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Totapally A, Fretz EA, Wolf MS. A narrative review of neuromonitoring modalities in critically ill children. Minerva Pediatr (Torino) 2024; 76:556-565. [PMID: 37462589 DOI: 10.23736/s2724-5276.23.07291-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Acute neurologic injury is common in critically ill children. Some conditions - such as traumatic brain injury, meningitis, and hypoxic-ischemic injury following cardiac arrest - require careful consideration of cerebral physiology. Specialized neuromonitoring techniques provide insight regarding patient-specific and disease-specific insight that can improve diagnostic accuracy, aid in targeting therapeutic interventions, and provide prognostic information. In this review, we will discuss recent innovations in invasive (e.g., intracranial pressure monitoring and related computed indices) and noninvasive (e.g., transcranial doppler, near-infrared spectroscopy) neuromonitoring techniques used in traumatic brain injury, central nervous system infections, and after cardiac arrest. We will discuss the pertinent physiological mechanisms interrogated by each technique and discuss available evidence for potential clinical application. We will also discuss the use of innovative neuromonitoring techniques to detect and manage neurologic complications in critically ill children with systemic illness, focusing on sepsis and cardiorespiratory failure requiring extracorporeal membrane oxygenation.
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Affiliation(s)
- Abhinav Totapally
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Emily A Fretz
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Michael S Wolf
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA -
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2
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Alexander GK, Namachivayam SP, Chiletti R, Butt W. Why do children not survive extracorporeal membrane oxygenation? J Paediatr Child Health 2024. [PMID: 39034664 DOI: 10.1111/jpc.16614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/14/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used in critically ill children with cardiac and/or respiratory failure. Use is increasing in children with high-risk comorbidities. Reasons children do not survive ECMO are poorly described. AIMS Describe characteristics and cause of death, compare mortality in children with high-risk comorbidities, evaluate mortality trends over a decade. METHOD All children <18 years old who received ECMO at this institution from 1 January 2011 to 31 December 2020 were described and categorised by outcome: died on or <48 h post-ECMO, died ≥48 h post-ECMO, survived to hospital discharge. Children who did not survive ECMO (DNSE) were categorised to: ECMO withdrawal for irrecoverable original condition, withdrawal for poor prognosis neurological condition, brain death, withdrawal for poor prognosis with multiple complex conditions, and unsupportable. Poison regression was used to analyse survival trends. RESULTS Four hundred twenty-eight children received ECMO, 19% DNSE, 14% died ≥48 h post-ECMO and 67% survived. ECMO was electively withdrawn for irrecoverable original condition (39%), poor prognosis for neurological condition (32%) or multiple complex conditions (18%). One hundred twenty-two children had ≥1 high-risk comorbidity. Children with genetic syndromes (58%), risk-adjusted congenital heart surgery score-1 ≥4 (53%), primary immunodeficiency (50%) had lower hospital survival. No children with malignancy/bone marrow transplant survived to hospital discharge. Overall hospital survival was 67%, with no significant change during the study period (P-trend = 0.99). CONCLUSION Children who DNSE have therapy electively withdrawn for irrecoverable disease or poor prognosis. Children with high-risk comorbidities have a reasonable chance of survival. This study informs clinicians ECMO may be a therapeutic option.
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Affiliation(s)
- Georgina K Alexander
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Siva P Namachivayam
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Roberto Chiletti
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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3
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Olutoye OO, Lee T, Todd HF, King A, Keswani SG. Extracorporeal Membrane Oxygenation Before 34 Wks' Gestation: A Single-Center Experience. J Surg Res 2024; 301:302-307. [PMID: 38996721 DOI: 10.1016/j.jss.2024.06.012] [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: 03/01/2023] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION Traditionally, gestational age <34 wk and weight <2 kg are considered relative contraindications to extracorporeal membrane oxygenation (ECMO). There is a paucity of information that explains the outcomes in this unique population of premature neonates. The purpose of this study is to examine outcomes of patients who undergo ECMO at <34 wk at a single institution. METHODS A single-center retrospective review was performed for neonates managed with ECMO in the neonatal intensive care unit from January 2012 to April 2022. Characteristics and outcome data were collected. The primary outcome studied was survival at discharge. Secondary outcomes were intraventricular hemorrhage, ischemic brain injury, and thrombosis. Data were analyzed with descriptive statistics. RESULTS Following exclusion, 107 patients were included with eight having initiating ECMO at <34 wk. Three (38%) patients, who received ECMO at <34 wk, incurred intraventricular hemorrhages compared to 14 (14%) in the ≥34-wk cohort. Two (25%), who underwent ECMO at <34 wk, exhibited signs of brain ischemia on imaging compared to 9 (9%) in those ≥34 wk, and 3 (38%) patients <34 wk experienced thrombosis compared to 31 (31%) in the ≥34-wk cohort. Five (63%) of those in the <34-wk cohort survived to discharge, similar to 61 (61%) in the ≥34 wk cohort. CONCLUSIONS Our data suggest that EGA <34 wk may not be a contraindication for ECMO, with appropriate counseling of potential risks.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Taylor Lee
- Lab for Regenerative Tissue Repair, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Hannah F Todd
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas.
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Guner YS, Hammond JD, Keene S, Gray B. The role of ECLS in the management of congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151440. [PMID: 38996506 DOI: 10.1016/j.sempedsurg.2024.151440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Abstract
In the complex arena of Congenital Diaphragmatic Hernia (CDH) management, Extracorporeal Life Support (ECLS) provides a strategic window for stabilization and surgical correction, during which time marginal gains in patient stability can tip the scales towards survival. In modern neonatal ECLS, the focus is increasingly on minimizing survivor morbidity, which calls for considerable multidisciplinary expertise to enhance patient outcomes. This review will delve into the most up-to-date literature on the management of CDH in the context of ECLS, providing a comprehensive synthesis of current insights.
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Affiliation(s)
- Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, United States; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States.
| | - J D Hammond
- Department of Pediatrics, University of California Irvine Medical Center, Orange, CA, United States; Division of Neonatology, Children's Hospital of Orange County, Orange, CA, United States
| | - Sarah Keene
- Division of Neonatology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Brian Gray
- Department of Surgery, Section of Pediatric Surgery, Indiana University, Indianapolis, IN, United States
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Bilodeau KS, Gray KE, McMullan DM. Extracorporeal cardiopulmonary resuscitation outcomes for children with out-of-hospital and emergency department cardiac arrest. Am J Emerg Med 2024; 81:35-39. [PMID: 38657347 DOI: 10.1016/j.ajem.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/29/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Data suggest extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with refractory cardiac arrest; however, ECPR outcomes in pediatric patients with out-of-hospital cardiac arrest (OHCA) is lacking. The primary aim of this study was to characterize pediatric patients who experience OHCA or cardiac arrest in the ED (EDCA). The secondary aim was to examine associations of cardiac arrest and location of ECPR cannulation with mortality. METHODS We performed a retrospective analysis of the Extracorporeal Life Support Organization registry. We included pediatric patients (age > 28 days to <18 years) who received ECPR for refractory OHCA or EDCA between 2010 and 2019. Patient, cardiac arrest, and ECPR cannulation characteristics were summarized. We examined associations of location of cardiac arrest and ECPR cannulation with in-hospital mortality using multivariable logistic regression. RESULTS We analyzed data from 140 pediatric patients. 66 patients (47%) experienced OHCA and 74 patients (53%) experienced EDCA. Overall survival to hospital discharge was 31% (20% OHCA survival vs. 41% EDCA survival, p = 0.008). In adjusted analyses, OHCA was associated with 3.9 times greater odds of mortality (95% confidence interval [CI] 1.61, 9.81) when compared to compared to EDCA. The location of ECPR cannulation was not associated with mortality (odds ratio 1.8, 95% CI 0.75, 4.3). CONCLUSIONS The use of ECPR for pediatric patients with refractory OHCA is associated with poor survival compared to patients with EDCA. Location of ECPR cannulation does not appear to be associated with mortality.
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Affiliation(s)
- Kyle S Bilodeau
- University of Washington, Department of General Surgery, Seattle, WA, United States of America
| | - Kristen E Gray
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA, United States of America; University of Washington, Department of Health Systems and Population Health, Seattle, WA, United States of America
| | - D Michael McMullan
- Seattle Children's Hospital, Division of Cardiac Surgery, Seattle, WA, United States of America.
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Kahveci F, Gurbanov A, Uçmak H, Ödemiş AS, Özen H, Balaban B, Botan E, Gün E, Havan M, Dikmen N, Ramoğlu MG, Uçar T, Eyileten Z, Akar AR, Kendirli T. Prolonged extracorporeal membrane oxygenation in pediatrics: How long did we wait? Perfusion 2024; 39:978-987. [PMID: 37137815 DOI: 10.1177/02676591231172607] [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: 05/05/2023]
Abstract
BACKGROUND In this study, we aimed to evaluate the duration of extracorporeal membrane oxygenation (ECMO) and its effect on outcomes. Also, we sought to identify hospital mortality predictors and determine when ECMO support began to be ineffective. METHODS This was a single-center, retrospective cohort study conducted between January 2014 and January 2022. The prolonged ECMO (pECMO) cut-off point was accepted as 14 days. RESULTS Thirty-one (29.2%) of 106 patients followed up with ECMO had pECMO. The mean follow-up period of the patients who underwent pECMO was 22 (range, 15-72) days, and the mean age was 75 ± 72 months. According to the results of our heterogeneous study population, life expectancy decreased dramatically towards the 21st day. Hospital mortality predictors were determined in the logistic regression analysis in all ECMO groups in our study as high Pediatric Logistic Organ Dysfunction (PELOD) two score, continuous renal replacement therapy (CRRT) use, and sepsis. The pECMO mortality was 61.2% and the overall mortality was 53.0%, with the highest mortality rate in the bridge-to-transplant group (90.9%) because of lack of organ donation in our country. CONCLUSIONS In our study, the PELOD two score, presence of sepsis, and use of CRRT were found to be in the predictors of in-hospital ECMO mortality model. Considering the complications, in the COX regression model analysis, the factors affecting the probability of dying in patients followed under ECMO were found to be bleeding, thrombosis, and thrombocytopenia.
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Affiliation(s)
- Fevzi Kahveci
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Anar Gurbanov
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aslı Samsa Ödemiş
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Özen
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Burak Balaban
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Edin Botan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emrah Gün
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Merve Havan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Gökhan Ramoğlu
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tayfun Uçar
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Eyileten
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Rüçhan Akar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
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7
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Powell E, Keller AP, Galvagno SM. Advanced Critical Care Techniques in the Field. Crit Care Clin 2024; 40:463-480. [PMID: 38796221 DOI: 10.1016/j.ccc.2024.03.003] [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: 05/28/2024]
Abstract
Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.
