineland-3]) and functional status (Functional Status Scale [FSS]). Patient characteristics were retrospectively collected. Forty-one ECMO survivors cannulated at 0.0-19.8 years (median: 2.4 [IQR: 0.0, 13.1]) were enrolled at 1.3-12.8 years (median: 5.5 [IQR: 3.3, 6.5]) postdecannulation. ECMO survivors scored significantly lower than the normative population in the Vineland-3 Adaptive Behavior Composite (85 [IQR: 70, 99], P < 0.001) and all domains (Communication, Daily Living, Socialization, Motor). Independent risk factors for lower Vineland-3 composite scores included extracorporeal cardiopulmonary resuscitation, electrographic seizures during ECMO, congenital heart disease, and premorbid developmental delay. Of the 21 patients with impaired function at discharge (FSS ≥8), 86% reported an improved FSS at follow-up. Pediatric ECMO survivors have, on average, mild neurobehavioral impairment related to adaptive functioning years after decannulation. Continued functional recovery after hospital discharge is likely.
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Affiliation(s)
- Ashley D Turner
- From the Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Madison M Streb
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Amy Ouyang
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Skyler S Leonard
- Division of Pediatric Psychology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Trevor A Hall
- Division of Pediatric Psychology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | | | - Cydni N Williams
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Réjean M Guerriero
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Mary E Hartman
- From the Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Ahmed S Said
- From the Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Kristin P Guilliams
- From the Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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Shafi O, Mir T, Liu D, Velumula PK, Tul Llah S, Korumilli R. Characteristics, outcomes, and 30-day readmissions following pediatric extracorporeal membrane oxygenation in the United States: A Nationwide Readmissions Database study. Perfusion 2024; 39:399-407. [PMID: 36509452 DOI: 10.1177/02676591221145646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is an increasingly used mode of critical care support for pediatric patients refractory to conventional therapy. We evaluated the characteristics, outcomes, and readmissions rates for pediatric ECMO in the United States. METHODS Data was extracted from the Nationwide Readmissions Database, a database designed to support national readmissions analyses, for patients aged 1-18 years undergoing ECMO between 2012-2018. Baseline demographics, comorbidities, and characteristics were identified using International Classification of Diseases codes. RESULTS Out of 897,117 index pediatric hospitalizations, 3706 patients underwent ECMO [median age 9 years (IQR 2,15); 51.6% males]. 2246 (60.6%) patients survived to hospital discharge, with a 30-day readmissions rate of 17% among survivors. Cardiac conditions associated with ECMO were congenital heart disease (25.3%), cardiogenic shock (23.6%), and congestive heart failure (16.2%). The common respiratory associations were sepsis (36.2%), pneumonia (35.6%), and asthma (15.4%). Patients who survived were more likely to have diagnoses of asthma, bronchiolitis, myocarditis, pneumonia, and sepsis. Acute kidney injury (51.5%), disseminated intravascular coagulation (22.5%), and surgical site bleeding (12.7%) were the commonly associated complications. The trend for yearly survival rates was not statistically significant (linear p-trend = 0.38). CONCLUSIONS Pediatric ECMO continues to be associated with notable mortality and complication rates. We did not observe a meaningful trend for the yearly survival rates over the study period, and over one-sixth of survivors were readmitted within 30-days. More research is needed to identify patients at high risk of mortality and readmissions, to help target resources more efficiently and improve survival.
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Affiliation(s)
- Obeid Shafi
- Clinical Informatics (Pediatrics), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Tanveer Mir
- Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Daniel Liu
- Pediatrics and Biomedical Informatics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Ritesh Korumilli
- Pediatric Cardiac Intensive Care, Sunrise Children's Hospitals, Las Vegas, NV, USA
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5
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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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6
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Delgado-Corcoran C, Wawrzynski SE, Flaherty B, Kirkland B, Bodily S, Moore D, Cook LJ, Olson LM. Extracorporeal membrane oxygenation and paediatric palliative care in an ICU. Cardiol Young 2023; 33:1846-1852. [PMID: 36278475 DOI: 10.1017/s1047951122003018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU. METHODS Retrospective review of clinical characteristics and outcomes of children (aged 0-21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation. MEASUREMENTS AND RESULTS One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation. CONCLUSIONS Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
- University of Utah, College of Nursing, 10 S 2000 E, Salt Lake City, UT, USA
| | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Brandon Kirkland
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Dominic Moore
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
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Zens T, Ochoa B, Eldredge RS, Molitor M. Pediatric venoarterial and venovenous ECMO. Semin Pediatr Surg 2023; 32:151327. [PMID: 37956593 DOI: 10.1016/j.sempedsurg.2023.151327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure. To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology. This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques. Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation. Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.
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Affiliation(s)
- Tiffany Zens
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Brielle Ochoa
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - R Scott Eldredge
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Mark Molitor
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States.
