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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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2
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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3
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Cook BH, Choi PM, Lucas DJ. Surgical outcomes in children with Trisomy 13: An ACS NSQIP - Pediatric review. J Pediatr Surg 2023; 58:384-388. [PMID: 36008197 DOI: 10.1016/j.jpedsurg.2022.08.010] [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: 04/01/2022] [Revised: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Trisomy 13 is a rare genetic condition with a characteristic set of severe congenital abnormalities. Traditionally, the standard of care was to provide palliative care only. However, there has been a recent shift towards life-prolonging care, including surgery. This study seeks to describe surgical outcomes in patients with trisomy 13 and compare them to comorbidity-matched controls. METHODS Using the ACS NSQIP Pediatric 2012-2019 Participant Use Data Files, patients with trisomy 13 were identified and described. A nearest-neighbor 10:1 propensity score match was performed using demographics, comorbidities, and procedural details. This yielded 254 patients with trisomy 13 and 2,422 controls. Risk ratios for morbidity and mortality by trisomy 13 status were determined using modified Poisson regression. The primary outcomes were thirty-day mortality and the occurrence of any morbidity. RESULTS The median age of patients with trisomy 13 was 16 months (IQR 87 months). 126 were male (49.6%) and 128 were female (50.4%). There were no differences in overall morbidity compared to controls (31.8% vs. 29.7%, RR 1.06, 95%CI 0.87-1.28, p = 0.554), but patients with trisomy 13 had markedly higher mortality (7.9% vs. 1.8%, RR 4.43, 95%CI 2.28-8.61, p<0.001). CONCLUSIONS We conclude that patients with trisomy 13 undergoing surgery have frequent morbidity and an elevated although not prohibitive risk of death. Compared to patients with similar comorbidities, they have similar rates of morbidity but a markedly higher risk of mortality. Parents of children with trisomy 13 require thorough counseling on these risks before deciding on surgery.
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Affiliation(s)
- Brittany H Cook
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Pamela M Choi
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, California 92134, United States of America
| | - Donald J Lucas
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, California 92134, United States of America.
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Rose AT, Keene S. Changing populations being treated with ECMO in the neonatal period - who are the others? Semin Fetal Neonatal Med 2022; 27:101402. [PMID: 36414493 DOI: 10.1016/j.siny.2022.101402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Extracorporeal life support via extracorporeal membrane oxygenation (ECMO) has served the sickest of neonates for almost 50 years. Naturally, the characteristics of neonates receiving ECMO have changed. Advances in care have averted the need for ECMO for some, while complex cases with uncertain outcomes, previously not eligible for ECMO, are now considered. Characterizing the disease states and outcomes for neonates on ECMO is challenging as many infants do not fall into classic categories, i.e. meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or congenital diaphragmatic hernia (CDH). Since 2017, over one third of neonatal respiratory ECMO runs reported to the Extracorporeal Life Support Organization Registry are grouped as Other, a catch-all that encompasses those with a diagnosis not included in the classic categories. This review summarizes the historical neonatal ECMO population, reviews advances in therapy and technology impacting neonatal care, and addresses the unknowns in the ever-growing category of Other.
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Affiliation(s)
- Allison T Rose
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA, 30322, USA.
| | - Sarah Keene
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA, 30322, USA.