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Affiliation(s)
- Elizabeth Powell
- Program in Trauma, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Alex P Keller
- Medical Modernization and Plans Division, 162 Dodd Boulevard, Langley Air Force Base, VA 23665, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street, S11C16, Baltimore, MD 21201, USA.
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Willems A, Anders MM, Garcia AV, Vogel AM, Yates AR, Muszynski JA, Alexander PMA, Steffen K, Emani S, Gehred A, Lyman E, Raman L. Management of Extracorporeal Membrane Oxygenation Anticoagulation in the Perioperative Period: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e53-e65. [PMID: 38959360 PMCID: PMC11216378 DOI: 10.1097/pcc.0000000000003490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic review-informed, modified Delphi consensus regarding the management of children on extracorporeal membrane oxygenation (ECMO) undergoing invasive procedures or interventions developed by the Pediatric Anticoagulation on ECMO CollaborativE (PEACE) Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION ECMO anticoagulation and hemostasis management in the perioperative period and during procedures. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Seventeen references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Four good practice statements, 7 recommendations, and 18 consensus statements are presented. CONCLUSIONS Although agreement among experts was strong, important future research is required in this population for evidence-informed recommendations.
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Affiliation(s)
- Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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9
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Rintoul NE, McMichael ABV, Bembea MM, DiGeronimo R, Patregnani J, Alexander PMA, Muszynski JA, Steffen K, Gehred A, Lyman E, Cheifetz IM. Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e66-e77. [PMID: 38959361 PMCID: PMC11216396 DOI: 10.1097/pcc.0000000000003489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION The management of bleeding and thrombotic complications of ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. CONCLUSIONS Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.
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Affiliation(s)
- Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Jason Patregnani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Barbara Bush Children's Hospital, Portland, ME
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
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10
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Alexander PMA, Bembea MM, Cashen K, Cheifetz IM, Dalton HJ, Himebauch AS, Karam O, Moynihan KM, Nellis ME, Ozment C, Raman L, Rintoul NE, Said AS, Saini A, Steiner ME, Thiagarajan RR, Watt K, Willems A, Zantek ND, Barbaro RP, Steffen K, Vogel AM, Almond C, Anders MM, Annich GM, Brandão LR, Chandler W, Delaney M, DiGeronimo R, Emani S, Gadepalli SK, Garcia AV, Haileselassie B, Hyslop R, Kneyber MCJ, Baumann Kreuziger L, Le J, Loftis L, McMichael ABV, McMullan DM, Monagle P, Nicol K, Paden ML, Patregnani J, Priest J, Raffini L, Ryerson LM, Sloan SR, Teruya J, Yates AR, Gehred A, Lyman E, Muszynski JA. Executive Summary: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE (PEACE) Consensus Conference. Pediatr Crit Care Med 2024; 25:643-675. [PMID: 38959353 PMCID: PMC11216385 DOI: 10.1097/pcc.0000000000003480] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference. DATA SOURCES Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children. STUDY SELECTION The management of ECMO anticoagulation for critically ill children. DATA EXTRACTION Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements. CONCLUSIONS The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.
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Affiliation(s)
- Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Oliver Karam
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Marianne E Nellis
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, New York Presbyterian Hospital-Weill Cornell, New York, NY
| | - Caroline Ozment
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Natalie E Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Arun Saini
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, MN
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin Watt
- Division of Clinical Pharmacology, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Christopher Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wayne Chandler
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Megan Delaney
- Division of Pathology and Lab Medicine and Transfusion Medicine, Children's National Hospital, Washington, DC
- Departments of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, and Department of Surgery, Harvard Medical School, Boston, MA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Robert Hyslop
- Heart Institute, Children's Hospital of Colorado, Aurora, CO
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lisa Baumann Kreuziger
- Versiti Blood Research Institute and Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Laura Loftis
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - D Michael McMullan
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, WA
| | - Paul Monagle
- University of Melbourne, and Kids Cancer Centre Sydney Children's Hospital, and Murdoch Children's Research Institute, and Royal Children's Hospital Melbourne Australia, Melbourne, VIC, Australia
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jason Patregnani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Barbara Bush Children's Hospital, Portland, ME
| | - John Priest
- Department of Respiratory Care, Boston Children's Hospital, Boston MA
| | - Leslie Raffini
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Lindsay M Ryerson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Steven R Sloan
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA
- CSL Behring, King of Prussia, PA
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Department of Pediatrics, Divisions of Cardiology and Critical Care Medicine, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital and The Ohio State University of Medicine, Columbus, OH
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11
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Holton C, Shah S, Miller JO. New Right Ventricular Dysfunction in Pediatric Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation. ASAIO J 2024:00002480-990000000-00508. [PMID: 38896850 DOI: 10.1097/mat.0000000000002257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
The development of new right ventricular (RV) dysfunction after cannulation to venovenous (VV) extracorporeal membrane oxygenation (ECMO) and its association with worse outcomes is increasingly recognized in adult patients, however, no studies have evaluated this phenomenon in pediatric patients. We report results of a single-center retrospective cohort study at a large academic children's hospital. New RV systolic dysfunction was present in 48% (12/25) of pediatric patients on VV ECMO for acute respiratory distress syndrome (ARDS). There was no statistically significant difference in survival, duration of mechanical ventilation, or hospital length of stay between those with and without RV dysfunction. Over half (5/9, 56%) of survivors with RV dysfunction on ECMO had RV dilation or RV hypertrophy on post-ECMO echocardiograms, and in two patients the RV dysfunction persisted for months following decannulation. Cardiac catheterization and autopsy reports suggested that echocardiographic assessment of RV systolic function alone may not be sufficient to diagnose clinically relevant RV injury. This is the first study to report the prevalence of RV dysfunction on VV ECMO for pediatric ARDS. Future multicenter collaboration is needed to create a clinically relevant definition of pediatric "RV injury" and to further evaluate risk factors and outcomes of RV dysfunction.
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Affiliation(s)
- Caroline Holton
- From the Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
| | - Sanket Shah
- Division of Cardiology, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
| | - Jenna O Miller
- From the Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
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12
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Martinez MJ, Romero T, Federman MD. Comparison of red blood cell transfusions and hemostatic transfusions and their relation to thromboses in pediatric patients receiving extracorporeal membrane oxygenation therapy. Perfusion 2024:2676591241260185. [PMID: 38850510 DOI: 10.1177/02676591241260185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
OBJECTIVE To evaluate the association of RBC transfusions with thrombosis in pediatric patients on extracorporeal membrane oxygenation (ECMO) and compare this with the transfusion of other blood products and their association with thrombosis. METHODS This was a secondary analysis of the Bleeding and Thrombosis during ECMO (BATE) study, which was a multicenter prospective observational study involving patients less than 19 years of age treated with ECMO. RESULTS 514 patients were analyzed, of which 282 (55%) were neonates (≤31 days) and 302 (58.7%) were male. When analyzing the entire cohort independently of other blood products, each 10 mL/kg of packed red blood cells (PRBCs) was associated with a 1.0% increase in the average number of thromboses (1.010; 1.008,1.013; p < .001). In neonates, each 10 mL/kg of PRBC was associated with a 0.9% increase in the average number of thromboses (1.009; 1.003,1.013; p < .001). In pediatric patients, each 10 mL/kg of PRBC was associated with a 1.2% increase in the average number of thromboses (1.012; 1.008,1.012; p < .001). The percent increase in the average number of thromboses was similar between PRBCs, platelets, and FFP, but increased significantly with cryoprecipitate. CONCLUSIONS RBC transfusions and hemostatic transfusions are likely associated with thromboses in pediatric patients on ECMO.
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Affiliation(s)
- Michael J Martinez
- Department of Pediatrics, Division of Cardiology, Hassenfeld Children's Hospital at NYU, New York, NY, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Myke D Federman
- Department of Pediatrics, Division of Critical Care Medicine, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
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13
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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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14
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Shaw M, Cross N, Richardson R, Crook R, Thirulchelvam T, Issitt RW. The effect of excessive gas to blood ratios in an ECMO oxygenator. Perfusion 2024:2676591241256089. [PMID: 38783478 DOI: 10.1177/02676591241256089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Oxygenators for paediatric Extracorporeal Membrane Oxygenation (ECMO) are required to operate over a wide range of flow rates, in a patient group ranging from neonates through to fully grown adolescents. ECMO oxygenators typically have a manufacturer's stated maximum gas: blood flow rate (GBFR) ratio of 2:1, however, many patients require greater ratios than this for adequate CO2 removal. Mismatches in GBFR in theory could result in high gas phase pressures. These increased pressures in theory could cause the formation of gross gaseous microemboli (GME) placing the child at higher risk of neurological injury. METHODS We evaluated 6 paediatric and 6 adult A.L.ONE™ ECMO oxygenators and assessed their gas phase pressures and GME release, in an ex vivo setting, in GBFR ratios up to greater than 2, across a range of gas flow (1L - 10 L/min) rates with a fraction of inspired oxygen (FiO2) content of 50% and 100%. RESULTS There were no increases above 10 mmHg observed in gas phase pressures in GBFR >= 2:1 in either adult or paediatric oxygenators. Laboratory examination of GME activity demonstrated a small increase in post-membrane GME release over the study period. GME release was unaffected by FiO2 setting or gas flow rate, with a maximum volume of < 6 µL in both paediatric and adult oxygenators. CONCLUSIONS In an ex vivo setting, increasing GBFR above 2:1 in a paediatric oxygenator, and to a GBFR of 2:1 in an adult oxygenator did not significantly increase gas phase pressures, and no oxygenator membrane rupture was observed. There were no associations between gas flow rates and GME production.
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Affiliation(s)
- Michael Shaw
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Nigel Cross
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Rebecca Richardson
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Timothy Thirulchelvam
- Cardiac Intensive Care Department, Great Ormond Street Hospital, London, UK
- Centre for Heart Failure, Transplantation and Extracorporeal Support, Research Department of Children's Cardiovascular Disease, UCL Institute of Cardiovascular Science, London, UK
| | - Richard W Issitt
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
- Centre for Heart Failure, Transplantation and Extracorporeal Support, Research Department of Children's Cardiovascular Disease, UCL Institute of Cardiovascular Science, London, UK
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15
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Han P, Rasmussen L, Su F, Dacre M, Knight L, Berg M, Tawfik D, Haileselassie B. High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation. Pediatr Crit Care Med 2024; 25:452-460. [PMID: 38299932 DOI: 10.1097/pcc.0000000000003461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
OBJECTIVES To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). DESIGN Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. SETTING Quaternary care children's hospital. PATIENTS Pediatric patients undergoing ECPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. CONCLUSIONS Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.
