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Gottschalk U, Köhne M, Holst T, Hüners I, von Stumm M, Müller G, Stark V, van Rüth V, Kozlik-Feldmann R, Singer D, Sachweh JS, Biermann D. Outcomes of extracorporeal membrane oxygenation and cardiopulmonary bypass in children after drowning-related resuscitation. Perfusion 2023; 38:109-114. [PMID: 34472993 PMCID: PMC9841817 DOI: 10.1177/02676591211041229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Drowning is one of the leading causes of accidental deaths in children worldwide. However, the use of long-term extracorporeal life support (ECLS) in this setting is not widely established, and rewarming is often achieved by short-term cardiopulmonary bypass (CPB) treatment. Thus, we sought to add our experience with this means of support as a bridge-to-recovery or to-decision. This retrospective single-center study analyzes the outcome of 11 children (median 23 months, minimum-maximum 3 months-6.5 years) who experienced drowning and subsequent cardiopulmonary resuscitation (CPR) between 2005 and 2016 and who were supported by veno-arterial extracorporeal membrane oxygenation (ECMO), CPB, or first CPB then ECMO. All but one incident took place in sweet water. Submersion time ranged between 10 and 50 minutes (median 23 minutes), water temperature between 2°C and 28°C (median 14°C), and body core temperature upon arrival in the emergency department between 20°C and 34°C (median 25°C). Nine patients underwent ongoing CPR from the scene until ECMO or CPB initiation in the operating room. The duration of ECMO or CPB before successful weaning/therapy withdrawal ranged between 2 and 322 hours (median 19 hours). A total of four patients (36%) survived neurologically mildly or not affected after 4 years of follow-up. The data indicate that survival is likely related to a shorter submersion time and lower water temperature. Resuscitation of pediatric patients after drowning has a poor outcome. However, ECMO or CPB might promote recovery in selected cases or serve as a bridge-to-decision tool.
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Affiliation(s)
- Urda Gottschalk
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Köhne
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theresa Holst
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ida Hüners
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria von Stumm
- Department for Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Müller
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Veronika Stark
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Victoria van Rüth
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominique Singer
- Center for Obstetrics and Pediatrics, Section Neonatology and Pediatric Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg S Sachweh
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Biermann
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Daniel Biermann, Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany.
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Identifying Injury to Improve Care in Infant Extracorporeal Membrane Oxygenation: Why Autopsy Is Important. Pediatr Crit Care Med 2021; 22:334-336. [PMID: 33657617 DOI: 10.1097/pcc.0000000000002624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation in the United States: A Multicenter Survey. ASAIO J 2019; 64:689-693. [PMID: 29251631 DOI: 10.1097/mat.0000000000000731] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The clinical use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LTx) has greatly increased in recent years. However, clinical practices for ECMO as a bridge to LTx vary widely between LTx centers. To better define the current practice of ECMO as a bridge to LTx, we surveyed pre-LTx ECMO practices among all adult LTx programs in the United States. All US LTx centers were surveyed (n = 57) between January and December 2014. Responses were received from 33 of 57 centers (58%). Of 33 responding centers, six (18%) performed ≥50 LTxs per year (defined as high volume) and two (6%) performed <10 LTxs per year (low volume). Two-third of responding centers, 22/33 (67%), reported use of ECMO as a bridge to LTx. Of these 22 centers, 18 (82%) successfully used venovenous (VV) ECMO as a bridge to LTx using the dual-lumen Avalon cannula. Patient >65 years of age was judged an ECMO contraindication in 15/33 (45%) of responding centers, but 12/33 (36%) centers, including the six high-volume centers, had no official age cutoff for ECMO candidacy. There was no consensus on the maximum acceptable duration of pre-LTx ECMO therapy; although 18/33 (55%) of programs had no defined maximal duration of ECMO pre-LTx, 10/33 (30%) considered >10 days on ECMO support contraindicated. Our survey suggests that in the United States, ECMO is used frequently pre-LTx, particularly VV ECMO at high-volume centers. However, criteria for ECMO initiation, age eligibility, bedside care, and maximum duration of support varied significantly between survey respondents.
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Chang TH, Wu ET, Lu CY, Huang SC, Yang TI, Wang CC, Chen JM, Lee PI, Huang LM, Chang LY. Pathogens and outcomes in pediatric septic shock patients supported by extracorporeal membrane oxygenation. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:385-391. [PMID: 28821378 DOI: 10.1016/j.jmii.2017.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/11/2017] [Accepted: 07/27/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Refractory septic shock is the leading cause of mortality in children. There is limited evidence to support extracorporeal membrane oxygenation (ECMO) use in pediatric septic shock. We described the etiology and outcomes of septic patients in our institution and attempted to find predictive factors. METHODS We retrospectively reviewed 55 pediatric patients with septic shock who required ECMO support in a tertiary medical center from 2008 to 2015. Septic shock was defined as culture proved or clinical suspected sepsis with hypotension or end-organ hypoperfusion. ECMO would be applied when pediatric advanced life support steps were performed thoroughly without clinical response. Patient's demographics, laboratory parameters before and after ECMO, and outcomes were analyzed. RESULTS Among 55 children with ECMO support, 31% of them survived on discharge. For 25 immunocompromised patients, causal pathogens were found in 17 patients: 7 due to bacteremia, 9 with preexisting virus infections and one with invasive fungal infection. Among 30 previously healthy patients, causal pathogens were found in 18 patients: 10 due to bacteremia (the most common was pneumococcus), 7 with preexisting virus infections including influenza (n = 4), adenovirus (n = 2), RSV, and 1 patient had mixed virus and bacterial infections. Predictive factors associated with death were arterial blood gas pH, CO2 and Glasgow Coma Scale (p < 0.05). SOFA score was a valuable predictive scoring system for outcome prediction (p < 0.05). CONCLUSIONS Pediatric patients with refractory septic shock had high mortality rate and ECMO could be used as a rescue modality, and SOFA score could be applied to predict outcomes.
