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Scott Eldredge R, Russell KW. Pediatric surgical interventions on ECMO. Semin Pediatr Surg 2023; 32:151330. [PMID: 37931540 DOI: 10.1016/j.sempedsurg.2023.151330] [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: 11/08/2023]
Abstract
Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.
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Affiliation(s)
- R Scott Eldredge
- Department of Surgery, Mayo Clinic, Phoenix, AZ, United States; Department of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, United States
| | - Katie W Russell
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States.
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Snyder AN, Cheng T, Burjonrappa S. A nationwide database analysis of demographics and outcomes related to Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia. Pediatr Surg Int 2021; 37:1505-1513. [PMID: 34398295 DOI: 10.1007/s00383-021-04979-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of the study was to understand the use of Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and its outcomes. METHODS The 2016 Kid's Inpatient Database (KID) obtained from the national Healthcare Cost and Utilization Project (HCUP) was used to obtain CDH birth, demographic, and outcome data associated with ECMO use. Categorical variables were analyzed and odds ratios (OR) with 95% confidence intervals (CI) are reported for variables found to have significance (p < 0.05). Appropriate regressions were used for comparing categorical and continuous data using SPSS 25 for Macintosh. RESULTS The database contained 1189 cases of CDH, of which 133 (11.2%) received ECMO. The overall mortality of neonates with CDH was 18.9% (225/1189). Newborns with CDH on ECMO had a survival of 46% (61/133) compared to 85.5% without ECMO (903/1056) (OR 6.966, p < 0.001, 95% CI 4.756-10.204). ECMO increased length of stay from 24.6 to 69.8 days (OR 2.834, p < 0.001, 95% CI 2.768-2.903) and average cost from $375,002.20 to $1641,586.83 (OR 4.378, p < 0.001, 95% CI 3.341-5.735). CONCLUSIONS Increased length of stay, costs, and outcomes with ECMO use in CDH should prompt an examination of criteria necessitating ECMO.
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Affiliation(s)
- Alana N Snyder
- University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Tiffany Cheng
- University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Sathyaprasad Burjonrappa
- Division Chief of Adolescent Obesity Surgery, RWJ Medical School, Rutgers, State University of New Jersey, 504 MEB, 1 RWJ Place, New Brunswick, NJ, 08901, USA.
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Pilkington M, Mychaliska GB, Jarboe MD, Arnold MA, Hirschl RB, Gadepalli SK. Safety of delayed decannulation of venoarterial cannulas in patients with congenital diaphragmatic hernia. J Pediatr Surg 2020; 55:29-32. [PMID: 31672411 DOI: 10.1016/j.jpedsurg.2019.09.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/29/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The practice of "cutting-away" from venoarterial extracorporeal life support (ECLS) and leaving indwelling heparinized cannulas prior to decannulation is controversial. This study aims to determine the safety and efficacy of this strategy in patients with congenital diaphragmatic hernia (CDH) who require ECLS. METHODS A single-center retrospective review of electronic health records was performed on all patients with CDH who underwent elective ECLS decannulation between January 2014 and September 2018. Descriptive statistics are presented as medians with interquartile range. RESULTS Seventy-three percent (19/26) of patients who underwent venoarterial ECLS for CDH were electively decannulated. After a median ECLS run of 10.7 days [6.1-19.5], patients were "cut-away" for a median of 26 h [19.8-43] prior to decannulation. One patient required re-initiation at 36 h for a pulmonary hypertensive crisis (5%). There were no major bleeding or embolic events while "cut-away", and four (21%) patients had clots removed from the cannulas without clinical sequelae. One patient was recannulated 16 days following initial decannulation. CONCLUSIONS Our data suggests that "cutting-away" from ECLS in patients with congenital diaphragmatic hernia is safe and allows a period of observation without significant complications. This strategy may be particularly helpful in patients at risk for recannulation, but better prognostic criteria are needed. LEVEL OF EVIDENCE Level IV. TYPE OF STUDY Treatment Study.
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Affiliation(s)
- Mercedes Pilkington
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Marcus D Jarboe
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Meghan A Arnold
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI.
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Valencia E, Nasr VG. Updates in Pediatric Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2019; 34:1309-1323. [PMID: 31607521 DOI: 10.1053/j.jvca.2019.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/28/2023]
Abstract
Extracorporeal membrane oxygenation is an increasingly used mode of life support for patients with cardiac and/or respiratory failure refractory to conventional therapy. This review provides a synopsis of the evolution of extracorporeal life support in neonates, infants, and children and offers a framework for areas in need of research. Specific aspects addressed are the changing epidemiology; technologic advancements in extracorporeal membrane oxygenation circuitry; the current status and future direction of anticoagulation management; sedative and analgesic strategies; and outcomes, with special attention to the lessons learned from neonatal survivors.