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Affiliation(s)
- Peggy Han
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Revive Initiative for Resuscitation Excellence, Stanford Children's Health, Palo Alto, CA
| | - Lindsey Rasmussen
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Department of Neurology, Stanford University School of Medicine, Stanford, CA
| | - Felice Su
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Revive Initiative for Resuscitation Excellence, Stanford Children's Health, Palo Alto, CA
| | - Michael Dacre
- Stanford University School of Medicine, Stanford, CA
| | - Lynda Knight
- Revive Initiative for Resuscitation Excellence, Stanford Children's Health, Palo Alto, CA
| | - Marc Berg
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Revive Initiative for Resuscitation Excellence, Stanford Children's Health, Palo Alto, CA
| | - Daniel Tawfik
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Bereketeab Haileselassie
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
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16
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Vandewalle RJ, Greiten LE. Diaphragmatic Defects in Infants: Acute Management and Repair. Thorac Surg Clin 2024; 34:133-145. [PMID: 38705661 DOI: 10.1016/j.thorsurg.2024.01.003] [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: 05/07/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex and highly variable disease process that should be treated at institutions with multidisciplinary teams designed for their care. Treatment in the neonatal period focuses on pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Extracorporeal membrane oxygenation (ECMO) can be considered in patients refractory to medical management. Repair of CDH early during the ECMO course seems to improve mortality compared with other times for surgical intervention. The choice of surgical approach to CDH repair should consider the patient's physiologic status and the surgeon's familiarity with the operative approaches available, recognizing the pros/cons of each technique.
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Affiliation(s)
- Robert J Vandewalle
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 844, Little Rock, AR 72202, USA.
| | - Lawrence E Greiten
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 677, Little Rock, AR 72202, USA
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17
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Young A, Patel K, Allen K, Ghadersohi S, Rowland M, Hazkani I. Flexible and Rigid Bronchoscopy for Critically Ill Children on Extracorporeal Membrane Oxygenation. Laryngoscope 2024. [PMID: 38651446 DOI: 10.1002/lary.31460] [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: 09/16/2023] [Revised: 03/13/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND We aim to describe our experience with bronchoscopy to diagnose and relieve tracheobronchial obstruction in anticipation of decannulation in children on extracorporeal membrane oxygenation (ECMO) support. METHODS A retrospective cohort study of children on ECMO between 1/2018 and 12/2022. RESULTS A total of 107 children required ECMO support during the study period for cardiac (n = 48, 45%), pulmonary (n = 38, 36%), or cardiopulmonary dysfunction (n = 21, 20%). Thirty-seven (35%) patients underwent 99 bronchoscopies while on ECMO. Most (76%, n = 75) experienced no improvement or worsening of chest radiography 24 hours following bronchoscopy. Clinical improvement in tidal volumes 48 hours after the first bronchoscopy was noted in 13/25 patients with available data (p = 0.05). Adverse events were seen in 18 (49%) patients who underwent bronchoscopy, including pneumothorax (n = 8, 22%), pneumonia (n = 7, 19%), pulmonary hemorrhage (n = 6, 16%), and sepsis (n = 5, 14%). ECMO courses were longer (25.4 ± 37.2 vs 6.1 ± 8.8 days, p < 0.0001) and more likely to be complicated by pneumonia (p = 0.0004) and sepsis (p = 0.047) in patients who underwent bronchoscopy compared with those who did not. Adverse events following bronchoscopy were associated with the number of bronchoscopies (p = 0.0003) and the presence of obstructive materials but not with the type of bronchoscopy or indication for ECMO. Mortality rates were similar between patients who underwent bronchoscopy and those who did not. CONCLUSION Children requiring bronchoscopy represent a subset of the sickest children on ECMO. Bronchoscopy may provide benefit in children with persistent cardiopulmonary failure who could not otherwise be decannulated. Adverse events are associated with the number of bronchoscopies and the presence of obstructive material. LEVEL OF EVIDENCE 4 Laryngoscope, 2024.
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Affiliation(s)
- Ashley Young
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Krupa Patel
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Kiona Allen
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
- Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Saied Ghadersohi
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Matthew Rowland
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
- Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Division of Critical Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Inbal Hazkani
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
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18
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Moynihan KM, Sharma M, Mehta A, Lillie J, Ziegenfuss M, Festa M, Chan T, Thiagarajan R. Race-Conscious Research Using Extracorporeal Life Support Organization Registry Data: A Narrative Review. ASAIO J 2024:00002480-990000000-00468. [PMID: 38648078 DOI: 10.1097/mat.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Race-conscious research identifies health disparities with 1) rigorous and responsible data collection, 2) intentionality and considered analyses, and 3) interpretation of results that advance health equity. Individual registries must overcome specific challenges to promote race-conscious research, and this paper describes ways to achieve this with a focus on the international Extracorporeal Life Support Organization (ELSO) registry. This article reviews ELSO registry publications that studied race with outcomes to consider whether research outputs align with race-conscious concepts and describe the direction of associations reported. Studies were identified via secondary analysis of a comprehensive scoping review on ECMO disparities. Of 32 multicenter publications, two (6%) studied race as the primary objective. Statistical analyses, confounder adjustment, and inclusive, antibiased language were inconsistently used. Only two (6%) papers explicitly discussed mechanistic drivers of inequity such as structural racism, and five (16%) discussed race variable limitations or acknowledged unmeasured confounders. Extracorporeal Life Support Organization registry publications demonstrated more adverse ECMO outcomes for underrepresented/minoritized populations than non-ELSO studies. With the objective to promote race-conscious ELSO registry research outputs, we provide a comprehensive understanding of race variable limitations, suggest reasoned retrospective analytic approaches, offer ways to interpret results that advance health equity, and recommend practice modifications for data collection.
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Affiliation(s)
- Katie M Moynihan
- From the Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Meesha Sharma
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, California
| | - Anuj Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine Denver Health and Hospital Authority, Denver, Colorado
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jon Lillie
- Pediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Marc Ziegenfuss
- Adult Intensive Care Services, Prince Charles Hospital, Queensland Intensive Care Clinical Network and State Emergency Coordination Centre, Brisbane, Australia
- Australian and New Zealand Intensive Care Society (ANZICS), Australia
| | - Marino Festa
- New South Wales Kids ECMO Referral Service, Australia
- Kids Critical Care Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ravi Thiagarajan
- From the Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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19
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Koh W, Zang H, Ollberding NJ, Hayes D. Lung Transplantation for Children with Refractory Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2024; 21:672-675. [PMID: 38241015 DOI: 10.1513/annalsats.202308-695rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Wonshill Koh
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
- University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
- University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Don Hayes
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
- University of Cincinnati College of Medicine Cincinnati, Ohio
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20
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Mensink HA, Desai A, Cvetkovic M, Davidson M, Hoskote A, O'Callaghan M, Thiruchelvam T, Roeleveld PP. The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO. Perfusion 2024; 39:81S-94S. [PMID: 38651582 DOI: 10.1177/02676591241236139] [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: 04/25/2024]
Abstract
Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.
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Affiliation(s)
- H A Mensink
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - A Desai
- Paediatric Intensive Care, Royal Brompton Hospital, London, UK
| | - M Cvetkovic
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M Davidson
- Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - A Hoskote
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M O'Callaghan
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - T Thiruchelvam
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - P P Roeleveld
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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21
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Schiller O, Pula G, Shostak E, Manor-Shulman O, Frenkel G, Amir G, Yacobovich J, Nellis ME, Dagan O. Patient-tailored platelet transfusion practices for children supported by extracorporeal membrane oxygenation. Vox Sang 2024; 119:326-334. [PMID: 38175143 DOI: 10.1111/vox.13583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Extracorporeal membrane oxygenation (ECMO) serves as cardiopulmonary therapy in critically ill patients with respiratory/heart failure and often necessitates multiple blood product transfusions. The administration of platelet transfusions during ECMO is triggered by the presence or risk of significant bleeding. Most paediatric ECMO programmes follow guidelines that recommend a platelet transfusion threshold of 80-100 × 109/L. To reduce exposure to platelets, we developed a practice to dynamically lower the threshold to ~20 × 109/L. We describe our experience with patient-tailored platelet thresholds and related bleeding outcomes. MATERIALS AND METHODS We retrospectively evaluated our platelet transfusion policy, bleeding complications and patient outcome in 229 ECMO-supported paediatric patients in our unit. RESULTS We found that more than 97.4% of patients had a platelet count <100 × 109/L at some point during their ECMO course. Platelets were transfused only on 28.5% of ECMO days; and 19.2% of patients never required a platelet transfusion. The median lowest platelet count in children who had bleeding events was 25 × 109/L as compared to 33 × 109/L in children who did not bleed (p < 0.001). Our patients received fewer platelet transfusions and did not require more red blood cell transfusions, nor did they experience more haemorrhagic complications. CONCLUSION We have shown that a restrictive, 'patient-tailored' rather than 'goal-directed' platelet transfusion policy is feasible and safe, which can greatly reduce the use of platelet products. Although there was a difference in the lowest platelet counts in children who bled versus those who did not, the median counts were much lower than current recommendations.
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Affiliation(s)
- Ofer Schiller
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Giulia Pula
- Children's Heart Centre, Division of Cardiology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Eran Shostak
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orit Manor-Shulman
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Georgy Frenkel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Gabriel Amir
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Joanne Yacobovich
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology-Oncology Center, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York, USA
| | - Ovadia Dagan
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Sperotto F, Alexander PMA, MacLaren G. Extracorporeal Cardiopulmonary Resuscitation in Children With Primary Noncardiac Diagnoses: Untangling a Complex Intervention. Crit Care Med 2024; 52:663-665. [PMID: 38483222 DOI: 10.1097/ccm.0000000000006204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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23
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Loaec M, Himebauch AS, Reeder R, Alvey JS, Race JA, Su L, Lasa JJ, Slovis JC, Raymond TT, Coleman R, Barney BJ, Kilbaugh TJ, Topjian AA, Sutton RM, Morgan RW. Outcomes of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories. Crit Care Med 2024; 52:551-562. [PMID: 38156912 DOI: 10.1097/ccm.0000000000006153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years. DESIGN Retrospective multicenter cohort study. SETTING Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021. PATIENTS Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time ( p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis ( p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge. CONCLUSIONS ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).