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Affiliation(s)
- Tu-Hsuan Chang
- Department of Pediatrics, Chi-Mei Medical Center, Tainan, Taiwan; Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - En-Ting Wu
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yi Lu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzu-I Yang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chia Wang
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jong-Min Chen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Ing Lee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Min Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Luan-Yin Chang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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Lohmann P, Lee TC, Kearney DL, Fernandes CJ. Pre-cannulation lung biopsy shortens ECMO course. Pediatr Surg Int 2016; 32:713-6. [PMID: 27086306 DOI: 10.1007/s00383-016-3890-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/26/2022]
Abstract
We describe the clinical course of an infant with respiratory failure who underwent lung biopsy prior to cannulation for undergoing extracorporeal membrane oxygenation (ECMO). Pathology revealed alveolar capillary dysplasia, and ECMO was discontinued. Rapid diagnosis allowed for closure and saved resources. We recommend considering early biopsy in infants with atypical pulmonary hypertension.
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Affiliation(s)
- Pablo Lohmann
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
- Texas Children's Hospital, Houston, TX, USA.
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Debra L Kearney
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
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Bairdain S, Betit P, Craig N, Gauvreau K, Rycus P, Wilson JM, Thiagarajan R. Diverse Morbidity and Mortality Among Infants Treated with Venoarterial Extracorporeal Membrane Oxygenation. Cureus 2015; 7:e263. [PMID: 26180687 PMCID: PMC4494564 DOI: 10.7759/cureus.263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 12/12/2022] Open
Abstract
Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized for cardiopulmonary failure. We aimed to qualify and quantify the predictors of morbidity and mortality in infants requiring VA-ECMO. Methods: Data was collected from 170 centers participating in the extracorporeal life support organization (ELSO) registry. Relationships between in-hospital mortality and risk factors were assessed using logistic regression. Survival was defined as being discharged from the hospital. Results: Six hundred and sixty-two eligible records were reviewed. Mortality occurred in 303 (46%) infants. Congenital diaphragmatic hernia patients (OR=3.83, 95% CI 1.96-7.49, p<0.001), cardiac failure with associated shock (OR= 2.90, 95% CI 1.46-5.77, p=0.002), and pulmonary failure including respiratory distress syndrome (OR=4.06, 95% CI 1.72-9.58, p=0.001) had the highest odds of mortality in this cohort. Birth weight (BW) < 3 kg (OR=1.83, 95% CI 1.21-2.78, p=0.004), E-CPR (OR=3.35, 95% CI 1.57-7.15, p=0.002), hemofiltration (OR=2.04, 95% CI 1.32-3.16, p=0.001), and dialysis (OR=6.13, 95% CI 1.70-22.1, p<0.001) were all independent predictors of mortality. Conclusion: Infants requiring VA-ECMO experience diverse sequelae and their mortality are high.
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Affiliation(s)
| | - Peter Betit
- Department of Respiratory Therapy, Boston Children's Hospital
| | - Nancy Craig
- Department of Respiratory Therapy, Boston Children's Hospital
| | | | | | - Jay M Wilson
- Department of Pediatric Surgery, Boston Children's Hospital
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Alvarado-Socarrás JL, Gómez C, Gómez A, Cruz M, Díaz-Silva GA, Niño MA. [Current state of neonatal extracorporeal membrane oxygenation in Colombia: description of the first cases]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2014; 84:121-7. [PMID: 24794914 DOI: 10.1016/j.acmx.2013.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 07/11/2013] [Accepted: 07/19/2013] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation is considered a rescue therapy and complex vital support with benefits in cardiorespiratory diseases during neonatal period that fulfil the characteristics of being reversible in neonates older than 34 weeks. The criteria for patient selection and its prompt use are critical for the final result. Even though new alternatives for management of hypoxemic respiratory failure in full term and almost full term neonates have decreased its use, congenital diaphragmatic hernia continues being a complex disease where it can have some applicability. Even though our experience is beginning, constant training will make of extracorporeal membrane oxygenation an option for complex patients in whom maximum therapy fails. This is a report of the first neonatal cases of hypoxemic respiratory failure managed at Fundación Cardiovascular de Colombia.
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Affiliation(s)
- Jorge Luis Alvarado-Socarrás
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.
| | - Carolina Gómez
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Andrea Gómez
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Mónica Cruz
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Gustavo Adolfo Díaz-Silva
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - María Azucena Niño
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
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Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012). Pediatr Crit Care Med 2013; 14:851-61. [PMID: 24108118 DOI: 10.1097/pcc.0b013e3182a5540d] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure. DATA SOURCE A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations. STUDY SELECTION Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation. DATA EXTRACTION Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies. DATA SYNTHESIS Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained. CONCLUSIONS Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.
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Smith AH, Hardison DC, Bridges BC, Pietsch JB. Red blood cell transfusion volume and mortality among patients receiving extracorporeal membrane oxygenation. Perfusion 2012; 28:54-60. [DOI: 10.1177/0267659112457969] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Red blood cell (RBC) transfusion is used in the critically ill with low hemoglobin concentrations to optimize oxygen utilization and delivery imbalance. Data suggest that RBC transfusion is also independently associated with significant morbidity. We seek to characterize RBC transfusion volumes among patients receiving extracorporeal membrane oxygenation (ECMO) support and test the hypothesis that red blood cell transfusion volume is an independent risk factor for mortality. Methods: Records of all patients receiving ECMO support from 2001 through 2010 at a university-affiliated children’s hospital were retrospectively reviewed. Results: Among 484 ECMO runs reviewed, indications for ECMO were classified as cardiac (40%), non-cardiac (42%) or institution of ECMO during cardiopulmonary resuscitation (CPR) (18%). Median duration of ECMO support was 4.6 days, with overall survival to hospital discharge significantly higher among non-cardiac patients (60%) relative to patients supported for cardiac (37%) or external CPR (ECPR) indications (34%, p<0.001). Median RBC transfusion volumes with respect to ECMO indication were significantly greater among cardiac (105 mL/kg/day ECMO) and ECPR patients (66 mL/kg/day ECMO) relative to patients supported for non-cardiac indications (20 mL/kg/day ECMO, p<0.001). Among patients supported with ECMO for non-cardiac indications alone (n=203), independent of covariates, including weight, venoarterial mode of ECMO support, presence of congenital diaphragmatic hernia and complications, including hemorrhage, neurologic injury, and renal insufficiency, each RBC transfusion volume of 10 mL/kg/day ECMO was associated with a 24% increase in the odds of in-hospital mortality (OR 1.024, 95% CI 1.004-1.046, p=0.018). Conclusions: Greater red blood cell transfusion volumes among patients supported with ECMO for non-cardiac indications are independently associated with an increase in odds of mortality. A prospective investigation of restrictive RBC transfusion practices while receiving ECMO may be warranted in this population.