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Hafezi N, Jensen AR, Saenz ZM, Collings AT, Colgate CL, Inanc Salih ZN, Geddes GC, Gray BW. Surgical history and outcomes in trisomy 13 and 18: A thirty-year review. J Pediatr Surg 2022:S0022-3468(22)00676-5. [PMID: 36402594 DOI: 10.1016/j.jpedsurg.2022.10.010] [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: 05/31/2022] [Revised: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with Trisomy 13(T13) and 18(T18) have many comorbidities that may require surgical intervention. However, surgical care and outcomes are not well described, making patient selection and family counseling difficult. Here the surgical history and outcomes of T13/ T18 patients are explored. METHODS A retrospective review of patients with T13 or T18 born between 1990 and 2020 and cared for at a tertiary children's hospital (Riley Hospital for Children, Indianapolis IN) was conducted, excluding those with insufficient records. Primary outcomes of interest were rates of mortality overall and after surgery. Factors that could predict mortality outcomes were also assessed. RESULTS One-hundred-seventeen patients were included, with 65% T18 and 35% T13. More than half of patients(65%) had four or more comorbidities. Most deaths occurred by three months at median 42.0 days. Variants of classic trisomies (mosaicism, translocation, partial duplication; p = 0.001), higher birth weight(p = 0.002), and higher gestational age(p = 0.01) were associated with lower overall mortality, while cardiac(p = 0.002) disease was associated with higher mortality. Over half(n = 64) underwent surgery at median age 65 days at time of first procedure. The most common surgical procedures were general surgical. Median survival times were longer in surgical rather than nonsurgical patients(p<0.001). Variant trisomy genetics(p = 0.002) was associated with lower mortality after surgery, while general surgical comorbidities(p = 0.02), particularly tracheoesophageal fistula/esophageal atresia(p = 0.02), were associated with increased mortality after surgery. CONCLUSIONS Trisomy 13 and 18 patients have vast surgical needs. Variant trisomy was associated with lower mortality after surgery while general surgical comorbidities were associated with increased mortality after surgery. Those who survived to undergo surgery survived longer overall. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Niloufar Hafezi
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 2500, Indianapolis, IN 46202, United States
| | - Amanda R Jensen
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 2500, Indianapolis, IN 46202, United States
| | - Zoe M Saenz
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 2500, Indianapolis, IN 46202, United States
| | - Amelia T Collings
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 2500, Indianapolis, IN 46202, United States
| | - Cameron L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall, Indianapolis, IN 46202, United States
| | - Zeynep N Inanc Salih
- Fetal Center at Riley Children's Health, Indiana University Health, 705 Riley Hospital Drive, Indianapolis, IN 46202, United States; Department of Pediatrics, Division of Neonatal Perinatal Medicine, Indiana University School of Medicine, 705 Riley Hospital Drive, RT 4600, Indianapolis, IN 46202, United States
| | - Gabrielle C Geddes
- Fetal Center at Riley Children's Health, Indiana University Health, 705 Riley Hospital Drive, Indianapolis, IN 46202, United States; Department of Molecular Genetics, Indiana University School of Medicine, 1002 Wishard Blvd, Indianapolis, IN 46202, United States
| | - Brian W Gray
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 2500, Indianapolis, IN 46202, United States; Fetal Center at Riley Children's Health, Indiana University Health, 705 Riley Hospital Drive, Indianapolis, IN 46202, United States.
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Geddes GC, Hafezi N, Gray BW. Misdiagnosis of trisomy 13 and trisomy 18 is more common than anticipated. Am J Med Genet A 2022; 188:3126-3129. [PMID: 35924647 PMCID: PMC9541165 DOI: 10.1002/ajmg.a.62937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gabrielle C. Geddes
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Niloufar Hafezi
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Brian W. Gray
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
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Bishop C, Jackson L, Brown A. Primary palliative care skills in caring for surgical patients in the neonatal intensive care unit. Semin Pediatr Surg 2022; 31:151201. [PMID: 36038212 DOI: 10.1016/j.sempedsurg.2022.151201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Torbert N, Neumann M, Birge N, Perkins D, Ehrhardt E, Weaver MS. Discipline-Specific Perspectives on Caring for Babies with Trisomy 13 or 18 in the Neonatal Intensive Care Unit. Am J Perinatol 2022; 39:1074-1082. [PMID: 33285605 DOI: 10.1055/s-0040-1721496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Care offerings vary across medical settings and between families for babies with trisomy 13 or 18. The purpose of this qualitative descriptive study was to explore nurse, advanced practice practitioner, and neonatologist perspectives on care for babies with trisomy 13 or 18 in the intensive care unit. STUDY DESIGN Voice-recorded qualitative interviews occurred with 64 participants (41 bedside nurses, 14 advance practice practitioners, and 9 neonatologists) from two neonatal intensive care units (NICU) in the midwestern United States. Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Content analyses occurred utilizing MAXQDA (VERBI Software, 2020). RESULTS Over half of NICU staff perceived care for babies with trisomy 13 or 18 as different from care for other babies with critical chronic illness. Qualitative themes included internal conflict, variable presentation and prognosis, grappling with uncertainty, family experiences, and provision of meaningful care. Neonatologists emphasized the variability of presentation and prognosis, while nurses emphasized provision of meaningful care. Phrases "hard/difficult" were spoken 31 times; primarily describing the comorbidities, complexities, and prognostic uncertainty. CONCLUSION Care for babies with these genetic diagnoses reveals need for a shared dialogue not only with families but also across staff disciplines. While perspectives differ, participants depicted striving to offer compassionate, family-centered care while also balancing biomedical uncertainty about interventions for children with trisomy 13 and 18. KEY POINTS · Care for babies with trisomy 13 or 18 has been recognized as shifting.. · Controversy exists across the diverse and changing range of care models.. · This study describes perspectives of bedside neonatal nurses, advanced practitioners, and neonatologists.. · Differences in perspectives warrant attentiveness to insights and dialogue across disciplines..