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Affiliation(s)
- Morgann Loaec
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adam S Himebauch
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Jonathan A Race
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Lillian Su
- Division of Cardiac Intensive Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Javier J Lasa
- Division of Cardiology and Critical Care, Department of Pediatrics, UT Southwestern Medical Center, Dallas TX
| | - Julia C Slovis
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care Medicine, Medical City Children's Hospital, Dallas TX
| | - Ryan Coleman
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston TX
| | - Bradley J Barney
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Todd J Kilbaugh
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis A Topjian
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robert M Sutton
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ryan W Morgan
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Resuscitation Science Center, CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
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24
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Siegel B, Taylor LS, Alizadeh F, Barreto JA, Daniel D, Alexander PMA, Lipsitz S, Moynihan K. Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital. Pediatr Crit Care Med 2024; 25:301-311. [PMID: 38193777 DOI: 10.1097/pcc.0000000000003422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. DESIGN Retrospective cohort study using mixed methods. SETTING Single-center quaternary pediatric hospital. PATIENTS Patients supported on ECMO (January 2012 to December 2021). INTERVENTIONS We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. MEASUREMENTS AND MAIN RESULTS Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). CONCLUSION EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.
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Affiliation(s)
- Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Lisa S Taylor
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Dennis Daniel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Peta M A Alexander
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Katie Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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25
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Hord EC, Hager MP, Bolch CM, Bonugli K, Guo LJ, Tuzun E, Criscione JC. Preclinical Proof-of-Concept of a Minimally Invasive Direct Cardiac Compression Device for Pediatric Heart Support. Cardiovasc Eng Technol 2024; 15:147-158. [PMID: 38110762 PMCID: PMC11116177 DOI: 10.1007/s13239-023-00703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 11/21/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE For pediatric patients, extracorporeal membrane oxygenation (ECMO) remains the predominant mechanical circulatory support (MCS) modality for heart failure (HF) although survival to discharge rates remain between 50 and 60% for these patients. The device-blood interface and disruption of physiologic hemodynamics are significant contributors to poor outcomes. METHODS In this study, we evaluate the preclinical feasibility of a minimally invasive, non-blood-contacting pediatric DCC prototype for temporary MCS. Proof-of-concept is demonstrated in vivo in an animal model of HF. Hemodynamic pressures and flows were examined. RESULTS Minimally invasive deployment on the beating heart was successful without cardiopulmonary bypass or anticoagulation. During HF, device operation resulted in an immediate 43% increase in cardiac output while maintaining pulsatile hemodynamics. Compared to the pre-HF baseline, the device recovered up to 95% of ventricular stroke volume. At the conclusion of the study, the device was easily removed from the beating heart. CONCLUSIONS This preclinical proof-of-concept study demonstrated the feasibility of a DCC device on a pediatric scale that is minimally invasive and non-blood contacting, with promising hemodynamic support and durability for the initial intended duration of use. The ability of DCC to maintain pulsatile MCS without blood contact represents an opportunity to mitigate the mortality and morbidity observed in non-pulsatile, blood-contacting MCS.
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Affiliation(s)
- Erica C Hord
- CorInnova, Inc. JLABS @ TMC, 2450 Holcombe Blvd Suite J, Houston, TX, 77021, USA
| | - Melanie P Hager
- Department of Biomedical Engineering, Texas A&M University, 5045 Emerging Technologies Building 3120 TAMU, College Station, TX, 77843-3120, USA
- Texas A&M University College of Medicine, 3050 Health Professions Education Building 1359 TAMU, Bryan, TX, 77807-1359, USA
| | - Christina M Bolch
- CorInnova, Inc. JLABS @ TMC, 2450 Holcombe Blvd Suite J, Houston, TX, 77021, USA
| | - Katherine Bonugli
- Texas A&M University Institute for Preclinical Studies, 4478 TAMU, College Station, TX, 77843-4478, USA
| | - Lee-Jae Guo
- Texas A&M University Institute for Preclinical Studies, 4478 TAMU, College Station, TX, 77843-4478, USA
| | - Egemen Tuzun
- Texas A&M University Institute for Preclinical Studies, 4478 TAMU, College Station, TX, 77843-4478, USA
| | - John C Criscione
- CorInnova, Inc. JLABS @ TMC, 2450 Holcombe Blvd Suite J, Houston, TX, 77021, USA.
- Department of Biomedical Engineering, Texas A&M University, 5045 Emerging Technologies Building 3120 TAMU, College Station, TX, 77843-3120, USA.
- Texas A&M University College of Medicine, 3050 Health Professions Education Building 1359 TAMU, Bryan, TX, 77807-1359, USA.
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26
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Tanaka M, Okubo R, Hoshi SL, Kondo M. Cost-effectiveness analysis of pertussis booster vaccination for adolescents in Japan. Vaccine 2024; 42:2081-2088. [PMID: 38418340 DOI: 10.1016/j.vaccine.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/31/2024] [Accepted: 02/12/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION In Japan, the introduction of a fifth diphtheria-tetanus-acellular pertussis (DTaP) vaccination has been considered, and adolescents aged 11-12 years old who are currently receiving the diphtheria-tetanus (DT) vaccine are one candidate group. We analyze the cost-effectiveness of replacing the DT vaccine with the DTaP vaccine for 11-year-old adolescents and investigate the indirect effect of vaccinated adolescents on unvaccinated infant siblings. We undertake two analyses using high- and low-morbidity pertussis cases, and based on the results, present suggestions for pertussis prevention in the post-COVID-19 pandemic era. METHOD We used the number of pertussis cases in 2019 as the high-morbidity case and the average number of cases in 2020-2021 as the low-morbidity case, and evaluated the incremental cost-effectiveness ratio (ICER) of the DTaP strategy to the DT strategy based on quality-adjusted life years (QALYs). The economic model contained adolescent and infant sub-models. The indirect effect for infants was considered as the probability of unvaccinated infants avoiding pertussis infection from their vaccinated siblings. RESULTS The ICER from the payers' perspective was Japanese yen (JPY) 4,254,515 per QALY gained in the high-morbidity case and JPY 62,546,776 per QALY gained in the low-morbidity case. The sensitivity analysis showed that the utility of pertussis had the greatest impact on the ICER, with a 60.58% and 0% probability that the ICER was less than JPY 5 million per QALY gained in the high-morbidity case and low-morbidity case, respectively. CONCLUSION The cost-effectiveness of replacing the DT vaccine with the DTaP vaccine is affected by the level of pertussis morbidity, with the ICER becoming more favorable in the high-morbidity case. The indirect effect has little impact on the ICER. Thus, policy-makers should continue to monitor the pertussis epidemic in the post-COVID-19 era, and determine the need to introduce a booster based on perceived trends.
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Affiliation(s)
- Motoko Tanaka
- Department of Health Care Policy and Management, Doctoral Program in Public Health, Degree Programs in Comprehensive Human Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki 3058577, Japan.
| | - Reiko Okubo
- Department of Health Care Policy and Health Economics, Institute of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki 3058577, Japan; Department of Clinical Laboratory Medicine, University of Tsukuba Hospital, 2-1-1, Amakubo, Tsukuba, Ibaraki 3058576, Japan
| | - Shu-Ling Hoshi
- Department of Health Care Policy and Health Economics, Institute of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki 3058577, Japan
| | - Masahide Kondo
- Department of Health Care Policy and Health Economics, Institute of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki 3058577, Japan
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27
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Sokou R, Parastatidou S, Konstantinidi A, Tsantes AG, Iacovidou N, Piovani D, Bonovas S, Tsantes AE. Contemporary tools for evaluation of hemostasis in neonates. Where are we and where are we headed? Blood Rev 2024; 64:101157. [PMID: 38016836 DOI: 10.1016/j.blre.2023.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
The assessment of hemostatic disorders in neonates is crucial, but remains challenging for clinicians. Although the concept of developmental hemostasis is widely accepted among hemostasis specialists globally, it is probably under-recognized by clinicians and laboratory practitioners. In parallel with age-dependent hemostatic status maturation, comprehension of the differences between normal values is crucial for the accurate diagnosis of potential hemorrhagic and thrombotic disorders of the vulnerable neonatal population. This review outlines the basics of developmental hemostasis and the features of the available coagulation testing methods, with a focus on novel tools for evaluating the neonatal hemostatic profile. Common errors, issues, and pitfalls during the assessment of neonatal hemostasis are discussed, along with their impact on patient management. Current knowledge gaps and research areas are addressed. Further studying to improve our understanding of developmental hemostasis and its reflection on everyday clinical practice is warranted.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece.
| | | | | | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
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28
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Shafi O, Mir T, Liu D, Velumula PK, Tul Llah S, Korumilli R. Characteristics, outcomes, and 30-day readmissions following pediatric extracorporeal membrane oxygenation in the United States: A Nationwide Readmissions Database study. Perfusion 2024; 39:399-407. [PMID: 36509452 DOI: 10.1177/02676591221145646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is an increasingly used mode of critical care support for pediatric patients refractory to conventional therapy. We evaluated the characteristics, outcomes, and readmissions rates for pediatric ECMO in the United States. METHODS Data was extracted from the Nationwide Readmissions Database, a database designed to support national readmissions analyses, for patients aged 1-18 years undergoing ECMO between 2012-2018. Baseline demographics, comorbidities, and characteristics were identified using International Classification of Diseases codes. RESULTS Out of 897,117 index pediatric hospitalizations, 3706 patients underwent ECMO [median age 9 years (IQR 2,15); 51.6% males]. 2246 (60.6%) patients survived to hospital discharge, with a 30-day readmissions rate of 17% among survivors. Cardiac conditions associated with ECMO were congenital heart disease (25.3%), cardiogenic shock (23.6%), and congestive heart failure (16.2%). The common respiratory associations were sepsis (36.2%), pneumonia (35.6%), and asthma (15.4%). Patients who survived were more likely to have diagnoses of asthma, bronchiolitis, myocarditis, pneumonia, and sepsis. Acute kidney injury (51.5%), disseminated intravascular coagulation (22.5%), and surgical site bleeding (12.7%) were the commonly associated complications. The trend for yearly survival rates was not statistically significant (linear p-trend = 0.38). CONCLUSIONS Pediatric ECMO continues to be associated with notable mortality and complication rates. We did not observe a meaningful trend for the yearly survival rates over the study period, and over one-sixth of survivors were readmitted within 30-days. More research is needed to identify patients at high risk of mortality and readmissions, to help target resources more efficiently and improve survival.