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Affiliation(s)
- AH Smith
- Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - DC Hardison
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - BC Bridges
- Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - JB Pietsch
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Abstract
PURPOSE OF REVIEW Cardiogenic shock still has a grave prognosis. We present the recent advances in mechanical circulatory support (MCS) for the treatment of refractory cardiogenic shock. RECENT FINDINGS The contraindications for short-term MCS in rapid-onset cardiogenic shock are becoming fewer and the threshold for its application has been progressively lowered. Short-term MCS is increasingly used in refractory cardiac arrest and will be probably integrated as the last means in the advanced cardiopulmonary resuscitation algorithm (provided there is experienced team and technical support). Improved device technology has contributed to improved results of long-term MCS. Emergent application of long-term MCS in patients with critical cardiogenic shock after a long history of progressively deteriorating end-stage chronic heart failure should be interpreted as delayed application associated with increased mortality. SUMMARY Although MCS can be life saving in cardiogenic shock, the results are still suboptimal. Mortality is associated with the critical presupport state and the adverse events during MCS. Early initiation of support that meets the patient's requirements, potent support in the early phase, adverse event prevention, global combined management (surgical, interventional, medical), balanced support duration, bridging to further therapeutic modalities including heart transplantation or longer-term support, and advanced technology could offer improved results.
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Bigdeli AK, Deutsch MA, Beiras-Fernandez A, Michel S, Kaczmarek I, Schmitz C, Sodian R. ECMO after prolonged cardiopulmonary resuscitation as a successful bridge to immediate cardiac retransplant in a 6-year-old girl. EXP CLIN TRANSPLANT 2012; 10:186-9. [PMID: 22432767 DOI: 10.6002/ect.2011.0131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heart failure, life-threatening arrhythmias, and sudden cardiac death are common complications in patients with advanced chronic cardiac allograft rejection--the major limiting factor of long-term survival after heart transplant. In patients with sustained cardiorespiratory arrest refractory to cardiopulmonary resuscitation extracorporeal membrane oxygenation therapy is a therapeutic option. We report the case of a 6-year-old girl with severe chronic allograft vasculopathy who was successfully bridged to cardiac retransplant through extracorporeal membrane oxygenation therapy after prolonged cardiopulmonary resuscitation. Our case demonstrates extracorporeal membrane oxygenation as a rescuing therapeutic option in high-risk, bridge-to-transplant patients, with cardiac arrest. Even after prolonged cardiopulmonary resuscitation, there were no neurologic events, and our patient recovered without any neurologic damage.
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Affiliation(s)
- Amir Khosrow Bigdeli
- Department of Cardiac Surgery, University Hospital Grosshadern, Munich, Germany.
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Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, Moon-Grady AJ, Coon PD, Noori S, Simpson J, Lai WW. Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: practice guidelines and recommendations for training. Writing Group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC). J Am Soc Echocardiogr 2012; 24:1057-78. [PMID: 21933743 DOI: 10.1016/j.echo.2011.07.014] [Citation(s) in RCA: 236] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Luc Mertens
- The Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
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Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, Moon-Grady AJ, Coon PD, Noori S, Simpson J, Lai WW. Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training: Writing group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC). EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2011; 12:715-36. [PMID: 21998460 DOI: 10.1093/ejechocard/jer181] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Luc Mertens
- The Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
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Development of a collaborative program to provide extracorporeal membrane oxygenation for adults with refractory hypoxemia within the framework of a pandemic. Pediatr Crit Care Med 2011; 12:426-30. [PMID: 21057349 DOI: 10.1097/pcc.0b013e3181ff41c1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We report the process used to rapidly develop a collaborative adult respiratory extracorporeal membrane oxygenation program as a response to caring for young adult patients with refractory hypoxemia in the setting of the pH1N1 pandemic. DESIGN Interdisciplinary response of a complex medical system to a public health crisis. PATIENTS, INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS: After the successful use of extracorporeal membrane oxygenation in young adults with pH1N1-induced acute respiratory distress syndrome refractory to conventional therapies, an adult venovenous extracorporeal membrane oxygenation program was implemented over an 8-wk period. Implementation of this program involved a number of key steps that were crucial in the development process, including administrative and institutional support, multidisciplinary leadership and collaboration, extensive interdisciplinary educational initiatives, and substantial technical modifications. CONCLUSIONS In the setting of the pH1N1 influenza pandemic, an adult respiratory extracorporeal membrane oxygenation program was successfully developed to complement an established neonatal-pediatric program. This program expansion integrated all of the necessary components involved in the development process from start to finish and confirms that a healthcare system can respond very quickly and successfully to an urgent healthcare need.
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Abstract
Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACD/MPV) is a rare, fatal developmental lung disorder of neonates and infants. This review aims to address recent findings in the etiology and genetics of ACD/MPV and to raise awareness of this poorly known disease, which may also present as milder, unclassified forms. Successively discussed are what is known about the epidemiology, pathogenesis, pathophysiology, diagnostic indicators and approaches, genetic testing, treatment, and cases of delayed onset. The review concludes with suggestions for future directions to answer the many unknowns about this disorder.
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Affiliation(s)
- Naomi B Bishop
- Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, NY 10065, USA.