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8
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Moynihan KM, Dorste A, Alizadeh F, Phelps K, Barreto JA, Kolwaite AR, Merlocco A, Barbaro RP, Chan T, Thiagarajan RR. Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature. Crit Care Med 2023; 51:843-860. [PMID: 36975216 DOI: 10.1097/ccm.0000000000005866] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). STUDY SELECTION Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. DATA EXTRACTION Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. DATA SYNTHESIS Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. CONCLUSIONS Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.
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Affiliation(s)
- Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kayla Phelps
- Department of Pediatrics, Children's Hospital New Orleans, Louisiana State University, New Orleans, LA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anthony Merlocco
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
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9
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Bembea MM, Loftis LL, Thiagarajan RR, Young CC, McCadden TP, Newhams MM, Kucukak S, Mack EH, Fitzgerald JC, Rowan CM, Maddux AB, Kolmar AR, Irby K, Heidemann S, Schwartz SP, Kong M, Crandall H, Havlin KM, Singh AR, Schuster JE, Hall MW, Wellnitz KA, Maamari M, Gaspers MG, Nofziger RA, Lim PPC, Carroll RW, Coronado Munoz A, Bradford TT, Cullimore ML, Halasa NB, McLaughlin GE, Pannaraj PS, Cvijanovich NZ, Zinter MS, Coates BM, Horwitz SM, Hobbs CV, Dapul H, Graciano AL, Butler AD, Patel MM, Zambrano LD, Campbell AP, Randolph AG. Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs. Pediatr Crit Care Med 2023; 24:356-371. [PMID: 36995097 PMCID: PMC10153593 DOI: 10.1097/pcc.0000000000003212] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) has been used successfully to support adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiac or respiratory failure refractory to conventional therapies. Comprehensive reports of children and adolescents with SARS-CoV-2-related ECMO support for conditions, including multisystem inflammatory syndrome in children (MIS-C) and acute COVID-19, are needed. DESIGN Case series of patients from the Overcoming COVID-19 public health surveillance registry. SETTING Sixty-three hospitals in 32 U.S. states reporting to the registry between March 15, 2020, and December 31, 2021. PATIENTS Patients less than 21 years admitted to the ICU meeting Centers for Disease Control criteria for MIS-C or acute COVID-19. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The final cohort included 2,733 patients with MIS-C ( n = 1,530; 37 [2.4%] requiring ECMO) or acute COVID-19 ( n = 1,203; 71 [5.9%] requiring ECMO). ECMO patients in both groups were older than those without ECMO support (MIS-C median 15.4 vs 9.9 yr; acute COVID-19 median 15.3 vs 13.6 yr). The body mass index percentile was similar in the MIS-C ECMO versus no ECMO groups (89.9 vs 85.8; p = 0.22) but higher in the COVID-19 ECMO versus no ECMO groups (98.3 vs 96.5; p = 0.03). Patients on ECMO with MIS-C versus COVID-19 were supported more often with venoarterial ECMO (92% vs 41%) for primary cardiac indications (87% vs 23%), had ECMO initiated earlier (median 1 vs 5 d from hospitalization), shorter ECMO courses (median 3.9 vs 14 d), shorter hospital length of stay (median 20 vs 52 d), lower in-hospital mortality (27% vs 37%), and less major morbidity at discharge in survivors (new tracheostomy, oxygen or mechanical ventilation need or neurologic deficit; 0% vs 11%, 0% vs 20%, and 8% vs 15%, respectively). Most patients with MIS-C requiring ECMO support (87%) were admitted during the pre-Delta (variant B.1.617.2) period, while most patients with acute COVID-19 requiring ECMO support (70%) were admitted during the Delta variant period. CONCLUSIONS ECMO support for SARS-CoV-2-related critical illness was uncommon, but type, initiation, and duration of ECMO use in MIS-C and acute COVID-19 were markedly different. Like pre-pandemic pediatric ECMO cohorts, most patients survived to hospital discharge.