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Affiliation(s)
- Obeid Shafi
- Clinical Informatics (Pediatrics), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Tanveer Mir
- Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Daniel Liu
- Pediatrics and Biomedical Informatics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Ritesh Korumilli
- Pediatric Cardiac Intensive Care, Sunrise Children's Hospitals, Las Vegas, NV, USA
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29
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Warnock B, Lafferty GM, Farhat A, Colgate C, Dhar A, Gray B. Peripheral Veno-Arterial-Extracorporeal Membrane Oxygenation for Refractory Septic Shock in Children: A Multicenter Review. J Intensive Care Med 2024; 39:196-202. [PMID: 37899622 DOI: 10.1177/08850666231193357] [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: 10/31/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is utilized as a rescue therapy in the management of pediatric patients with refractory septic shock. Multiple studies support the use of a central cannulation strategy in these patients. This study aimed to assess the survival of and identify mortality risk factors in pediatric patients supported with peripheral veno-arterial (VA) ECMO in the setting of septic shock. METHODS We retrospectively reviewed and compared clinical characteristics of 40 pediatric patients supported with peripheral VA ECMO for refractory septic shock, at two tertiary care children's hospitals from 2006 to 2020. Our hypothesis was that peripheral VA ECMO is effective in supporting cardiac function and improving tissue oxygenation in most pediatric patients with refractory septic shock. RESULTS The overall rate of survival to discharge was 52.5%, comparable to previously reported survival for pediatric sepsis on ECMO. With the exclusion of patients with an oncologic process, the survival rate rose to 62.5%. There was a statistically significant difference in mean pump flow rates within 2 hours of initiation of ECMO between survivors and non-survivors (98 mL/kg/min vs 76 mL/kg/min, P = .050). There was no significant difference between pre-ECMO vasoactive inotropic score (VIS) in survivors and non-survivors. A faster decrease in VIS in the first 24 hours was associated with lower mortality. CONCLUSIONS From this large case series, we conclude that peripheral VA ECMO is a safe and effective modality to support pediatric patients with refractory septic shock, provided there is establishment of high ECMO pump flows in the first few hours after cannulation and improvement in the VIS.
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Affiliation(s)
- Brielle Warnock
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indiana University Health, Indianapolis, IN, USA
| | - Gina Maria Lafferty
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
- Pediatric Intensive Care Unit, Children's Medical Center, Dallas, TX, USA
| | | | - Cameron Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Archana Dhar
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
- Pediatric Intensive Care Unit, Children's Medical Center, Dallas, TX, USA
| | - Brian Gray
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indiana University Health, Indianapolis, IN, USA
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30
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Tabet M, Custer C, Khan IR, Sanford E, Sharma J, Choe R, Singh S, Sirsi D, Olson DM, Morriss MC, Raman L, Busch DR. Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care. ASAIO J 2024; 70:167-176. [PMID: 38051987 DOI: 10.1097/mat.0000000000002107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.
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Affiliation(s)
- Margherita Tabet
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Chasity Custer
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ethan Sanford
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Jayesh Sharma
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, New York
| | - Sumit Singh
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Deepa Sirsi
- Division of Pediatric Neurology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Department of Pediatrics, The University of Texas Southwestern medical center
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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Michel A, Vedrenne-Cloquet M, Kossorotoff M, Thy M, Levy R, Pouletty M, De Marcellus C, Grimaud M, Moulin F, Hully M, Simonnet H, Desguerre I, Renolleau S, Oualha M, Chareyre J. Neurologic Outcomes and Quality of Life in Children After Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2024; 25:e158-e167. [PMID: 38088764 DOI: 10.1097/pcc.0000000000003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
RATIONALE Use of life support with extracorporeal membrane oxygenation (ECMO) is associated with brain injury. However, the consequences of these injuries on subsequent neurologic development and health-related quality of life (HRQoL) are poorly described in children. OBJECTIVES The aim of this preliminary study was to describe short- and long-term neurologic outcomes in survivors of ECMO, as well as their HRQoL. DESIGN Retrospective identified cohort with contemporary evaluations. SETTING Necker Children's Hospital academic PICU. PATIENTS Forty survivors who underwent ECMO (October 2014 to January 2020) were included in follow-up assessments in May 2021. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS We first reviewed the outcomes of ECMO at the time of PICU discharge, which included a summary of neurology, radiology, and Pediatric Overall/Cerebral Performance Category (POPC/PCPC) scores. Then, in May 2021, we interviewed parents and patients to assess HRQoL (Pediatric Quality of Life Inventory [PedsQL]) and POPC/PCPC for children 3 years old or older, and Denver II test (DTII) for younger children. An evaluation of DTII in the youngest patients 1 year after ECMO decannulation was also added. Median age at ECMO was 1.4 years (interquartile range [IQR], 0.4-6 yr). Thirty-five children (88%) underwent a venoarterial ECMO. At PICU discharge, 15 of 40 patients (38%) had neurologic impairment. Assessment of HRQoL was carried out at median of 1.6 years (IQR, 0.7-3.3 yr) after PICU discharge. PedsQL scores were over 70 of 100 for all patients (healthy peers mean results: 80/100), and scores were like those published in patients suffering with chronic diseases. In May 2021, seven of 15 patients had a normal DTII, and 36 of 40 patients had a POPC/PCPC score less than or equal to 3. CONCLUSIONS None of our patients presented severe disability at long term, and HRQoL evaluation was reassuring. Considering the risk of neurologic impairment after ECMO support, a systematic follow-up of these high-risk survivor patients would be advisable.
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Affiliation(s)
- Alizée Michel
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Meryl Vedrenne-Cloquet
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | | | - Michaël Thy
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Raphaël Levy
- Radiologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marie Pouletty
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Charles De Marcellus
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marion Grimaud
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Florence Moulin
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marie Hully
- Neurologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Hina Simonnet
- Service de Rééducation Pédiatrique Hôpital Trousseau, Paris, France
| | | | - Sylvain Renolleau
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Mehdi Oualha
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Judith Chareyre
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
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32
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Jacobson JC, Ryan ML, Vogel AM, Mehl SC, Acker SN, Prendergast C, Padilla BE, Lee J, Chao SD, Martin NR, Russell KW, Larsen K, Harting MT, Linden AF, Ignacio RC, Slater BJ, Juang D, Jensen AR, Melhado CG, Pelayo JC, Zhong A, Spencer BL, Gadepalli SK, Maamari M, Jimenez Valencia M, Qureshi FG, Pandya SR. Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections. ASAIO J 2024; 70:146-153. [PMID: 37816012 DOI: 10.1097/mat.0000000000002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.
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Affiliation(s)
- Jillian C Jacobson
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark L Ryan
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Division of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Connor Prendergast
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Justin Lee
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Stephanie D Chao
- Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Nolan R Martin
- Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Katie W Russell
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Kezlyn Larsen
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Allison F Linden
- Section of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Romeo C Ignacio
- Division of Pediatric Surgery/Department of Surgery, University of California School of Medicine, La Jolla, California
| | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Aaron R Jensen
- Department of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, California
| | - Caroline G Melhado
- Department of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, California
| | - Juan Carlos Pelayo
- Division of Pediatric Surgery and Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Allen Zhong
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Brianna L Spencer
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan
- Department of Pediatric Surgery, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, Ann Arbor, Michigan
| | - Mia Maamari
- Division of Critical Care Medicine, UT Southwestern Medical Center, Children's Medical Center, Dallas, Texas
| | - Maria Jimenez Valencia
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faisal G Qureshi
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samir R Pandya
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Peng DM, Kwiatkowski DM, Lasa JJ, Zhang W, Banerjee M, Mikesell K, Joong A, Dykes JC, Tume SC, Niebler RA, Teele SA, Klugman D, Gaies MG, Schumacher KR. Contemporary Care and Outcomes of Critically-ill Children With Clinically Diagnosed Myocarditis. J Card Fail 2024; 30:350-358. [PMID: 37150502 DOI: 10.1016/j.cardfail.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE To describe contemporary management and outcomes in children with myocarditis who are admitted to a cardiac intensive care unit (CICU) and to identify the characteristics associated with mortality. METHODS All patients in the Pediatric Cardiac Critical Care Consortium (PC4) registry between August 2014 and June 2021 who were diagnosed with myocarditis were included. Univariable analyses and multivariable logistic regression evaluated the factors associated with in-hospital mortality. RESULTS There were 847 CICU admissions for myocarditis in 51 centers. The median age was 12 years (IQR 2.7-16). In-hospital mortality occurred in 53 patients (6.3%), and 60 (7.1%) had cardiac arrest during admission. Mechanical ventilation was required in 339 patients (40%), and mechanical circulatory support (MCS) in 177 (21%); extracorporeal membrane oxygenation (ECMO)-only in 142 (16.7%), ECMO-to-ventricular assist device (VAD) in 20 (2.4%), extracorporeal cardiac resuscitation in 43 (5%), and VAD-only in 15 (1.8%) patients. MCS was associated with in-hospital mortality; 20.3% receiving MCS died compared to 2.5% without MCS (P < 0.001). Mortality rates were similar in ECMO-only, ECMO-to-VAD and VAD-only groups. The median time from CICU admission to ECMO was 2.0 hours (IQR 0-9.4) and to VAD, it was 9.9 days (IQR 6.3-16.8). Time to MCS was not associated with mortality. In multivariable modeling of patients' characteristics, smaller body surface area (BSA) and low eGFR were independently associated with mortality, and after including critical therapies, mechanical ventilation and ECMO were independent predictors of mortality. CONCLUSION This contemporary cohort of children admitted to CICUs with myocarditis commonly received high-resource therapies; however, most patients survived to hospital discharge and rarely received VAD. Smaller patient size, acute kidney injury and receipt of mechanical ventilation or ECMO were independently associated with mortality.
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Affiliation(s)
- David M Peng
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI.
| | | | - Javier J Lasa
- Texas Children's Hospital, 6621 Fannin Street, Houston, TX
| | - Wendy Zhang
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
| | - Mousumi Banerjee
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
| | - Katherine Mikesell
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
| | - Anna Joong
- Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL
| | - John C Dykes
- Lucile Packard Children's Hospital Stanford, 725 Welch Road, Palo Alto, CA
| | | | - Robert A Niebler
- Children's Hospital Wisconsin, 8915 West Connell Court, Milwaukee, WI
| | - Sarah A Teele
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA
| | - Darren Klugman
- The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD
| | - Michael G Gaies
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH
| | - Kurt R Schumacher
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
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34
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Tonna JE, Boonstra PS, MacLaren G, Paden M, Brodie D, Anders M, Hoskote A, Ramanathan K, Hyslop R, Fanning JJ, Rycus P, Stead C, Barrett NA, Mueller T, Gómez RD, Kapoor PM, Fraser JF, Bartlett RH, Alexander PM, Barbaro RP. Extracorporeal Life Support Organization Registry International Report 2022: 100,000 Survivors. ASAIO J 2024; 70:131-143. [PMID: 38181413 PMCID: PMC10962646 DOI: 10.1097/mat.0000000000002128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) maintains the world's largest extracorporeal membrane oxygenation (ECMO) registry by volume, center participation, and international scope. This 2022 ELSO Registry Report describes the program characteristics of ECMO centers, processes of ECMO care, and reported outcomes. Neonates (0-28 days), children (29 days-17 years), and adults (≥18 years) supported with ECMO from 2009 through 2022 and reported to the ELSO Registry were included. This report describes adjunctive therapies, support modes, treatments, complications, and survival outcomes. Data are presented descriptively as counts and percent or median and interquartile range (IQR) by year, group, or level. Missing values were excluded before calculating descriptive statistics. Complications are reported per 1,000 ECMO hours. From 2009 to 2022, 154,568 ECMO runs were entered into the ELSO Registry. Seven hundred and eighty centers submitted data during this time (557 in 2022). Since 2009, the median annual number of adult ECMO runs per center per year increased from 4 to 15, whereas for pediatric and neonatal runs, the rate decreased from 12 to 7. Over 50% of patients were transferred to the reporting ECMO center; 20% of these patients were transported with ECMO. The use of prone positioning before respiratory ECMO increased from 15% (2019) to 44% (2021) for adults during the coronavirus disease-2019 (COVID-19) pandemic. Survival to hospital discharge was greatest at 68.5% for neonatal respiratory support and lowest at 29.5% for ECPR delivered to adults. By 2022, the Registry had enrolled its 200,000th ECMO patient and 100,000th patient discharged alive. Since its inception, the ELSO Registry has helped centers measure and compare outcomes across its member centers and strategies of care. Continued growth and development of the Registry will aim to bolster its utility to patients and centers.