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Rood KL, Teele SA, Barrett CS, Salvin JW, Rycus PT, Fynn-Thompson F, Laussen PC, Thiagarajan RR. Extracorporeal membrane oxygenation support after the Fontan operation. J Thorac Cardiovasc Surg 2011; 142:504-10. [PMID: 21353253 DOI: 10.1016/j.jtcvs.2010.11.050] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/08/2010] [Accepted: 11/25/2010] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation has been used to support children with cardiac failure after the Fontan operation. Mortality is high, and causes of mortality remain unclear. We evaluated the in-hospital mortality and factors associated with mortality in these patients. METHODS Extracorporeal Life Support Organization registry data on patients requiring extracorporeal membrane oxygenation after the Fontan operation from 1987 to 2009 were retrospectively analyzed. Demographics and extracorporeal membrane oxygenation data were compared for survivors and nonsurvivors. A multivariable logistic regression model was used to identify factors associated with mortality. RESULTS Of 230 patients, 81 (35%) survived to hospital discharge. Cardiopulmonary resuscitation was more frequent (34% vs 17%, P = .04), and median fraction of inspired oxygen concentration was higher (1 [confidence interval, 0.9-1.0] vs 0.9 [confidence interval, 0.8-1.0], P = .03) before extracorporeal membrane oxygenation in nonsurvivors compared with survivors. Extracorporeal membrane oxygenation duration and incidence of complications, including surgical bleeding, neurologic injury, renal failure, inotrope use on extracorporeal membrane oxygenation, and bloodstream infection, were higher in nonsurvivors compared with survivors (P < .05 for all). In a multivariable model, neurologic injury (odds ratio, 5.18; 95% confidence interval, 1.97-13.61), surgical bleeding (odds ratio, 2.36; 95% confidence interval, 1.22-4.56), and renal failure (odds ratio, 2.81; 95% confidence interval, 1.41-5.59) increased mortality. Extracorporeal membrane oxygenation duration of more than 65 hours to 119 hours (odds ratio, 0.33; 95% confidence interval, 0.14-0.76) was associated with decreased mortality. CONCLUSIONS Cardiac failure requiring extracorporeal membrane oxygenation after the Fontan operation is associated with high mortality. Complications during extracorporeal membrane oxygenation support increase mortality odds. Prompt correction of surgical bleeding when possible may improve survival.
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Affiliation(s)
- Kelly L Rood
- Department of Cardiology, Children's Hospital Boston, Mass 02115, USA.
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Factors associated with survival in pediatric extracorporeal membrane oxygenation--a single-center experience. J Pediatr Surg 2010; 45:1995-2003. [PMID: 20920718 DOI: 10.1016/j.jpedsurg.2010.05.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 11/24/2022]
Abstract
AIM We aimed to examine outcomes of extracorporeal membrane oxygenation (ECMO) therapy in the pediatric population and identify pre-ECMO and on-ECMO characteristics that are associated with survival. METHODS We retrospectively reviewed the ECMO records at our institution between 1999 and 2008 and selected pediatric patients who were cannulated for respiratory failure or hemodynamic instability resistant to conventional interventions. We recorded details of pre-ECMO clinical characteristics, including blood gas variables and mechanical ventilatory support, and details of ECMO therapy including survival off ECMO and to hospital discharge. Predictors of survival were analyzed using logistic regression modeling and a prediction algorithm was developed. RESULTS Of the 445 ECMO runs, data from 58 consecutive patients were analyzed: 57% were successfully decannulated, and 48% survived to discharge from the hospital. The cohort included 32 (55%) female patients, 22 postoperative patients (38%), and 15 (26%) with an immunosuppressive condition, with a median age of 5 years and weight 19.5 kg, The mean duration of pre-ECMO respiratory support was 3 days, in the form of high-frequency oscillatory ventilation (n = 28, 48%) and conventional mechanical ventilation (n = 13, 22%). The median duration (interquartile range) of ECMO support was 142 hours (60, 321) or 5.9 days. Pre-ECMO pH above 7.2 (P < .001) and oxygenation index below 35 (P = .021) were associated with the highest survival rates. Pre-ECMO PaCO(2) and duration of mechanical ventilation were not associated with survival. CONCLUSIONS Based on our results, ECMO therapy should be considered early in children with oxygenation index greater than 35 with worsening metabolic status. The restriction of ECMO based on ventilator days alone needs to be revisited in this era of lung protective ventilation.
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Abstract
OBJECTIVES To investigate outcomes among neonates with herpes virus infection reported to the Extracorporeal Life Support Organization (ELSO) Registry and analyze factors associated with death before hospital discharge with this virus. Currently, scant data exist regarding extracorporeal membrane oxygenation support in neonates with herpes virus infection. DESIGN Retrospective analysis of ELSO Registry data set from 1985 to 2005. SETTING A total of 114 extracorporeal membrane oxygenation centers contributing data to the ELSO Registry. PATIENTS Patients, 0 to 31 days of age, with herpes simplex virus infection supported with extracorporeal membrane oxygenation and reported to the ELSO Registry. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical characteristics, outcomes, and factors associated with death before hospital discharge were investigated for patients in the virus group. Kaplan-Meier estimates of survival to hospital discharge according to virus type were investigated. Newborns with herpes simplex virus infection requiring extracorporeal membrane oxygenation support demonstrated much lower hospital survival rates (25%). Clinical presentation with septicemia/shock was significantly associated with mortality for the herpes simplex virus group on multivariate analysis. There was no difference in herpes simplex virus mortality when comparing two eras (> or =2000 vs. <2000). CONCLUSIONS In this cohort of neonatal patients with overwhelming infections due to herpes simplex virus who were supported with extracorporeal membrane oxygenation, survival was dismal. Patients with disseminated herpes simplex virus infection presenting with septicemia/shock are unlikely to survive, even with aggressive extracorporeal support.