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Affiliation(s)
- Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura L Loftis
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Timothy P McCadden
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Amanda R Kolmar
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Sabrina Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit, MI
| | - Stephanie P Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Kevin M Havlin
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Louisville, and Norton Children's Hospital, Louisville, KY
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Kari A Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Health Medical Center, Dallas, TX
| | - Mary G Gaspers
- Department of Pediatrics and Banner Children's at Diamond Children's Medical Center, University of Arizona, Tucson, AZ
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Peter Paul C Lim
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Ryan W Carroll
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA
| | - Alvaro Coronado Munoz
- Pediatric Critical Care Division, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX
| | - Tamara T Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Pia S Pannaraj
- Division of Infectious Diseases, Children's Hospital Los Angeles and Departments of Pediatrics and Molecular Microbiology and Immunology, University of Southern California, Los Angeles, CA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Matt S Zinter
- Department of Pediatrics, Divisions of Critical Care Medicine and Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, San Francisco, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Steven M Horwitz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Charlotte V Hobbs
- Department of Pediatrics, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS
| | - Heda Dapul
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, NY
| | - Ana Lia Graciano
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Andrew D Butler
- Division of Pediatric Critical Care, St. Christopher's Hospital for Children, Philadelphia, PA
| | - Manish M Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura D Zambrano
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Angela P Campbell
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, MA
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10
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Abstract
Neonatal and pediatric extracorporeal membrane oxygenation (ECMO) has evolved over the past 50 years. Advances in technology, expertise, and application have increased the number of centers providing ECMO with expanded indications for use. However, increasing the use of ECMO in recent years to more medically complex critically ill children has not changed overall survival despite increased experience and improvements in technology. This review focuses on ECMO history, circuits, indications and contraindications, management, complications, and outcome data. The authors highlight important areas of progress, including unintubated and awake patients on ECMO, application during the COVID-19 pandemic, and future directions.
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Affiliation(s)
- Katherine Cashen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC, USA; Duke University Medical Center, 2301 Erwin Road, Suite 5260Y, DUMC 3046, Durham, NC 27710, USA.
| | - Katherine Regling
- Division of Pediatric Hematology Oncology, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, USA; Central Michigan University, Mt. Pleasant, MI, USA
| | - Arun Saini
- Division of Pediatric Critical Care Medicine, Texas Children's Hospital, 6651 Main Street, Suite 1411, Houston, TX 77030, USA; Baylor University School of Medicine, Houston, TX, USA
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11
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Delgado-Corcoran C, Wawrzynski SE, Mansfield KJ, Flaherty B, DeCourcey DD, Moore D, Cook LJ, Ullrich CK, Olson LM. An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers. J Palliat Med 2022; 25:952-957. [PMID: 35319287 DOI: 10.1089/jpm.2021.0452] [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: 11/12/2022] Open
Abstract
Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Methods: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Results: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusions: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.,Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA.,College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Christina K Ullrich
- Division of Pediatric Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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12
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Yuhang Y, Ni Y, Tiening Z, Lijie W, Wei X, Chunfeng L. Functional status of pediatric patients after extracorporeal membrane oxygenation: A five-year single-center study. Front Pediatr 2022; 10:917875. [PMID: 35989988 PMCID: PMC9385987 DOI: 10.3389/fped.2022.917875] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) is a widely used treatment for circulatory and pulmonary support in newborns and young children. Over the past decade, the number of children successfully treated with ECMO has gradually increased. However, despite an increasing number of survivors, new morbidity and long-term health issues are becoming more prevalent. A better understanding of the pediatric ECMO prognosis contributes to improved treatment and care programs and minimizes the risk of sequelae and dysfunctions. We aimed to determine the incidence of new morbidity, prognoses, and follow-up data of survivors treated with ECMO in pediatric intensive care units (PICU) using the Functional Status Scale (FSS). METHODS We retrospectively collected and analyzed clinical data of patients in the PICU who received ECMO from January 2016 to January 2020. Clinical and functional outcomes were assessed at admission and discharge using the FSS. Twenty-seven patients aged between 1 month and 14 years who received ECMO in the PICU were included. Fifty-two percent were male, and the median age was 36 months (interquartile range, 21-114 months). The patients were admitted for fulminant myocarditis (n = 13), acute respiratory distress syndrome (ARDS) (n = 11), and septic shock (n = 3). RESULTS This study reviewed a single-center experience using the FSS for ECMO treatment in a PICU. The patients' original conditions included fulminant myocarditis, ARDS, and septic shock. Of the 27 patients who received ECMO, 9 (33%) died, 12 (67%) showed improved condition, and 6 (33%) discontinued treatment and left the hospital. Furthermore, the following adverse events were observed in the survivors who were discharged: nine (50%) cases of lower extremity deep vein thrombosis, seven (39%) jugular vein thrombosis, six (33%) acute kidney injury, five (27%) intracranial hemorrhage and cerebral infarction, and one each of (6% each) pulmonary embolism and peripheral nerve injury. Of the 12 patients who survived through 1 year after discharge, five (42%) recovered completely, whereas seven (58%) showed mild to moderate communication and motor dysfunction. The short-term survival rate and 1-year survival rate of ECMO patients were 67% (18/27) and 44% (12/27), respectively. Additionally, approximately one-third of the patients developed a new morbidity after ECMO treatment (6/18). CONCLUSIONS High mortality and new morbidity were common in patients who received ECMO treatment. New morbidity increased the risk of death and exacerbated the functional state. Follow-up and rehabilitation after discharge are essential to achieve positive outcomes.
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Affiliation(s)
- Yang Yuhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yang Ni
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhang Tiening
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wang Lijie
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xu Wei
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Liu Chunfeng
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
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