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Affiliation(s)
- Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah
| | - Philip S. Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore
| | - Matthew Paden
- Department of Surgery, Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Daniel Brodie
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Anders
- Department of Surgery, Division of Critical Care, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Aparna Hoskote
- Department of Surgery, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Surgery, Institute of Cardiovascular Science, University College London, Zayed Centre for Research into Rare Diseases in Children, London, UK
| | - Kollengode Ramanathan
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Surgery, Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rob Hyslop
- Department of Surgery, Heart Institute, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffrey J. Fanning
- Department of Pediatrics, Extracorporeal Life Support Program, Medical City Children’s Hospital, Dallas, Texas
| | - Peter Rycus
- Department of Surgery, Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan
| | - Christine Stead
- Department of Surgery, Extracorporeal Life Support Organization (ELSO), University of Michigan, Ann Arbor, Michigan
| | - Nicholas A. Barrett
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Surgery, Centre for Human & Applied Physiological Sciences, King’s College London, London, UK
| | - Thomas Mueller
- Intensive Care Medicine, Department of Internal Medicine II, University Hospital Regensburg, Germany
| | - Rene D. Gómez
- Department of Surgery, Terapias Avanzadas de Soporte Cardiopulmonar, Hospitales Tec Salud, Escuela de Medicina ITESM, Monterrey, Mexico
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology and Critical Care, Cardio Thoracic Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - John F. Fraser
- Department of Surgery, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | | | - Peta M.A. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
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35
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Lin M, Liao J, Li L. The Timing of Surgery for Congenital Diaphragmatic Hernia in Infants, on or after Weaning from Extracorporeal Membrane Oxygenation: A Meta-Analysis. Eur J Pediatr Surg 2024. [PMID: 38092047 DOI: 10.1055/a-2228-6969] [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: 01/19/2024]
Abstract
OBJECTIVES We conducted a meta-analysis of trials to determine the optimal time to conduct surgery for congenital diaphragmatic hernia (CDH) in infants, on or after weaning from extracorporeal membrane oxygenation (ECMO). METHODS We searched the PubMed, Embase, Scopus, and Cochrane Library databases to identify relevant articles published prior to May 2023 in which surgery was performed to treat CDH in infants. Data were collected, and continuous data were represented by the mean difference (MD) and 95% confidence interval (CI). Dichotomous data were represented by the odds ratio (OR) and 95% CI. Review Manager V.5.4 and Stata were used to synthesize results and to assess publication bias. RESULTS The results showed that infants undergoing surgery after being weaned from ECMO had reduced mortality (OR, 2.40; 95% CI, 1.23-4.69; p = 0.01) and postoperative bleeding rates (OR, 16.20; 95% CI, 5.73-45.76; p < 0.00001) and reduced ECMO duration (MD, 3.47; 95% CI, 1.89-5.05; p < 0.0001) compared with those who underwent surgery while on ECMO. There was no statistically significant difference in hospital duration (MD, 5.48; 95% CI, -8.66 to 19.62; p = 0.45) or ventilator duration (MD, -1.93; 95% CI, -8.55 to 4.68; p = 0.57). CONCLUSION We recommend weaning patients with CDH from ECMO before performing surgery.
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Affiliation(s)
- Minhua Lin
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiachi Liao
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Le Li
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
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36
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Choi YH, Jhang WK, Park SJ, Choi HJ, Oh MS, Kwon JE, Kim BJ, Shin JA, Lee IK, Park JD, Lee B, Chung H, Na JY, Choi AY, Cho J, Choi J, Cho HJ, Kim AY, Shin YR, Byun JH, Kim Y. Pediatric Extracorporeal Membrane Oxygenation in Korea: A Multicenter Retrospective Study on Utilization and Outcomes Spanning Over a Decade. J Korean Med Sci 2024; 39:e33. [PMID: 38258365 PMCID: PMC10803205 DOI: 10.3346/jkms.2024.39.e33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/02/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Over the last decade, extracorporeal membrane oxygenation (ECMO) use in critically ill children has increased and is associated with favorable outcomes. Our study aims to evaluate the current status of pediatric ECMO in Korea, with a specific focus on its volume and changes in survival rates based on diagnostic indications. METHODS This multicenter study retrospectively analyzed the indications and outcomes of pediatric ECMO over 10 years in patients at 14 hospitals in Korea from January 2012 to December 2021. Four diagnostic categories (neonatal respiratory, pediatric respiratory, post-cardiotomy, and cardiac-medical) and trends were compared between periods 1 (2012-2016) and 2 (2017-2021). RESULTS Overall, 1065 ECMO runs were performed on 1032 patients, with the annual number of cases remaining unchanged over the 10 years. ECMO was most frequently used for post-cardiotomy (42.4%), cardiac-medical (31.8%), pediatric respiratory (17.5%), and neonatal respiratory (8.2%) cases. A 3.7% increase and 6.1% decrease in pediatric respiratory and post-cardiotomy cases, respectively, were noted between periods 1 and 2. Among the four groups, the cardiac-medical group had the highest survival rate (51.2%), followed by the pediatric respiratory (46.4%), post-cardiotomy (36.5%), and neonatal respiratory (29.4%) groups. A consistent improvement was noted in patient survival over the 10 years, with a significant increase between the two periods from 38.2% to 47.1% (P = 0.004). Improvement in survival was evident in post-cardiotomy cases (30-45%, P = 0.002). Significant associations with mortality were observed in neonates, patients requiring dialysis, and those treated with extracorporeal cardiopulmonary resuscitation (P < 0.001). In pediatric respiratory ECMO, immunocompromised patients also showed a significant correlation with mortality (P < 0.001). CONCLUSION Pediatric ECMO demonstrated a steady increase in overall survival in Korea; however, further efforts are needed since the outcomes remain suboptimal compared with global outcomes.
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Affiliation(s)
- Yu Hyeon Choi
- Department of Pediatrics, Seoul Medical Center, Seoul, Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, Korea
| | - Seong Jong Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, Korea
| | - Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Min-Su Oh
- Department of Pediatrics, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Jung Eun Kwon
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Beom Joon Kim
- Department of Pediatrics, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Ae Shin
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyung Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Bongjin Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chung
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Jae Yoon Na
- Department of Pediatrics, Hanyang University College of Medicine, Seoul, Korea
| | - Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaeyoung Choi
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, Korea
| | - Ah Young Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yu Rim Shin
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Joung-Hee Byun
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Younga Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
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Miller N, Sandhu HS, Anton-Martin P. "Extracorporeal membrane oxygenation outcomes in multisystem inflammatory syndrome of childhood - An extracorporeal life support organization registry study". Perfusion 2024:2676591231226290. [PMID: 38179967 DOI: 10.1177/02676591231226290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Multisystem inflammatory disease in childhood (MIS-C) is a novel pediatric syndrome after a COVID-19 infection that causes systemic injury, with potential life-threatening hemodynamic compromise requiring Extracorporeal Membrane Oxygenation (ECMO) support. We performed an observational retrospective cohort study in children aged 0-18 years with MIS-C and non-MIS-C myocarditis on ECMO between January 2020 and December 2021, using the ELSO Registry database. We aimed to compare the outcomes of both populations and to identify factors for decreased survival in MIS-C patients on ECMO. The Extracorporeal Life Support Organization (ELSO) Registry reported 310 pediatric ECMO patients with MIS-C (56.1%) and non-MIS-C myocarditis (43.9%). No difference was found in survival to hospital discharge between groups (67.2% for MIS-C vs 69.1% for non-MIS-C myocarditis, p 0.725). Multivariable analysis demonstrated that ECPR and co-infection were significantly associated with decreased survival to hospital discharge in MIS-C patients (OR 0.138, p 0.01 and OR 0.44, p 0.02, respectively). Outcomes of children with MIS-C on ECMO support are similar to those of non-MIS-C myocarditis despite higher infectious, multiorgan dysfunction and respiratory complications accompanying COVID-19 infections. The use of ECMO for MIS-C patients seems to be feasible and safe. Prospective studies on the use of ECMO support in MIS-C patients may improve outcomes in this pediatric population.
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Affiliation(s)
- Noah Miller
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital Memphis, Memphis, TN, USA
| | - Hitesh S Sandhu
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Le Bonheur Children's Hospital Memphis, Memphis, TN, USA
| | - Pilar Anton-Martin
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Brown SR, Assy J, Anderson MP, Thiagarajan RR, Brogan TV. Outcomes After Respiratory Extracorporeal Life Support in Teens and Young Adults: An Extracorporeal Life Support Organization Registry Analysis. Crit Care Med 2024; 52:11-19. [PMID: 38095517 DOI: 10.1097/ccm.0000000000006049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVES A recent study from Germany found that survival after respiratory extracorporeal life support (ECLS) was lower among patients 10-20 years old than 20-30 years old. The objective of this study was to compare survival between teenage and young adult patients who receive respiratory ECLS. DESIGN Retrospective cohort study. SETTING Extracorporeal Life Support Organization registry, an international prospective quality improvement database. PATIENTS All patients ages 16-30 years cannulated for respiratory indications from 1990 to 2020 were included. Patients were divided into two groups, teens (16-19 yr old) and young adults (20-30 yr old). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was survival to discharge. Variables were considered for the multivariate logistic regression model if there was both a statistically significant difference (p ≤ 0.05) and a clinically meaningful absolute difference between the groups. A total of 5,751 patients were included, of whom 1,653 (29%) were teens and 4,098 (71%) were young adults. Survival to discharge was higher in young adults than teens, 69% versus 63% (p < 0.001). Severity of illness was higher among teens; however, survival within each stratum defined by Pao2/Fio2 ratio was higher in young adults than in teens. Use of venoarterial ECLS was higher in teens than in young adults, 15% versus 7%, respectively. Teens were more likely to receive high-frequency oscillatory ventilation and this therapy was associated with a longer time from admission to ECLS initiation. After adjusting for variables that differ significantly between the groups, the odds ratio for survival in young adults compared with teens was 1.14 (95% CI, 1.004-1.3). CONCLUSIONS In this large multicenter retrospective study, mortality was higher in teens than in young adults who received respiratory ECLS. This difference persisted after adjusting for multiple variables and the mechanism underlying these findings remains unclear.