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Larsson M, Talving P, Palmér K, Frenckner B, Riddez L, Broomé M. Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage? Perfusion 2010; 25:217-23. [DOI: 10.1177/0267659110375864] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Venoarterial ECMO has been utilized in trauma patients to improve oxygenation, particularly in the setting of pulmonary contusions and ARDS. We hypothesized that venoarterial ECMO could reduce the central venous pressure in the trauma scenario, thus, alleviating major venous hemorrhage. Methods: Ten swine were cannulated for venoarterial ECMO. Central venous pressure, mean arterial pressure, portal vein pressure and portal vein flow were recorded at three different flow rates in both a hemodynamic normal state and a setting of increased central venous pressure and right ventricular load, mimicking acute lung injury. Results: Venoarterial ECMO reduced the central venous pressure (CVP sup) from 9.4±0.8 to 7.3±0.7 mmHg (p<0.01) and increased the mean arterial pressure from 103±8 to 119±10 mmHg (p<0.01) in the normal hemodynamic state. In the state of increased right ventricular load, the CVPsup declined from 14.3±0.4 to 11.0±0.7mmHg (p<0.01) and the mean arterial pressure (MAP) increased from 66±6 to 113 ±5 mmHg (p<0.01). Conclusion: Venoarterial ECMO reduces systemic venous pressure while maintaining or improving systemic perfusion in both a normal circulatory state and in the setting of increased right ventricular load associated with acute lung injury. ECMO may be a useful tool in reducing blood loss during major venous hemorrhage in both trauma and selected elective surgery.
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Affiliation(s)
| | - Peep Talving
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Louis Riddez
- Karolinska University Hospital, Stockholm, Sweden
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Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation. Pediatr Crit Care Med 2009; 10:445-51. [PMID: 19451851 DOI: 10.1097/pcc.0b013e318198bd85] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) to aid failed cardiopulmonary resuscitation (CPR) in children is associated with a high incidence of neurologic injury. We sought to identify risk factors for acute neurologic injury in children undergoing ECMO to aid CPR (E-CPR). DESIGN Retrospective cohort study using data reported to the Extracorporeal Life Support Organization registry. SETTING Multi-institutional data. PATIENTS Patients <18 years of age undergoing E-CPR during 1992-2005. INTERVENTIONS None. MEASUREMENTS AND RESULTS We defined acute neurologic injury as the occurrence of brain death, brain infarction, or intracranial hemorrhage identified by ultrasound or computerized tomography imaging. Of 682 E-CPR patients, 147 (22%) patients had acute neurologic injury. Brain death occurred in 74 (11%), cerebral infarction in 45 (7%), and intracranial hemorrhage in 45 (7%). The in-hospital mortality rate in patients with acute neurologic injury was 89%. In a multivariable logistic regression model, pre-ECMO factors including cardiac disease (odds ratio [OR] 0.46 [95% confidence interval {CI} 0.28-0.76]) and pre-ECMO blood pH > or =6.865 (> or =6.865-7.120; OR 0.49 [95% CI 0.25-0.94]; pH >7.120; OR 0.47 [95% CI 0.26-0.85]) compared with pH <6.865 were associated with decreased odds of neurologic injury. During ECMO, neurologic injury was associated with ECMO complications including pulmonary hemorrhage (OR 1.93, 95% CI 1.1-3.4), dialysis use (OR 2.36, 95% CI 1.4-4.0), and CPR during ECMO support (OR 2.08, 95% CI 1.6-3.8). CONCLUSIONS Neurologic injury is a frequent complication in children undergoing E-CPR. Children with cardiac disease, less severe metabolic acidosis before ECMO, and an uncomplicated ECMO course have decreased odds of sustaining neurologic injury. Providing effective CPR and inclusion of brain protective therapies on ECMO should be considered in the future to improve neurologic outcomes for patients undergoing E-CPR.
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Extracorporeal life support for support of children with malignancy and respiratory or cardiac failure: The extracorporeal life support experience*. Crit Care Med 2009; 37:1308-16. [DOI: 10.1097/ccm.0b013e31819cf01a] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Segura S, Cambra FJ, Moreno J, Thió M, Riverola A, Iriondo M, Mayol J, Palomeque A. [ECMO: experience in paediatrics]. An Pediatr (Barc) 2009; 70:12-9. [PMID: 19174114 DOI: 10.1016/j.anpedi.2008.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 07/24/2008] [Accepted: 08/01/2008] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION ECMO (Extracorporeal Membrane Oxygenation) provides a vital support to patients with supposed reversible respiratory and/or cardiac failure, in whom conventional support techniques have been previously unsuccessful. OBJECTIVES To determinate the criteria used in our hospital to put paediatric patients on ECMO, compare their clinical course depending on their pathology (respiratory failure, congenital heart disease or sepsis) and identify the sequelae attributable to this technique. MATERIAL AND METHOD A retrospective review of clinical records of all patients on ECMO support in our centre, excluding those presenting typically in neonatal period. RESULTS ECMO was used on 16 patients from June 2001 to January 2007, of which 50% were males. The median age was 7 months (from 21 days to 11 years). The reason for starting ECMO was respiratory failure in 11 cases (oxygenation index >40 and/or alveolar-arterial oxygen gradient >605), congenital heart disease in 2 and sepsis in 3 (due to shock unresponsive to adequate resuscitation). The median time to starting ECMO from PICU admission was 3.58 days (from 12h to 9 days). Venovenous cannulation was used initially in 8 patients, but 5 of them needed venoarterial ECMO later. The technique was used for a mean of 8 days (from 1 to 28 days). The main complication was the isolation of bacteria in different cultures (8 patients). The overall survival was 50% (6 patients with respiratory failure and both patients submitted to cardiac surgery). Extracorporeal support was withdrawn in 7 children because their clinical situation was irreversible. Another patient died seven days after successful decannulation. We have not found any serious sequel among survivors that could be attributable to this technique. CONCLUSIONS Survival among children supported with ECMO in our hospital is similar to that recorded by the ELSO in 2004, although the prognosis depends on the initial pathology. There are different criteria for starting this technique depending on the underlying diseases: respiratory index of poor prognosis in patients with respiratory failure, haemodynamic instability in those with sepsis or cardiac failure after cardiovascular surgery. We have not found any serious sequel among the survivors which could be attributable to this technique.