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Affiliation(s)
- Eleonore Valencia
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Delaplain PT, Jancelewicz T, Di Nardo M, Zhang L, Yu PT, Cleary JP, Morini F, Harting MT, Nguyen DV, Guner YS. Management preferences in ECMO mode for congenital diaphragmatic hernia. J Pediatr Surg 2019; 54:903-908. [PMID: 30786989 DOI: 10.1016/j.jpedsurg.2019.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 01/27/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study was to identify management preferences that may exist in the care of infants with CDH receiving ECMO with emphasis on VV-ECMO. METHODS A survey was created to measure treatment preferences regarding ECMO use in CDH. The survey was distributed to all APSA and ELSO/Euro-ELSO members via e-mail. Survey results were summarized using descriptive statistics. RESULTS The survey had 230 respondents. The survey participants were surgeons (75%), neonatologists/intensivists (23%), and "other" (2%). The mean annual center volume was 11.6(±9.6) CDH cases, and the average number treated with ECMO was 4.5 (±6.4) cases/yr. The most agreed upon criteria for ECMO initiation were preductal O2 saturation <80% refractory to ventilator manipulation and medical therapy (89%), oxygenation index >40 (80%), severe air-leak (79%), and mixed acidosis (75%). Over 60% of respondents agreed the VV-ECMO would be optimum for average risk neonates. However, this preference diminished as the pre-ECMO level of cardiac support increased. When asked about why each respondent would choose VA-ECMO over VV-ECMO, the responses varied significantly between surgeons and non-surgeons. CONCLUSION While there seem to be areas of consensus among practitioners, such as criteria for initiation of ECMO, this survey revealed substantial variation in individual practice patterns regarding the use of ECMO for CDH. TYPE OF STUDY Qualitative, Survey. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Patrick T Delaplain
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Lishi Zhang
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science, Irvine, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
| | - John P Cleary
- Children's Hospital of Orange County, Division of Neonatology, Orange, CA
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Yigit S Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
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Ares GJ, Buonpane C, Helenowski I, Reynolds M, Hunter CJ. Outcomes and associated ethical considerations of long-run pediatric ECMO at a single center institution. Pediatr Surg Int 2019; 35:321-328. [PMID: 30683989 PMCID: PMC6433597 DOI: 10.1007/s00383-019-04443-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Survival of neonatal and pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) ≥ 21 days has not been well described. We hypothesized that patients would have poor survival and increased long-term complications. METHODS Retrospective, single center, review and case analysis. Tertiary-care university children's hospital including neonatal, pediatric and cardiac intensive care units. After institutional review board approval, the charts of all patients < 18 years of age undergoing ECMO for ≥ 21 continuous days were performed, and they were compared to comparative patients undergoing shorter runs. Overall survival, incidence of complications, and post-discharge recovery were recorded. RESULTS Overall survival was 36% in patients undergoing ≥ 21 days of ECMO (N = 14). 5/8 patients with cardiopulmonary failure from acquired etiologies survived versus 0/6 patients with congenital anomalies. 1/5 survivors achieved complete recovery with no neurologic deficits. The remaining survivors suffer from multiple medical and neurodevelopmental morbidities. CONCLUSION ECMO support for ≥ 21 days is associated with poor survival, particularly in neonates with congenital anomalies. Long-term outcomes for survivors ought to be carefully weighed and discussed with parents given the high incidence of neurologic morbidities in this population.
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Affiliation(s)
- Guillermo J. Ares
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, 211 E Chicago Avenue, Box 63, Chicago, IL 60611, USA,Department of Surgery, University of Illinois at Chicago, 840 South Wood Street, Suite 376‑CSN, Chicago, IL 60612, USA
| | - Christie Buonpane
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, 211 E Chicago Avenue, Box 63, Chicago, IL 60611, USA
| | - Irene Helenowski
- Feinberg School of Medicine, Northwestern University, 310 East Superior Street, Morton 4‑685, Chicago, IL 60611, USA
| | - Marleta Reynolds
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, 211 E Chicago Avenue, Box 63, Chicago, IL 60611, USA
| | - Catherine J. Hunter
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, 211 E Chicago Avenue, Box 63, Chicago, IL 60611, USA,Feinberg School of Medicine, Northwestern University, 310 East Superior Street, Morton 4‑685, Chicago, IL 60611, USA
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