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Affiliation(s)
- Stephanie R Brown
- Division of Pediatric Critical Care Medicine, Oklahoma Children's Hospital, Oklahoma City, OK
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jana Assy
- Department of Pediatrics, Division of Pediatric Critical Care, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Michael P Anderson
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Harvard Medical School, Boston, MA
| | - Thomas V Brogan
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
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Devlin PJ, Argo M, Habib RH, McCrindle BW, Jegatheeswaran A, Jacobs ML, Jacobs JP, Backer CL, Overman DM, Karamlou T. Contemporary Applications and Outcomes of Pulmonary Artery Banding: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2024; 117:128-135. [PMID: 37774761 DOI: 10.1016/j.athoracsur.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/21/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Pulmonary artery banding (PAB) in isolation or combined with a congenital cardiac surgical procedure is common and has important mortality. We aimed to determine patient characteristics, clinical outcomes, variation in clinical outcomes by diagnoses, and center variation in PAB use. METHODS Using The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD), this study evaluated outcomes of patients undergoing PAB across diagnoses, participating centers, and additional procedures. Patients were identified by procedure and diagnosis codes from 2016 to 2019. We separated patients into groups of main and bilateral PAB and described their outcomes, focusing on patients with main PAB. RESULTS This study identified 3367 PAB procedures from 2016 to 2019 (3% of all STS CHSD cardiovascular cases during this period): 2677 main PAB, 690 bilateral PAB. Operative mortality was 8% after main PAB and 26% after bilateral PAB. There was significant variation in use of main PAB by center, with 115 centers performing at least 1 main PAB procedure (range, 1-134; Q1-Q3, 8-33). For patients with main PAB, there were substantial differences in mortality, depending on timing of main PAB relative to other procedures. The highest operative mortality (25%; P < .0001) was in patients who underwent main PAB after another separate procedure during their admission, with extracorporeal membrane oxygenation being the most frequent preceding procedure. CONCLUSIONS PAB is a frequently used congenital cardiac procedure with high mortality and variation in use across centers. Outcomes vary widely by banding type and patient diagnosis. Main PAB after cardiac surgical procedures, especially extracorporeal membrane oxygenation, is associated with very high operative mortality.
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Affiliation(s)
- Paul J Devlin
- Division of Cardiac Surgery, Northwestern Medicine, Chicago, Illinois.
| | - Madison Argo
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Brian W McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Kentucky
| | - David M Overman
- Division of Cardiovascular Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Tara Karamlou
- Pediatric Cardiac Surgery, Cleveland Clinic Children's Hospital, Cleveland, Ohio
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Tisminetzky M, Nepomuceno R, Kung JY, Singh G, Parhar KKS, Bagshaw SM, Fan E, Rewa O. Key performance indicators in extracorporeal membrane oxygenation (ECMO): protocol for a systematic review. BMJ Open 2023; 13:e076233. [PMID: 38070916 PMCID: PMC10728968 DOI: 10.1136/bmjopen-2023-076233] [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: 05/31/2023] [Accepted: 10/29/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an intervention used in critically ill patients with severe cardiopulmonary failure that is expensive and resource intensive and requires specialised care. There remains a significant practice variation in its application. This systematic review will assess the evidence for key performance indicators (KPIs) in ECMO. METHODS AND ANALYSIS We will search Ovid MEDLINE, Ovid EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and databases from the National Information Center of Health Services Research and Health Care Technology, for studies involving KPIs in ECMO. We will rate methodological quality using the Newcastle-Ottawa Quality Assessment Scale. Randomized controlled trials (RCTs) will be evaluated with the Cochrane Risk of Bias tool, and qualitative studies will be evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN checklist). Grey literature sources will be searched for technical reports, practice guidelines and conference proceedings. We will identify relevant organisations, industry leaders and non-profit organisations that represent key opinion leads in the use of ECMO. We will search the Agency of Healthcare Research and Quality National Quality Measures Clearinghouse for ECMO-related KPIs. Studies will be included if they contain quality measures that occur in critically ill patients and are associated with ECMO. The analysis will be primarily descriptive. Each KPI will be evaluated for importance, scientific acceptability, utility and feasibility using the four criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, KPIs will be evaluated for their potential operational characteristics, their potential to be integrated into electronic medical records and their affordability, if applicable. ETHICS AND DISSEMINATION Ethical approval is not required as no primary data will be collected. Findings will be published in a peer-reviewed journal and presented at academic. PROSPERO REGISTRATION NUMBER 9 August 2022. CRD42022349910.
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Affiliation(s)
| | - Roman Nepomuceno
- Department of Critical Care Medicine, Alberta Health Services, Edmonton, Alberta, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Gurmeet Singh
- Department of Critical Care Medicine, Department of Surgery, Division of Cardiac Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Ken Kuljit Singh Parhar
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Eddy Fan
- Department of Medicine, UHN, Toronto, Ontario, Canada
| | - Oleksa Rewa
- Critical Care Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
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Drop JG, Wildschut ED, de Maat MPM, van Rosmalen J, de Boode WP, de Hoog M, Heleen van Ommen C. Acquired von Willebrand disease in children undergoing extracorporeal membrane oxygenation: a prospective observational study. J Thromb Haemost 2023; 21:3383-3392. [PMID: 37579879 DOI: 10.1016/j.jtha.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/20/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides cardiopulmonary support for children with severe cardiac and/or pulmonary failure. The incidence of bleeding complications during ECMO support is high. Acquired von Willebrand disease (AVWD) might contribute to the development of bleeding complications. OBJECTIVE To study the incidence and longitudinal profile of AVWD during the first 14 days of ECMO support in children and to investigate the association between AVWD and bleeding complications. METHODS This prospective observational study included pediatric patients (0-17 years) receiving ECMO. Blood was sampled prior to and after ECMO start, daily and 12 to 24 hours after stopping ECMO. von Willebrand factor (VWF) parameters and multimer patterns were determined. Clinical data were collected for each patient. AVWD was defined as loss of high-molecular weight multimers (ie, decreased compared with baseline) or a VWF:collagen binding/VWF: antigen (Ag) ratio or VWF:activity/VWF:Ag ratio below 0.7. RESULTS All of 50 (100%) patients developed AVWD during ECMO. The VWF:collagen binding /VWF:Ag ratio, VWF:activity/VWF:Ag ratio, and high-molecular weight multimers decreased during the initial days and recovered to baseline level within 24 hours after stopping ECMO. The incidence and longitudinal profile of AVWD were similar in patients with and without major bleeding complications. CONCLUSION Children receiving ECMO support commonly develop AVWD. AVWD develops rapidly after ECMO initiation and recovers quickly after ECMO cessation. Importantly, AVWD appears to be independent of major bleeding.
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Affiliation(s)
- Joppe G Drop
- Department of Paediatrics, Division of Paediatric Hematology, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Paediatrics, Division of Pediatric Intensive care and Pediatric surgery, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Enno D Wildschut
- Department of Paediatrics, Division of Pediatric Intensive care and Pediatric surgery, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem P de Boode
- Division of Neonatology, Dept. of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Matthijs de Hoog
- Department of Paediatrics, Division of Pediatric Intensive care and Pediatric surgery, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - C Heleen van Ommen
- Department of Paediatrics, Division of Paediatric Hematology, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands.
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Salha A, Chowdhury T, Singh S, Luyt J, Harky A. Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population. J Pediatr Intensive Care 2023; 12:245-255. [PMID: 37970139 PMCID: PMC10631840 DOI: 10.1055/s-0041-1731682] [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: 03/16/2021] [Accepted: 05/29/2021] [Indexed: 10/20/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a rapidly emerging advanced life support technique used in cardiorespiratory failure refractory to other treatments. There has been an influx in the number of studies relating to ECMO in recent years, as the technique becomes more popular. However, there are still significant gaps in the literature including complications and their impacts and methods to predict their development. This review evaluates the available literature on the complications of ECMO postcardiotomy in the pediatric population. Areas explored include renal, cardiovascular, hematological, infection, neurological, and hepatic complications. Incidence, risk factors and potential predictors, and scoring systems for the development of these complications have been evaluated.
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Affiliation(s)
- Ahmad Salha
- Department of Medicine, St George's Hospital Medical School, London, United Kingdom
| | - Tasnim Chowdhury
- Department of Medicine, St George's Hospital Medical School, London, United Kingdom
| | - Saloni Singh
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Jessica Luyt
- Department of Paediatric Intensive Care, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Amer Harky
- Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, United Kingdom
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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43
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Walczak AB, Bigelow AM, Schneider B, Deitemyer M, Duffy V, Lloyd EA, Frazier WJ, Seabrook RB, Halaweish IF, McConnell PI. Experience With the Crescent• Right Atrial Jugular Dual Lumen Catheter for Pediatric Venovenous Extracorporeal Membrane Oxygenation: A Case Series. ASAIO J 2023; 69:e526-e530. [PMID: 37678262 DOI: 10.1097/mat.0000000000002004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
The Crescent dual lumen right atrial (RA) cannula has recently been introduced for the support of pediatric patients in need of venovenous extracorporeal membrane oxygenation (VV ECMO) support. We present the first pediatric case series illustrating utility of the Crescent RA cannula in the pediatric patient population at a single institution over a 10 month period. From December 2021 to August 2022, six pediatric patients were adequately supported on seven VV ECMO runs at our institution with the Crescent RA cannula. ECMO cannulation, circuit design, anticoagulation management, ECMO circuit pressures, flow rates, and recirculation were similar to our standard of care for VV ECMO. The Crescent RA cannula can be used safely and effectively to provide adequate support for pediatric patients requiring VV ECMO.