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Affiliation(s)
- S Segura
- Servicio de Cuidados Intensivos Pediátricos, Hospital Sant Joan de Déu-Clínic, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España.
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Extracorporeal Membrane Oxygenation Circulatory Support After Congenital Cardiac Surgery. ASAIO J 2009; 55:53-7. [DOI: 10.1097/mat.0b013e31818f0056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Affiliation(s)
- Sung-Woo Lee
- Emergency Department, Ansan Hospital, Korea University, 425-707 Seoul, South Korea.
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Extracorporeal membrane oxygenation in immunocompromised patients: Avoiding the incurable or missing opportunities? Pediatr Crit Care Med 2008; 9:442-4. [PMID: 18496400 DOI: 10.1097/pcc.0b013e318172ec69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Multiple organ system extracorporeal support effectively supports brain, heart, lung, liver, kidney, coagulation, red blood cell, and immune cell function in the sickest infants and children who have multiple organ system failure. These therapies have optimum benefit if: (1) the underlying disease is reversible; (2) the therapies are performed expertly and are monitored to prevent and minimize systemic hemolysis; and (3) the therapies are provided in a goal-directed manner. These therapies represent a significant advance in pediatric critical care medicine. This article provides a framework for this multidisciplinary team approach for implementing these therapies.
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Affiliation(s)
- Joseph A Carcillo
- Pediatric Critical Care, Children's Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213, USA.
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Coppola CP, Tyree M, Larry K, DiGeronimo R. A 22-year experience in global transport extracorporeal membrane oxygenation. J Pediatr Surg 2008; 43:46-52; discussion 52. [PMID: 18206454 DOI: 10.1016/j.jpedsurg.2007.09.021] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 09/02/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Transport extracorporeal membrane oxygenation (ECMO) is currently available at 12 centers. We report a 22-year experience from the only facility providing global transport ECMO. Indications for transport ECMO include lack of ECMO services, inability to transport conventionally, inability to wean from cardiopulmonary bypass, extracorporeal cardiopulmonary resuscitation, and need to move a patient on ECMO for specialized services such as organ transplantation. METHODS Retrospective database review of children undergoing inhouse and transport ECMO from 1985 to 2007. RESULTS Sixty-eight children underwent transport ECMO. Fifty-six were transported on ECMO into our facility. The remaining 12 were moved between 2 outside locations. Ground vehicles and fixed-wing aircraft were used. Distance transported was 8 to 7500 miles (13-12070 km), mean 1380 miles (2220 km). There were 116 inhouse ECMO runs. No child died during transport. Survival to discharge after transport ECMO was 65% (44/68) and, for inhouse ECMO, was 70% (81/116). CONCLUSIONS Transport ECMO is feasible and effective, with survival rates comparable to inhouse ECMO. We have used transport ECMO to help children at non-ECMO centers with pulmonary failure who have not improved with inhaled nitric oxide and high-frequency ventilation. We have also transported a child after extracorporeal cardiopulmonary resuscitation, which may represent an emerging indication for transport ECMO. Transport ECMO often is the only option for children too unstable for conventional transport or those already on ECMO and requiring a specialized service at another facility, such as organ transplantation.
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Affiliation(s)
- Christopher P Coppola
- Department of Surgery, Wilford Hall Medical Center, San Antonio, Lackland AFB, TX 78236, USA.
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Thiagarajan RR, Laussen PC, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation to aid cardiopulmonary resuscitation in infants and children. Circulation 2007; 116:1693-700. [PMID: 17893278 DOI: 10.1161/circulationaha.106.680678] [Citation(s) in RCA: 255] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used to support cardiorespiratory function during pediatric cardiopulmonary resuscitation (CPR). We report on outcomes and predictors of in-hospital mortality after ECMO used to support CPR (E-CPR). METHODS AND RESULTS Outcomes for patients aged <18 years using E-CPR were analyzed with data from the Extracorporeal Life Support Organization, and predictors of in-hospital mortality were determined. Of 26,242 ECMO uses reported, 695 (2.6%) were for E-CPR (n=682 patients). Survival to hospital discharge was 38%. In a multivariable model, pre-ECMO factors such as cardiac disease (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.31 to 0.82) and neonatal respiratory disease (OR 0.28, 95% CI 0.12 to 0.66), white race (OR 0.65, 95% CI 0.45 to 0.94), and pre-ECMO arterial blood pH >7.17 (OR 0.50, 95% CI 0.30 to 0.84) were associated with decreased odds of mortality. During ECMO, renal dysfunction (OR 1.89, 95% CI 1.17 to 3.03), pulmonary hemorrhage (OR 2.23, 95% CI 1.11 to 4.50), neurological injury (OR 2.79, 95% CI 1.55 to 5.02), CPR during ECMO (OR 3.06, 95% CI 1.42 to 6.58), and arterial blood pH <7.2 (OR 2.23, 95% CI 1.23 to 4.06) were associated with increased odds of mortality. CONCLUSIONS ECMO used to support CPR rescued one third of patients in whom death was otherwise certain. Patient diagnosis, absence of severe metabolic acidosis before ECMO support, and uncomplicated ECMO course were associated with improved survival.