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Affiliation(s)
- Nicholas Torbert
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Marie Neumann
- Division of Palliative Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Nicole Birge
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Donnetta Perkins
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Elizabeth Ehrhardt
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Meaghann S Weaver
- Division of Palliative Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
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Brown G, Moynihan KM, Deatrick KB, Hoskote A, Sandhu HS, Aganga D, Deshpande SR, Menon AP, Rozen T, Raman L, Alexander PMA. Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure. ASAIO J 2021; 67:463-475. [PMID: 33788796 DOI: 10.1097/mat.0000000000001431] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.
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Affiliation(s)
- Georgia Brown
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hitesh S Sandhu
- Department of Pediatrics, Critical Care Division, Le Bonheur Children's Hospital, University of Tennessee, Memphis, Tennessee
| | - Devon Aganga
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shriprasad R Deshpande
- Pediatric Cardiology Division, Heart Transplant and Advanced Cardiac Therapies Program, Children's National Heart Institute, Washington, D.C
| | - Anuradha P Menon
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Thomas Rozen
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lakshmi Raman
- Department of Critical Care, University of Texas Southwestern Medical Center, Texas
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Abstract
This case report shares the story of a family who sought care elsewhere after their daughter was denied cardiac surgery in their home state because she had trisomy 18. This case report recommends case-by-case assessment of cardiac surgical interventions for children with trisomy 13 or 18 as informed by review of goals, assessment of comorbidities, and literature-informed practice. Coordinated care planning and interdisciplinary communication are relevant in cardiac surgical considerations for children with these underlying genetic conditions.
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Weaver MS, Anderson V, Beck J, Delaney JW, Ellis C, Fletcher S, Hammel J, Haney S, Macfadyen A, Norton B, Rickard M, Robinson JA, Sewell R, Starr L, Birge ND. Interdisciplinary care of children with trisomy 13 and 18. Am J Med Genet A 2020; 185:966-977. [PMID: 33381915 DOI: 10.1002/ajmg.a.62051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/21/2020] [Accepted: 12/12/2020] [Indexed: 01/20/2023]
Abstract
Children with trisomy 13 and 18 (previously deemed "incompatible with life") are living longer, warranting a comprehensive overview of their unique comorbidities and complex care needs. This Review Article provides a summation of the recent literature, informed by the study team's Interdisciplinary Trisomy Translational Program consisting of representatives from: cardiology, cardiothoracic surgery, neonatology, otolaryngology, intensive care, neurology, social work, chaplaincy, nursing, and palliative care. Medical interventions are discussed in the context of decisional-paradigms and whole-family considerations. The communication format, educational endeavors, and lessons learned from the study team's interdisciplinary care processes are shared with recognition of the potential for replication and implementation in other care settings.
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Affiliation(s)
- Meaghann S Weaver
- Division of Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Venus Anderson
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jill Beck
- Division of Oncology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey W Delaney
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Cynthia Ellis
- Division of Developmental Pediatrics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA.,Munroe-Meyer Institute for Genetics and Rehabilitation, Omaha, Nebraska, USA
| | - Scott Fletcher
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Cardiology, Department of Pediatrics, Creighton University, Omaha, Nebraska, USA
| | - James Hammel
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Suzanne Haney
- Division of Child Advocacy, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew Macfadyen
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bridget Norton
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mary Rickard
- Division of Neurology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey A Robinson
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ryan Sewell
- Division of Otolaryngology, Department of Pediatrics, Children's Hospital and Medical Center and ENT Specialists PC, Omaha, Nebraska, USA
| | - Lois Starr
- Munroe-Meyer Institute for Genetics and Rehabilitation, Omaha, Nebraska, USA.,Division of Genetics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nicole D Birge
- Division of Neonatology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
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