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Affiliation(s)
- Ashley B Walczak
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Amee M Bigelow
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Brian Schneider
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Matthew Deitemyer
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Vicky Duffy
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Eric A Lloyd
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Department of Critical Care, Nationwide Children's Hospital, OH
| | - W Joshua Frazier
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Department of Critical Care, Nationwide Children's Hospital, OH
| | - Ruth B Seabrook
- Division of Neonatology, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Ihab F Halaweish
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
- Department of Clinical Surgery, The Ohio State University, Columbus, OH
| | - Patrick I McConnell
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH
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Felling RJ, Kamerkar A, Friedman ML, Said AS, LaRovere KL, Bell MJ, Bembea MM. Neuromonitoring During ECMO Support in Children. Neurocrit Care 2023; 39:701-713. [PMID: 36720837 DOI: 10.1007/s12028-023-01675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
Extracorporeal membrane oxygenation is a potentially lifesaving intervention for children with severe cardiac or respiratory failure. It is used with increasing frequency and in increasingly more complex and severe diseases. Neurological injuries are important causes of morbidity and mortality in children treated with extracorporeal membrane oxygenation and include ischemic stroke, intracranial hemorrhage, hypoxic-ischemic injury, and seizures. In this review, we discuss the epidemiology and pathophysiology of neurological injury in patients supported with extracorporeal membrane oxygenation, and we review the current state of knowledge for available modalities of monitoring neurological function in these children. These include structural imaging with computed tomography and ultrasound, cerebral blood flow monitoring with near-infrared spectroscopy and transcranial Doppler ultrasound, and physiological monitoring with electroencephalography and plasma biomarkers. We highlight areas of need and emerging advances that will improve our understanding of neurological injury related to extracorporeal membrane oxygenation and help to reduce the burden of neurological sequelae in these children.
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Affiliation(s)
- Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, USA.
| | - Asavari Kamerkar
- Department of Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, IN, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Manzoni F, Raffaeli G, Cortesi V, Amelio GS, Amodeo I, Gulden S, Cervellini G, Tomaselli A, Colombo M, Artoni A, Ghirardello S, Mosca F, Cavallaro G. Viscoelastic coagulation testing in Neonatal Intensive Care Units: advantages and pitfalls in clinical practice. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:538-548. [PMID: 36795342 PMCID: PMC10645350 DOI: 10.2450/2023.0203-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/01/2022] [Indexed: 02/17/2023]
Abstract
The expression "developmental hemostasis" indicates the age-related physiological changes occurring during the maturational process of the hemostatic system. Despite the quantitative and qualitative alterations, the neonatal hemostatic system is competent and well-balanced. Conventional coagulation tests do not provide reliable information as they only explore the procoagulants during the neonatal period. In contrast, viscoelastic coagulation tests (VCTs), such as viscoelastic coagulation monitoring (VCM), thromboelastography (TEG or ClotPro), and rotational thromboelastometry (ROTEM), are point-of-care assays that provide a quick, dynamic and global view of the hemostatic process, allowing prompt and individualized therapeutic intervention when necessary. Their use in neonatal care is on the increase and they could help monitor patients at risk of hemostatic derangement. In addition, they are crucial for anticoagulation monitoring during extracorporeal membrane oxygenation. Moreover, implementing VCT-based monitoring could optimize blood product use.
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Affiliation(s)
- Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo S. Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Tomaselli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marta Colombo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Zhang QL, Chen XH, Zhou SJ, Zheng YR, Cao H, Chen Q. Surgical experience in repairing the right common carotid artery and the right internal jugular vein after ECMO in neonates: early clinical results. Ital J Pediatr 2023; 49:149. [PMID: 37950294 PMCID: PMC10636893 DOI: 10.1186/s13052-023-01556-y] [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: 02/08/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The purpose of this study was to summarize the early clinical results and surgical experience of repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates. METHODS We retrospectively collected the clinical data of 16 neonates with circulatory and respiratory failure who were treated with ECMO via the right common carotid artery and the right internal jugular vein in our hospital from June 2021 to December 2022. The effects of repairing the common carotid artery and internal jugular vein were evaluated. RESULTS All 16 patients successfully underwent right cervical vascular cannulation, and the ECMO cycle was successfully established. Twelve patients were successfully removed from ECMO. The right common carotid artery and the right internal jugular vein were successfully repaired in these 12 patients. There was unobstructed arterial blood flow in 9 patients, mild stenosis in 1 patient, moderate stenosis in 1 patient and obstruction in 1 patient. There was unobstructed venous blood flow in 10 patients, mild stenosis in 1 patient, and moderate stenosis in 1 patient. No thrombosis was found in the right internal jugular vein. Thrombosis was found in the right common carotid artery of one patient. CONCLUSION Repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates was feasible, and careful surgical anastomosis techniques and standardized postoperative anticoagulation management can ensure early vascular patency. However, long-term vascular patency is still being assessed in follow-up.
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Affiliation(s)
- Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiu-Hua Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Si-Jia Zhou
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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Lasa JJ, Guffey D, Bhalala U, Thiagarajan RR. Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database. Pediatr Crit Care Med 2023; 24:910-918. [PMID: 37458512 DOI: 10.1097/pcc.0000000000003321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population. DESIGN Retrospective analysis of the Virtual Pediatric System database (VPS, LLC, Los Angeles, CA). SETTING PICUs categorized as either cardiac-only versus mixed ICU cohort type. PATIENTS Consecutive cardiac patients less than 18 years old experiencing cardiac arrest in the ICU and resuscitated using E-CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Event and time-stamp filtering identified E-CPR events. Patient, hospital, and event-related variables were aggregated for independent and multivariable mixed effects logistic regression to assess the association between ICU cohort type and survival. Among ICU admissions in the VPS database, 2010-2018, the prevalence of E-CPR was 0.07%. A total of 671 E-CPR events (650 patients) comprised the final cohort; congenital heart disease (84%) was the most common diagnosis versus acquired heart diseases. The majority of E-CPR events occurred in mixed ICUs (67%, n = 449) and in ICUs with greater than 20 licensed bed capacity (65%, n = 436). Survival to hospital discharge was 51% for the overall cohort. Independent logistic regression failed to reveal any association between survival to hospital discharge and ICU type (ICU type: cardiac ICU, odds ratio [OR], 1.01; 95% CI, 0.71-1.44; p = 0.95). However, multivariable logistic regression revealed an association between cardiac surgical patients and greater odds for survival (OR, 2.03; 95% CI, 1.40-2.95; p < 0.001). Also, there was an association between ICUs with capacity greater than 20 (vs not) and lower survival odds (OR, 0.65; 95% CI, 0.43-0.96). CONCLUSIONS The overall prevalence of E-CPR among critically ill children with cardiac disease observed in the VPS database is low. We failed to identify an association between ICU cohort type and survival. Further investigation into organizational factors is warranted.
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Affiliation(s)
- Javier J Lasa
- Division of Cardiology, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX
- Division of Critical Care, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX
| | - Utpal Bhalala
- Division of Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, TX
| | - Ravi R Thiagarajan
- Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA
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Beni CE, Rice-Townsend SE, Esangbedo ID, Jancelewicz T, Vogel AM, Newton C, Boomer L, Rothstein DH. Outcome of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Patients Without Congenital Cardiac Disease: Extracorporeal Life Support Organization Registry Study. Pediatr Crit Care Med 2023; 24:927-936. [PMID: 37477526 DOI: 10.1097/pcc.0000000000003322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVES To describe the use of extracorporeal cardiopulmonary resuscitation (ECPR) in pediatric patients without congenital heart disease (CHD) and identify associations with in-hospital mortality, with a specific focus on initial arrest rhythm. DESIGN Retrospective cohort study using data from pediatric patients enrolled in Extracorporeal Life Support Organization (ELSO) registry between January 1, 2017, and December 31, 2019. SETTING International, multicenter. PATIENTS We included ECPR patients under 18 years old, and excluded those with CHD. Subgroup analysis of patients with initial arrest rhythm. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 567 patients: neonates (12%), infants (27%), children between 1 and 5 years old (25%), and children over 5 years old (36%). The patient cohort included 51% males, 43% of White race, and 89% not obese. Most suffered respiratory disease (26%), followed by acquired cardiac disease (25%) and sepsis (12%). In-hospital mortality was 59%. We found that obesity (adjusted odds ratio [aOR], 2.28; 95% CI, 1.21-4.31) and traumatic injury (aOR, 6.94; 95% CI, 1.55-30.88) were associated with greater odds of in-hospital mortality. We also identified lower odds of death associated with White race (aOR, 0.64; 95% CI, 0.45-0.91), ventricular tachycardia (VT) as an initial arrest rhythm (aOR, 0.36; 95% CI, 0.16-0.78), return of spontaneous circulation before cannulation (aOR, 0.56; 95% CI, 0.35-0.9), and acquired cardiac disease (aOR, 0.43; 95% CI, 0.29-0.64). Respiratory disease was associated with greater odds of severe neurologic complications (aOR, 1.64; 95% CI, 1.06-2.54). CONCLUSIONS In children without CHD undergoing ECPR, we found greater odds of in-hospital mortality were associated with either obesity or trauma. The ELSO dataset also showed that other variables were associated with lesser odds of mortality, including VT as an initial arrest rhythm. Prospective studies are needed to elucidate the reasons for these survival differences.
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Affiliation(s)
| | | | - Ivie D Esangbedo
- Department of Pediatrics, Section of Cardiac Critical Care, University of Washington, Seattle, WA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Christopher Newton
- Department of Surgery, University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA
| | - Laura Boomer
- Department of Surgery, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
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Sperotto F, Gearhart A, Hoskote A, Alexander PMA, Barreto JA, Habet V, Valencia E, Thiagarajan RR. Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review. Eur J Pediatr 2023; 182:4289-4308. [PMID: 37336847 PMCID: PMC10909121 DOI: 10.1007/s00431-023-05055-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Victoria Habet
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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50
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Weber MD, Conlon T, Connelly J, Himebauch AS. Bedside placement of tunneled femorally inserted central catheters in pediatric patients on extracorporeal life support: A case series and discussion. J Vasc Access 2023:11297298231199117. [PMID: 37731355 DOI: 10.1177/11297298231199117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Pediatric patients requiring extracorporeal life support (ECLS) often need central venous access for extended periods of time. In this population, the placement of an upper extremity peripherally inserted central catheter (PICC) can be challenging due to the location and size of the venous ECLS cannula. Bedside placement of a tunneled femorally inserted central catheters (T-FICC) can be a viable alternative to a traditional PICC. METHODS In this case series we present five children who were on ECLS and had a T-FICC placed at the bedside. RESULTS In this series of five patients we successfully placed T-FICCs while the patients were on ECLS. The T-FICCs dwelled from 15 to 182 days. There were no events of central line associated blood stream infections or deep vein thrombosis. There was only one unintentional line dislodgement noted. CONCLUSION The use of T-FICCs placed at the bedside is a safe and reliable alternative for secure long-term venous access in children who are on ECLS.
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Affiliation(s)
- Mark D Weber
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas Conlon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James Connelly
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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