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Affiliation(s)
- Ravi R Thiagarajan
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Maclaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution's experience. Pediatr Crit Care Med 2007; 8:447-51. [PMID: 17693912 DOI: 10.1097/01.pcc.0000282155.25974.8f] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report our institutional experience of venoarterial extracorporeal membrane oxygenation (ECMO) in children with septic shock and circulatory collapse. DESIGN Retrospective case series. SETTING Intensive care unit of a tertiary pediatric referral center. PATIENTS Forty-five children with refractory septic shock who received venoarterial ECMO for hemodynamic support. INTERVENTIONS Venoarterial ECMO. MEASUREMENTS AND MAIN RESULTS We measured mean arterial pressure and inotropes before cannulation, ventilator settings, oxygenation, site and cause of infection, time on ECMO, complications of ECMO relating to the circuit or anticoagulation, survival to hospital discharge, and functional outcome assessment. Between July 1988 and October 2006, 441 children at our institution received extracorporeal life support for a variety of indications. Forty-five (10%) with septic shock received venoarterial ECMO specifically for hemodynamic support. Eighteen (40%) of these had suffered cardiac arrest and were receiving chest compressions immediately before cannulation. The median time spent on ECMO was 84 hrs (range, 32-135). There were mechanical problems with the ECMO circuit requiring intervention in 17 (38%) patients, such as oxygenator or pump head failure, clots in the circuit, or cannulae malposition. This caused no long-term harm in any but one of the patients, who died during a circuit change. Eleven patients (24%) had clinically apparent episodes of bleeding that required surgical intervention or blood transfusion. Twenty-one (47%) patients survived to hospital discharge. Atrioaortic cannulation through a sternotomy incision was associated with an improvement in survival to hospital discharge (73% of those with central cannulation survived vs. 44% without, p = .05). No survivors had severe disability at long-term follow-up. CONCLUSIONS Extracorporeal membrane oxygenation can be safely used to resuscitate and support children with sepsis and refractory shock. Sepsis and multiorgan failure should not be considered a contraindication to ECMO. This study adds support to existing guidelines.
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Affiliation(s)
- Graeme Maclaren
- Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
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Rega FR, Evrard V, Bollen H, Peeters G, Vercaemst L, Meuris B, Herijgers P, Sergeant P, Hermans G, Vlasselaers D, Meyns B. pH 48 h after onset of extracorporeal membrane oxygenation is an independent predictor of survival in patients with respiratory failure. Artif Organs 2007; 31:384-9. [PMID: 17470208 DOI: 10.1111/j.1525-1594.2007.00396.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure in patients with severe respiratory failure, unresponsive to conventional therapy. We reviewed our series of 70 ECMO runs (April 1997 to December 2005) in patients with respiratory distress, refractory to standard ventilation. Survival at 90 days was 42.7%. Besides age, we found no statistical significant difference in patient demographics or preoperative patient data between survivors and nonsurvivors. Univariate analyses indicated that pH values at 24 and 48 h after onset of ECMO were significantly higher in survivors. In multivariate analysis, age and pH at 48 h remained independent predictors of survival. ECMO in respiratory failure saves lives. No other demographic or preoperative, patient-related parameter than age was identified as predictor of survival. Although there was no difference in pH at onset of ECMO, blood gas analysis at 48 h revealed pH as an independent predictor of survival.
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Affiliation(s)
- Filip R Rega
- Department of Cardiac Surgery, University Hospital Gasthuisberg, Leuven, Belgium
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Potapov EV, Stiller B, Hetzer R. Ventricular assist devices in children: current achievements and future perspectives. Pediatr Transplant 2007; 11:241-55. [PMID: 17430478 DOI: 10.1111/j.1399-3046.2006.00611.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Mechanical circulatory support systems for the treatment of acute and chronic heart failure are now available for use in several clinical situations and are designed for different indications and support times. In children, particularly in small infants, extracorporeal membrane oxygenation and centrifugal pumps have been most widely used in the past. These systems are preferred for support after cardiac operations and for use in patients who have concomitant respiratory failure, but they are suitable for short-term application only and intensive care is obligatory. VADs are designed for long-term application and allow patients to be discharged home. Pneumatic pulsatile VADs have been available in pediatric sizes since 1992. Currently at our institution, 74 children have been supported with pediatric extracorporeal VADs for up to 14 months. In the past five yr, a notable rise in survival has been achieved by improvements in pump design and pre- and post-operative management. We have been able to discharge 78% of the infants under one yr old. In this review, our current VAD experience in children will be presented in the light of improvements in decision-making, device technology, and implantation techniques, and in coagulation monitoring and anticoagulation. Additionally, new developments in the field of pediatric assist devices will be presented.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany.
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Mills L, Redpath S, Liddell M, Simpson J, Davis C, Skeoch C, Jackson L. Predictors of clinical outcome for infants transferred for extracorporeal life support consideration. Arch Dis Child Fetal Neonatal Ed 2007; 92:F233. [PMID: 17449861 PMCID: PMC2675341 DOI: 10.1136/adc.2006.107466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Flamant C, Lorino E, Nolent P, Hallalel F, Chevalier JY, Fau S, Gold F, Renolleau S. Survie et devenir clinique des nouveau-nés mis en assistance respiratoire extracorporelle. Arch Pediatr 2007; 14:354-61. [PMID: 17306967 DOI: 10.1016/j.arcped.2007.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Revised: 12/29/2006] [Accepted: 01/18/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the prognosis of newborn infants with refractory hypoxemia who required extracorporeal membrane oxygenation (ECMO). METHODS Eighty-nine newborn infants treated by ECMO during more than 24 hours over a 8-year period (1996-2003) were included in this observational cohort study with a 9-month and 24-month evaluation. RESULTS Respiratory failure mainly resulted from meconium aspiration syndrome (MAS, 43%), congenital diaphragmatic hernia (CDH, 15%) and sepsis (15%). Overall survival at hospital discharge was 67%. Infants with MAS had the best survival rate (82%) and those with CDH had the worst (46%). Of the remaining 60 survivors, 53% remained oxygen dependent at 28 days and 33% at 45 days. At the age of 2 years, only 1 infant remained oxygen dependent (but did not required oxygen at 3 years) and only 3 infants had significant neurodevelopmental problems. CDH group was associated with a prolonged duration in supplementary oxygen (P<0.001) and a prolonged duration for tube feeding (P=0.01) as compared with other diagnoses. Regarding neurologic outcome, CDH infants had the poorer neurological acquisition rate at 9 months but a very good evolution by the time of the 24-month evaluation. CONCLUSIONS Morbidity in ECMO survivors is low considering the severity of illness in the newborn period, mainly related to pulmonary and feeding dysfunctions during the first months, in particular for the CDH group. Outcome at the age of 2 years of CDH infants is most often favourable regarding growth and neurodevelopmental evolution.
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Affiliation(s)
- C Flamant
- Service de réanimation néonatale et pédiatrique, Assistance publique-Hôpitaux de Paris, hôpital d'enfants Armand-Trousseau, 26 avenue du Docteur-A.-Netter, 75571 Paris cedex 12, France.
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Bennett M, Kissoon N. Is cardiopulmonary resuscitation warranted in children who suffer cardiac arrest post trauma? Pediatr Emerg Care 2007; 23:267-72. [PMID: 17438445 DOI: 10.1097/pec.0b013e3180403088] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of cardiopulmonary resuscitation (CPR) is accepted universally for patients with cardiovascular compromise. However, outcomes from CPR in subsets of trauma patients may not be as good as initially thought. This article reviews the literature on outcomes from traumatic arrest in both adults and children. Outcomes for adults and children are similar, although the types of injuries may differ. Patients with asystolic arrest at the scene have very poor survival, and those who do survive sustain severe neurological injury. Recognizing that most providers would feel uncomfortable at not attempting resuscitation, the length and degree of aggressiveness of CPR is addressed. Finally, we discuss possible reasons to resuscitate. Organ donation and the ethics of nontherapeutic ventilation and other strategies to increase the donor pool are discussed. We hope to stimulate discussion around a very difficult issue.
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Affiliation(s)
- Mary Bennett
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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Yamamoto LG, Young LL. Acute-onset dysrhythmia heralding fulminant myocarditis and refractory cardiac arrest treated with ED cardiopulmonary bypass and extracorporeal membrane oxygenation. Am J Emerg Med 2007; 25:348-52. [PMID: 17349913 DOI: 10.1016/j.ajem.2006.05.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Accepted: 05/15/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The outcome of refractory cardiac arrest is poor. The purpose of this report is to describe two cases presenting with fulminant myocarditis and refractory cardiac arrest treated with emergency department cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), with subsequent recovery. METHODS Report of two cases. RESULTS Two patients presented with a new onset dysrhythmia heralding fulminant myocarditis and cardiac arrest refractory to advanced life support measures. Chest compressions and positive pressure ventilation maintained oxygenation and perfusion until CPB could be initiated in the ED followed by ECMO. Spontaneous cardiac recovery followed, associated with normal neurocognitive function. CONCLUSION While CPB and ECMO initiation in the ED is a rare event, this could provide patients with cardiac arrest presentations suggestive of myocarditis, additional time for recovery to occur. Clinical factors suggesting a good outcome are witnessed cardiac arrest in a previously healthy child with immediate initiation of effective CPR and good brain perfusion and function as evidence by substantial bodily movement during CPR. Significant dysrhythmias in a previously healthy child may herald substantial deterioration and cardiac arrest.
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Affiliation(s)
- Loren G Yamamoto
- Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI 96826, USA.
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Ignacio RC, Falcone RA, Brown RL. A case report of severe tracheal obstruction requiring extracorporeal membrane oxygenation. J Pediatr Surg 2006; 41:E1-4. [PMID: 17011250 DOI: 10.1016/j.jpedsurg.2006.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The authors describe the case of a near-fatal airway obstruction requiring extracorporeal membrane oxygenation. The patient presented with severe respiratory distress owing to a bean impacted in the distal trachea. The foreign body could not be removed by bronchoscopy because of instability of the patient. The patient was placed on extracorporeal membrane oxygenation for temporary pulmonary support, and the foreign body was removed using a rigid bronchoscope. The patient had a full recovery and suffered no neurologic sequelae.
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Affiliation(s)
- Romeo C Ignacio
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Abstract
BACKGROUND Safety and efficacy of extracorporeal membrane oxygenation (ECMO) in pregnancy is unknown. CASE A 33-year-old pregnant woman at 23 weeks of gestation presented with acute respiratory distress syndrome unresponsive to conventional mechanical ventilation. Early initiation of ECMO therapy along with protective mechanical ventilation strategy resulted in an excellent maternal and fetal outcome. CONCLUSION Extracorporeal membrane oxygenation can be life saving when initiated early in pregnant patients with severe acute respiratory insufficiency unresponsive to conventional mechanical ventilation.
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Affiliation(s)
- Jennifer A Cunningham
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Hetzer R, Stiller B. Technology Insight: use of ventricular assist devices in children. ACTA ACUST UNITED AC 2006; 3:377-86. [PMID: 16810173 DOI: 10.1038/ncpcardio0575] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2005] [Accepted: 03/15/2006] [Indexed: 11/08/2022]
Abstract
Mechanical circulatory support systems for the treatment of end-stage heart failure are now available for a wide variety of clinical situations and support times. Extracorporeal membrane oxygenation and centrifugal pump circuits have been most widely used in children, particularly in small infants. These systems are preferred for support after cardiac operations and for use in patients who have concomitant respiratory failure, but are suitable for short-term application only and intensive care is obligatory. True ventricular assist devices (VADs) qualify for long-term application and allow patients full mobilization. These features are important in patients awaiting heart transplantation as well as in those with myocarditis and cardiomyopathy, who might achieve complete cardiac recovery. Pneumatic pulsatile VADs have been available in pediatric sizes since 1992. At our institution, VAD use lasting from several days to 14 months in 70 infants and children with myocarditis and cardiomyopathy has led to a notable rise in survival in the past 5 years. We have been able to discharge 78% of the infants under 1 year old. In this review we present current VAD experience in children in the light of improvements in decision making, device technology, implantation techniques, and in coagulation monitoring and anticoagulation.
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Affiliation(s)
- Roland Hetzer
- Department of Thoracic and Cardiovascular Surgery, Deutsches Herzzentrum Berlin, Germany.
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